SCCD : G .G.

AFRICAN DEVELOPMENT BANK AFRICAN DEVELOPMENT FUND

THIS REPORT HAS BEEN PRODUCED FOR THE EXCLUSIVE USE OF THE BANK GROUP

OPERATIONS EVALUATION DEPARTMENT

ADB/ADF/OPEV/2006/14 AUGUST 2006 Original: English Distribution: Limited

REVIEW OF BANK ASSISTANCE EFFECTIVENESS TO THE HEALTH SECTOR

(1987-2005)

TABLE OF CONTENTS Page EXECUTIVE SUMMARY ........................................................................................................vi-x Chapter 1 INTRODUCTION ......................................................................................................... 1

1.1 Objectives, Scope and Methodology ....................................................................................... 1 1.2 Limitations of the Review 2 Chapter 2 HEALTH CHALLENGES IN AFRICA...................................................................... 3

2.1 Economic Development Context ............................................................................................. 3 2.2 Diseases and Demographics .................................................................................................... 4 2.3 Health Financing...................................................................................................................... 5

2.4 Health Systems 7 Chapter 3 REVIEW OF BANK POLICIES AND STRATEGIES ............................................. 9

3.1 Major Policy Initiatives ........................................................................................................... 9 3.2 Policy Implementation........................................................................................................... 12

Chapter 4 OVERVIEW OF HEALTH SECTOR PORTFOLIO.............................................. 15

4.1 Distribution of Projects across Sub-Sectors .......................................................................... 15 4.2 Health Sector Operations across Financing Instruments ....................................................... 16 4.3 Trends of Bank Health Sector Financing............................................................................... 16 4.4 Thematic Spread and MDG Alignment of Bank Health Financing....................................... 17 4.5 Health Indicators in RMCs and Bank Financing for Health Sector ...................................... 18 4.6 Co-Financed Projects............................................................................................................. 18 4.7 Private Sector Health Projects ............................................................................................. 19 4.8 Trends in Composition of Project Financing......................................................................... 19

Chapter 5 EFFECTIVENESS OF BANK ASSISTANCE TO THE HEALTH SECTOR...... 20 5.1 Project Design Quality 20

5.2 Implementation Performance................................................................................................. 24 5.3 Project Performance: Immediate Outcomes ................................................... 28

Chapter 6 TOWARDS ENHANCING BANK EFFECTIVENESS IN HEALTH ................... 39

6.1 Organisational Constraints to Effectiveness .......................................................................... 39 6.2 Prerequisites for Effectiveness .............................................................................................. 40 6.3 Bank’s Potential Areas of Strength in Health........................................................................ 42 6.4 Strategic Areas for Development in the Health Sector.......................................................... 43

Chapter 7 CONCLUSION, LESSONS LEARNED AND RECOMMENDATIONS .............. 46

7.1 Conclusion ............................................................................................................................. 46 7.2 Lessons Learned 47

7.3 Recommendations ................................................................................................................. 48 Annexes

1. Framework for Assessment

2. Statistical Tables

3. List of Projects in the Health Sector Portfolio Since 1987

4. References

5. List of Various Documents Reviewed

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Independent Evaluation for Fostering African Development

The Operations Evaluation Department (OPEV) aims at conducting independent evaluations of the Bank Group assistance policies, strategies, operations, and processes, in order to enhance its assistance effectiveness towards improving quality of life of African population.

In order to meet this mandate, the Department has evolved over time and achieved greater autonomy and independence. OPEV has also scaled up its evaluation work to include Project/Programme Evaluations; Sector, Policy and Thematic Reviews; Country Assistance Evaluations; and Corporate Evaluations. Furthermore, the Department contributes to the development of an evaluation culture on the continent through the organisation of evaluation workshops.

OPEV reports can be accessed from: www.afdb.org.

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FOREWORD

This Review of Bank Assistance to the Health Sector (1987-2005) is part of the OPEV Work Programme 2005-2006 as approved by the Board. It is the first comprehensive sector level review undertaken by OPEV, to be followed by several others including Agriculture and Rural Development, Education, Regional Integration, and Gender, as planned in the Three-Year Rolling Work Programme 2006-2008. The review aims to assess the effectiveness of Bank assistance in the health sector in order to draw lessons and recommendations to management of the Bank in its endeavour to substantially improve its health policy, strategies and interventions to better address the daunting health challenges in Africa.

The review underscores the fact that while the health challenges in Africa and cost-effective solutions to most of them are well known, there is serious financing deficit by the governments and the donor community despite several national and international resolutions that they have subscribed to, and a growing recognition that the health sector is central to development through a mutually reinforcing relationship between health and economic growth. Based on the assessment of Bank effectiveness in health sector by using the evaluation criteria of relevance, efficacy, efficiency, sustainability and institutional development, the report invites the Management of the Bank to undertake significant steps to improve the quality of the health portfolio by selecting strategic priority areas for its health interventions, improving the design quality of its operations, and stepping up the implementation performance. Due to the huge gap between needs for and supply of good health care delivery in Africa and the fact that health MDGs are unlikely to be met by most countries, the review pleads for increased Bank assistance to the health sector in sustainable way. However, this increase must be contingent upon improved Bank performance in the sector and enhanced commitment by the RMCs to ensure that increased assistance to the health sector leads to enhanced capacity of the health system to efficiently deliver health services.

Towards enhancing Bank effectiveness in the health sector, the review identifies key organisational constraints and strategic priorities for development in the sector. The review concludes that although the Bank’s achievements in the health sector leave much to be desired, it has the potential to become a far more important and positive force in improving health of Africa’s population, drawing on lessons and recommendations opportune in the context of the new Bank management committed to achieving results and to enhancing the Bank’s research function that could significantly improve the sectoral knowledge. Last but not the least, the review calls for a stronger government and other stakeholders’ commitment to the health sector as in its absence, the rapidly growing international assistance for health and HIV/AIDS will make little impact.

Douglas Barnett, Ph.D. Acting Director

Operations Evaluation Department

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ACKNOWLEDGEMENTS

This report was prepared by Albert-Enéas Gakusi, Principal Evaluation Officer and Team Leader; M. P. Madhusoodhanan, Long Term Consultant; and Marc Mitchell, Short Term Consultant and Lecturer on International Health at Harvard School of Public Health, Boston. Matthew Hodge, Short Term Consultant, undertook the health project design quality analysis. Getinet W. Giorgis, former Director of Operations Evaluation Department (OPEV), provided guidance since the initial phase of the review in July 2005 until his retirement at the end of January 2006. Douglas Barnett, Acting Director took over since February 2006 and gave it a new momentum. Mohamed Manai, Chief Evaluation Officer at OPEVprovided advice on methodological issues and the organisation of the report. The report received very valuable comments from Osvaldo Feinstein on the approach paper and a thorough peer review and advices from Edward Elmendorf on the draft report. Detlev Puetz, Principal Evaluation Officer at OPEV read the final draft report and provided editorial comments.

The review benefited from comments and discussions on substantive issues with Zeinab El Bakri, presently Vice-President and former Director of Social Development Department* (Centre and West); Alice Hamer, Director of Social Development Department (North, East and South) and their respective Division Managers, Youssouf Mohammed and Tshinko B. Ilunga; Luciano Borin, Director at Operations Private Sector Department; Michel N’Kodia-Bomba, Former President of Staff Council; Karin Millet, Director of Joint Africa Institute; Félix Ndukwe, Chief of Division at Operations, Policies and Review Department; Mohamed Bourenane, Chief of Division at Operations Private Sector Department; Patience Kuruneri, Principal Social Sector Specialist at Operations, Policies and Review Department; Theophilus Fadayomi, Principal Demographer at PSDU, Anouk Fouich, Senior Gender Expert, Adama Traoré, Portfolio Management Expert at Operations Private Sector Department. The following experts of the Social Development Departments participated in interviews and/or provided comments on the draft report: Bineta Ba; Dirk Bronselaer; Makhete Aboubacar Cisse; Maimouna Diop Ly; Jason Mochache, Daouda Malle, Mohamed Chakroun, Mousssa Coulibaly, Neo Modisi, Walter Muchenje, Justin Murara, Mr. Mvula, Nina Okagbue, Wael F. Saleh, Ibrahim Sanogo, Richard Ngah Wanji, and Pap J. Williams.

In the search for comparator indicators, the following colleagues from sister institutions provided valuable assistance: Kei Kawabata, Sector Manager, Health, Nutrition, and Population, Human Development at the World Bank; Savitha Subramanian and Eni Bakallbashi and of the same Department; Kus Hardjanti, Principal Evaluation Specialist, Asian Development Bank; and Roberto Iunes, Office of Evaluation and Oversight, Inter-American Development Bank.

The report benefited from an OPEV mission led to Brazzaville by A-E. Gakusi and M. P. Madhusoodhanan during 6-10 February 2006 for consultations with development partners in the health sector. Luis Gomes Sambo, Regional Director, WHO/AFRO, Paul-Samson Lusamba-Dikassa, Director Programme Management, and the experts of various operational divisions of WHO/AFRO, shared their views on exploring better opportunities for improving health in Africa. Bernadino Cardoso provided valuable assistance for arranging appointments within WHO/AFRO, the Ministry of Health and Population of the Republic of Congo, UNICEF, meetings with the French Co-operation Mission, the European Union, the World Bank Resident Mission, and representatives of 32 NGOs in the Republic of Congo. ____________ * The titles and departments mentioned are those prevailing before 1 July 2006 when the new Bank‘s structure became effective.

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The OPEV Department professional staff, Afework Aklilu, Francois Botes, Athanasius Coker, Gennet Yirga-Hall, Mohamed Manai, A.E. N’diaye, H. Razafindramanana, Paul-Andre Rochon and Foday Turay, commented on the draft report at different stages of the preparation. The portfolio analysis received support from Efessou Lawson, Data Business Analyst at Operations, Policies and Review Department, and Jonathan Kaliwata, Systems Applications Products Specialist at Cooperate Information Management and Methods. Joseph Mouanda and Kechelfi Sarhan provided research assistance for data collection for the portfolio analysis. The secretarial assistance for this review was provided by Aminata Kone, Ruby Adzobu-Agyare and Fatma Gaddour.

____________ Any further matters relating to this report may be referred to D. A. Barnett, Acting Director, OPEV, extension 2041, or to A-E. Gakusi, Principal Evaluation Officer, OPEV, extension 3449.

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ACRONYMS AND ABBREVIATIONS

ADB African Development Bank ADF African Development Fund APPR Annual Portfolio Performance Review ART Anti-Retroviral Therapy CFAF Communauté Financière Africaine Franc CPIA Country Policy Institutional Assessment CPR Country Portfolio Review CSP Country Strategy Paper DFID Department for International Development (UK) EA Executing Agency EPCP Economic Prospects and Country Programming EPI Expanded Programme on Immunisation GDP Gross Domestic Product HDI Human Development Index IADB Inter-American Development Bank ICD Institutional Capacity Development ICT Information Communication Technology IDA International Development Agency IFAD International Fund for Agricultural Development IMR Infant Mortality Rate MDB Multilateral Development Bank MDGs Millennium Development Goals MIC Middle Income Countries MMR Maternal Mortality Rates MOH Ministry of Health NGO Non-Governmental Organisation NTF Nigeria Trust Fund OPD Outpatients Department OPEC Oil and Petroleum Exporting Countries OPEV Operations Evaluation Department PAR Project Appraisal Report PCG Pharmacie Centrale de Guinée PCR Project Completion Report PHC Primary Health Care PIU Project Implementation Unit PRSP Poverty Reduction Strategy Paper RMC Regional Member Country SHC Secondary Health Care SRF Special Relief Fund SSA Sub-Saharan Africa STD Sexually Transmitted Disease SWAp Sector-wide Approach THC Tertiary Health Care UA Unit of Account (of ADB, equivalent to IMF’s SDR) UNDP United Nations Development Programme UNFPA United Nations Population Fund WHO World Health Organisation

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EXECUTIVE SUMMARY 1. Health Challenges: Africa faces major health challenges, which are adversely impacting economic development, human development, and poverty reduction efforts. In addition to a high disease burden resulting from persistence of such infectious diseases as HIV/AIDS, malaria and TB, ongoing demographic and epidemiological transitions have precipitated a substantial rise in prevalence of non-communicable diseases,1 accidents and injuries. Furthering this problem is the poor health delivery systems in most of Africa, the migration of health professionals to urban areas and to other countries and continents, the weak infrastructure including lack of clean water, poor roads and communications, and poorly maintained health facilities. Underlying all of this is a very poor funding base for health and historic biases towards urban curative care. However, during the past decade, funding for health in Africa from international agencies has dramatically increased and governments have become more aware of the importance of health in economic and social development. It is therefore an opportune time for the African Development Bank2 to increase its commitment to health and focus its activities on those areas that will have the greatest impact on health improvement as discussed below. 2. Objective and Methodology of the Review: 3 This review aims to assess how effective are the Bank policies, strategies and interventions in the health sector in order to draw lessons for future policies, strategies and operations. The review was carried out through an extensive review of Bank documents dealing with policy, project and post-evaluations; relevant literature on the health sector in Africa; analysis of Bank project-related data; consultations with Bank health staff and managers in charge of policy formulation and project and programme implementation. The review also benefited from a field mission led to Brazzaville during 6-10 February 2006, for consultations with development partners and sharing the main findings. 3. Review of Policies and Strategies: To respond to Africa’s health problems, Bank interventions in the health sector were initiated in 1975. The first and second health sector policies were formulated respectively in 1987 and 1996, and the health sector policy guidelines were prepared in 1998. The policies and guidelines have been of only limited use in health interventions priority setting. While they have generally reflected international thinking and consensus on health sector policies, strategies, and interventions, they have not set forth operationally practical priority areas in which to invest. The broad nature of the policies have thus led the Bank to accommodate diverse Regional Member Countries (RMCs) requests, including some that may not have been most effective in addressing problems at hand and some in which the Bank’s strength was not evident.4 Though the health policy guidelines were prepared as recently as 1998, the paper was not made available to the health experts and task managers who are expected to translate the policy into practice adding to a weak project-policy linkage for some priority areas like human resource development and reproductive health.

1 Non-communicable diseases include arterial high blood pressure, cardiovascular diseases, diabetes, cancers, mental illness, etc. 2 Referred to in this report as the Bank, which includes African Development Bank, the African Development Fund, and the Nigeria Trust Fund. 3 The term review is used instead of evaluation to reflect the scope of the report, which does not go beyond the limited outcome assessment (OECD, 2003a). 4 The 53 sovereign countries in the African continent constitute the Regional Member Countries of the Bank, including Libya, which is a non-borrowing country.

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4. Quality of Project Design: The review examined the project design quality with respect to the following criteria: quality of project justification, objectives and components, epidemiological analysis, economic and sector analysis, institutional and political analysis, performance indicators and evaluation, project management, demandingness,5 and complexity of projects. While the projects are generally relevant in their stated objectives, few have appropriate data to substantiate them, especially before the introduction of Logical Framework in 1993. Weak use of the sector analysis, coupled with the superficial treatment of epidemiological data, recurrent costs, and the lack of specific cost projections based on expected service levels, have hindered the Bank projects in meeting quality standards for epidemiological and economic analyses. Institutional and political analysis is also weak with inadequate discussion on the political economy of the health sector. Project management shows that in-country co-ordination with other external donors and funding agencies has increased. Demandingness of the project is high and it has increased due to the combined effect of shrinking capacity of the Ministries of Health and the increasing complexity of the projects. Finally, complexity of the Bank projects has been increasing with increased requirements for donor co-ordination, number of different activities in any given project, and more emphasis on capacity building by moving away from the focus on health infrastructure. 5. Health Sector Portfolio and Resource Distribution: During the period under review, 1987-2005, the bank financed 154 operations corresponding to 108 projects spread in 39 countries for a total commitment of UA 990.72 million.6 Commitments to health-targeted projects have constituted a low level of 3.4 per cent of the total Bank commitment to all sectors. This percentage for the last 10 years is 3.7 and that of the last five years only 3.5. This implies that the Bank financing did not increase significantly towards the achievement of the health millennium development goals.7 During the last 10 years, the number and the size of the health projects have slightly increased but the size of health projects increased less than proportionate to the total Bank portfolio, which resulted in a slight decrease in the percentage of health projects financing in the total Bank portfolio. The average size of health projects is UA 9.17 million with operations spread over many sub-sectors, compared to UA 17.3 million for the total Bank commitments for almost the same period (Table 4.2).8 During the earliest years of health activities, the highest share of commitments went to development and rehabilitation of infrastructure, but in more recent years, health projects infrastructure’s share has declined substantially, offset by increased commitment to institutional capacity development, health reform and disease specific activities.

5 Demandingness refers to the extent to which the project could be expected to strain the economic, institutional and human resources of the government and implementing agencies. 6 A project is composed of either a loan alone or a combination of loan and grant(s). To obtain 108 projects, we put together loan and grant(s) as appropriate. Terminated projects and projects having zero disbursement even after 5 years or more after Board approval, were also removed. The exact period covered is 23 March 1987 through 27 July 2005. 7 The Millennium Development Goals adopted by the United Nations in September 2000 to reduce poverty contain the following explicitly health components: a) reducing child mortality rate by two-thirds by 2015; b) reducing the maternal mortality by three-quarters by 2015; c) controlling HIV/AIDS, malaria, and tuberculosis; d) giving access to safe drinking-water and sanitation; and e) alleviating hunger and malnutrition. For the World Bank, the Health Nutrition and Population Sector represented 17.1 per cent of the total assistance commitment to Africa (data provided by Health and Population Advisory Service with caveat on difficulties to make an exclusive classification of sectors/themes). 8 The average project size of UA 17.3 million corresponds to the period 23 March 1987 to 31 December 2005. The average project size for health sector during this period is UA 8.1 million (Table 3, Annex 3).

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6. Implementation Performance: The Bank’s health sector portfolio has demonstrated a lacklustre overall implementation performance, with a stagnant score around 50 per cent of all projects doing satisfactorily for the period 1998-2005 where coherent data are available. Only financial performance registered improvement over this period while procurement performance, the quality of activities and works including project management, as well as compliance with conditions declined. Time and cost overruns have been significant. Borrower performance has been marred by long delays in effectiveness, deficiencies in management capacity, delays in providing counterpart funds, auditing, and reporting irregularities. At the Bank level, inadequate quality-at-entry and insufficient project supervisions are prominent among the major impediments in implementation performance. 7. Bank Assistance Effectiveness: 9 The Bank has not invested adequately in documenting performance of its project interventions in order to know what works. For instance, only 14 of 59 health projects completed since 1987 have PCRs and only 2 have PPERs. Insufficiency of PCRs curtails the conduct of independent evaluation and it restricts the Bank capacity to learn from its operations and to be accountable to its Members. Only 5 of the 12 completed projects having PCRs showed a satisfactory overall outcome performance.10 In their stated objectives, all projects considered in this review have some relevance to the Bank health policy as well as to the policies and strategies of the RMCs but only less than 10 per cent have justified this relevance appropriately. Among the outcome performance indicators, Relevance and Achievement of Objectives was satisfactory or better in 6 out of 12 cases. Institutional Development was considered satisfactory in 5 out of 12 cases, signalling glaring gaps in project management capacity and training of health human resources. Sustainability, satisfactory in only 4 out of 12 cases, was considerably undermined by inadequate resource provision for recurrent expenditures, non-availability of trained health personnel to operate modern medical equipment provided and, in some cases, poor equipment quality and structures. Overall, the analysis of available information shows that the Bank’s performance in health sector has not been satisfactory, and that there is a need for significantly improving the quality of its interventions to produce better results. This should be seen and understood against performance of most African countries - which is poor and needs to be improved - and performance of other RMC development partners. 8. Removing Constraints to Effectiveness: The Bank often spends insufficient time to assess risks, RMCs’ capacity to implement projects, and the demand for the programmed services. This is in part due to the incentive structure at the Bank, which rewards the staff, including senior managers, for the number of projects sent to and approved by the Board, without sufficient regard for project quality. The health document review and interviews with the Bank’s staff indicate that the lack of emphasis on performance-based project design and responsibility for achieving results, both at the staff and project levels, make it difficult for the Bank to hold staff accountable for implementing demonstrably effective projects and programmes. Further, while the Bank health experts appear to be competent and experienced, their skills are of limited use because most health experts appear to spend the majority of their time performing administrative rather than technical work. Task managers of health projects operate under intense pressure to manage even small details without sufficient administrative support, leaving little time and incentive to direct expertise towards policy and strategy development or provide technical support for project design and implementation.

9 Effectiveness (or efficacy) is the extent to which the development objectives have been achieved taking into account all relevant circumstances. 10 Two of the PCRs are on studies and are not included in the review.

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This problem is compounded by the limited sharing of knowledge that seems to occur at the bank among health staff due to the “silo-like” structure that separate the staff. 9. Pre-requisites for Effectiveness: The Bank’s unique position as a major African institution with 40 years of experience in African development financing and significant possibilities for raising funding resources confer it access to key decision-makers including in the health sector. Further, the Bank has laid many of the building blocks and undertaken significant reforms necessary to provide leadership in selected health areas. In this context, removing constraints to effectiveness can help the Bank strategies and projects to produce better health impacts in Africa. The major pre-requisites include: a) strategic selection of interventions which have the greatest impact on health; b) establishment and maintenance of technical leadership and increasing project design and supervision skills in areas selected; c) effective and efficient use of staff to implement strategy on the basis of appropriate incentives and rewards, and re-profiling of staff where necessary; d) enhancement of the knowledge base through Economic and Sector Analysis and effective use of analysis to inform project identification, design, and implementation, along with associated policy dialogue; and e) increase in resource commitment to the sector. 10. Strategic Areas for Development in the Sector: The strategic areas where the Bank investments could be concentrated for better results include: supporting health human resources development, reproductive health, developing sustainable and integrated health systems, policy dialogue for financing and economic reforms, advocacy for African institutions with other donors, promoting African technical assistance institutions, and developing appropriate health infrastructures. 11. Lessons Learned: a) Inadequate attention given to preparation and appraisal leads to unreasonable estimates of time and cost required for project implementation and inadequate attention to risk factors, eventually jeopardising implementation and outcome performance; b) The participation of different stakeholders in the design of health project enables enhanced utilisation and sustainability of the facilities; c) Lack of adequate monitoring and evaluation system prevents the Bank and RMCs from learning from health investments and from being fully accountable towards stakeholders and African populations; d) Lack of adequate incentives makes it difficult to attract and retain qualified personnel in rural areas and to find a solution to human resources deficit and regional imbalances; and e) Lack of emphasis on performance-based project design and responsibility for achieving results makes it difficult for the Bank to hold the staff accountable for implementing demonstrably effective projects and programmes; f) When governments are part of the private sector project implementation arrangements, there is a need to adopt more stringent forms of legal obligations; g) Government’s commitment and quality of institutions are crucial for making successful equitable investments from national revenue and international assistance. 12. Health Sector Specific Recommendations: a) The Bank should revise its current health sector policy and guidelines to make them more operationally focused by identifying areas where the Bank can have the greatest impact on health; b) The Bank is recommended to improve the quality of its health sector projects at the design and appraisal stages through adequate assessment of the capacity within the Bank and in RMCs to design, monitor and implement projects; c) The Bank should actively participate in or initiate Sector-Wide Approaches in the health sector; d) The Bank should take a lead in selected policy dialogue with RMCs; e) Staff should be rewarded for contributing to effectively promoting national policies that have a positive impact on the health outcomes and the Bank should enhance its

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co-operation with other Development Partners in the health based on the strengths of each participating organisation; e) The Bank should augment its assistance to selected areas of strategic importance with high priority given to development of health human resources, integrated health system, and reproductive health;11 f) The Bank should promote feasibility studies aiming at exploring possibilities to effectively support the private sector financing; g) The health sector policy guidelines should contain detailed guidance for performing technical aspects in project design and management. 13. Generic Recommendations: a) The Bank should rigorously execute portfolio improvement measures, including those bearing on quality-at-entry, quality-at-implementation, and quality-at-exit12 in close collaboration with the RMCs to encourage them to play a more active role in the project cycle. The Bank should give priority to drawing upon well informed economic and sector analysis in developing appropriate country strategies and relevant lending programmes; b) The Bank should effectively use existing tools to facilitate assessment of project/programme outcomes and impacts, and the staff incentive structure must incorporate monitoring and supervision activities as a factor in staff performance evaluation; c) The Bank should provide administrative support to technical staff and consider increasing current staffing profiles and levels of both professional and administrative personnel; and d) The Bank should make sure that managers have appropriate skills, capacity and incentives to manage for sustainable results on the ground. 14. The Way Forward: The initial step by the Bank management to implement the above recommendations should be to prioritise and cost the recommended actions. Contributing to this, a process is underway in the Operations Policy and Compliance Department (former Operations Policy and Review Department) for the revision of the 1996 Health Sector Policy. The Operations Evaluation Department should prepare a follow-up report in two-three years time to assess how the recommendations have been addressed. It also should carry out specific evaluations of Bank assistance to the health sub-sector themes in order to better know what interventions really succeed and what the factors of success are.

11 Several studies relying on data from 1980s and 1990s demonstrate the likelihood of a causal relationship between high fertility and poverty (Birdsall et al. 2001). 12 As for the other sectors, the Bank should clear the huge health PCRs backlog on a priority basis.

CHAPTER 1. INTRODUCTION

The African Development Bank began its support for health sector interventions in RMCs in 1975 and it formulated its health policy in 1987, which was revised in 1996. These policy papers were complemented by several disease and sub-sector-specific guidelines and strategies that were prepared to direct interventions in the health sector. During this 30-year period, the Bank committed UA 1.25 billion to support over 206 diverse health operations corresponding to 172 projects in 46 countries. This review covers the period from 23 March 1987 through 27 July 2005, the 18-year period covered by the two policy papers, with a portfolio of 154 operations corresponding to 85 projects and 23 studies spread in 39 countries for a total commitment of UA 990.72 million. It is the first comprehensive sectoral review done by OPEV and advances on a review of selected rural health projects carried out in 1999 and several project level evaluations of completed projects and programmes (ADB 1999b; list of documents reviewed, Annex 5). 1.1 Objectives, Scope and Methodology 1.1.1 This review aims to assess Bank policies, strategies and interventions in the health sector in order to learn lessons from past experience and to strengthen future Bank policies, strategies and procedures, and thereby, to improve the quality of operations towards achieving better results. This review was carried out through an extensive review of Bank documents dealing with policy, guidelines, and post-evaluation reviews, relevant literature on the health sector in Africa, project-related data, consultations with Bank health staff and managers in charge of policy formulation and programme implementation. The findings and conclusions of the review were shared with main development partners and their feedback taken into account into the report.13 The review has three major components: Health Sector Policy and Strategy Review; Cross-Country Portfolio Review; and Country Sector Reviews. 1.1.2 Health Sector Policy and Strategy Review: The policy and strategy review assesses the health situation, trends, prospects and challenges in meeting health development targets in Africa, and situates in context Bank engagements and contributions to health outcomes in RMCs. The work was based on a desk review of Bank health policy and other health sector documents and intensive interviews mainly with Bank health analysts, other social sector experts, managers and directors of Social Development Departments. 1.1.3 Cross-country Portfolio Review: The cross-country portfolio review analyses quality-at-entry, project implementation performance and outcomes. The Analysis of Project Design, which is part of the quality-at-entry assessment, was based on 80 project appraisal reports covering three-quarters of the 85 projects and 23 project preparation studies initiated during the review period (23 March 1987 to 27 July 2005). Appraisal reports were reviewed using different criteria including: Project Justification and Objectives, Epidemiological Analysis, Economic Analysis, Institutional and Political Analysis, Performance Indicators and Evaluation, Project Management, Demandingness, Complexity. 1.1.4 The Analysis of Implementation Performance and Outcomes was based on project-related data on all 85 projects and 23 studies, 56 projects in 31 countries profiled in Country Portfolio Reports, Supervision Reviews for 74 projects, 14 Project Completion Reports, 2

13 Consultations were held in Brazzaville, Republic of Congo, from 6 to 10 February 2006, with main development partners including the World Health Organisation Regional Office for Africa (WHO/AFRO), UNICEF, the Ministry of Health and Population, World Bank Resident Mission, European Union, French Co-operation Mission, and Representatives of Non-Government Organisations. Unfortunately, it was not possible to organise consultations with the policy-making headquarters staff of development partners.

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Project Performance Evaluation Reports, 3 Country Sector Reviews, Reviews of Evaluation Results (1982-2002), Country Assistance Evaluation performed by OPEV for 10 countries, and an analysis of socio-economic data on African countries including population and disease profiles. 1.1.5 Country Health Sector Reviews: Country health sector reviews for Ghana, Morocco and Tanzania carried out by OPEV during 2005 have been used in this study. OPEV used desk reviews and field missions to collect and analyse data relating to health projects effectiveness. The findings and lessons learned from the reviews have been integrated in different sections of the report. 1.1.6 Organisation of the Review: The review is organised in 7 chapters. The introductory chapter presents the background, objectives, scope and methodology. Chapter 2 is a brief analysis of the health challenges in Africa followed by a chapter on a critical review of the Bank’s health policies and strategies and a chapter on the portfolio review. Chapter 5 analyses the effectiveness of Bank assistance to health sector by looking into the project design quality, implementation performance, and intermediate outcomes. Chapter 6 discusses issues in enhancing Bank effectiveness in health, and chapter 7 presents conclusions, lessons learned and recommendations. A simplified framework showing how the Bank influences the health outcomes and impacts in the RMCs through lending and non-lending activities in the health sector is presented in Annex 1 and all statistics supporting the review are presented in Annexes 2 and 3. 1.2 Limitations of the Review A comprehensive assessment of the outcomes of the Bank’s interventions in health sector was constrained by the limited number of probably not very representative PCRs, PPERs and country health sector reviews. The review could not carry out detailed country case studies sufficiently focussing on the impacts of Bank interventions. In spite of the shortfalls in the available data, a careful and comprehensive review of all relevant documents and data from self- and independent evaluations along with in-depth interviews with the Bank staff and consultations with other development partners have enabled reasonable assessment of the Bank assistance effectiveness and drawing up of lessons and recommendations for the Bank management.

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CHAPTER 2. HEALTH CHALLENGES IN AFRICA

Most countries in Africa remain entrenched at the bottom of the development ladder, both in terms of economic and social welfare and calculations based on available data show that most of sub-Saharan African countries will not meet the MDGs goals if their recent pace of progress is sustained (ADB 2006a). While many issues contribute to this situation, this report underscores that poor health in Africa has been a major determinant of weak economic performance. There is strong evidence to show that better health contributes to economic growth, and that sound investment in health is necessary for both economic development and poverty reduction (World Health Organisation 2001). In addition to facilitating human development, better health and increased life expectancy contribute to economic development by improving educational attainment, increasing workforce productivity, and facilitating long-term savings and investment – all key determinants of economic growth. Conversely, economic growth favours increase in government revenue and allow governments to commit additional domestic financial resources to health (Anand and Chen 1996; Sachs 2001). 2.1 Economic Development Context 2.1.1 During the past 18 years covered in this review, poor economic performance coupled with the burden of high public debt, economic decline, and resulting structural adjustment programmes have made it particularly difficult for the African governments to address the huge burden of disease that hampers African development.14 Shortages of essential drugs, limited transport and communications infrastructure, lack of clean water, and grossly under-resourced health facilities all contribute to the inability to address the health problems throughout Africa. Furthermore, economic uncertainty and inadequate agricultural policies have made African populations subject to periods of extreme food shortages and high levels of under-nutrition and deficiencies of specific micronutrients such as iron and vitamin A. This malnutrition contributes to the high death rates among infants and children (Table A2.1 in Annex 2). Compounding these problems, the resources that are available for health are often not used effectively. In conditions of economic decline, the governments tend to protect the wage bill and public employment at the expense of supplies and particularly at the expense of supportive on-going technical supervision in health facilities, which creates a de-motivating context for health personnel. 2.1.2 On a continent where poverty and several debilitating diseases such as HIV/AIDS, malaria, TB and malnutrition are widespread, human capital returns to health investments in Africa could be substantial. In Africa, malaria is estimated to have slowed economic growth by more than a percentage point every year from 1965 to 1990, HIV/AIDS to have caused up to 1.7 per cent annual decline in full income15 from 1990 to 2000, and under-nutrition to have significantly reduced economic potential, with anaemia alone accounting for 1 per cent decline in GDP of several developing countries (Ross and Horton 1998; Gallup and Sachs 2001; Jamison, Sachs et al. 2001). Were life expectancy to enjoy a 10 per cent improvement, GDP in Africa would rise by an estimated 0.3-0.4 percentage points per year (World Health Organisation 2001).

14 During this period, the economic performance of Africa has been very disappointing. For the continent as a whole, annual growth of GDP per capita averaged 0.8 per cent. This figure would have been substantially lower if not taken into account the contribution of the middle income countries of North Africa and the countries of southern Africa with an annual average growth between 1.4 per cent and 1.7 per cent (World Bank 2005b). 15 Estimates of changes in full income are generated by adding the values of changes in annual mortality rates to changes in annual GDP per capita (Bloom et al. 2004).

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2.2 Diseases and Demographics 2.2.1 Communicable Diseases: Communicable diseases continue to be a major obstacle to economic and social development in Sub-Saharan Africa. Over 23 million people in Africa currently live with HIV/AIDS, presenting a huge challenge, particularly in the Southern, Central, and Eastern regions (Table A2.2 in Annex 2). The pandemic has overwhelmed public sector health care delivery systems, which are unable to cope with the rapidly growing number of AIDS patients – particularly women – suffering from acute malnutrition, infections and impending death. The impact of AIDS is so profound that the UN estimates life expectancy in Southern Sub-Saharan Africa to decline by 18.7 years between 1990-95 and 2005-201016 from 61.7 to 43 years. Economically, AIDS was estimated to have cost Africa as much as US$ 60 billion in 1999, or 20 per cent of GNP (Hamoudi and Sachs 2002). 2.2.2 In addition to HIV/AIDS, the burden of several other infectious diseases such as malaria and TB continues to grow. 17 A variety of factors contribute to the rising mortality, including health system weaknesses ensuing from health sector personnel shortage; inadequately conceived and deteriorating physical infrastructures and programme fragmentation; ecological factors, such as the emergence and spread of drug-resistant malaria strains; and, socio-political factors, such as large-scale migration and conflict-related internal displacement that facilitate the diffusion of communicable diseases. Other non-lethal infectious diseases, such as trachoma, schistosomiasis, and worm infestation also contribute to Africa’s high disease burden. 2.2.3 Non-communicable Diseases: Non-communicable diseases, especially mental illness, trauma and accidents, and chronic diseases, appear to be on the rise in Africa. For instance, in Morocco, available data show that in 2001 about 10 per cent of the population of over 20 years old presented signs of diabetes, about 30 per cent of adults had arterial high blood pressure, more than 15 per cent of health consultations were due to depression. The total number of the traffic accidents increased from 24,238 in 1981 to 52,137 in 2002, that of the wounded persons from 32,224 to 81,365, and that of the persons killed from 2,320 to 3,761. These correspond respectively to an annual increase of 10.9 per cent for the accidents, 13.2 per cent for the injured persons, and 6.9 per cent for the persons killed.18 Health systems in Africa are ill-equipped to manage contributory factors such as aging populations especially in middle income countries and in urban areas, high levels of armed conflict and displacement, and unprecedented growth of road networks and vehicle traffic. Chronic diseases in particular rely on the delivery of a continuum of health care with good records and functioning referral systems that are lacking in Africa (Mitchell, Mayhew et al. 2004). Additionally, the prevailing high cost and widespread shortages of drugs for acute diseases give scant hope about the adequate availability of drugs for mental health and chronic illnesses.

16 For the 32 sub-Saharan African countries studied by Garenne and Gakusi (2006) for the period 1950-2000, only a quarter had a smooth health transition with a monotonic mortality decline. Another quarter had a long-term decline with some minor rises over short periods of time. Eight countries had periods of major increases in mortality due to political or economic crises, and in seven countries mortality stopped declining for several years. In at least eight other countries mortality increased in recent years as a result of paediatric AIDS. 17 In Africa, communicable diseases account for two-thirds of all deaths, while cancers, circulatory, and other non-communicable diseases account for less than a quarter of deaths. The situation is reversed in Europe where communicable diseases account for less than 10 percent of deaths, while cancers, circulatory, and non-communicable diseases account for more than four-fifths of deaths (White et al. 2006, p. 27). 18 Recueil d'accidents corporels de la circulation routière, 1991 et 2002, Ministère de l'équipement et du transport, cité par Politique de santé au Maroc: acquis, défis et objectifs. Plan d’action 2005-2007, p. 20 of the draft report.

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2.2.4 Reproductive Health: Sexual and reproductive ill-health accounts for an estimated one third of the global burden of illness and early death borne by women of reproductive age, and 20 per cent for all people worldwide. Access to effective reproductive health services, including family planning, remains meagre in almost all of sub-Saharan Africa due partly to the low government priority put on these activities. 19 Modern contraceptive use among married women 15–49 years of age remains around 20 per cent in all of Africa and as low as 10 per cent in West and Central Africa (Population Reference Bureau 2005). 20 Gross inequities between the poorest and wealthiest quintiles also prevail in use of contraception. The result has been a high incidence of unwanted pregnancy, sexually transmitted diseases, infant mortality and maternal mortality among the poor, as well as continuing high rates of population growth. In sub-Saharan Africa, for instance, one woman in 16 dies from childbirth compared to 1 in 140 in South-East Asia while in industrialised countries the ratio approaches 1 in 4,000.21 2.2.5 Lack of health facilities in which woman can deliver safely, poor communication and transportation networks, high fertility rates, and traditional bias against delivery in hospitals all contribute to the excessively high maternal mortality. Although most African governments have policies to reduce birth rates, international commitment to support their implementation has undoubtedly weakened and funding has decreased (Cleland and Sinding 2005). 2.3 Health Financing 2.3.1 African health systems face huge funding deficits. Compared to a global average of 5.4 per cent of GDP, current government spending averages 2.5 per cent of GDP and falls far short of that needed even for basic care provision. While spending on health care in high-income countries exceeded US$ 2,000 per person per year, in Africa it averaged between US$ 13 and US$ 21 in 2001 (Commission for Africa 2004). The Commission for Macroeconomics and Health recommended that spending for health care in sub-Saharan Africa should rise to US$ 34 per person per year by 2007, and to US$ 38 by 2015, which represent roughly 12 per cent of GNP. This is the minimum amount needed to deliver basic treatment and care for the major communicable diseases (HIV/AIDS, TB and malaria), and early childhood and maternal illnesses.22 2.3.2 Health systems in Africa need US$ 22 billion per year to achieve critical health functions and US$ 5 billion per year for research and development, and provision of global public goods in health. Most of this amount should be forthcoming from donors as most African countries will not be able to contribute substantially until the longer term. In 2002, the share of government contribution to total health spending was only 38 per cent in 19 The understanding of these trends is severely limited by the lack of reliable data and research capacity in Africa. 20 It was about 15 per cent in the early 1990s. 21 WHO, Reproductive Health Strategy, Geneva, May 2004. It is estimated that more than 37 per cent of maternal mortality occur in sub-Saharan Africa whereas women aged 15 to 49 years in the region account for only 10 per cent of that age group worldwide. 22 The estimate does not include some key categories such as family planning, tertiary care, trauma and emergency care, which are part of any operational health system. In 2000, WHO estimated US$ 60 per capita for the functioning of a more comprehensive health care system (OECD 2003b).

Table 2.1: Incidence (%) of Public Sector Spending on Health All levels of health Primary level only

Quintile Quintile Countries

Poorest Richest Poorest Richest Cote d'Ivoire 11 32 14 22 Ghana 12 33 10 31 Guinea 4 48 10 36 Kenya (rural) 14 24 22 14 Madagascar 12 30 10 29 Tanzania 17 29 18 21 Average 12 33 14 26 Source: (Filmer 2003)

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sub-Saharan Africa. In addition to raising funding levels, addressing inequities will require providing health care to rural areas and reversing the disproportionate share of resources supporting tertiary care that primarily serve the urban and financially better off populations. 2.3.3 Alternative Financing Strategies: Most funding agencies have promoted a number of alternative financing strategies to increase resources for health care in Africa, including user fees, social insurance and greater private sector involvement. The strategies have mostly been unsuccessful in mobilising additional resources and, in some cases, may have had a deleterious impact on the health of the most vulnerable populations. In the case of user fees, evidence suggests that even low fees may significantly reduce utilisation of basic health services while raising only modest amounts for local use.23 Consequently, most institutions, including the African Development Bank, do not at present support user fees for basic health services (ADB, 2004a). 2.3.4 Social insurance has also been difficult to implement in countries where large parts of the population are outside the formal economy. Further, since most community financing schemes do not cover major illness requiring hospitalisation they have little impact on financial risk protection. As shown in Table 2.2, except for Southern Africa, private insurance covers only a very small percentage of the population. 2.3.5 The private health sector in Africa is large, heterogeneous and accounts for over 45 per cent of all health spending in Africa (Table 2.2). Made up of traditional healers, pharmacies, drugs available in markets, home remedies, doctors in private practice, community-based NGOs, faith-based and other international NGOs, discussions of ‘the private sector’ and ‘public-private partnerships’ are meaningful only when the specific nature of this term is defined. With widespread concerns about the uneven quality of care being provided by some private practitioners, particularly to the poor, governments have an important new role to shoulder as regulators, licensers, and quality controllers for the private sector. The large size of private health sector raises a major issue on how to support the private sector in strengthening health systems and outcomes in Africa. Otherwise, what to do about private spending and services that could reduce the excessive health care demand to the public sector? The Bank faces the issue of how it could relate to them, as it would be inappropriate to continue to ignore nearly 50 per cent of health spending, especially if the Bank wants to get into policy issues. 2.4 Health Systems 2.4.1 Limited Capacity: Despite substantial investments in health infrastructure over the years, the limited capacity of public sector health systems has been a major obstacle to improved health care and health outcomes. This issue has been dramatically demonstrated by the inability of most African countries to deliver anti-retroviral treatment to AIDS patients even when drugs are available. Limitations of logistics systems, patient record systems, transportation, and especially limited health care personnel have impeded the ability to deal 23 For instance, in Morocco, the household living standards measurement survey of 1998-99 revealed that more than 34 per cent of the sick persons did not access health care because of the high cost. The rate was 55 per cent for the quintile representing the poorest population), quoted by OPEV Bank Moroccan Country Health Sector Review, 2005.

Table 2.2: Health Expenditures and Insurance Region Private health

expenditure as % of total health expenditure

Private insurance as % of total health expenditure

Central Africa 43.7 .. East Africa 46.5 1.4 North Africa 47.7 3.5 Southern Africa 41.3 9.9 West Africa 48.7 2.3 Total 45.8 3.6 Source: (Sekhri and Savedoff 2005)

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with this pandemic. In other health programmes such as immunisations, malaria, family planning, tuberculosis, and parasitic infections, the lack of personnel, data, control systems and general management capacity have impeded programme effectiveness. The problem has been further exacerbated by fragmented and decentralised institutional structures that rely on middle-level managers to plan and implement health programmes. 2.4.2 Human Resources Crisis: Perhaps the most striking problem faced by African health systems is the current crisis in the level, distribution and quality of trained health personnel (Table A2.3 in Annex 2). While Africa has 13.8 per cent of the world population and 25 per cent of the global disease burden, it has only 1.3 per cent of the health workforce (Commission for Africa 2004). The sparseness is the result of a variety of factors, including migration of doctors and nurses to Europe and North America notably due to the poor working conditions and low status of health workers in Africa, death of health personnel due to HIV/AIDS, and the increasing physical and emotional demands of HIV/AIDS patients on an already overstretched workforce (WHO 2006). For example, for Ghana which is known as one of the African countries with the highest rate of brain drain in the medical sector, it is estimated that about a third of Ghana’s trained health personnel left the country during 1993-2002.24 This shortage of health workers cannot be resolved through training alone. Rather, broader-based approaches that address working conditions and supervision of health workers, incentives to stay in a country’s public service, and changes in levels of qualifications and licensure within countries (Narasimhan, Brown et al. 2004; Lucas 2005). 2.4.3 Decentralisation: Difficulties in delivering health services have led to a variety of structural changes in public health systems. The most striking has been the wide application of decentralised health systems with increased budgetary and administrative control devolved to district and regional health managers. While decentralisation is intended to improve resource allocation, service delivery and responsiveness to local needs and priorities, its effectiveness in Africa has been scant, at best (Bossert and Beauvais 2002; Bossert, Chitah et al. 2003). Health sector personnel even at the national level often lack the administrative and financial skills required to manage the decentralisation process. Evidence shows that decentralisation, without the appropriate capacity and resource complement, is associated with weakened public health delivery programmes – including those engaged in vaccination, and malaria and TB control. For example, the WHO Expert Committee on Malaria recently concluded that national-level personnel are often unable to provide adequate strategic direction, policy, norms/standards and other oversight functions for malaria programmes, while those at the sub-national level lack technical expertise and resources25. 2.4.4 Integrated Programmes: Another structural change has been the effort to integrate programmes at national and sub-national levels in an attempt to more efficiently use resources and provide better care. However, this, too, has been problematic since the management of integrated programmes requires strong management capacity at every level and makes it more difficult for both funding agencies and government officials to measure the impact of these programmes (Mitchell, Mayhew et al. 2004). Ironically, while programmes are often integrated at the administrative levels, they remain separate at the level of care. Thus in many countries, patients who have both AIDS and TB will need to go to separate clinics for each resulting in poor continuity of care and poor outcomes for the patient.

24 African Development Bank and OECD (2004f), p. 175. 25 Decentralization may or may not be helpful according to the country, the design of the programme and how it is implemented. It cannot be seen as a panacea for all health sector problems.

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2.4.5 Drug Supply: Drug supply management has gained increased attention on account of the ongoing HIV/AIDS pandemic. But widespread logistics problems, cost recovery issues, and fluctuations in global pharmaceutical markets indicate that ensuring a stable and adequate drug supply remains a major problem. Without drugs, a health system cannot function, and with the increasing costs of drugs for infectious and chronic diseases, addressing drug supply logistics is essential to better health care delivery. Yet, though pharmaceuticals account for 20-50 per cent of government health expenditures, access to essential medicines remains woefully low in many countries. Sound National drug policies – comprising adequate monitoring, regulation and oversight, distribution systems, storage and quality control – are crucial to ensuring pharmaceutical access and rational use. However, 17 African countries still have no national drug policies, fewer than 10 countries monitor safety through the WHO’s Programme for International Drug Monitoring, and pharmaceutical logistics systems are hampered by severe difficulties (World Health Organisation 2004; World Bank 2005). As a result, over one-half of those in Africa’s poorest countries lack access to essential medicines, inappropriate use of medicines remain widespread, while trade in counterfeit drugs plague markets, reaching up to 70 per cent of sales in some countries (WHO/IFPMA 1992; Maiga, Haddad et al. 2003; World Bank 2005, Transparency International 2006).

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CHAPTER 3. REVIEW OF BANK POLICIES AND STRATEGIES

This chapter reviews Bank health policies and strategies that are formulated to guide its assistance to RMCs. The review aims to determine the adequacy of the policies and strategies in directing Bank interventions to activities that achieve substantial impact on health outcomes. Bank policy documents have generally reflected the international consensus on major health problems and approaches to address them. However, they only provide a broad menu of possible activities and do not clarify priorities or give sufficient detail to guide preparation of programmes and projects by Bank health experts and their government counterparts. 3.1 Major Policy Initiatives 3.1.1 The 1987 and 1996 Health Sector Policy Documents 3.1.1.1 The Health Sector Policy Papers of 1987 and 1996 are the two basic documents formulated to establish the Bank’s position on its health assistance. The 1987 paper presented a review of major health issues in Africa, including population problems, health and nutrition status, health delivery systems, and financial problems. It highlighted the relationship between health and socio-economic development, reviewed the Bank’s lending in the sector from 1975 to 1985, and set forth guiding principles for lending in the sector. The priorities identified in the policy were health service management and planning, health manpower planning, control of communicable diseases, procurement and distribution of essential drugs, health care delivery, and population and nutrition. To enhance the planning and management capabilities of health programmes, the policy gave priority to improving skills of administrators through training and technical assistance. 3.1.1.2 In 1996, the health policy was revised to better respond to new challenges, such as the HIV/AIDS pandemic,26 and to place relatively greater emphasis on institution strengthening, considered to be a key element of the health sector. 27 Laying the foundation for health investments during the subsequent decade, the 1996 policy paper was comprehensive and reflected the thinking at the time. It acknowledged that public health programmes were often organised and managed vertically and that a large share of public funds went to urban-based hospital curative care, leaving the rural population unattended. It discussed a wide variety of approaches that might be used to rectify some of these problems, including the role of the private sector, user fees and insurance to make up for low public expenditures on basic health services, stakeholder participation in the preparation of projects, and a focus on primary health care to provide services to the poor.28 Still, several critical areas are mentioned only in passing, including malnutrition and access to safe water and sanitation. Some of the gaps were later addressed through other policy documents, such as policies on malaria and population, as well as through the Policy Guidelines.

26 Rapid population growth, and increase in female-headed households were also arguments put forward for policy revision but are not convincing, as population growth was not a new phenomenon and there is no evident link between increase in female-headed households and the revision of the Bank health policy. 27 It was estimated that 80 per cent of the Bank’s investments were spent on infrastructure development. 28 Primary health care is a set of principles outlined at Alma-Ata in 1978 consisting of universal access to health care and coverage on the basis of need; commitment to health equity; community participation; and inter-sectoral approaches to health (WHO 1978 and 2003). However, empirical evidence shows that even services undertaken specifically to help the disadvantaged, usually end up reaching the better-off groups more frequently. A recent World Bank study on 21 developing countries indicates that, on average, the benefit going to the best-off 20 per cent is two-thirds higher than that accruing to the poorest 20 per cent (World Bank 2006). See also Gwatkin et al. (2004).

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3.1.1.3 These policy documents indicate the Bank’s recognition that health investments must take into account Africa’s complex environments and the multitude of factors that contribute to poor health. The documents note that health investments must go beyond buildings and physical infrastructure to include investments in human resources, logistics and supply systems, delivery systems and specific problems that address population, nutrition and health priorities. For example, they call for investments in effective national policies that create a supportive environment for health development and the necessary staff, equipment, pharmaceuticals and health systems that can deliver high quality curative and preventative health services. In their detailed descriptions of both disease trends in Africa and functioning of the health systems, the policy documents note that poor management and inadequate resource allocation aggravate the problems of the sector. 3.1.1.4 While the description of health problems is thorough, proposals to address them are less so. The strategy component of the policy is presented in general and broad terms and does not provide operationally helpful indications on the type of interventions envisioned as priorities. 3.1.2 Health Sector Policy Guidelines 1998 3.1.2.1 Following the development of the Health Sector Policy of 1996, the Bank drafted the Health Sector Policy Guidelines in December 1998. The Guidelines were designed to operationalise the Bank’s policies and to ensure quality project development and execution by the Bank and RMCs. The document reviews Bank procedures for project identification and assessment, and summarises the Health Sector Policy that identified the following three lending priorities: public health/health promotion, 29 health systems, and supportive environment. 3.1.2.2 The Guidelines then detail how projects should be planned, negotiated with the country, and managed, with formats for use in project management. The following major points are made in the guidelines:

Need for extensive sector work prior to the identification of projects in a country, including independent assessments of the health situation, institutional capacities for implementing health policy, strategies, programmes, and organisation as well as management of the health sector.

Review of project plans for their consistency with Bank health policies and priorities, using data from the sector analysis.

Development of a project brief and logical framework in which planning assumptions are made explicit and assessed for validity. This and subsequent Bank procedures were to be done in a collaborative manner within the Bank, drawing on necessary expertise as needed for effective planning and review.

An implementation study that tests the validity of project design assumptions. An objective project appraisal that again looks at implementation capacity, outputs

and objectives of the project. Project supervision is explicitly described.

3.1.2.3 The Guidelines provide both a general overview of health status, health systems and health financing problems and a practical guide to the process of developing projects in the Bank. It also orients Bank staff and national counterparts to focus on public health priorities,

29 Notably community compliance with health interventions in population dynamics including reproductive health with special emphasis on family planning, maternal and child health, nutrition, prevention and control of HIV/AIDS, other sexually transmitted diseases and communicable and endemic diseases.

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health systems and supportive environment. Nevertheless, the Guidelines were never disseminated to Bank staff and were not used. 3.1.3 Disease-Specific Policy Documents 3.1.3.1 Subsequent to the approval of the health policy paper, a number of other policy documents were prepared in specific disease areas. The documents include: HIV-AIDS Strategy Paper (2001a) Malaria Control Strategy (2002); Guidelines for Policy on Population (2004a); and Guidelines on Communicable Diseases (2004b). These guidelines and policy documents are comprehensive and reflect contemporary thinking in the development community. They detail demographic and health contexts, assistance modality relevant to the particular disease, and potential opportunities for Bank engagement in the area. 3.1.3.2 However, the guidelines do not provide guidance for setting priorities; rather, they offer a complete menu of possible interventions without indicating the kind of activities which yield high demonstrable impacts in particular circumstances. The set of “priorities” encompasses disease prevention, communications strategies, clinical treatment, infrastructure support, and impact mitigation. This array is so broad that almost any investment proposal in the area could be considered a priority. For instance, the almost unlimited choice in investment allocation within communicable diseases is accompanied by little guidance on what types of investments might be most effective from the Bank’s perspective. 3.1.3.3 In addition, although the disease-specific guidelines reflect a general consensus, they do not always reflect the most recent thinking on issues in some areas. The Malaria Control Strategy Paper, for example, supports the current WHO approach to malaria control although recent evidence has raised serious questions about its effectiveness and even the basic approach. While the paper mentions the issue of increasing parasite resistance to conventional therapy, the strategy itself does not provide any guidance on facilitating provision of updated, effective therapies for SSA.30 Yet others have pointed out that drug-resistant malaria is a key issue undermining the effectiveness of the WHO’s Roll Back Malaria (RBM) approach to combat malaria in sub-Saharan Africa (Attaran, Barnes et al. 2004). 3.1.3.4 The Policy on HIV/AIDS takes a narrower view of priority areas, focusing on advocacy and policy dialogue, mainstreaming HIV/AIDS control in Bank operations, and partnership development. Yet even this approach provides little guidance to project planners on intervention areas that offer the highest likelihood of success. The Guidelines for the Implementation of Bank Policy on Population are also broad in terms of the specific areas of intervention to follow. The list of priority areas include: formulation and implementation of population policy; access to reproductive health services and rights; integrated population activity providing social, economic and political empowerment; migration management, rural development and environmental issues; displaced persons and involuntary population settlements; youth and women empowerment; and research and capacity building. Such a broad agenda does not provide guidance on specific country interventions and it refrains from some controversial choices about the expansion of family planning services to adolescents, abortion, or post-abortion care.

30 The problem here is the reported lack of comprehensive WHO malaria treatment guidelines and contradiction between the WHO policy to support artemisinin-class combination therapies (ACT) against malaria and its assistance for cheaper but less effective drugs like chloroquine and sulfadoxine-pyrimenthamine.

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3.1.4 Health Reform Policies 3.1.4.1 The Bank has also developed a number of policies on financing, including: Guidelines on Budget Support (2003); Guidelines for SWAps (2004c); and Guidelines on User Fees in Health and Education (2004d). These guidelines were developed in the context of significant changes by multilateral and bilateral donors focussing on health reform. During the 1990s, donors and governments alike voiced frustration with the way health systems were working as well as the role assumed by donors and lending institutions in shaping the health agenda in much of Africa. There was also a realisation that, at prevailing funding levels, health facilities in most countries would not provide even a modest array of services and that government systems were often inefficient both technically and in allocating resources. 3.1.4.2 Out of this emerged a series of health reforms that have largely driven the health agenda for the past 10 years. These reforms include: (a) alternative financing strategies, including user fees and insurance schemes; (b) decentralisation of the health system to put more resources and decision-making power into the hands of local health managers and policy makers; (c) financial autonomy of some hospitals and health facilities; (d) increased involvement and recognition of the private sector’s role in health care delivery; (e) greater focus on results of health systems in terms of health outcomes, including those established in the Millennium Development Goals; and (f) funding mechanisms that shifted from project-specific financing to budget support and Sector-Wide Approaches (SWAp). The Bank joined other development agencies and formulated policy documents on user fees, SWAp, and budget support, while also backing the other reform elements in its programming activities. 3.1.4.3 Like the disease-specific policy documents, the health reform policy documents set out the rationale of the policies in considerable detail. They do reflect current World Bank and WHO thinking on these issues, though they need to be updated with more recent evidence. Like the other policy documents, they provide a wide menu, without clear priority setting criteria and without focusing project design on specific areas. 3.2 Policy Implementation 3.2.1 Unused Health Policy Guidelines: From the analysis of the current lending portfolio and interviews with Bank staff, it is clear that the health policies and guidelines have been of limited use to strategically orientate health lending. In addition to the fact that the Bank health staff have rarely used relevant information from policy documents, the availability of the Health Sector Guidelines has been lacking: only two of the 11 health analysts interviewed were aware of its existence, and even those two had not read it nor knew where to locate it. The lack of circulation of this document since its approval in December 1998 is indicative of inadequate attention given to systematic project development, follow-up and supervision in health lending. 3.2.2 Limited Use of Disease-Specific and other Guidelines: Though availability of the disease-specific and health reform guidelines does not appear to be a problem, they have been used only in a limited way to guide project design, approval, supervision and review activities. While the staff seem to be sensitised to the issues leading to the design of the various disease-specific projects, the projects themselves do not follow the specifics of the guidelines (Table 4.1). 3.2.3 Legal Hurdles: Despite the policy documents on SWAp, the Bank participation in such a lending scheme in health is still limited due to the “rules of origin” condition which has become an obstacle to harmonising donor procurement procedures for goods and works

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(Box 3.1). Rules of origin are one of the tenets of the Bank’s fundamental legal requirements; but because they restrict the purchase of goods and services to Bank member countries, the rules sometimes run counter to the general principles and objectives underpinning the sectoral approach.31 However, the Bank has recently started to participate to the SWAp arrangement without pooling its financial contribution, as it is the case in the support to the health sector programme in Malawi. In this case, the Bank resources were earmarked to finance the reduction of maternal and newborn mortality and morbidity while continuing to use its own procedures for disbursement (ADB 2005a). Other examples of such ‘ring-fencing’ of activities include the Bank support to health sector programmes in Mauritania, Ethiopia, and Uganda, to name a few. Box 3.1: Health SWAp in Ghana and the Bank

The Government of Ghana adopted health SWAp in 1994. Thereafter it has vigorously pursued extensive health sector development plans, and mobilised most of the health sector development partners fully or partially through a proven working SWAp arrangement. The Government has been able to provide leadership and co-ordination in this process.

The move towards SWAp in Ghana was necessitated by the established limitations of the traditional project approach. The traditional project approach is characterised by fragmentation and duplication of efforts in the sector, lack of coherent policy and prioritisation, inadequate attention to strategic and systemic issues, parallel systems failing to address local capacity, high transaction costs, and limited long term impact.

The health SWAp in Ghana has a good track record of co-operation of an active sector group of most major stakeholders. However, there are several challenges that the SWAp has to face. They include: (a) improving physical and financial access to health services; (b) overstretched human resources; (c) lack of comprehensive policy on information, monitoring and evaluation of the sector; and (d) slow engagement of private sector and civil society.

The Bank has not yet participated in the health SWAp. All participating donors and the Government are urging the Bank to be more proactive in policy dialogue, sector work and new financing instruments. However, the Bank is still continuing with its focus on the traditional project approach. Aid co-ordination with the Government and other development partners is not effective mainly due to the absence of a Country Office in Ghana. Hence, the Bank is physically absent in most donor co-ordination meetings in the country. More importantly, since the Bank has not carried out any substantial sector work in health and has no proven capabilities in policy dialogue, it appears that the Bank is still not prepared to participate in SWAp.

Source: OPEV, Ghana – Evaluation of Bank Assistance to Health Sector (ADB 2005b). 3.2.4 Policy–CSP Disconnect: The Bank has not made health a strategic priority nor conveyed the message through documents such as CSPs that are intended to direct Bank activities in each country. These documents usually contain descriptions of the existing health status and health systems but they provide little detail on addressing specific problems. For instance, the Bank did not have a clear strategy when it intervened in Ghana to strengthen the Government’s health programme. In CSPs prepared prior to 1996, the analysis of the health sector was limited to some description of health system characteristics. The CSPs do not clearly define the strategic priorities and consequently cannot provide a context for project identification and preparation. Even the main diseases prevailing during different periods are not mentioned, except for HIV/AIDS which is considered as a big development challenge in CSPs prepared during 1996-1998. Malaria is also mentioned in the 2005-2009 Country Strategy Paper of Ghana. Further, while the 1999-2001 CSP of Ghana had planned to allocate 23 per cent of the Bank assistance to the social sector, only 2.1 per cent were actually allocated.

31 See the African Development Bank. 2004. Revised Guidelines for Bank Group Operations using Sector-wide Approaches (SWAps), p. 11. Tunis: African Development Bank.

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3.2.5 Unfocussed Funding Responses: All 11 health analysts interviewed for this evaluation suggested that the project development process is not informed by policy guidelines, but rather by country requests in areas where other donors have not provided funding.32 Rather than developing a clear orientation for funding projects and programmes that reflect development-oriented priorities and expertise, the Bank has been responding to a wide variety of country requests, including some with limited potential for demonstrable impacts. This approach leads to a portfolio of projects where there is little emphasis on health outcomes and long-term improvement of the population’s health. While it is important to respond positively to country priorities, there is also a need for independent analysis of a country’s needs and priorities as well as a mechanism for participation of NGOs and civil society organisations in planning, designing and implementation of projects, as recommended in the health sector policy guidelines of 1998.

32 The interviews were guided by a set of semi-structured questionnaires.

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CHAPTER 4. OVERVIEW OF HEALTH SECTOR PORTFOLIO

‘Health sector’ here includes Health, Population and Nutrition sub-sectors of the social sector and does not include health-related projects financed by the Bank in other ‘non-Health sectors’ such as Water Supply and Sanitation.33 This review classifies the components of health sector projects to include: Primary Health Care, Secondary health care, Tertiary health care, HIV/AIDS, Disease control (control of communicable diseases other than HIV/AIDS), Pharmaceuticals, Institutional capacity development, Studies including support for preparation of national health sector plans and feasibility studies, Disability rehabilitation, Population and nutrition, and Health sector reforms.

4.1 Distribution of Projects across Sub-Sectors

4.1.1 Since 1987 the Bank initiated 108 projects and studies with different sub-sectoral foci. Primary health care sub-sector has dominated the Bank interventions as recommended by the health policy as an analysis of appraisal report objectives shows (Table 4.1). Studies, which were commissioned mostly for project preparation, represent 21.3 per cent of the number of the projects but with only 2.1 per cent of the total financial commitment, as most of the studies cost only US$ 500,000.

Table 4.1: Distribution of Project Components within Sub-sectors a

Sub-sector components

No. of projects with main focus on the

sub-sector

%

No. of other projects with the

sub-sector component

% Total no. of projects with the sub-sector

component %

Total Amount

(UA million)

%

Primary Health Care 30 27.8 7 6.5 37 20.9 350.5 35.4Secondary Health Care 13 12.0 8 7.4 21 11.9 162.4 16.4Health Sector Reforms 3 2.8 3 2.8 6 3.4 129.4 13.1Institutional Capacity Development 10 9.3 23 21.3 34 19.2 120.9 12.2Tertiary Health Care 9 8.3 4 3.7 13 7.3 92.1 9.3HIV/AIDS 10 9.3 14 13.0 24 13.6 42.9 4.3Disease Control (excluding HIV/AIDS) 5 4.6 4 3.7 9 5.1 40.9 4.1Studies b 23 21.3 0 0.0 23 13.0 20.5 2.1Pharmaceutical Development 2 1.9 2 1.9 4 2.3 15.2 1.5Population and Nutrition 2 1.9 3 2.8 5 2.8 15.1 1.5Disability Rehabilitation 1 0.9 0 0.0 1 0.6 0.9 0.1Total 108 100 - - 177c 100 990.7 100

a Projects are identified and classified by their principal sub-sector components when their activities could be grouped under several sub-sectors; b This also includes 4 Studies in Population and Nutrition sub-sector; c As many sub-sector components are computed more than one time.

4.1.2 The table shows that projects with primary health care have received the highest proportion of Bank resources followed by secondary health care, health sector reforms, institutional capacity development, and tertiary health care. However, this overall picture masks evolving Bank intervention behaviour. During the first policy period (1987-1996), 84 per cent of health sector investments were made in primary, secondary and tertiary health care. In the second policy period (1997-2005), emphasis shifted to Institutional Capacity Development and Disease Control. Among the most recent projects, disease control and HIV/AIDS are given highest priority. Together, they constitute 44.3 per cent of health sector financing and nearly 25 per cent of resources have been earmarked for health sector reforms among ongoing projects (Tables A4.1 and A4.2 in Annex 2). The country/region-wise distribution of financing for various health sub-sectors since 1987 is presented in Table A4.3 33 Health sub-sector includes medical infrastructure, teaching of medical professionals and technicians, provision of medical equipment and care, production of pharmaceuticals, primary health care and disease control. Population and nutrition sub-sector comprises fertility and family planning, mortality, with special emphasis on HIV/AIDS, migration, refugees and displaced persons and family structures.

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in Annex 2. However, the table also shows that the Population sub-sector including reproductive health and nutrition has been neglected while population problems including high fertility constitutes one of the biggest challenges faced by African countries and one of the priority areas defined in the Bank health policy. 34 4.2 Health Sector Operations across Financing Instruments

During the first policy period, Project Loans were the predominant financing instrument, accounting for over 92.1 per cent of total financing. During the second policy period, financing instruments were more diversified with scaling down of loans to 65.3 per cent largely replaced by interventions aiming to reform the health sector (Table A4.4 in Annex 2). Though Project Cycle Technical Assistance Loans were discontinued, there was a substantial increase to Institutional Support and Rehabilitation Grants, a trend consonant with that of other multilateral development banks. Box 4.1: Definitions of Financing Instruments Project Loans: Discrete investments aimed at creating specific productive assets or increasing identifiable

outputs. Project Cycle Grants: Grants for financing feasibility and engineering studies. Sector Investment and Rehabilitation Loans: Investments aimed at strengthening or rehabilitating sector-

specific planning, production or marketing capabilities; often used to finance imports of equipment or inputs for the sector; and financing of reconstruction and rehabilitation following major disasters and economic dislocations.

Project Cycle Technical Assistance Loans: Loans for financing feasibility and engineering studies. Structural Adjustment Loan: Investment in support of macroeconomic policy and institutional reforms aimed

at improving economy-wide efficiency. Sectoral Adjustment Loan: Financing in support of policy and institutional reforms in the sector.

Source: Compendium of Statistics on Bank Group Operations, 2004.

4.3 Trends of Bank Health Sector Financing 4.3.1 Health sector financing has accounted for an average of 3.4 per cent of overall Bank financing between 1987 and 2004. The health sector financing is marked by three distinct periods: a) a period of increase between 1987 and 1992 where investments increased by 18 per cent a year from UA 34.4 to UA 84.64 millions; b) a period of decrease from 1992 to 1995 which corresponds almost to the crisis the Bank faced in the early nineties to the extend that by 1994-95 due to non-availability of ADF resources, the Bank financed very few projects without any health project;35 and c) a period of increase between 1995 and 2004 where health net approval increased from nil in 1995 to UA 101.3 millions in 2004. The fall in health financing in 2003 corresponds to the political crisis in Côte d’Ivoire and the relocation of the Bank from Abidjan to Tunis. The exceptional increase in 2002 is mainly explained by two loans approved by the Bank, one for medical insurance reforms in Morocco and another for health system development in Nigeria, respectively of UA 94.3 million and UA 34.7 million.

34 For the World Bank, the population operations represented approximately 16.9% of the total assistance commitments to Africa in Health Nutrition and Population sector (data provided by Health and Population Advisory Service of the World Bank with a caveat on difficulties in making an exclusive classification of sectors/themes). 35 During the early 1990s, the Bank experienced poor performance due in part to the loss of confidence of shareholders. The negotiations of the ADF VII took a long time and the Fund was unable to commit any new resources during the period 1994-95 and the first half of 1996 (Kabbaj 2004, chapter 10).

17

0

1

2

3

4

5

6

7

8

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Year

Per

cent

age

Tota

l Net

App

rova

l

0

50

100

150

200

250

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Year

Tota

l Net

App

rova

l (U

A m

illion

)

Table 4.2. Recent Trends in Bank Health Financing Percentage of Total Net Approval Sector 1996-2005 1996-2000 2001-2005Education 4.5 7.6 3.1Health 3.7 4.1 3.5Social 9.8 14.8 7.5Percentage of Total Number of projects approved Sector 1996-2005 1996-2000 2001-2005Education 7.1 6.9 7.3Health 8.2 7.6 8.6Social 19.8 20.0 19.8Mean Size of projects Sector 1996-2005 1996-2000 2001-2005Education 13.7 16.0 11.3Health 9.1 7.9 10.2Social 9.9 10.4 9.3Total Bank Portfolio 19.9 15.4 24.4

Figure 4.1: Health Sector Net Approval Figure 4.2: Health Sector Financing (percentage)

4.3.2 As table 4.2 shows, for the period 1996-2005, the number and the size of the health projects have slightly increased but the size of health projects increased less than proportionate to the total Bank portfolio. This resulted in a slight decrease in the percentage of health projects financing in the total Bank portfolio from 4.1 per cent during 1996-2000 to 3.5 per cent for 2001-2005, the period covered by the MDGs commitment. 4.3.3 During the period covered by the review, 1987-2005, ADF resources account for 84.7 per cent of health sector financing, followed by ADB and NTF representing respectively 14.3 per cent and 1 per cent. While ADF financing increased over time in absolute terms, its relative share declined during the second policy period due to increase in ADB funding. There has been only a marginal increase in NTF funding (Table A4.5 in Annex 2). 4.4 Thematic Spread and MDG Alignment of Bank Health Financing 4.4.1 Activities contributing to health outcomes have been mainstreamed into several “non-health sectors,” including Water Supply and Sanitation, Education, Agriculture and Rural Development, and Urban Development. Based on the analysis of health themes’ share in Bank portfolio on a sample of selected 199 ongoing projects, a thematic analysis of Bank projects carried out by OPEV as part of the Bank Report on Development Effectiveness 2006, assessed the relative shares of resource allocation in all Bank projects that contribute directly to the health MDGs and indirectly through poverty reduction. 4.4.2 While Bank investment in the health sector constitutes only 3.4 per cent of total investments, the thematic classification estimates that an average of 11.1 per cent of Bank resources have been earmarked for health themes during 1988-2004. Health themes accounted for 13.9 per cent of resources in ADF and Blend countries, with close to one-half of resources directly contributing to MDG health goals and just over one half indirectly contributing to poverty reduction (Table A4.6a in Annex 2). Health themes accounted for only 7.2 per cent of resources in ADB countries, which do not benefit from Bank concessional loans. In fact, ADB countries are reluctant to borrow at market rates to invest in the social sector and are able to find less expensive finance notably from bilateral sources. This situation is very similar to that prevailing in the Asian Development Bank where the

18

health policy special evaluation has recommended introduction of concessional funds to make the cost of loans for the social sectors cheaper than ordinary capital resources (Asian Development Bank 2005). 4.5 Health Indicators in RMCs and Bank Financing for Health Sector Table 4.3 indicates a very significant negative correlation between Bank health sector financing and under-five mortality, and a weak correlation with other prominent health indicators such as HIV/AIDS, life expectancy at birth, and immunisation. In fact, some of the countries that have received less Bank assistance in the health sector are also the problematic ones in terms of their track record of working with the Bank (longstanding arrears and the resultant Bank sanctions), civil conflicts and lower CPIA ratings. The table shows a positive significant correlation between health financing and country population size. As it is a common pattern in international assistance, there is a small country bias by which countries get more assistance per capita than larger ones, so a region with lots of small countries will get more aid per capita than a region with a few large countries (White and Feeney 2003; Iseman 1976). 4.6 Co-Financed Projects 4.6.1 The Bank has initiated and/or participated in 17 co-financed projects in the health sector since 1987, accounting for about 24 per cent of the net loan commitments and 16 per cent of the total number of projects. There are several agencies participating in co-financed projects, including the European Union, World Bank, bilateral agencies, OPEC Fund, BADEA and UNDP (Table A4.7 in Annex 2). The Bank’s contribution is the largest among the co-financiers (28.4 per cent), followed by that of the European Union (16.8 per cent) and World Bank (11.1 per cent); RMC’s contribution is just under 15 per cent.

4.6.2 Co-financed projects are generally complex, have very high transactions costs, entail wide coverage in terms of area and people, and require co-ordination of several financing partners. The Bank’s large stake in over 70 per cent of the co-financed projects, with a contribution of over 50 per cent, indicates the potential leverage the Bank can exercise through co-financed projects involving other international development agencies. Co-financing represents potential opportunities for inter-agency co-operation in support of multinational, as well as major country projects that require large investments.

4.7 Private Sector Health Projects

The Bank has so far supported only one private sector health project, viz. Abuja International Diagnostic Centre (AIDC) in Nigeria. This was a co-financed project with International Finance Corporation (IFC). IFC invested US$ 750,000 in equity and provided a loan of US$ 1.75 million. The Bank approved and fully disbursed US$ 3.0 million in September 1997. The project turned out be a failure and is now headed towards liquidation.

Table 4.3 Correlations between Bank Health Financing and Some Socio-Economic Variables

Appr Pop Apprp CPIAHIV/ AIDS Q(5) Eo Measles GNIP HDI

APP 1 0.56* 0.07 0.34* -0.22 -0.08 0.09 -0.01 -0.03 0.02 Pop 0.56** 1 -0.34 0.00 -0.22 0.01 0.04 -0.22 -0.17 0.09 Apprp 0.07 -0.34 1 0.22 0.26 -0.36* 0.19 0.19 0.30 -0.37 CPIA 0.34* 0.00 0.22 1 0.05 -0.28 0.10 0.57** 0.10 -0.07 HIV/AIDS -0.22 -0.22 0.26 0.05 1 0.03 -0.49** 0.15 0.09 -0.07 Q(5) -0.08 0.01 -0.36* -0.28 0.03 1 -0.78** -0.40 -0.31** 0.80 Eo 0.09 0.04 0.19 0.10 -0.49** -0.78** 1 0.30 0.20 -0.79* Measles -0.01 -0.22 0.19 0.57* 0.15 -0.40* 0.30 1 -0.05 -0.36* GNIP -0.03 -0.17 0.30 0.10 0.09 -0.31 0.20 -0.05 1 -0.39* HDI 0.02 0.09 -0.37* -0.07 -0.07 0.80** -0.79** -0.36* -0.39* 1 *The correlation is significant at 0.01 (bilateral) * The correlation is significant at 0.05 (bilateral) APP: Net Approval Eo: Life Expectancy at birth Pop: Population Q(5): Infant Mortality Apprp: Net Approval per capita GNIP: Gross Nation Income per Capita CPIA: Country Political and Institutional Assessment HDI: Human Development Index

19

The project failed because the Nigerian local government, which was responsible for utility connections (water, electricity, etc.) to the facility, did not deliver, and the project incurred a high pre-operational cost of US$ 1.5 million not budgeted, leading to high cost overruns. However, the Bank’s Private Sector Department is planning to expand assistance to private sector health facilities/services in Africa. Towards this end, the Vice-Presidency of Infrastructure, Private Sector, and Regional Integration is considering a major partnership with a reputable Asian leader in the sector, where Public Private Partnership approach is particularly suitable. Within the private sector, the issue of HIV/AIDS treatment would be considered as requiring exceptional measures, as most African economies cannot sustain the costs involved in providing retroviral treatment of HIV patients, no matter what the level of efficiency of local health systems might be. 36 The Bank should engage in financing health services by reputable private providers (who could be NGOs or for-profit organisations), directly and/or through financial intermediaries.

4.8 Trends in Composition of Project Financing

There have been conspicuous changes over the years in the priorities attached to various project components and categories.

Figure 4.4 shows that infrastructure category in Bank financing declined from an average of 79 per cent of the base costs during the first policy period 1987-1996 to an average of 64 per cent in the second policy period and reaching a low level of about 50 per cent since 2003. This trend is in line with the general trend in international health financing in which most bilateral and multilateral development agencies are receding from infrastructure and focussing instead on health sector reforms and capacity development. Since

2002, substantial increases have been made to the share of study, supervision and specialist services, which appear to be part of the efforts to improve project quality-at-entry and implementation performance. Apart from an exceptional drop between 1991 and 1993, the operating costs vary around a stationary tendency. Bank support for drugs and supplies has declined over time, from about 18 per cent of total project expenditures in 1989 to nil in 2004. The share of training, which followed an increasing trend before the crisis in the early 1990s, has considerably increased between 1994 and 1999 from 1 per cent to 14 per cent. It then sharply decreased to 1 per cent in 2004. The share of the technical assistance followed the same pattern before 1994 but it only recovered in 1995 and then it followed a downward trend (Table A5.1 in Annex 2).

36 Correspondence with the Director of the Bank’s Private Sector, 20 June and 9 August 2006.

Figure 4.3 Project Expenditure by Categories (% of Total Planned Approval)

0102030405060708090

100

1987 1989 1991 1993 1995 1998 2000 2002 2004

Year

Perc

enta

ge

Infrastructures

Others categories

20

CHAPTER 5. EFFECTIVENESS OF BANK ASSISTANCE TO THE HEALTH SECTOR

This chapter analyses the effectiveness of Bank assistance to the health sector since 1987 by looking into project design quality, implementation performance and achievement of intermediate outcomes. These assessments are based on a review of all project documents including project appraisal reports, and various documentations from self- and independent evaluation instruments of the Bank.37 The quality of self-evaluation data is influenced by several factors including an element of subjectivity in assessment by the task managers of different implementation performance criteria during supervision missions, or the changes in the rating methodology (ADB 1999a). It is only from 2000 that the data present a coherent evolution.38 It may be noted that the analysis has identified inconsistency between high rating on expected achievement of development objectives by the task managers and other implementation performance indicators, which engage the responsibility of the managers who must be accountable for objective evaluation by task managers.

5.1 Project Design Quality

The project design quality assessment examines whether the objectives were clear, realistic and important for the country/sector and how responsive to the borrower circumstances and development priorities. From a post-project perspective, the assessment resorted to a checklist of 40 project design quality variables adapted from Stout et al. (1997) and from a check list of the Bank’s operational manual criteria, review of relevant project documents and interviews with the Health Experts, Managers and Directors in the Social Development Departments of the Bank. The analysis is based on in-depth review of Appraisal Reports of 59 projects and 21 studies out of a total of 85 projects and 23 studies which covered interventions in two policy periods and various health sub-sectors.39 5.1.1 Project Justification and Objectives Every Project Appraisal Report (PAR) has sought to justify the proposed project by identifying its consistency with government policy, but only less than 10 per cent of them have presented data to substantiate this linkage. Although many Appraisal Reports indicate a pre-appraisal discussion of options, they do not contain a comparison of the proposed project to other health projects or projects in other sectors in terms of health outcomes or cost-effectiveness. With the introduction of Logical Framework in 1993, there has been notable improvement in the clarity, realism and specificity of project objectives: 37 per cent of projects (19 of 52) have included specific government health objectives such as reductions in disease frequency. While all projects approved in 2004 contained specific government health objectives, none from the first policy era (1987-1996) contained such objectives. It may be noted that Government health objectives may be appropriate to address the country’s health

37 Bank self-evaluation instruments for monitoring implementation progress comprise project supervisions, country portfolio reviews and project completion reports, carried out by the Operations Complex. Independent post-evaluations are carried out by OPEV and include Project Completion Report Reviews, Project Performance Evaluation Reports, Country Sector Reviews, Country Assistance Evaluation, Sector/Thematic Reviews, and Reviews of Evaluation Results. 38 The following events have influenced the quality of the data: a) since 1996, the Bank started publishing its Annual Portfolio Performance Review in order to enhance the efficiency and effectiveness of operations but it is only in 1998 that the Bank recruited a permanent data business analyst; b) in 2001 the Bank moved from the Projects and Loans Management System (PALMS) to Systems Application Products (SAP) for project data management; and c) the temporary relocation of the Bank from Abidjan to Tunis in 2003. 39 For details on the methodology and results, see OPEV background document of this report, Analysis of Project Design, Health Sector, May 2006.

21

needs or not and that, the health practice and funding may be at great variance from stated objectives.

5.1.2 Epidemiological Analysis Epidemiological and economic analyses were found to be weak in the Bank health projects. While 90 per cent of PARs (75 of 80) discussed the health needs of the country, only 1 PAR included attempted to estimate the burden of disease. Since the late 1990s, even though descriptions of the malaria situation in PARs for projects in malaria-affected countries have presented detailed analysis of burden of malaria in health and health services terms, few of these projects included malaria-specific measures, whether preventive or treatment-related. The PARs are conspicuous in the absence of information on MDG indicators or on systems for their measurement. In many cases, this absence could have been effectively addressed through co-ordination with other multilateral institutions, including WHO and UNICEF, who routinely collect such information. 5.1.3 Economic Analysis 5.1.3.1 No adequate attention has been given to realistically estimate the recurring costs and assessment of the financial means available to meet these costs, resulting in a sustainability risk of ADB-funded facilities.40 While 72 per cent of projects (44 of 61) estimated recurrent costs, no consistent method was identifiable. In several projects, the PAR acknowledges likely significant increases in recurrent costs but states that these are within the scope of planned spending increases in the health sector. None of the 82 PARs reported even a rudimentary cost-effectiveness analysis except unsubstantiated statements that the facilities constructed/rehabilitated would be cost-effective. 5.1.3.2 Excluding studies, 38 per cent of PARS (31 of 82) included information on private and public providers. However, the information was limited to numbers of establishments (clinics, hospitals) or providers (doctors, nurses) and did not include the volume and scope of services or relative prices of similar services where public and private provision exists.

40 Health projects, like many other social sector investments, face a particular set of cost issues. Even when initial capital spending for a health facility is modest the scale is dwarfed by the costs for personnel, supplies, and maintenance needed to provide the service. By contrast, a road or port construction typically entails a larger upfront capital expenditure but generates a stream of economic benefits, some of which government or quasi-governmental bodies can capture through taxation and fees. The capture of privately experienced improvements in health or avoidance of death is not immediately realizable as revenue, but is clearly an important upstream input into economic development.

Box 5.2. Previous Findings from the Review of 17 Rural Health Projects The main problems encountered in Bank rural health projects stem from the identification, preparation, appraisal and implementation of the projects through the project cycle. Government’s commitment to sustainability of project benefits is inadequate (...). At appraisal, baseline performance indicators were not included as measuring tools for monitoring, supervising, and evaluating the project (...). Further, inadequate assessment of recurrent budget capability was the sources of problems of inability to fully meet recurrent costs in the health centers and district hospitals, which adversely affected their functioning (...). Every rural health project experienced, in varying degrees, constraints in staffing of the health centres, shortages of supplies of drugs and essential consumables, and little or no support for equipment and physical maintenance (...). Despite its awareness of inadequacies in the rural health, the Bank failed to provide hitherto the advisory services for relevant technical guidance to borrowers. Technical supervision often had unsatisfactory skill mix, were irregular and sometimes there were long intervals between mission. There were instances when timely application of corrective measures might have averted poor result.

OPEV, Review of Bank’s Experience in Rural Health, 1999, pp. 3-5.

22

Overall, weak use of the sector analysis, coupled with the superficial treatment of recurrent costs and the lack of specific cost projections based on expected service levels, have hindered the Bank projects in meeting quality standards. 5.1.4 Institutional and Political Analysis

Institutional and political analysis is an area that needs substantial improvement since there is little of either and exacerbated by weak use of sector work beyond making references to the recipient government policy. Government involvement and commitment were difficult to assess, as the PARs do not present sufficient information on the process of negotiations that takes places between the government and the Bank prior to project preparation. Given ADB’s emphasis on construction and the use of ‘studies’ to design and prepare tender documentation for these facilities, national government involvement appears to be limited to pre-project negotiation, a process hinted at but not elaborated in the PARs. Only 18 per cent of PARs (15 of 82) contained any discussion on institutions. Incentive structures of officials and service providers were not analysed. Finally, analysis of the political economy of the health sector was not identified in any PAR, beyond the observation that providers cluster in urban areas and skilled providers may work in both public and private sectors simultaneously. However, empirical data supporting this observation were not identified and no information on interest group influence was provided. 5.1.5 Performance Indicators and Evaluation

Performance indicators and evaluation have shown improvement since the adoption of the Logical Framework. Ensuring that the Logical Framework’s objectives, the project activities, and the targets are closely linked would significantly improve Project Design Quality. Nevertheless, there are inconsistencies in the way Logical Frameworks are prepared, manifested in the project activities disconnected from expected outcomes and the identified outcomes are not always mentioned in the proposed approach to monitoring and evaluation. Overall, the Logical Framework is yet to be used as an effective tool for improving project design and implementation. Also, it is essential to ensure that attention to gender and environment is embedded within the selected outcomes and that systems for gathering such disaggregated data be put in place. 5.1.6 Project Management Recent move of the Bank to increase capacity development components in projects have broadened the relevance of the Bank projects but have also necessitated intensification of project management as the number of partners and contracts expands significantly from the number required in a typical construction project. In-country co-ordination with other external donors and funding agencies is also more important with this shift and PARs suggest this co-ordination is increasing. The Bank has joined other multilateral institutions in efforts to improve and deepen co-ordination,41 as part of a growing investment in harmonisation of donor practices (OECD 2003c). This work spans a range of activities including measuring, monitoring and managing for development results. The Bank’s commitment to this effort is likely to open new opportunities for collaboration with other donors and potentially significant changes away from the reliance on time-limited, project-specific PIUs (Bank Press Release 2002/243/S).

41 MFDR principles in Action: Sourcebook on Emerging Good Practices. Available at http://www.mfdr.org/sourcebook.html.

23

Table 5.1: Summary of Changes in Health Sector Project Design Quality during the Two Policy Periods

Project Design Quality Dimensions

1987-1996

1997-2005

Project Objectives & Components

Strong emphasis on health facility construction

Decreased emphasis on construction, expansion of other components, particularly capacity development and disease control

Epidemiological Analysis Generally weak or not provided Persistent weakness with regard to epidemiological analysis; unchanged from earlier policy period

Economic and Sector Analysis

Particularly poor in the analyse of cost-effectiveness, recurring costs, and health service provision environment

Persistent weakness in economic and sector analysis; unchanged from earlier policy period

Institutional & Political Analysis

Weak; no evidence of rigorous institutional and political analysis

Remain unchanged

Performance Indicators & Evaluation

Rarely provided, beyond supervision reports focused on construction progress

Attention to performance indicators improved; however, indicators identified in Logframe and text are sometimes inconsistent

Project Management PIU implementation PIU implementation; more consistent note on donor co-ordination via recipient government

5.1.7 Demandingness42 The Bank’s health projects have most often been implemented through PIUs. PIUs were used in 73 per cent of projects (60 of 82) and 10 per cent (8 of 82) were implemented through steering committees. During the most recent policy period, demandingness has increased due to the combined effect of shrinking capacity in Ministries of Health and the increasing complexity of the projects. From this perspective, demandingness and complexity are intertwined and arguably positively correlated. In countries with high rates of HIV infection, the loss of skilled staff has been particularly marked. During the second policy era, 16 per cent of projects (10 of 61) included contracted relationships with NGOs, suggesting that the shift in service delivery from implementing Ministries to NGOs may have been a response to increasing difficulties for government in implementation and service delivery. However, the PARs contained no details of NGO participation in project conception design, implementation, and services delivery. 5.1.8 Complexity

The Bank health project complexity arises primarily from the range and number of proposed activities. These typically span sub-sectors, for example a single project may include facility construction, equipment purchase, and training, all delivered through distinct contracts. During the review period, ADB has initiated and/or participated in 17 co-financed projects most of them in the last decade. ADB staff have cited several procurement complexities arising from this mix of activities as having increased markedly over the last decade. Complexity has also increased with the reduction in project expenditures going to infrastructure for which procurement and supervision are reported to be more straightforward compared to capacity building and community development activities. The shift away from facility construction funding is, notwithstanding increased complexity, consistent with the

42 See footnote 5.

24

current development thinking about how health can be improved and contribute to development. 5.2 Implementation Performance 5.2.1 Trends in Implementation Performance 5.2.1.1 Of the 108 projects in the portfolio, supervision ratings are recorded for 74 projects (245 supervisory visits in total) with ratings made on: (a) Compliance with Conditions; (b) Procurement Performance; (c) Financial Performance; (d) Activities and Works including project management; and (e) Development Objectives. Individual components are rated on a 0─3 scale indicating, respectively, ‘highly unsatisfactory,’ ‘unsatisfactory,’ ‘satisfactory’ and ‘highly satisfactory’ performance, with overall performance averaged across components. To be satisfactory, a criterion must have a score of 2 and above. Figure 5.1 traces the trends in project performance with respect to the above assessment criteria (Table A5.1 in Annex 2).

5.2.1.2 Stagnant Overall Project Performance: The overall performance has remained more or less unchanged at only around 50 per cent of projects since 2000 rated satisfactory on overall performance, in spite of the recent efforts towards portfolio improvement. 5.2.1.3 Declining Compliance with Conditions: Incidence of non-compliance with conditions is about 35 per cent of the projects between 1998 and 2005, but seems to increase up to 40 per cent in recent years. Three type of conditions are considered here: (a) conditions precedent to loan effectiveness such as Borrower adherence to the timeframe indicated in appraisal reports for fulfilment of conditions; (b) general conditions implying quality and timeliness of reports submitted including audit and quarterly progress reports; and, (c) other conditions specific to the country context agreed upon by the government and the Bank. Non-compliance with conditions is identified as a major cause of time overrun in project implementation, widely seen in most Bank projects, beginning with delays in effectiveness. The most important reasons for delayed effectiveness are protracted legislative processes for loan ratification in some countries, difficulty in establishing Executing Agencies due to institutional and human resource capacity weaknesses, and political instabilities (ADB 2004). 5.2.1.4 Decline in Procurement Performance: Procurement Performance deals with procurement of consultancy services, goods and works and the extent to which governments follow Bank related rules and guidelines. Despite the concerted efforts to streamline procurement practices since the mid-1990s, procurement performance has shown a declining tendency with exceptionally high performance in 1999 and 2001.

Figure 5.1: Trends in Satisfactory Project Performance

0

10

20

30

40

50

60

70

80

90

1996 1998 2000 2002 2004 2006

Year

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cent

age

of P

roje

cts

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Project Management

0

20

40

60

80

100

120

1996 1998 2000 2002 2004 2006

Year

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cent

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of P

roje

cts

Overall Performance

Compliance with the Conditions

Development Objectives

25

5.2.1.5 Improvement in Financial Performance: Financial performance refers to availability of foreign exchange and of local currency that indicates timeliness and adequacy of disbursements made by the government, disbursement flows methods and effectiveness, cost management/recovery indicating whether project implementation proceeds within budget or incurs cost overruns, and performance of contributions by co-financiers in adhering to agreements. The financial performance of health sector projects has overall marginal positive trends implying some improvement over the years. 5.2.1.6 Low and Declining Quality of Project Management: Quality of project management is consistently the lowest among all project performance indicators and is explained by weak executing agencies’ capacity, non-adherence to implementation schedules, and procurement delays recorded in country portfolio review reports. Nearly half of all projects reviewed faced these problems. 5.2.1.7 Overstated Expectations on Achievement of Development Objectives: Development Objectives has four criteria: achieving project objectives; realising and sustaining benefits

beyond the project investment stage; project contribution to institutional capacity; and expected rate of return. Figure 5.2 shows that the achievement of development objectives as assessed by task managers during supervision missions was increasing during 1998-2000 period followed by a decline in 2000-04, and rising again in 2005. However, only 42 per cent of PCRs available indicate overall satisfactory performance, and only 50 per cent show

satisfactory achievement of development objectives. Furthermore, the country sector reviews carried out by OPEV in Ghana, Morocco and Tanzania in 2005, although satisfactory, present a less rosy situation. It may be unrealistic to put a high premium on self-evaluation of achievement of development objectives when performances of most other related indicators are less satisfactory.43 5.2.2 Performance of Problem Projects 5.2.2.1 The Bank uses the concept of ‘problem projects’ to identify projects needing intense supervision during implementation. A project is rated ‘problematic’ when the average score of Development Objectives or the average score of Implementation Progress indicators is less than 1.5 on a scale of 0─3. A comparison of health sector projects’ performance with those in all sectors shows that the problem projects are declining over time even though the overall performance has remained more or less stagnant.

43 Data from the World Bank indicate that the difference between self- and independent evaluations on the percentage of satisfactory ratings for Health Nutrition and Population (African Region) for 1999-2005 was 10 points for Outcome, 14 points for Institutional Development and Sustainability, 13 points for World Bank Overall Performance, and 7 points for Borrower Performance.

Figure 5.2: Project outcome performance

70

80

90

100

1998 1999 2000 2001 2002 2003 2004 2005Year

Per

cent

age

Outcome Sustainability

Institutional Development

26

5.2.2.2 Health Sector Performance vs. All Sectors: The social sector in general and the health sector in particular have lower performance than other sectors (Table A5.2 in Annex 2). The social sector projects are usually complex, incorporating several policy and institutional development components, entail the involvement of multiple institutions, comprise a number of project components, need to surmount weak health sector institutions; and in some cases can require co-ordinating co-financiers (ADB 2001b). However, as shown in Figure 5.2, performance in health sector projects and in all Bank projects are showing a movement towards convergence, with the number of problem projects declining since 1998.45 5.2.3 Time Overruns 5.2.3.1 Health sector projects are subjected to considerable delays in all stages of the project cycle. The first notable delay occurs between the time of Board project approval and its effectiveness date. The second delay happens between the effectiveness date and that of first disbursement. And a third happens through the course of implementation, which can be captured by the time taken between approval and the planned final disbursement. The long time overrun reflects a combination of poor project design, low government commitment to the projects, and/or low relevance of the projects. 5.2.3.2 Delays in Effectiveness: Projects are normally expected to be signed within six months after Board approval and to become effective after another six months. In the case of health projects, only 50 per cent of the projects became effective within 12 months while the other 50 per cent have taken more than a year to become effective (Table A5.3 in Annex 2). One of the most time-consuming procedures in effectiveness is project ratification by the countries’ respective parliaments. 5.2.3.3 Delays Leading to First Disbursement: There have been considerable delays in the time taken between effectiveness and first disbursement. Country governments have to fulfil several conditions before the first disbursement can get through, including setting up the PIU, procuring goods and services, and submitting a disbursement application to the Bank. Applications are delayed if they fail to follow the prescribed formats. More importantly, governments need to obtain a no-objection certificate from the Bank on procurement. Conflicts can, at times, arise on this point. In addition to this, the government has to fulfil specific conditions agreed upon with the Bank before the first disbursement. It may be noted that only 15 per cent of the projects received the first disbursement within one month of effectiveness, and more than half within 6 months (Table A5.3 in Annex 2). Nearly half of the projects had their first disbursement delayed by between 13 and 42 months. This indicates premature appraisal and approval. 5.2.3.4 Age of Projects: While the average stipulated age of health sector projects at appraisal is 3.7 years, the actual average age of health sector projects (except studies) is 9.1 years 44 The data on Problem Projects for All Bank Projects were taken from the APPRs. Comparison of Problem Projects in Health Sector with All Bank Projects was not possible for 2004 and 2005 due to lack of data. 45 There are very few supervision ratings available for health sector before 1998 and hence the percentages of problem projects during that period are not comparable over time.

Figure 5.2: Problem Projects44

0

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1998 1999 2000 2001 2002 2003 2004 2005

Year

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during which projects may loose their relevance, unlike large infrastructure projects which retain their relevance for many years. Studies, on average, have taken 8.4 years to complete. Taking duration of projects between approval and planned final disbursement of completed projects as a proxy for the age of the project, 86 per cent of the projects have taken over 5 years to complete final disbursement, with 54.1 per cent taking between 5 and 10.1 years and 32 per cent between 10.1 and 14.3 years (Table A5.4 in Annex 2). Nearly half of the projects in primary health care, secondary health care, tertiary health care, disease control and pharmaceutical development have taken more than 10 years to complete and indicates the gravity of the problem. 5.2.3.5 Considering the time taken between effectiveness and planned final disbursement of completed projects, the actual time taken for implementation presents a slightly different picture. Nearly a third of the projects were completed within 5 years and 15 per cent took more than 10 years to complete (Table A5.4 in Annex 2). This is primarily observed among the projects dealing with institutional capacity development and primary, secondary and tertiary health care. Disease control, HIV/AIDS, pharmaceuticals and studies have taken more than 10 years to complete. 5.2.4 Quality and Frequency of Supervision 5.2.4.1 Quality and frequency of supervision are one of the major determinants of implementation performance and development outcome. At the country level, it is the responsibility of the government and its executing agencies to implement and supervise the projects. At the Bank, project supervisions are carried out in various ways, including field supervision, desk supervision, mid-term reviews, and country portfolio reviews. Standard projects must receive 1.5 field supervisions per year, (i.e., one visit every nine months), while “problem projects” are expected to be supervised twice a year. In principle, all active projects are to be supervised in a given year. In practice, however field supervision visits were held less than once per year for ongoing projects.46 5.2.4.2 The quality and frequency of supervisions and the skills-mix of the supervision team are reported to be inadequate. PCRs show that the technical supervision teams, in most cases, consist of a health expert and an architect.47 A health economist was part of a supervision team in 1 out of 5 cases. The average frequency of supervision was 1 mission per year per project, with duration of 9 and 7 days per project per year for health experts and architects, respectively. The health analysts have spent on average 33 days per year on supervision missions.48 Overall, the available supervision records show that, since 1996, only 74 projects were supervised out of a total of 99 completed and ongoing projects in the health sector portfolio. 5.2.4.3 The severe staff shortage makes it difficult for the Operations staff to supervise all active projects in a given year. The number of projects per Operations staff in the Bank is 4.31 – much higher than that of other MDBs. For example, project per Operations staff at the

46 African Development Bank (2004e). Stepping up to the Future: An Independent Evaluation of ADF-VII, VIII and IX. Tunis: African Development Bank, p.105. 47 For Health, Nutrition, and Population Sector of the African Region of the World Bank, at least 6 different experts comprise the corresponding mission to deal with several aspects of the project, such as health, evaluation, financial management, operations, procurement, and management. 48 Note that currently there are 40 ongoing projects in the portfolio to be supervised by 11 Health Experts. This means that on average there are 3.64 projects per Health Expert who spends on average 9 days per project per year for supervision, adding up to a total of 33 days per year. These estimates are based on data given in PCRs.

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World Bank is 0.88, and at the Inter-American Development Bank it is 1.63. The project-staff49 ratio in Health is 3, which is better than the Bank average. 5.2.4.4 Additionally, the lack of incentives for supervision inhibits staff engagement in the activity. In fact, the incentive system for the Operations staff gives predominance to the number of projects initiated and approved; the number or quality of supervisions carried out by staff do not factor in performance assessment. Another adverse element is the Bank’s inadequate field presence, which hampers effective supervision and monitoring function. Bilateral donors and other MDBs have stronger field presence compared to the Bank, which has only 8 Country Offices and 2 Regional Offices to deal with 52 countries. The decentralisation process currently underway of Bank operations with establishment of up to 25 country representations could improve the quality of the Bank portfolio. 5.3 Project Performance: Intermediate Outcomes

This chapter draws on the limited available information from PCRs, PPERs and country health sector reviews. Of the 59 projects completed since 1987, the Bank has prepared only 14 PCRs including 2 PCRs for studies, and 2 PPERs. This observation constitutes an indication of the emphasis put by the Bank on providing loans and grants at the expense of monitoring and measuring progress toward the health outcomes and impacts in RMCs. PCRs assess project performance through: (a) implementation performance, directly implying the performance of governments and executing agencies; (b) Bank performance; and (c) project outcomes, reflecting the relevance and achievement of objectives, institutional development and sustainability (Table A5.5 in Annex 2).50 In addition, information from 56 projects examined under country portfolio reviews has been used to analyse project performance, as well as the country health sector reviews carried out by OPEV in 2005.51 5.3.1 Overall Project Performance

From the 12 available PCRs, 5 projects have satisfactory ‘overall performance,’ which corresponds to 42 per cent, acknowledging the element of non-representativeness of the PCRs. ‘Bank performance’ has been satisfactory in 50 per cent of the cases while that of borrowers has been satisfactory in only 25 per cent of the cases. The ‘relevance and achievement of objectives’ criteria are satisfactory in 50 per cent of the cases, while ‘institutional development’ and ‘sustainability’ are satisfactory in only a 33 per cent of the cases. As an indication, the World Bank Operations Evaluation Department rated 64 per cent satisfactory of the 107 HNP projects completed between 1975 and 1998, compared with 79 per cent for non-HNP projects. For the World Bank projects completed in 1997-98, 79 per cent achieved their development objectives satisfactorily, close to the World Bank average of 77 per cent. Only half of all completed HNP projects between 1975 and 1998 were rated as likely to be sustainable, this figure rose to two-thirds in 1997-98. Institutional development was rated as substantial in only 22 per cent of completed HNP projects, a figure that rose to 25 per cent in 1997-98, well below the World Bank average of 38 per cent (World Bank, 1999).

49 The ‘staff’ considered here include Health Experts, Managers and Directors. 50 These projects cover the sub-sectors of primary/secondary/tertiary health care, disease control, institutional capacity development and pharmaceuticals. 51 In 2005, OPEV carried out health sector reviews for Ghana, Morocco and Tanzania.

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5.3.2 Relevance

Overall, the Bank interventions in the health sector has proved to be relevant in their stated objectives. They aim to improve access to health by the population in RMCs by focusing on primary health care, which is in accordance with Bank and RMCs policy priorities. 52 Except disease control and institutional capacity development, most of the projects in the above-listed sub-sectors aimed to construct health facilities or rehabilitate those which were deteriorating due to neglect and lack of maintenance or were ill-equipped in essential medical equipment, supplies, medical and paramedical personnel and functional delivery systems. Disease control projects were implemented in areas with high rates of such communicable diseases as Schistosomiasis, Oncocerciasis and HIV/AIDS. Pharmaceutical projects have addressed the need for production, procurement, storage, and supply of essential drugs at affordable prices at national and regional levels. Nevertheless, the Bank neglected population sub-sector including reproductive health, and nutrition in its health portfolio while these constitute one of the biggest challenges faced by African countries.53 It also should be noted that the health sector portfolio is composed of projects of small size with several components each, which prevents significant impacts for each component. 5.3.3 Efficacy 5.3.3.1. The Bank health interventions aimed at improving technical effectiveness, access and equity, quality and efficiency of health care delivery systems. Selected indicators of efficacy are briefly discussed below: 5.3.3.2 Technical Effectiveness: With a very limited health portfolio compared to the health challenges of the RMCs, the Bank projects have attempted to address different issues related to technical effectiveness through support for infrastructure including buildings, furniture and medical equipment, medical supplies, human resource development, and strengthening country health delivery systems at the ministerial or directorate levels.54 However, there are several cases where the medical equipment installed at the health facilities was of poor quality or delivered without trained personnel to make it function in a proper way.55 For example, the Health System strengthening project in the post-war period in Congo experienced inadequate procurement planning which resulted in the equipment being delivered before the hospital construction was completed; there also was no provision for a trained technician to operate the X-ray machine, which eventually fell into disuse. In Ghana also, some medical equipment purchased has not been installed, or broke down within a short

52 Countries reviewed here had their own health sector policies, strategies and priorities articulated either through specific health sector policies, poverty reduction strategy papers (PRSPs), or as part of national five-year plans. Bank health sector policies, Country Strategy Papers, and the Economic Prospects and Country Programming (EPCP) papers guided Bank interventions. 53 The Bank health sector is characterised by the near absence of any significant Economic and Sector Work including a study on Zambia, which remained in its draft status (ADB 2001c). On the other hand, for the period 2001-05, the World Bank carried out 20 Economic and Sector Works for the African Region. 54 Technical effectiveness relates to: (a) whether available goods and services of the health care delivery system supported by the Bank are up-to-date and locally appropriate for a number of health conditions, especially those of greatest epidemiological significance; and, (b) whether the level of training and capability of the health service providers are commensurate with their requirements (Stout et al. 1997 use the term clinical instead of technical). 55 Equipment includes: CT scanners, orthopaedics, surgery, ICUs, renal and peritoneal dialysis, specialised radiology for cancer treatment, and urology (Uganda); modern equipment for laboratory, radiology, surgery, dental and physiotherapy (Zambia); establishment of departments for OPD, Medicine, Surgery, Maternity and Paediatrics with related service units such as theatre, X-ray, pharmacy and laboratory (Uganda); use of selective population chemotherapy, and selective mollusciciding and use of Kato technique for Schistosomiasis (Egypt).

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time after commissioning. An example is Kibi hospital pharmacy block, where the workbench has not been delivered, and part of the kitchen equipment was installed in the pharmacy and has never been in use. 5.3.3.3 Poor quality has been reported in several other constructed or rehabilitated structures as well. In some cases, contractors used substandard construction materials (Ghana, Burkina Faso) and suppliers chosen through International Competitive Bidding delivered outdated, low-quality equipment (Cote d’Ivoire, Burkina Faso). In Chad and Ghana, modern medical equipment at project hospitals fell into disuse for lack of trained personnel to operate them. In Chad, even after rehabilitation, operation theatres were not air-conditioned and impervious to the elements, while hospitals were encumbered by leaky roofs. In this context, it may be noted that 12.5 per cent of the projects considered in CPRs had not complied with Bank specifications on quality of works. In Morocco, the health facility design contained serious defects. At Bab Taza's hospital in the province of Chefchaouen, the passage to the delivery room is so narrow that the patient is obliged to get down from the stretcher and walk to reach the delivery room. The radiology room is very small and the technician is not protected from exposure to radiation. Women find it difficult to use the common toilets, which are not provided separately for women and men. Many of these defects could have been avoided had the medical staff and the beneficiaries been involved in the design of the hospital.

5.3.3.4 Accessibility: Bank projects have helped to improve the geographical accessibility of health facilities to catchment populations. In several cases, utilisation rates have substantially increased after the health facilities were rehabilitated. Yet there are also instances where, due to weak preparation and appraisal, health facilities were located in areas without adequate population threshold. For example, the Zambia Rural Health Services Project initially planned to provide a 250-bed district hospital. Due to several institutional and managerial problems experienced during implementation, the hospital was eventually constructed with a reduced 100-bed capacity. In Burkina Faso, use of health facilities constructed in rural areas was diminished by the predominantly nomadic lifestyle of the area’s inhabitants. More generally in Africa, low population densities and inadequate transport and communication facilities remain a challenge for health policy makers to provide facilities and for people to access such facilities. The rural regions of Burkina Faso, for instance, have a low density of

Box 5.2: Services Provided by the Project Hospitals

Some examples of the services provided in project hospitals are stated here. The higher order health services at secondary and tertiary levels, in addition to providing referral health care services, are also expected to carry out supervisory, outreach and training functions.

Uganda: The Uganda Health Services Rehabilitation Project provides outreach services in immunisation, maternal and child health care, nutritional monitoring, health education, sanitation, population and family planning, as well as control of diarrhoea, vector borne diseases, HIV/AIDS, and other sexually transmitted diseases. They also serve as a storage centre for distribution of essential drug kits to the peripheral level, apart from creating linkage between the peripheral and regional hospitals.

Zambia: The Zambia Rural Health Services Project has 5 health centres to which it caters. They carry out outpatient consultations, child immunisations, prenatal care, health education, family planning, and outreach activities to the population living in remote areas.

Lesotho: The Lesotho Rural Health Services Project IV rehabilitated the Berea, Mokhotlong and Qacha’s Nek district hospitals. Public health services delivery within the three health service areas has been strengthened to a great extent with the provision of referral services and technical support, such as outreach services in immunisation, maternal and child health, nutritional monitoring, health education, sanitation, population and family planning, as well as control of diarrhoea, vector borne diseases, HIV/AIDS, and other STDs. But due to severe staff shortages, hospitals have not been able to meet the increasing demand for referral services.

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20 persons per square kilometre and the people still have to walk long distances before they could access a health facility. 5.3.3.5 Equity: Geographical or physical accessibility to health facilities do not necessarily ensure use of the services by all sections of the society and most of the poor are still not able to access public health services. Most health facilities rehabilitated by the Bank are charging user fees and payment for medicines; 75 per cent of the project appraisal reports either encouraged collection of user fees or intended to study its feasibility. Even though the practice of user fees has helped the health facilities to meet some of the running costs, the extremely poor find it a major obstacle to access the services. Some countries such as Uganda have therefore abandoned user fees at the lower levels of the health system hierarchy, while others like Cote d’Ivoire have not raised user fees for many years.56 While 42 per cent of the project appraisal reports asserted that the poor would benefit from the project, 58 per cent made no mention of it. It is likely that rehabilitation and provision of new facilities has increased access to specialised services. For instance, the CT-Scan installed in Mulago national hospital (Uganda) is being used on average by 1000 patients per year compared to earlier situations when only 15 patients accessed CT-Scan services abroad. However, from the available data it is not possible to ascertain how far this has benefited the poor. 5.3.3.6 Quality and Service Utilisation: There has been a positive trend in the services provided in some cases. In Tanzania, the opening in 2004 of a child health unit and maternity ward in Kitunda hospital increased by four-fold the number of deliveries attended in the facility between the first and the fourth quarter after the maternity ward was opened in June 2004, despite the fact that the maternity ward was still functioning without regular water supply. In the Bab Taza local hospital in Morocco, between the end of hospital rehabilitation in 2000 and 2003, the total number of patients using the facility increased by 51 per cent, postnatal consultations by 52 per cent, antenatal consultations by 45 per cent and family planning by 19 per cent. Deliveries at the hospital multiplied 2.6 times, while coverage of delivery complications and post-partum rose from less than 10 per cent to more than 50 per cent; coverage of pregnancies-at-risk improved and referrals to higher level facilities of this type of pregnancy declined from 95 per cent to less than 10 per cent. Immunisation increased to cover over 95 per cent of children and 85 per cent of women in the age group of 15-45 years. 5.3.3.7 Available data show that some interventions have had declining trends as well (Table A5.6 in Annex 2). The health facilities in Lesotho Rural Health Services IV Project have shown a decline of 4 per cent in the number of antenatal first visits and a decline of 69 per cent in referral services over 1998-2002, a situation exacerbated by the increase in referrals made from the facility to other hospitals. These indicate the poor performance of the rehabilitated hospitals due mainly to severe staff shortages. Similarly, there has been a decline in the immunisation coverage in the Burkina Faso Project for the Renovation of Dori and Djibo Health Facilities. In Morocco, approximately 4 per cent of the 917 primary health care facilities realised are closed due to the lack of health personnel and some laboratories and x-ray facilities are not used due to the lack of qualified personnel. 5.3.3.8 The positive trend in facility use may be considered as a proxy indicator for user satisfaction. The rehabilitated hospitals generally are well-equipped and have better intake capacity and cleaner premises. Many of them have provisions for safe disposal of hospital wastes which otherwise would be a threat to public health. But there are issues that considerably undermine the effectiveness of these facilities. Some of the serious problems

56 Cote d’Ivoire has not increased the user fees since the devaluation of CFA Franc in 1994.

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haunting many project hospitals include inadequate health personnel, lack of incentives to serve in rural areas, and insufficient provisions for recurrent expenditures. 5.3.4 Efficiency 5.3.4.1 Project efficiency indicates whether the Bank and the country had selected the most cost-effective project, and whether the country could implement the projects without spending any more resources than necessary. 5.3.4.2 Cost-Effectiveness of Projects: The design quality analysis has found that none of the project appraisal reports have made even preliminary cost-effectiveness analysis. Only 4 per cent of the project appraisal reports have attempted to justify the project with cost-effectiveness criterion, but no details were provided on the indicators of effectiveness used to choose among alternatives. In addition, for non-construction components, even the unit costs of immunisation (e.g., cost for fully immunising a child), or other commodity distribution efforts available from alternative sources are not included in appraisal reports, and no cost-effectiveness or cost-benefit analysis is provided in any of the projects. In most cases, efficiency in the Bank interventions was undermined by inadequate appraisal. For example, in Ghana, due to mistakes made in the Appraisal Report in 1988, the scope of the project changed in the Health Services Rehabilitation Project I. As the tenders for construction and for procurement of equipment were tendered simultaneously, the equipment arrived before the buildings were ready for equipment installation. As a result of the delay, the infrastructure deteriorated, the equipment was stored in containers for about three years, and suffered theft of parts. The service contract for the equipment expired before installation. These delays have implied higher costs. 5.3.4.3 Time Overrun: About 86 per cent of completed projects exceeded the time anticipated at appraisal (Section 5.3 and Table A5.3 in Annex 2). Delays have occurred at all stages of the project cycle, including approval, effectiveness, and implementation. They also occurred in disbursement. Since this is a recurrent issue, it is likely that the estimates made at the preparation and appraisal stages were frequently unrealistic. While the average stipulated age of the health sector projects is 3.7 years, the actual average age of health sector projects (except studies) is 9.1 years. Studies, on average, have taken 8.4 years to complete. This is a strong indication of poor quality of project appraisal and design. 5.3.4.4 Cost Overrun: Cost overrun is less frequent than time overrun, though the latter might have contributed to cost escalation. In terms of external factors, devaluation of national currency and sharp increase in prices have contributed to cost overruns in several cases. Internally, the Bank does not provide for contingencies due to inordinate delays even though some provisions are made at appraisal to meet financial contingencies. Cost overruns were substantial in some cases (e.g. Cote d’Ivoire Hospital Infrastructure Rehabilitation and Basic Health Care Support Project had spent 55 per cent more than the appraisal estimate; the Egypt Bilharzias Control Project III had spent 23 per cent more than the appraisal estimate). Some 30 per cent of PCRs and only 7 per cent of CPRs cited this as a major problem. It is the responsibility of the country to arrange resources to complete implementation, as the Bank does not generally provide additional funds for this purpose. 5.3.4.5 Cost Savings: About 20 per cent of completed projects reported cost savings due either to efficient use of available resources or under-utilisation/inability of the government to claim the un-disbursed balance from the Bank. The case of Uganda Second Health Services Rehabilitation Project could be cited as an example of cost savings due to efficient use of resources: though delayed by 2 years, the project was able to save 13.7 per cent on planned

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financial resources. The case of Burkina Faso Renovation of Dori and Djibo Health Facilities is an example of a delayed project losing financial resources: the government was unable to claim un-disbursed balance of some 26.5 per cent of Bank assistance. In Ghana, both Health Projects I and II closed without fully utilising the approved funds and yet without achieving all outputs, which indicates inefficiency over the project cycle. In Morocco, despite the long delay in project implementation, the Government had to cancel 25 per cent of the finances approved. 5.3.5 Sustainability 5.3.5.1 Project Sustainability refers to the likelihood of a project yielding continued long-term benefits and its resilience to risks that impede net benefit flows over time. Bank health sector projects in many cases have enhanced the quality of infrastructure and trained personnel for project hospitals, but need to do more to ensure government commitment and development of institutional capacity. Sustainability of the Bank health sector projects with respect to indicators such as technical soundness, government commitment, socio-political support, health human resources development, environmental safety and resilience to exogenous factors is given below. 5.3.5.2 Technical Soundness: Many health facilities rehabilitated with Bank support are of sound quality. But, there are instances of poor quality construction, cheap and outdated equipment installed in health facilities, inadequate provisions for safe waste disposal, lack of regular water and electricity supply, and quality medical equipment falling into disuse for lack of trained personnel to operate it. There are examples of contractors building poor quality structures and unheeded Bank advice regarding required construction standards. In some cases, as in Chad, the health facilities were not constructed according to local requirements and a uniform design was adopted on all sites leading to inadequacies and wastes. However, there are examples of proper use of equipment installed under the project as in Uganda and Burkina Faso where with adequate government commitment and support the equipment provided would yield long-term returns. 5.3.5.3 Government Commitment: In some cases, government commitment to financing recurrent health facilities expenditures – such as maintenance, staff costs and supplies – is satisfactory. The Ugandan government, for instance, has shown commitment to increase allocation of resources to the health sector and is taking steps to implement the Health Sector Strategic Plan under the new Sector-wide Approach (SWAp). SWAp is expected to mobilise support from the donor community to finance some of the recurrent costs of the facilities rehabilitated by the Bank. But many governments find it difficult to make budgetary provisions for financing recurrent costs of health facilities. This has led to lack of resources to maintain infrastructure and qualified personnel in Chad, Lesotho, Burkina Faso and Mali, for example. This also reflects a low government priority in health sector financing and the strength of the SWAp is to put all donors together in a medium term financial framework. 5.3.5.4 People’s Participation: In spite of a stated Bank commitment, people’s participation in the projects cycle from identification to evaluation is generally missing in most projects reviewed for this study. In fact, 92.5 per cent of the project appraisal reports did not carry any mention about beneficiary participation. People’s participation is mostly reduced to making users share the cost of services rendered by facilities, though there have also been recent attempts at soliciting community support to mobilise resources for financing health facilities like in Uganda and Lesotho. Cost sharing by users is reported to have improved financial viability of project hospitals in Uganda and Cote d’Ivoire and this has enabled them to extend

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services to some remote areas. But user fees elsewhere reportedly have had adverse effects on the use of health facilities by the poor (e.g., Lesotho, Morocco). 5.3.5.5 Health Human Resources: Inadequacy of trained personnel has undermined the utility of many project health facilities. There are several instances where the quality of infrastructure and medical equipment provided under the project was excellent but the equipment was not operated due to lack of qualified technicians (Congo, Lesotho, Mali, Zambia). In other cases, equipment was damaged due to mishandling by inadequately trained staff (Cote d’Ivoire). Overall, training for health managers, maintenance staff, and strengthening the Project Implementation Unit, have been partially achieved and sometimes abandoned, as is the case of Morocco. There are, however, some good examples of health human resource creation under Bank projects (Box 5.2), although the Bank has not addressed the issue of the health human resources required by the country’s health system as a whole. Loss of qualified health personnel through out-migration constitutes a major threat to sustainability of health facilities, including those supported by the Bank. Only very few governments are taking concerted actions to stem the outflow e.g. Ghana (WHO 2006). Box 5.3: Training Health Personnel: Successful Cases

Uganda: High attrition rates and absenteeism among health workers, as well as deteriorating technical schools and acute shortage of trained tutors, troubled the health sector in Uganda. Investments within the project framework improved the staff complement and public health facilities. Local seminars and workshops (on Maternal and Child Health, EPI, HIV/AIDS, STD, Family Planning) helped to train staff at peripheral health facilities. To strengthen the national health care delivery system, capacity building activities were extended to the secondary and tertiary institutions and the Ministry of Health Planning Unit. Between 1992 and 1997, 74 staff members were trained abroad in management and specialised medical care, including Urology, Clinical Neurology, Cardiac Psychotherapy, Health Information System, and Health Economics. Local training under the project included 6 diploma courses in Health Service Management for 113 participants, and 6 Ultra Sound courses for 67 participants. To improve the quantity and quality of health training, the Tutors College and Dental School were rehabilitated. Apart from the impact of these training courses on the quantity, quality and management of health service delivery, the health sector now has a core team of resource group and trainers.

Egypt: The training of health personnel was reported to have long-lasting impact on the health system in Egypt Bilharzias Control Project III where a large number of health personnel were trained in the control of the highly infectious schistosomiasis disease. The country now not only has enough health personnel for future schistosomiasis control but also to serve other countries if necessary.

5.3.5.6 Environmental Safety: Projects that aimed at constructing and rehabilitating health facilities have improved the environmental quality of those facilities, or taken care to minimise environmental damages ensuing from the operation of the facilities. For instance, in Tanzania, the Muhimbili hospital did not have an incinerator and hazardous wastes used to be deposited in dams, frequented by scavengers. The Muhimbili Hospital Rehabilitation project financed an incinerator, which was capable of incinerating hazardous waste, thus protecting the environment from hospital waste. In Cote d’Ivoire, construction of appropriate sewerage system, storm water drainage and landscaping have improved the quality of hospital premises. However, environmental safety is a concern in the case of Morocco. The ‘Projet de Renforcement des Soins de Santé de Base en Zones Rurales’ was classified in the category 3 with an insignificant impact on the environment whereas there is a concern with the treatment of the medical solid waste. 5.3.5.7 Vulnerability to Exogenous Factors: A prominent external factor that makes health projects vulnerable is the armed conflicts plaguing several African countries. Armed conflicts may destroy health facilities or disrupt project implementation even in neighbouring countries. For example, a project-related training in Cote d’Ivoire for health care management personnel from Burkina Faso was disrupted as a result of the armed civil conflict in Cote

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d’Ivoire. Projects are also dependent on country reliance on unpredictable external funds in addition to insufficient allocation of national resources, especially in the case of low economic growth where the government cannot collect substantial taxes to increase state revenue and expenditure. Likewise, as underscored by the Bank Rural Health Review of 1998, budgetary cuts, as a result of the widespread economic decline and consequential implementation of structural adjustment programmes in the RMCs, made it extremely difficult to finance the recurrent expenditure of health facilities (ADB 1999b, Serageldin, Elmendorf, and Eltigani 1994). 5.3.6 Institutional Development 5.3.6.1 Institutional development components in Bank-financed health projects focussed on: a) developing project management capabilities; b) training health manpower to meet medical, paramedical and hospital management needs; c) strengthening information technology, and d) supporting reforms in sector policies and institutional arrangements. 5.3.6.2 Project Management: Almost all Bank projects have a project management support component, which accounts for, on average, 10 per cent of project costs.57 Management capacity of executing agencies continues to be weak and is considered as one of the major reasons for inordinate delays in implementing projects. The CPRs indicate that over 48 per cent of projects have suffered because of executing agencies’ poor management capacity. Lack of experienced and qualified staff and/or the absence of fulltime project executing agencies have worsened performance. There are, however, some positive examples of project management capabilities developed by Technical Assistance in: effective management support systems (Lesotho); strengthening the pharmaceutical inspectorate through training (Guinea); and, providing tools for health planning, materials management, financial and human resources (Chad). 5.3.6.2 Training of Health Personnel: Barring a few exceptions, most project health facilities lacked adequate number of health personnel in the medical, paramedical, technician and engineering categories. Usually, the Bank makes provisions to train health personnel as part of the project. However, some countries have not even responded to Bank initiatives to train health personnel. Some examples are: neglect of the training component in spite of the provisions in the project budget (Chad); under-utilisation of the budget for training health personnel and the Ministry of Health and Social Welfare not having clear health human resources strategy (Lesotho); personnel trained under the project made unavailable to the project facility (Burkina Faso); lapse of training budget for lack of government nominating candidates for training (Mali); and, personnel trained under the project joining the private sector seeking better opportunities (Cote d’Ivoire). However, some health project facilities had a sufficient number of trained staff, with consequent positive impacts on service delivery and sustainability of the health system (Egypt, Cote d’Ivoire, Uganda, Guinea; see Box 5.3 for cases of successful training of health personnel).

57 Project management support includes long-range project and manpower development planning capability; financial systems, budgetary controls and procedures; systems for billing and collection of accounts, and inventory control; internal and external auditing systems; systems and procedures for operation and maintenance; and information storage and retrieval systems.

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5.3.7 Borrower Performance 5.3.7.1 In principle, RMCs have the responsibility for identification, preparation, implementation, monitoring and sustainable operation of projects financed by the Bank. As borrowers, they are expected to assume ownership and responsibility during all stages of the project cycle, foster stakeholder participation, and ensure project sustainability. Analysis of borrower performance in health sector projects has brought out several common and specific problems encountered at different stages of the project cycle (see Table A5.7 in Annex 2 for regional distribution of the problems). 5.3.7.2 Delay in Effectiveness: Delay in effectiveness is a chronic problem in a substantial number of projects and ensues from governments’ failures to fulfil loan/grant conditions precedent to effectiveness. Nearly half of projects reviewed in CPRs identify this as an important reason for poor project performance, especially for subsequent delays in project implementation. 5.3.7.3 Low Capacity of Executing Agency: In nearly half of the projects reviewed in CPRs, strikingly deficient capability of project executing agencies had serious implications on procurement, financial management, physical implementation, and adherence to mandatory reporting procedures. No executing agency was formed specifically for the project in some extreme situations, while in other instances executing agencies’ staff were not able to work fulltime on the project (Swaziland), performed weakly (Zambia) or were not adequately monitored by governments (Ivory Coast, Mali). 5.3.7.4 Non-adherence to Procurement Rules: Portfolio reviews show that in 20 per cent of the projects, implementing agencies’ failure to adhere to Bank procurement rules led to implementation delays. Sometimes, non-adherence to Bank procurement rules seemed to be deliberate attempts to circumvent them, not a lack of awareness about rules. An example is the procurement problem of Ghana Health Services Rehabilitation Project III, where the government’s failure to follow Bank rules in recruiting the PIU staff and consequent irregularities led to long delays in project start-up. 5.3.7.5 Procurement Delays: Project implementation requires different types of specialised services, some of which can be procured from within the country while others are to be procured internationally through International Competing Bidding. Executing agencies were found to be incurring excessive delays in the procurement process – in inviting tenders, evaluating the bids, getting the shortlist approved by the Bank, and awarding the tender. In many cases the Bank has found the shortlists inappropriate and asked the government to reconsider them. These conflicts cause overall delays in project implementation and cost overrun. 5.3.7.6 Non-adherence to Implementation Schedule: Non-adherence to implementation schedule is a common phenomenon and delays have happened at all stages of the project cycle – approval, signature, effectiveness, start-up, procurement, physical implementation and reporting. Even though the primary responsibility for implementation lies with executing agencies, the government, the Bank and many external factors have contributed to delays. 5.3.7.7 Non-availability of Counterpart Funds: More than a quarter of the projects have suffered because RMCs could not make counterpart funds available on time for project implementation, often due to serious financial difficulties, or, sometimes, armed conflict. Some examples of completed projects that showed poor performance due to inordinate delays in counterpart funds availability are those in Guinea, Chad, and Burkina Faso.

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5.3.7.8 Irregular Submission of Audit Reports: Over one-fifth of projects faced long delays in disbursements due to non-submission of project audit reports. In several instances, the Bank suspended project financing when governments failed to submit annual audit reports – 12 projects from 11 countries faced implementation problems for this reason. Certain countries have not submitted audit reports even long after completion of the project (Cote d’Ivoire, Nigeria, Senegal). 5.3.7.9 Irregularity in Reporting: Submission of quarterly reports by project executing agencies is a mandatory Bank requirement. Notwithstanding, one-fifth of the projects were chronically failing to report on progress. Another feature is that 50 per cent of the countries that were irregular in providing quarterly reports were also irregular in submitting audit reports (Mauritania, Equatorial Guinea, Rwanda, Senegal and Cote d’Ivoire). 5.3.7.10 Other Problems: There are several other problems affecting project performance for which a government could be held responsible. They are the failure to fulfil other conditions specific to the project, inadequate government monitoring of project executing agencies, and government inability to meet the recurrent expenditures of completed projects. 5.3.8 Bank Performance 5.3.8.1 The Bank’s main role is to ensure project quality-at-entry, and to establish arrangements for satisfactory implementation and future operation of projects (ADB 2001d). A review of Bank performance brings out several generic and specific problems encountered at various stages. 5.3.8.2 Inadequate Quality-at-Entry: Quality-at-Entry is reflected in the standard of project design, strength of the assumptions about relevant external factors and project risks. Only 59 per cent of the project appraisal reports discuss institutional, economic, environmental and other risks. Inadequate quality-at-entry remains a major generic problem of Bank projects, as also confirmed in the report of Task Force on Project Quality for the African Development Bank the in 1994, known as Knox report, the Review of Bank’s Experience in Rural Health presented to the Board by OPEV in January 1999, the ADF VII-IX Evaluation Study in 2004 and the country health sector reviews on Morocco, Ghana and Tanzania carried out by OPEV in 2005. While many projects have pre-investment studies to support project preparation and appraisal, inadequate information, inattention to critical details and/or significant time lag between the study and implementation, rendering the study outdated or even irrelevant and leading to unsatisfactory results (e.g., Cote d’Ivoire, Zambia, Mali). Specific examples of problems arising from inadequate quality-at-entry include: appraisal missions’ inability to properly determine the catchment population and institutional environment (Zambia); inadequate provisions made for institutional capacity strengthening (Lesotho); failure to identify faulty engineering designs (Burkina Faso); and underestimating time and cost of implementation (e.g. Sousse Teaching Hospital of Tunisia). 5.3.8.3 Inadequate Supervisions: It is necessary to have an interdisciplinary team of experts in supervision teams (e.g., health expert, demographer, economist, engineer, architect, procurement expert, gender and environment experts) to appropriately address project’s complexities. It may not be feasible to have such an ideal team for all supervision missions but when necessary the deficiencies in skill-mix could be filled by engaging experienced consultants. Though projects that were satisfactory on completion had received adequate supervision during implementation (Chad, Egypt, Uganda), frequent supervision didn’t guarantee success (Lesotho, Cote d’Ivoire) and this may be due to flawed design. In most of the unsatisfactory projects, supervision frequency was less than the planned provision of 2

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supervisions per year. The Operations Complex’s severe staff shortage to manage project tasks, as well as the skills mix and performance of supervision teams, contributed to this shortfall. There were instances where supervision missions could not respond competently to technical issues that needed immediate attention, as in the Uganda Second Health Rehabilitation Project and the Burkina Faso Project for Renovation of Dori and Djibo Health Facilities. 5.3.8.4 Unfamiliarity of RMCs with Bank Procurement Rules: In 23 per cent of the health projects reviewed, RMCs were recorded as being genuinely unfamiliar with Bank procurement rules. Out of the 13 projects where the executing agencies were unfamiliar with Bank procurement rules, all faced procurement delays and 8 projects incurred considerable physical implementation delays. While improving the condition may be considered as a joint responsibility of the Bank and the Borrower, the Bank needs to play a proactive role in informing and training RMCs about its procurement rules. 5.3.8.5 ‘Inflexible’ Procurement Procedures: Some RMCs have complained about ‘inflexible’ Bank procurement procedures. In the ongoing primary health care project in Ethiopia, for example, the RMC feels that flexibility in Bank procurement procedures and decentralisation of decision-making to Bank country offices could have prevented the project’s long delays in procurement of goods and services. In order to avoid corruption and/or put unreasonable pressure on over-worked local staff, there is a need to appraise (or rely on others’ appraisals) Government procurement and financial management systems before decentralising procurement procedures.

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CHAPTER 6. TOWARDS ENHANCING BANK EFFECTIVENESS IN HEALTH

The present analysis indicates that the Bank would do well to take a pause and review its approach to health sector interventions with a view to enhancing its effectiveness in addressing persisting and emerging challenges in the sector. It examines the current constraints to the Bank effectiveness, prerequisites for becoming more effective in the health sector, potential areas of strength on which to build, and strategic areas for health sector development that the Bank might consider. 6.1 Organisational Constraints to Effectiveness 6.1.1 There are several organisational issues that inhibit Bank capacity to develop and implement well-designed and effective health projects and programmes. These issues relate to project designs and the staff incentive system, the technical skills-mix and utilisation of the health staff, very limited opportunity for internal and external knowledge-sharing and weak administrative support for technical staff. 6.1.2 Project Designs and Incentive System: Like many funding organisations, the Bank is eager to demonstrate efficiency in developing and implementing loans and grants, as well as completing activities. However, in its rush to get projects approved, the Bank often spends insufficient time to assess risks, RMCs’ capacity to implement projects, and the demand for the programmed services. This has partly contributed to many health projects being implemented with time overrun of 5 years in average and often completed with unsatisfactory results. As noted in recent ADB reports (2004e; 2005c) and in interviews for this review, the Bank incentive system has contributed to this problem: Bank managers and staff are evaluated mainly on the number of projects sent to and approved by the Board, without sufficient regard to project quality. The reports and interviews indicate that the lack of emphasis on performance-based project design and responsibility for achieving results, make it difficult for the Bank to hold staff accountable for their assistance to implementing demonstrably effective projects and programmes. 6.1.3 Technical Skills-Mix and Staff Utilisation: Based on staff interviews and reports analysed, it appears that the technical skills mix of health professionals in the Bank requires significant improvement. The Social Development Department lacks specialists for different areas including: a) health sector reform and health economics; b) financial analysis; c) communicable diseases; d) population; e) reproductive health; and f) health management/planning.58 This is compounded by the fact that the existing skills are not used effectively as most health experts appear to spend the majority of their time performing administrative rather than technical work. Task managers of health projects operate under intense pressure to manage even small details without sufficient administrative support, leaving little time and incentive to direct expertise towards policy and strategy development or provide technical support for project design and implementation. The burden of administrative tasks serves as a disincentive for experts to exercise their expertise in ways that would improve the health portfolio. This creates frustration among health analysts.

58 The number of health specialists required will depend on the volume of health operations in the new Bank structure. However, what is expected from the Bank (or from other donors) is not to have all the skills systematically represented on the staff but the capacity to recognise the need for application of specific, defined skills to certain project situations, and ability to mobilise and supervise experienced consultant services that are required.

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6.1.4 Effective use of staff skills also requires regular updating to reflect changes in the health environment and new approaches that are being developed. The health staff are not able to devote the required time for this purpose (e.g., keeping abreast of current evidence). This problem is exacerbated by isolation among the health staff. While there is recognition for the staff to meet and discuss technical issues, the last such meeting of the Bank’s Health and Population Group was held in Abidjan, more than 2 years ago. 6.1.5 Another area of concern is the inadequate attention given to developing staff project management skills. Technical competence in the field of specialisation does not always equip the staff to effectively manage the project cycle. While these skills are most usefully honed through years of experience, they can be imparted to some extent through short courses conducted by specialists in project cycle management. Health experts also indicate that staff skills use is hindered by a lack of technical leaders in health. While most health experts have years of experience, there is no lead health specialist of international stature who could advance the policy development process or support technical discussions. Everyone is so busy with managing tasks that there is no time left for developing qualities of a sector specialist – a case of the urgent displacing the important. 6.1.6 Limited Opportunities for Internal and External Knowledge-Sharing: Compounding the problem of staff mix, there are very limited opportunities for health experts to share their knowledge and learn from each other’s experience. This is due in part to the ‘silo nature’ of the organisational structure, in which Eastern, Northern and Southern regions are compartmentalised in a complex separated from the Western and Central regions. Further, technical review meetings are held as country review meetings implying the presence of only one health person, with most time spent on other major sectors and health given passing attention. This leaves little scope for dialogue among health professionals. Further, managers who might be in a position to disseminate the technical lessons across the staff spare little time with them. As far as external knowledge sharing is concerned, health experts have very limited possibility to participate in international conferences or training in order to update their knowledge.59 The institutional reforms set up by the Bank’s new management aiming at structural changes grouping sectoral experts into larger departments, changes in policy and process, better human resource management and knowledge management could be an appropriate answer to these shortcomings (ADB 2006a). 6.2 Prerequisites for Effectiveness 6.2.1 Strategic Selectivity: No institution can have the expertise and resources to address all the needs of the health sector in Africa. As noted in Chapter 3, policies that are written present an almost unlimited array of potential areas for investment and the approach on the ground is to find niche areas where other donors are not working and support these, independent of whether these investments will have the greatest impact on health. The Bank needs to develop a limited set of well-designed policies and programmes, which build on its strengths and in which it can become a recognised leader. With other donors focusing on disease-specific programmes – such as HIV/AIDS, TB and Malaria – the Bank is unlikely to make a major difference in those areas. Instead, the Bank should build expertise to focus on broader policies, including: a) improving human resource capacities; b) reproductive health; c) strengthening logistics and information systems; and d) building integrated services delivery organisations. Such focusing would allow the Bank to address Africa’s health priorities but also contribute to overcome its own unsatisfactory performance in project

59 If conference participation is to be encouraged, there will be a need to have rigorous management follow-up, with action planning and conversion of externally acquired knowledge into changed behaviour on the job.

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outcomes (e.g., disuse of modern medical equipment due to non-availability of trained health personnel to operate it). Commitment to selected areas would thus strengthen the Bank’s reputation and provide a needed complement to the vertical and disease-specific programmes of other major donors operating in Africa. 6.2.2 Technical Leadership: The Bank’s ability to demonstrate technical leadership will emerge only if it sharply narrows its interventions and focuses on a limited number of areas. The current health portfolio is not focused enough to demonstrate the Bank’s effectiveness or unique advantages. Indeed, quality-at-entry has been identified as a recurring problem for the Bank, and some interventions have such limited scope in practice that their impact on the problem at issue is unsubstantial. For instance, support of laboratories for HIV/AIDS, while important in themselves, are limited in demonstrating the impact of Bank interventions on the incidence and treatment of HIV/AIDS, since the intervention selected is not a significant route of HIV/AIDS transmission. Technical leadership requires improved capacity to design and implement effective projects. This means developing more rigorous and evidence-based project design, appraisal and monitoring processes to ensure better quality-at-entry and supervision. 6.2.3 Effective Use of Staff Skills: At the core of an effective organisation’s technical capacity is: a) a staff skills profile appropriate to the work; and (b) productive use of its staff. The Bank should be able to use staff technical expertise and to draw on outside experts for specific areas of competence. Such staff would require adequate administrative support so that technical experts have time for such important issues as policy dialogue with country counterparts, project design, portfolio management, monitoring and evaluation, and staying abreast of technical advances. This requires the Bank management to review the skills profile in light of the new Bank structure and a new determination of the work to be done. 6.2.4 Economic and Sector Work: Countries vary in their needs and the Bank activities in each country will need to be better informed by strong analysis of the health sector including epidemiology of disease, strengths and weakness of the health delivery system, both private and public, and an assessment of other contributing factors such as malnutrition, access to clean water and the state of the supporting infrastructure. It is therefore essential that the Bank has increased knowledge of the health sector to focus its assistance on selected areas, design cost-effective interventions with greater impacts, and acquire a knowledge base to engage in policy dialogue with RMCs.60 Towards this end, the Bank should increase its collaboration on technical and analytical aspects with institutions having health sector specialised experience, such as WHO, UNFPA, UNICEF and the World Bank. The use of local expertise and consultants can also contribute to these assessments. Without this type of analysis the Bank will not be able to identify those activities which will make the greatest contribution to better health in Africa nor be able to measure the impact of these investments in the future. 6.2.5 Resource Commitment: The Bank’s fragmented and piecemeal approach to health lending does not enable it to demonstrate expertise and commitment to health and population programmes and projects that are likely to have a significant impact on major problems. Bank’s share in the overall development assistance to the health sector in Africa for 1990-2004 stands at 8.1 per cent, reflecting the low priority given to health development. The

60 The Operations Departments are not carrying out ESWs reportedly for two reasons. Firstly, there are no researchers in the department to carry out the ESW, and secondly, there is no budgetary provision for carrying out the ESW. The departments usually propose provisions for carrying out ESW in its annual work programmes. But they end up focussing only on core activities (lending and supervision) due to large cuts in the proposed budget.

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corresponding share is 17.0 per cent for the World Bank.61 Though mobilising additional funds for health would be a desirable longer-term goal, a prior step would be to commit more of available resources to the sector, and to show that results can be achieved even with limited funding. Raising priority to health can be demonstrated by augmenting the health sector’s relative share in Bank funding, by incrementally increasing the Bank’s share in all donor funding for the sector, and by leveraging other resources through co-financing of projects that require large investments. 6.3 Bank’s Potential Areas of Strength in Health 6.3.1 At the time the Bank was formulating its strategic plan for the future (ADB 2004g), there was considerable discussion about its areas of strength. At the present time, there does not appear to be a consensus on the matter. When the Bank staff were asked for their opinion with regard to health during this review, the array of answers ranged from, “none” to “infrastructure,” “staff,” and “being an African Institution.” Based on discussions with staff and knowledgeable outsiders, review of Bank documents and recent statements by the new Bank President, the following three areas are proposed for consideration in defining the Bank’s future role in health assistance. 6.3.2 Status as an African Institution and Access to Key Decision-makers: The Bank’s involvement in Africa for the past 40 years has conferred it considerable recognition among RMCs as an African institution. Because of its long history and the nature of the Board, the Bank has ready access to key decision makers in Africa and internationally. The cross-country experience of Bank staff and opportunity for policy dialogue with Ministers of Finance, Planning and Health, as well as representatives of other multilateral institutions, places the Bank in a unique position to advocate for Africa’s development interests. 6.3.3 Health Experts and Expertise in Infrastructure Development: Bank health experts possess wide array of skills, experience and regional expertise and have a strong commitment to African development. The Bank, for its part, has invested substantial resources in developing health sector infrastructure and has employed a pool of architects and engineers to support planning and management of these projects. The Bank expertise, garnered over the years, can be used to advantage in the development of appropriate health infrastructures arising in the context of an overall strategic plan for the improvement or expansion of health services. In this situation, infrastructures – buildings and equipment – are to be complemented by drugs, information systems, water, and other things that are needed for the delivery of health services. Adequate attention must also be given to trained health personnel and from failure to meet recurrent expenditures. 6.3.4 Synergy from Working in Many Sectors: Unlike many multinational organisations, the Bank intervenes in several interlinked sectors including governance, transportation, industry, water, agriculture and education. Indeed, its investments in water, agriculture and general infrastructure have the potential to contribute to health outcomes though they are not considered part of the health portfolio. The Bank therefore has a potential advantage in addressing the health issues, which require a multi-sectoral approach including nutrition, pharmaceutical management, water, and referral networks. This entails the existence of strong and determined country directors.

61 ADF and ADB have earmarked respectively 4.5 and 0.9 per cent; the corresponding percentages for IDA and IBRD are 15 and 2.4 per cent (Table 4, in Annex 3). Health here includes Population and Nutrition.

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6.4 Strategic Areas for Development in the Health Sector 6.4.1 The Bank needs to consider current strengths and capacities that can be developed by drawing on its linkages with other African institutions, sector problems that can be addressed in ways that demonstrate significant impact, and areas that are not well-covered by other major donors. To make a lasting impact on the health sector, the Bank should thus consider selecting areas to channel its resources among: a) human resources development; b) reproductive health; c) sustainable and integrated health systems; d) policy advocacy for financing and economic reforms in the health sector; e) advocacy for African interests with other donors; f) development of African technical assistance institutions; and g) appropriate infrastructure development. Selecting and prioritising the above strategic areas call for the Bank management to evaluate the cost implied in terms of the required staff skills profiles and budgets. 6.4.2 Human Resources Development: Health systems in Africa suffer from a lack of health professionals due to a variety of causes, including: low salaries and benefits; minimal opportunities for career development; non-recruitment of qualified medical personnel to the health system; migration to wealthier countries, both in and outside of Africa; and, increasingly, attrition from diseases such as AIDS. There are no quick fixes to such systemic problems, and time and resources are needed to arrest and reverse the deterioration. A multi-sectoral set of measures that could improve the workplace include: restructuring conditions of service, creating opportunities for professional advancement, giving incentives for professionals to live in underserved areas, providing training that is appropriate to work conditions, and, instituting flexibility in medical personnel’s working conditions. The Bank can contribute to such efforts by building on its multi-sectoral experience to define needs and embark on collaboration with local and regional educational institutions that train health personnel; the arrangement will be complemented, where necessary, with international training support. Although there have been some recent initiatives raising the issue of human resources,62 few donors have devoted significant commitments to the area though it is one that can show demonstrable impact. 6.4.3 Reproductive Health: With the highest fertility rates in the world, Sub-Saharan Africa's population has more than doubled between 1975 and 2005, rising from 335 to 751 million, and is currently growing at the rate of 2.2 per cent a year and projected to be 1.16 billion by 2025.63 The region's unmet need for family planning among married women is the highest in the world. UNFPA estimates that an additional US$ 275 million a year is needed to make up the gap in reproductive health commodities. This lack of access to contraception and resultant high fertility is also a major contributor to the high rates of maternal and infant mortality in Africa. This problem can only be addressed with improved access to contraception and improvements to countries’ health systems to provide effective emergency obstetric care. The Bank can have a significant impact on women’s health by investing directly in reproductive health commodities and health facilities that provide reproductive health services. It can also be effective in policy advocacy for reproductive health since governments themselves must appreciate the need for effective reproductive health laws, policies and services as a critical component of their development agenda. Reproductive health constitutes an area of enormous needs in Africa. The Bank could engage in it with required technical skills and working out a partnership with UNFPA.

62 This includes the Joint Learning Initiative and several articles in the Lancet. 63 UNFPA Country Profiles Overview: Sub-Saharan Africa (http://www.unfpa.org/profile/africa_overview.htm) 2006. The projection is authors’ calculation.

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6.4.4 Development of Sustainable and Integrated Health Systems: There is general agreement that a key constraint to health improvement in Africa is the poor quality of most public health care delivery systems. In the continued absence of robust logistics, information, referral, communications, transportation, personnel, and financial systems, patients will continue to receive inadequate care. The systems focus is especially critical to the care of more complex diseases such as HIV/AIDS and chronic diseases, but even simple cases of malaria or diarrhoea become lethal in the absence of a functioning health system. However, improvement in health systems requires time and a long-term focus on integrated system development rather than the current vertical disease orientation followed by most other donors – as when dealing with HIV/AIDS, malaria, tuberculosis, parasitic diseases, and polio. There is growing evidence that the focus on disease-specific programmes has led to declining effectiveness of already poorly developed MCH and other multi-purpose primary care services. While the impact of some investments in integrated health systems are difficult to demonstrate, it is possible to develop appropriate intermediate indicators to show significant progress in this area (Gottret and Schieber 2006). 6.4.5 Policy Dialogue for Financing and Reforms in Health: As a development finance institution with a pool of economists, financiers, and analysts, the Bank has expertise in the area of economic and financial analysis. Health financing poses one of the most difficult dilemmas in Africa today since government funding is insufficient and alternative mechanisms, such as user fees and health insurance, have not proven viable at addressing this issue. An independent voice, with technical expertise and moral authority, is needed to work with each country to develop strategies that reduce government subsidies to the relatively well-off through the funding of urban tertiary health facilities, and re-channel these resources to the rural and urban poor. At the same time, such strategies as employer-based or government-owned insurance schemes could assist the growing African middle class when they use private health care and prevent financial ruin in the case of catastrophic illness. Analysis of costs or relative viability of health systems or services is noticeably lacking from both country and Bank documents even though such information is critical for studies of alternative strategies for health investments. The Bank could make a positive contribution by funding costing studies of various health models and programmes, as well as research programmes that assess the relative impact of alternative investment strategies over the long-term. This would require a close examination of the skills that would be required to design and supervise such research studies, and the cost of acquiring and keeping them if they are found non-existent in the present staff complement. 6.4.6 Advocacy for African Interests with other Donors: The Bank is in a unique position for policy advocacy with both African governments and international donor institutions. Building on its legitimacy as an African institution, the Bank could assist RMCs in developing plans for other donor funding by framing a supportive negotiating position that is built on successful African experience. In addition, the Bank could work with donors and governments to develop appropriate policies and co-financing of projects in human resources, pharmaceuticals, resource allocation, financing, and systems development so that the longer-term perspective needed for effective sustainable development could be realised. 6.4.7 Development of African Technical Assistance Institutions: Africa today has many well-trained and experienced health professionals working in development agencies outside Africa who would return home if appropriate opportunities were available. At the same time, governments and donor institutions that look for technical assistance often turn for help to experts from Europe and North America. The Bank could augment its assistance to countries by nurturing and contracting world class African universities, institutes and consulting firms to work both with countries and the Bank itself in key technical leadership areas, such as

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pharmaceuticals management, financing, information systems, and policy development. At present, the Bank’s use of skilled individual consultants does not foster institutional capacity in Africa, or at the Bank. The Bank is in a good position to develop a roster of African institutions that can provide the Bank with on the ground sector analysis, and technical assistance to support its projects. 6.4.8 Appropriate Health Infrastructure: In the past, the Bank has overly focused on health infrastructure and not enough on system and capacity needed for the infrastructure to make a significant impact on health outcomes. Though Africa clearly has a huge health infrastructure deficit, experience indicates the need for a balanced approach. The Bank should selectively build on existing expertise to focus on areas where infrastructure development has been particularly effective and critical. Combined with the work in other areas, a model of complementary activities could be developed and built on the Bank’s strength in this area.

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CHAPTER 7. CONCLUSION, LESSONS LEARNED AND RECOMMENDATIONS 7.1 Conclusion 7.1.1 The burden of disease in Africa remains the highest in the world and is predominantly characterised by infectious diseases that could be either prevented or cured in cost-effective way. Since the 1980s, the health situation has faced more formidable challenges including emergence of HIV/AIDS and Chloroquine resistant malaria strains, increase in non-communicable diseases, continuing population growth, and poor economic performance. The health system is very ill-equipped and the financing is inadequate to cope with the many health challenges. 7.1.2 Despite the Bank commitment to MDGs, the health sector remained under-funded with a decreasing proportion of the health sector from 4.1 per cent of the total Bank portfolio during 1996-2000 period to 3.5 per cent during 2001-2005 period. For the period under review the Bank has spent only 3.4 per cent of its development assistance on health. The Bank’s share of the total donor funding for heath and population sectors in Africa for 1990-2004 period represents only 5.4 per cent and this limited resource is thinly spread across RMCs in small projects, which have, at best, generated localised impacts.64 Further, the portfolio analysis shows also that the Bank neglected the population sub-sector including reproductive health and nutrition while these constitute one of the biggest challenges faced by African countries. 7.1.3 The Bank interventions have been mainly oriented to primary health care, the most appropriate health care strategy recommended since the Alma-Ata conference in 1978 for its universal access, equity, community participation, and inter-sectoral approaches to health, although difficult to implement (WHO 1990; Rainhorn and Burnier 2001; Schieber et al. 2006). Towards this end, the Bank interventions have responded to the policies and priorities of RMCs guided by recommendations of specialised international organisations, notably WHO, UNAIDS, UNFPA, and UNICEF. Nevertheless, health sector receives a small share of the total Bank portfolio in spite of increasing recognition that human capital is critical for economic development and poverty reduction. The portfolio analysis shows also that the Bank neglected the population sub-sector including reproductive health and nutrition while these constitute one of the biggest challenges faced by African countries. Further, the Bank has not yet undertaken significant actions to support the private sector which represents nearly 50 per cent of the total health spending. 7.1.4 The Bank has diversified its health portfolio from infrastructure to health sector reforms and capacity building in tune with other international development organisations. Infrastructure category financing declined from an average of 79 per cent during the first policy period 1987-1996 to an average of 64 per cent in the second policy period 1996 up to now. This percentage is about 50 per cent since 2003. 64 According to the DAC-OECD database on international aid flows, between 1990 and 2004, the Bank assistance aggregated to US$ 1,229.7 million (US$ 1,017.9 million from ADF and US$ 211.8 million from ADB) of a total of US$ 22,902.2 million spent by all donors to African Health and Population sectors. The corresponding amount for the World Bank was US$ 2,992.3 million (of which 3,424.2 million were from IDA and 568.1 from IBRD), which represented 17.4 per cent of all donors. When health sector alone is taken into account, the Bank assistance amount to US$ 1,150.7 million (938.8 million from ADF and US$ 211.8 million from ADB) of US$ 14,167 million spent by all donors to African health sector. The corresponding amount for the World Bank is US$ 2,407.8 million (US$ 1,865.7 million from IDA and US$ 542.1 million from IBRD). In this case, the Bank and the World Bank assistance represent respectively 8.1 per cent and 17.0 per cent. The difference indicates the Bank’s low investment in the population sector.

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7.1.5 Available data show that the Bank continues to have difficulties in improving the quality of its health portfolio in terms of implementation and outcome performance contrary to what is observed from other development partners like the World Bank, UNDP or DFID (World Bank 1999; UNDP 2000). Only 50 per cent of Bank health projects have a satisfactory overall implementation performance. While the number of ‘problematic projects’ has declined since 1998, compliance with Bank rules for procurement, adherence to implementation schedules and quality of activities and works have registered declines despite several portfolio improvement measures. Only 42 per cent of completed health projects with PCRs achieved satisfactory performance, with Bank performance satisfactory in 50 per cent of cases and Borrower performance satisfactory only 25 per cent of the time. Among outcome indicators, relevance and achievement of objectives (50 per cent) did better than institutional development (42 per cent) and sustainability (33 per cent). Although Bank projects provided modern equipment for health facilities, in many cases, shortage of trained health personnel and inadequate provisions for recurrent expenses undermined project sustainability. Facilities have generally increased physical accessibility and service utilisation, but user fees have deterred the poor from accessing the facilities. 7.1.6 Though the Bank’s achievements in the health sector leave much to be desired, it has the potential to become a far more important and positive force in improving Africa’s health. At present, however, this potential is largely unrealised due to the low priority given to health investment, a reactive rather than proactive approach to project identification and funding, and a staffing and incentive structure that emphasises administrative procedures and project approvals rather than effective implementation and measurable results on the ground. These issues present significant obstacles to the Bank in realising its potential to influence health outcomes in Africa. While challenging, the needed transformation are well within the Bank’s reach, given the Bank prevailing support environment for change, the institution’s real advantages of being an African institution and access to key decision makers, potential synergy from working in many different sectors, and expertise in infrastructure development. 7.2 Lessons Learned 7.2.1 Weak use of economic and sector analysis (done either by the Bank or by other institutions) prevents the Bank from producing qualitatively superior project designs, carrying out comprehensive appraisals and effective implementations, adversely affecting project results. 7.2.2 The incentive structure at the Bank, which rewards the staff, including senior managers, for the number of projects sent to and approved by the Board, without sufficient regard for project quality presents a serious threat to effectiveness of Bank projects. In other words, inadequate attention given to preparation and appraisal lead to unreasonable estimates of time and cost required for project implementation, inadequate attention to risk factors, eventually jeopardising implementation and outcome performance. 7.2.3 Lack of adequate monitoring and evaluation system prevents the Bank and RMCs from learning from health investments and from being fully accountable towards stakeholders and African populations. 7.2.4 The participation of different stakeholders – including medical personnel, beneficiary population and NGOs – in the design of health projects ensures that the technical and cultural aspects are adequately taken into account, and enables enhanced utilisation and sustainability of the facilities.

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7.2.5 Government’s commitment and quality of institutions are crucial for making successful equitable investments from national revenue and international assistance. 7.2.6 Lack of adequate incentives in terms of accommodation and transportation facilities makes it difficult to attract and retain qualified personnel in rural areas and to find a solution to human resources deficit and regional imbalances. In addition, installing medical equipment and constructing or renovating hospital buildings may not necessarily lead to significant improvement in quality of services if the staff are not in place, the equipment does not work, power supply is erratic and the hospital cannot maintain equipment. 7.2.7 From the private Abuja Health Clinic, the lesson learned is that when governments are part of the private project implementation arrangements, there is a need to adopt more stringent forms of legal obligations. 7.3 Recommendations

A. Health Specific Recommendations 7.3.1 Health Policy and Policy Guidelines: It is recommended that the Bank revise its current health sector policy, strategies, and guidelines to update them and make them more operationally focused and identify areas where it can have the greatest impact on health.65 In order to identify these areas, the Bank needs to undertake an intensive consultation process with its donor partners, financiers and clients before coming to final conclusions and ways forward. The policy development process should be as inclusive as possible with involvement of health specialists at the country/regional levels and at the Bank. The Bank should make use of health policy guidelines mandatory for project identification, preparation and appraisal to ensure that the projects and programmes financed by the Bank reflect the operational priorities articulated in the policy. Internal process should ensure accountability for use of guidelines, and responsibility for managers for this result. The health sector policy guidelines should contain detailed guidance for performing technical aspects in project design and management. 7.3.2 Quality of the Projects: The Bank needs to make substantial efforts to improve the quality of its health sector projects at the design and appraisal stages through adequate assessment of the capacity within the Bank and in RMCs to monitor and implement projects. In order to facilitate this, the Bank needs to determine: a) appropriate skills-mix required for its health interventions; and b) a realistic workload for its health experts allowing them to improve the quality of project appraisal based on appropriate analysis of the health sector including health demand, institutional capacity, and risks assessment. To this end, the Bank management should carry out an assessment of the existing technical skills profile of its health professionals by sub-areas of health in light of renewed health policy directions. 7.3.3 Participation in SWAp: The Bank should actively participate in and even initiate Sector-Wide Approaches (SWAp) in the health sector. To facilitate this process, the Bank needs to draw effectively upon good Economic and Sector Work carried out by the Bank or by others institutions. Incentives need to be established to ensure that the Bank staff use suitable analysis. Country readiness for engaging in SWAp must be analysed.

65 This would also entail the Bank to specify areas of health that it would decline to finance so that its clients could turn to other sources of finance. This would also help rationalise the use of health personnel, as the work of the existing staff could be focussed on key areas.

49

7.3.4 Policy Dialogue, Advocacy, and Partnership: On the basis of new health policy and guidelines, the Bank should take a lead in selected policy dialogue with RMCs supported by detailed Economic and Sector Analysis. Staff should be rewarded for contributing to effectively promoting evidence-based national policies that have a positive impact on the health status of the population. Also, the Bank should enhance its partnership with other Development Partners in the health sector based on the strengths of each participating organisation. 7.3.5 Priority Investments: The Bank should augment its assistance to selected areas of strategic importance with high priority to training health personnel, integrated health system, and in supporting reproductive health on account of their importance, inadequate attention by donors, as well as the potential to produce substantial demonstrable results. The Bank should formulate a strategy for health human resources development, as the existing ones do not provide sufficient operational direction. To reduce the burden on clients, the strategy should be harmonised among MDBs. 7.3.6 Private Sector Financing: The Bank should undertake feasibility studies aiming at exploring possibilities to effectively engage in private sector financing. Based on the Abuja International Diagnostic Centre experience, the Bank should ensure that all financial, infrastructural, legal and other institutional pre-requisites are in place prior to any project support to avoid risky investments. The new Bank health policy should define how to encourage the public-private partnership building on respective comparative advantages of each sector. 7.3.7 Resource Commitment: It is recommended that the Bank look into the possibility of increasing funding support for health sector interventions. It should consider increasing the average size of health sector loans as administrative burden, especially for non-SWAp un-pooled loans, prove to be excessive. Resource can be augmented in phases and be contingent on the Bank improving its portfolio performance and adopting a strategically focussed approach to addressing health sector problems.

B. Generic recommendations 7.3.8 Portfolio Improvement: It is recommended that the Bank rigorously implement portfolio improvement measures, including those bearing on quality-at-entry, quality-at-implementation, and quality-at-exit66 in close collaboration with the RMCs to encourage them to play a more active role in the project cycle. Priority should be given to Economic and Sector Work in order to build the knowledge and evidence base for improving the relevance and strategic positioning of Bank interventions. This will enable the Bank to develop more appropriate country strategies and lending programmes. 7.3.9 Results Orientation in Project Management: working in close collaboration with other Development Partners, the Bank should develop a more effective set of tools that can track and demonstrate the project and programme impacts not only on outputs but also on intermediate outcomes. This implies that the Bank needs to take active actions to strengthen the health information systems in the RMCs in order to enable them set up adequate monitoring and evaluation systems, able to collect reliable information including on intermediate outcomes. The staff incentive structure must incorporate monitoring and supervision activities as a factor in staff performance evaluation. The managers’ performance

66 It is therefore imperative that the Bank clears the huge backlog of PCRs on a priority basis.

50

should include the consistency, the quality of self-evaluation and the actual performance which should benefit from a peer-review. 7.3.10 Efficiency in Staff Management: The Bank should provide administrative support to technical staff and consider increasing current staffing profiles and levels of both professional and administrative personnel. Technical staff should receive sustained training in project management techniques and methods including logical framework and results-based management techniques. It is also of paramount importance to the Bank to make sure that managers have the appropriate skills, capacity and incentives to manage for sustainable results on the ground instead of tactical behaviour responding to in-house requests and avoiding risk taking for innovative actions. Sufficient time should be allowed for peer review and this activity needs to be factored in the staff’s work programme and performance evaluation.

C. The Way Forward

Based on the above recommendations, it is proposed that the Bank management prioritise the report recommendations and carry out an analysis of the cost in terms of the required staff skills profiles and budget. Contributing to this, a first step to revise the 1996 Health Sector Policy, the Operations Policy and Compliance Department lunched the process with a workshop organised in Tunis on 14 and 15 June 2006, following the Post-High Level Forum on the Health co-hosted on 12 and 13 June 2006 by the Bank, World Bank and the World Health Organisation. The Operations Evaluation Department should prepare a follow-up report in two-three years time to assess how the recommendations have been addressed. It also should carry out specific evaluations of Bank assistance to the health sub-sector themes in order to better know what interventions really succeed and what the factors of success are.

Annex 1 Page 1 of 2

FRAMEWORK FOR ASSESSMENT An Analytical Framework for international assistance to African Health Sector67

H e a lth Im p a c ts• R e d uc tio n in M o rta lity• R e d uc tio n in M o rb id ity• C o n tro l o f F e r tility• E nh an ce m e n t o f N u tr itio n a l S ta tu s

IMPACTS

In d iv id u a l / H o u se h o ld B eh a v io u rO u tco m esS e rv ic es U tilisa tio n

OUTCOMES

E xter n a l F a cto rs• A rm ed C o nflic ts• N a tu ra l D isa ste rs & E p id e m ics• In te rna tio n a l M a rk e t F lu c tua tio n s• C h an ge s in In te rn a tio na l F un d ing P rio ritie s

H ea lth S y stem P er fo rm a n c eS e rv ic e c o v e rag e , ac ce s, q ua lity , an d e ffic ien cy

L e n d in g E ffe c t iv en ess F a cto rs• B an k P e rfo rm an ce• B o rro w e r P e rfo rm a nc e• G o v ernm en t P o lic y P r io ritie s• G o v erna n c e

OUTPUTS

C o -fin an ce d P ro je c ts an d p ro g ram m es

O th e r D ev e lo p m en t P a r tn e rs(M u ltila te ra l, B ila te ra l A ge n c ies , N G O s, P r iv a te S ec to r)

A fr ic a n D e v e lo p m e n t B a n kL en d ing an d n o n -len d ing a c tiv itie s

I

N

P

U

TS

1. This shows a simplified framework that attempts to model how the Bank influences the health outcomes and impacts in the RMCs through lending and non-lending activities in the health sector.68 These include direct project/programme support, technical assistance and initiation and participation in co-financed projects/programmes. The Bank’s investments aims at strengthening health system performance in improving services coverage and utilisation, resulting in fine in changes in mortality, morbidity, fertility and nutritional status of the people through changes in individual and household behaviour. As will be discussed later, data are not available or insufficient to analyse interactions. 2. The Bank is only one of several players in the African health sector. Other development partners include multilateral and bilateral development agencies, non-government organisations and the private sector. The Bank financing in the health sector represents 5.4 per cent of commitments to African health and population sectors of all donors

67 This conceptual framework is adapted from different sources notably from the World Bank HNP publications (Stout et al. 1997; World Bank-OED 1999; World Bank-OED 2005). 68 The framework does not address variables outside the health sector that have an impact on health outcomes.

Annex 1 Page 2 of 2

2

over 1990-2004. The corresponding share for the World Bank is 17.4 per cent.69 Currently, the Bank interventions are mainly focussed on individual projects, technical assistance and co-financed initiatives. The co-financed projects represent 24.2 per cent of UA 990.7 million invested by the Bank in the health sector since 1987.70 3. Health system performance, and thereby health outcomes and impacts, are greatly influenced by policy. Agencies such as WHO, UNICEF, UNFPA, and World Bank, are playing leading roles in policy influencing and reforms in African health sector. The Bank contribution in this regard is not substantial, as the Bank has neither undertaken ESWs nor do its staff have time to learn from available analysis done by other organisations to enable assumption of such a role. The Bank role in the health sector is therefore still too limited to produce significant impacts, as most of Bank interventions are primarily focused on small and limited number of projects scattered across the RMCs, in the absence of any major policy level work.

69 DAC-OECD database. 70 The Bank contribution to cumulative total cost of co-financed projects and programmes up to 2002 represents 17.3 per cent of $98.6 billion (Kabbaj, p. 139).

Annex 2 Page 1 of 9

STATISTICAL TABLES

Table A2.1: Selected Health Indicators – Child/Maternal health Region 1-year-old children

immunised against measles (%) †

Child Deaths from Vaccine-Preventable

Diseases (%) †**

Maternal mortality ratio (/100,000 live

births) †

Births attended by skilled health personnel (%) †

1980- 1989

1990- 1999

2000- 2004

2000- 2004

1990- 1999

2000-2004

2000- 2004

All Africa 49 65 70 10.2 872 770 55 SSA 47 63 68 11.4 940 845 52 Central Africa 42 53 57 1117 903 52 East Africa 44 61 72 943 774 45 North Africa 57 84 86 366 209 79 South Africa 63 78 76 676 790 66 West Africa 42 59 65 1002 889 48

CEE/CIS 85 89 94 3.1 53 53 95 EAP 54 80 81 3.8 262 199 83 Ind. Countries 72 88 90 0.3 12 12 99 LAC 58 85 90 1.2 185 165 85 Middle East 52 86 93 185 114 87 S. Asia 31 68 74 11.6 683 585 37

** WHO region classification system: CEE/CIS corresponds to EMRO; EAP corresponds to WPRO; Ind. Countries corresponds to AMRO A, EURO A; LAC corresponds to AMRO B-E; Middle East corresponds to MENA; S. Asia corresponds to SEARO † MDG indicator Sources: World Health Organisation 2004; United Nations Statistics Division 2005

Table A2.2: Selected Health Indicators – General health Adult

Prevalence of

HIV/AIDS†

Contraceptive Use (any method),

married women (%)†

Malaria death rate (all ages) (per 100,000

pop.)†

Tuberculosis: prevalence (per 100,000 pop.)†

Tuberculosis: DOTS

treatment success (%)†

Region

2001-2003 2001-2003 2000 1990- 1999

2000-2004

1990- 1999

2000-2004

All Africa 8.0 20 124 358 402 68% 71 SSA 9.2 26 138 382 441 66 69 Central Africa 6.7 45 141 264 391 64 67 East Africa 4.6 29 99 413 443 76 78 North Africa 0.4 14 17 166 101 80 83 South Africa 21.9 21 115 433 477 61 68 West Africa 3.1 25 178 404 448 62 65

CEE/CIS 0.2 56 0 89 108 78 80 EAP 0.5 55 9 377 173 79 84 Ind. Countries 0.2 71 0 32 16 75 70 LAC 1.2 59 0 132 84 76 79 Middle East 0.1 43 3 103 59 76 82 S. Asia 0.4 35 5 538 327 79 85

† MDG indicator Source: United Nations Statistics Division 2005

Table A2.3: Selected Personnel Indicators (1990-2003) Density of Health Personnel (per 100,000 pop.) Region

Physicians Nurses Midwives Pharmacists All Africa 24.3 97.5 27.1 5.9

SSA 15.7 80.4 27.1 3.3 Central Africa 15.0 54.9 9.2 1.1 East Africa 25.3 94.0 67.9 3.5 North Africa 91.7 228.8 - - 22.7 South Africa 16.9 155.0 43.3 5.0 West Africa 8.9 38.6 12.2 3.0

CEE/CIS 219.2 612.9 28.0 36.5 EAP 171.1 239.0 34.2 35.8 Ind. Countries 184.3 836.6 30.7 26.0 LAC 187.3 212.7 34.8 32.5 Middle East 186.0 278.7 25.7 18.5 S. Asia 192.0 47.6 35.0 42.1

Source: World Health Organisation 2005

Annex 2 Page 2 of 9

Table A4.1: Status of Health Sector projects since 1987 Amount in UA millions

Approved Ongoing Completed Total Percentages Sub-sector No. Amt No. Amt No. Amt No. Amt Apvd. Ongo. Comp. Total Primary Health Care 1 23.18 18 214.53 11 112.75 30 350.46 21.4 40.8 31.7 35.4 Secondary Health Care 4 55.18 9 107.22 13 162.4 10.5 30.1 16.4 Tertiary Health Care 1 20.6 8 71.45 9 92.05 3.9 20.1 9.3 Disease Control 2 31 1 2 2 7.91 5 40.91 28.6 0.4 2.2 4.1 HIV/AIDS 3 16.99 6 25 1 0.86 10 42.85 15.7 4.7 0.2 4.3 Pharmaceutical 2 15.2 2 15.2 4.3 1.5 Institutional Capacity 1 22 5 76.95 4 21.92 10 120.87 20.3 14.6 6.2 12.2 Studies 1 1.75 22 18.77 23 20.52 0.3 5.3 2.1 Disability Rehabilitation 1 0.93 1 0.93 0.2 0.1 Population & Nutrition 2 15.13 2 15.13 14 1.5 Reforms 3 129.4 3 129.4 24.6 13.1 Total 9 108.3 40 526.34 59 356.08 108 990.72 100 100 100 100

Note: The four studies in Population and Nutrition sub-sector have been grouped under ‘Studies.’

Table A4.2: Investment priorities across sub-sectors 1987-2005

Amount in UA million 1987-1996 1997-2005 Total 1987-1996 1997-2005 Total Sub-sectors No. Amount No. Amount No. Amount Amt. (%) Amt. (%) Amt. (%)

Primary Health Care 12 125.57 18 224.89 30 350.46 34.6 35.8 35.4 Secondary Health Care 9 107.22 4 55.18 13 162.40 29.6 8.8 16.4 Tertiary Health Care 8 71.45 1 20.60 9 92.05 19.7 3.3 9.3 Institutional Capacity 4 21.92 6 98.95 10 120.87 6.0 15.8 12.2 Studies 18 15.38 5 5.15 23 20.52 4.2 0.8 2.1 Pharmaceutical 2 15.20 2 15.20 4.2 1.5 Disease Control 1 5.91 4 35.00 5 40.91 1.6 5.6 4.1 HIV/AIDS 10 42.85 10 42.85 6.8 4.3 Disability Rehabilitation 1 0.93 1 0.93 0.1 0.1 Population and Nutrition 2 15.13 2 15.13 2.4 1.5 Reforms 3 129.40 3 129.40 20.6 13.1 Total 54 362.65 54 628.07 108 990.72 100 100 100 Note: The four studies in Population and Nutrition sub-sector have been grouped under ‘Studies.’

Table A4.3: Country/region-wise distribution of financing for various health sub-sectors since 1987 Amount in UA million

Sub-sectors Regions/ Countries PHC SHC THC DC HIV Phar. ICD Study Dis. P&N Reform Total %

Western 129.2 67.3 65.0 25.0 22.0 15.2 98.0 3.4 5.3 430.5 42.0 % 29.1 16.2 15.6 6.0 3.8 3.7 23.6 0.7 1.3 100

Benin 5.7 8.6 2.7 22.0 39.1 3.9 Burkina Faso 10.0 8.1 25.0 5.0 0.6 0.7 49.5 5.0 Côte d'Ivoire 4.1 4.1 0.4 Gambia 7.0 5.5 12.5 1.3 Ghana 18.6 24.7 43.3 4.4 Guinea 7.6 9.5 7.1 24.1 2.4 G-Bissau 0.7 10.0 0.1 10.8 1.1 Mali 8.9 9.6 8.3 15.0 1.3 43.1 4.4 Niger 16.4 9.2 3.0 28.5 2.9 Nigeria 60.5 25.5 34.7 120.7 12.2 Senegal 21.4 0.5 21.9 2.2 Sierra Leone 10.5 1.0 11.5 1.2 Togo 5.7 1.0 6.7 0.7 Central 45.1 2.0 9.8 3.8 12.1 72.8 8.8

% 51.5 9.1 11.2 4.8 13.9 100 Burundi 3.1 3.1 0.3 Cameroon 8.1 6.7 1.2 12.1 28.1 2.8 Centrafrique 1.5 1.5 0.2 Chad 8.3 6.0 0.5 14.7 1.5 D.R.C. 25.0 25.0 2.5 Eq. Guinea 2.2 1.0 3.2 0.3 Gabon 5.5 5.5 0.6 Rwanda 4.4 2.0 6.4 0.6 Eastern 112.8 65.4 20.6 6.0 6.9 211.7 21.4

% 53.3 30.9 9.7 2.8 3.3 100 Djibouti 4.0 4.0 0.4 Ethiopia 29.7 29.7 3.0 Kenya 31.2 1.5 32.7 3.3 Madagascar 13.2 6.0 19.2 1.9 Mauritius 20.6 20.6 2.1 Seychelles 0.4 0.4 0.0 Tanzania 15.0 3.1 18.1 1.8

Annex 2 Page 3 of 9

Sub-sectors Regions/ Countries PHC SHC THC DC HIV Phar. ICD Study Dis. P&N Reform Total %

Uganda 32.5 52.2 2.3 87.0 8.8 Northern 20.6 5.9 10.1 122.0 158.6 16.0

% 13.0 3.7 6.4 76.9 100 Egypt 5.9 12.0 17.9 1.8 Mauritania 6.9 10.1 17.0 1.7 Morocco 12.3 110.0 122.3 12.3 Sudan 1.3 1.3 0.1 Southern 42.7 29.7 6.4 1.9 2.9 2.6 7.4 93.7 9.5

% 45.6 31.7 6.8 2.0 3.1 2.8 7.9 100 Angola 6.5 2.9 0.4 9.9 1.0 Lesotho 29.7 0.8 7.4 37.9 3.8 Malawi 10.0 0.9 0.7 11.6 1.2 Mozambique 17.3 0.2 17.5 1.8 Swaziland 0.5 0.5 0.0 Zambia 8.9 6.4 1.0 16.3 1.6 Multinational 4.0 17.0 1.5 0.9 23.4 2.4

% 17.1 72.7 6.3 4.0 100 Total 350.5 162.4 92.0 40.9 42.8 15.2 120.9 18.2 0.9 17.5 129.4 990.7 100 % 35.4 16.4 9.3 4.1 4.3 1.5 12.2 1.8 0.1 1.8 13.1 100 Sub-sector Key: PHC = Primary Health Care; SHC = Secondary Health Care; THC = Tertiary Health Care; DC = Disease Control; HIV = HIV/AIDS; Phar. = Pharmaceutical; ICD = Institutional Capacity Development; Dis. = Disability Rehabilitation; P&N = Population and Nutrition

Table A4.4: Distribution of operations according to financing instruments since 1987 Amount in UA millions

Approval/Policy Periods 1987-1996 1997-2005 Total Percentage Financing Instruments Amount Amount Amount 1987-1996 1997-2005 Total Project Loans 333.96 410.35 744.31 92.09 65.33 75.13 Project Cycle Grants 15.63 34.19 49.81 4.31 5.44 5.03 Sector Investment & Rehab. 9.58 16.51 26.09 2.64 2.63 2.63 Inst. Support and Rehab. Grant 2.41 46.03 48.44 0.66 7.33 4.89 Project Cycle TA Loans 1.08 1.08 0.3 0.11 Sector Adjustment Loans 121 121 19.26 12.21

Total 362.65 628.07 990.72 100 100 100

Table A4.5: Bank Health Sector financing compared with financing for all sectors

Amounts in UA million Amount Percentage

Financing Sources 1987-1996 1997-2005 Total 1987-1996 1997-2005 Total Health Sector ADF 342.34 497.1 839.44 94.4 79.15 84.73 ADB 15.48 125.87 141.35 4.27 20.04 14.27 NTF 4.83 5.1 9.93 1.33 0.81 1 Total 362.65 628.07 990.72 100 100 100 % to Bank Total 2.94 3.68 3.37 All Sectors ADB 7,953.58 10,836.42 18,790.00 64.4 63.5 63.9 ADF 4,142.74 6,064.76 10,207.50 33.5 35.5 34.7 NTF 103.68 49.71 153.39 0.8 0.3 0.5 SRF 14.5 14.5 0.1 MIC 0.1 0.1 IFAD 115.27 7.85 123.12 0.9 0.4 OPEC 38.62 93.85 132.47 0.3 0.5 0.5 Bank Total 12,353.89 17,067.19 29,421.08 100 100 100 Note: ADB = African Development Bank; ADF = African Development Fund; NTF = Nigeria Trust Fund; SRF = Special Relief Fund; MIC = Middle Income Countries Fund; IFAD = International Fund for Agricultural Development; OPEC = OPEC Fund.

Table A4.6a: Relative shares of health themes in the Bank portfolio during 1988-2004 N = 199

Investments Amount (UA million) Percentage Health Themes in the Ongoing Projects

ADF & Blend ADB Total

ADF & Blend ADB Total

Health MDG Goals / Indicators (Direct Poverty Reduction and Human Development) 1. Reduce child mortality / Under-5 year child mortality 45.3 45.3 2.0 1.2 2. Combat HIV/AIDS / Prevalence in women aged 15-24 54.4 54.4 2.4 1.4 3. Improve maternal health / Births attended by skilled physician 52.1 8.1 60.2 2.3 0.5 1.5 Indirect Poverty Reduction 1. Health 163.1 109.1 272.2 7.2 6.7 7.0 Total Assistance for Health 314.8 117.2 432.1 13.9 7.2 11.1 Total Assistance for all Sectors 2,264.9 16,28.3 3,893.2

Source: Adapted from the Bank Group Report on Development Effectiveness 2005 Note: Amounts are in nominal terms.

Annex 2 Page 4 of 9

Table A4.6b: Health Indicators of the RMCs and corresponding average CPIAs, Net Loans from the Bank for Health Sector Operations, Gross National Income and Human Development Indices

No. Country Net Loan

(UA million) Population (millions)

Net Loan per

Capita (UA)

CPIA (Average

2003-2004)

HIV/AIDS Prevalence

(%)

Under-5 Mortality (per '000)

Life Expectancy

at Birth (years)

Immuni-sation against

Measles (%)

GNI Per Capita (US$)

HDI

1 Angola 9.87 14.07 0.70 2.60 4 260 47 62 1,030 1662 Benin 39.09 6.92 5.65 3.98 2 154 53 83 530 1613 Burkina Faso 49.46 13.39 3.69 3.92 2 207 43 76 360 1754 Burundi 3.08 7.05 0.44 2.90 6 190 42 75 90 1735 Cameroon 28.12 16.31 1.72 3.71 7 166 48 61 800 1416 Centrafrique 1.54 3.91 0.39 2.41 14 180 42 35 310 1697 Chad 14.74 8.85 1.67 3.51 5 200 48 61 260 1678 Côte D'Ivoire 4.05 16.90 0.24 2.68 7 192 45 56 770 1639 DRC 25.00 54.36 0.46 2.43 4 205 45 54 120 168

10 Djibouti 4.00 0.71 5.61 3.11 3 138 43 66 1,030 15411 Egypt 17.91 73.37 0.24 3.75 0 39 69 98 1,310 12012 Eq Guinea 3.20 0.51 6.31 2.36 .. 146 52 51 10913 Ethiopia 29.72 72.42 0.41 3.44 4 169 42 52 110 17014 Gabon 5.49 1.35 4.06 3.11 8 91 53 55 3,940 12215 Gambia 12.47 1.46 8.51 3.28 1 123 53 90 290 15516 Ghana 43.31 21.38 2.03 3.97 3 95 54 80 380 13117 Guinea 24.12 8.60 2.80 2.91 3 160 46 52 460 16018 G-Bissau 10.81 1.54 7.03 2.37 .. 204 46 61 160 17219 Kenya 32.66 32.44 1.01 3.68 7 123 45 72 460 14820 Lesotho 37.92 1.80 21.02 3.65 29 110 37 70 740 14521 Madagascar 19.19 17.90 1.07 3.45 2 126 56 55 300 15022 Malawi 11.59 12.34 0.94 3.30 14 178 38 77 170 16523 Mali 43.12 13.40 3.22 3.86 2 220 41 68 360 17424 Mauritania 17.02 2.98 5.71 3.79 1 107 51 71 420 15225 Mauritius 20.60 1.23 16.72 4.43 .. 18 72 94 4,640 64 26 Morocco 122.34 31.06 3.94 3.83 0 39 69 90 1,520 12527 Mozambique 17.51 19.19 0.91 3.56 12 147 41 77 250 17128 Niger 28.52 12.41 2.30 3.44 1 262 46 64 230 17629 Nigeria 120.74 127.15 0.95 2.93 5 198 45 35 390 15130 Rwanda 6.40 8.50 0.75 3.82 5 203 40 90 220 15931 Senegal 21.86 10.34 2.11 4.03 1 137 52 60 670 15732 Seychelles 0.37 0.08 4.49 2.64 .. 15 73 99 8,090 35 33 Sierra Leone 11.52 5.18 2.22 2.87 .. 284 37 73 200 17734 Sudan 1.33 34.35 0.04 2.61 2 93 59 57 530 13935 Swaziland 0.46 1.09 0.43 3.83 39 153 43 94 1,660 13736 Tanzania 18.13 37.68 0.48 3.90 9 165 43 97 330 16237 Togo 6.71 5.02 1.34 2.52 4 140 50 58 380 14338 Uganda 87.00 26.66 3.26 3.95 4 140 43 82 270 14639 Zambia 16.33 10.93 1.49 3.53 16 182 36 84 450 164

Note: The data presented in the above table consist of only 39 countries that borrowed from the Bank for health sector operations during the review period (1987-2005). Sources: a. Population, HIV/AIDS Prevalence, Under-5 Mortality Rates, Life Expectancy at Birth, Immunisation against Measles, and

GNI per capita are extracted from the World Bank database accessible at www.worldbank.org. HDIs (Human Development Index) are extracted from Human Development Report 2004, prepared by UNDP.

Annex 2 Page 5 of 9

Table A4.7: Donor participation in co-financed projects since 1987 Amounts in UA million

Country Year Bank Group

EU World Bank

Bila-teral

OPEC Fund

NGOs Nordic Fund

BADEA UNDP Others Govt. Share

Project Cost

BG % share

1 Lesotho 1990 7.07 2.50 0.83 10.39 68.05 2 Uganda 1990 30.33 3.78 3.18 37.28 81.36 3 Tanzania 1997 15.00 7.34 3.60 3.11 29.05 51.64 4 Egypt 1998 12.00 89.11 66.83 59.41 73.55 300.90 3.99 5 Multinat’nl 1998 1.66 1.80 0.10 3.55 46.76 6 Multinat’nl 1999 2.00 16.40 27.00 11.00 50.60 7.32 114.32 1.75 7 Chad 2001 6.00 6.42 0.61 13.03 46.05 8 Djibouti 2002 4.00 2.01 0.67 6.68 59.88 9 Ghana 2002 18.64 8.88 0.40 1.81 29.73 62.70 10 Lesotho 2002 7.40 2.07 1.22 10.69 69.22 11 Morocco 2002 80.00 35.78 16.00 131.78 60.71 12 Multinat’nl 2002 2.00 12.75 61.75 8.50 85.00 2.35 13 Multinat’nl 2003 6.00 0.32 0.23 6.55 91.60 14 Cameroon 2004 12.13 0.40 1.11 13.64 88.93 15 Kenya 2004 23.18 4.75 3.55 31.48 73.63 16 M’gascar 2004 6.00 3.41 0.34 1.85 11.60 51.72 17 Multinat’nl 2004 6.00 0.82 0.34 0.47 7.63 78.64

Total 239.40 141.29 93.83 60.23 32.28 23.75 8.88 3.60 0.40 115.55 124.10 843.31 28.39 % 28.39 16.75 11.13 7.14 3.83 2.82 1.05 0.43 0.05 13.70 14.72 100

Table A4.8: Distribution of project costs in health sector by categories of expenditure

N=76 Amount (UA million) Percentage Categories of Expenditure 1987-96 1997-04 1987-04 1987-96 1997-04 1987-04

Study, Supervision, Professional Services 12.56 66.22 78.78 2.59 13.34 8.03 Construction Works 283.23 196.62 479.85 58.45 39.61 48.91 Equipment and Furniture 86.36 126.07 212.43 17.82 25.39 21.65 Drugs and Supplies 31.06 20.23 51.29 6.41 4.07 5.23 Training 14.93 30.79 45.72 3.08 6.20 4.66 Operating Costs 32.48 37.27 69.75 6.70 7.51 7.11 Technical Assistance 23.94 19.52 43.46 4.94 3.93 4.43 Base Cost 484.58 496.44 981.03 100 100 100 Physical Contingencies 30.42 35.34 65.77 6.28 7.12 6.70 Price Contingencies 87.14 43.35 130.48 17.98 8.73 13.30

TOTAL PROJECT COST 602.14 575.13 1177.28 124.26 115.85 120.00 Source: Data extracted from 76 Project Appraisal Reports (including 32 projects during 1987-1996 and 44 projects during

1997-2004 out of a total of 83 projects during this period). Note: Estimates do not include studies.

Table A5.1: Implementation Performance of Health Sector Projects 1998-2005 Year of Supervision

Performance Indicators 1998 1999 2000 2001 2002 2003 2004 20051 Number of Projects Total Projects Supervised 13 24 24 34 40 43 39 28 Satisfactory Compliance with Conditions 9 16 16 22 29 28 23 16 Satisfactory Procurement Performance 7 18 16 25 27 27 24 18 Satisfactory Financial Performance 8 16 17 23 26 35 26 20 Satisfactory project management 4 15 10 13 16 17 15 8 Satisfactory Development Objectives 9 17 23 32 31 39 33 26 Satisfactory Overall Performance 6 18 11 16 19 25 19 14 Percentage of Projects Satisfactory compliance with conditions 69 67 67 65 73 65 59 57 Satisfactory procurement performance 54 75 67 74 68 63 62 64 Satisfactory financial performance 62 67 71 68 65 81 67 71 Satisfactory project management 31 63 42 38 40 40 38 29 Satisfactory Development Objectives 69 71 96 94 78 91 85 93 Satisfactory Overall Performance 46 75 46 47 48 58 49 50 1 The figures are updated till August 2005

Annex 2 Page 6 of 9

Table A5.2: Performance of Health Sector compared with all Bank projects

Year of Supervision Performance Indicators 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 PP as per IP of Health Sector (%) 44.4 0.0 30.8 20.8 20.8 11.8 27.5 7.0 15.4 14.3 PP as per IP of All Sectors (%)* 25.0 16.0 15.0 7.6 12.2 10.4 11.5 7.8 n/a n/a PP as per DO of Health Sector (%) 11.1 0.0 7.7 4.2 0.0 0.0 5.0 4.7 10.3 3.6 PP as per DO of All Sectors (%)* 16.0 15.0 11.1 4.9 6.7 4.6 3.8 4.9 n/a n/a PP as per IP/DO of Health Sector (%) 44.4 0.0 30.8 20.8 20.8 11.8 27.5 9.3 15.4 14.3 PP as per IP/DO of All Sectors (%)* 29.0 21.0 20.0 11.2 13.9 12.2 14.3 10.7 n/a n/a Notes: PP = Problem Projects; IP = Implementation Progress; DO = Development Objective; N/A = not available * Source: APPRs 1996-2003.

Table A5.3: Analysis of delay in effectiveness and disbursement

Months of Delay between Approval and Effectiveness

Months of Delay between Approval and Effectiveness

Years of Delay between Approval and Planned Final

Disbursement 1

Regions < 6 6- 12

13- 24

25- 46 Total < 1

1- 6

7- 12

13- 24

25- 42 Total < 5

5.1- 10

10.1- 14.3 Total

Number of Projects Number of projects Number of Projects Western 4 12 13 10 39 2 16 7 4 3 32 3 13 11 27 Central 3 5 4 12 3 2 2 1 2 10 5 1 6 Eastern 2 10 6 18 6 4 4 1 15 7 2 9 Northern 2 4 1 7 1 2 3 1 7 1 3 4 Southern 3 9 6 18 4 6 4 4 18 3 7 1 11 Multinational 4 1 1 6 4 1 5 1 1 2 Total 13 37 35 15 100 13 32 19 16 7 87 8 32 19 59 Percentage of Projects Percentage of projects Percentage of Projects Western 10 31 33 26 100 6 50 22 13 9 100 11 48 41 100 Central 25 42 33 100 30 20 20 10 20 100 83 17 100 Eastern 11 56 33 100 40 27 27 7 100 78 22 100 Northern 29 57 14 100 14 29 43 14 100 25 75 100 Southern 17 50 33 100 22 33 22 22 100 27 64 9 100 Multinational 67 17 17 100 80 20 100 50 50 100 Total 13 37 35 15 100 15 37 22 18 8 100 14 54 32 100

1 Completed projects.

Table A5.4: Sub-sectoral distribution of age of projects and implementation period Duration between Approval and Planned

Final Disbursement Duration between Effectiveness and

Planned Final Disbursement Years Up to 5 5.1-10 10.1-14.3 Total Up to 5 5.1-10 10.1-12 Total Sub-sectors Number of Projects Number of Projects Primary Health Care (3.8) 1 5 5 11 2 6 3 11 Secondary Health Care (3.8) 5 4 9 6 3 9 Tertiary Health Care (2.6) 1 3 4 8 2 4 2 8 Disease Control (4.5) 1 1 2 1 1 2 HIV/AIDS (2.0) 1 1 1 1 Institutional Capacity (3.8) 1 2 1 4 2 1 1 4 Pharmaceutical (3.5) 1 1 2 1 1 2 Studies (1.6) 3 16 3 22 9 13 22 Total (3.12) 8 32 19 59 31 54 15 100 Percentage of Projects Percentage of Projects Primary Health Care 9 45 45 100 18 55 27 100 Secondary Health Care 56 44 100 67 33 100 Tertiary Health Care 13 38 50 100 25 50 25 100 Disease Control 50 50 100 50 50 100 HIV/AIDS 100 100 100 100 Institutional Capacity 25 50 25 100 50 25 25 100 Pharmaceutical 50 50 100 50 50 100 Studies 14 73 14 100 41 59 100 Total 14 54 32 100 18 32 9 59 Note: Figures in parentheses denote average project duration estimated during appraisal.

Annex 2 Page 7 of 9

Table A5.5: Performance of Health Sector projects according to the PCRs

1 2 3 4 5 6 7 8 9 10 11 12 Project Country Mali Zambia Guinea Egypt Lesotho Ivory Coast Uganda Mali Burkina Lesotho Chad UgandaRegion West South West North South West East West West South Centre East Approval Year 1987 1989 1989 1989 1990 1990 1990 1991 1991 1992 1993 1993 PCR Year 2000 1997 2001 2000 1997 2001 2003 2000 2001 2004 2005 2001 Performance Indicators:

Implementation Performance Ratings: 2 2 2 2 3 1 3 2 2 3 2 2 Bank Performance Ratings: 2 2 2 3 3 2 3 2 2 3 3 3 Outcome Ratings: Relevance and Achievement of Objectives: 2 2 2 4 3 2 3 2 2 3 3 3 Institutional Development: 2 2 2 3 3 2 3 2 2 2 3 3 Sustainability: 2 2 2 3 2 2 3 2 2 2 3 3 Overall Outcome Ratings: 2 2 2 3 3 2 3 2 2 2 3 3

Project Key: 1: Mali Health Facilities Strengthening Project in Koulikoro, Nara and Niafunke; 2: Zambia Rural Health Project; 3: Guinea Public Pharmaceutical Sector Rehabilitation Project; 4: Egypt Bilharzia Control Project III; 5: Lesotho Rural Health Services Project III; 6: Ivory Coast Hospital Infrastructure Rehabilitation and Basic Health Support; 7: Uganda Health Services Rehabilitation Project; 8: Mali Renovation of Four Health Centres; 9: Burkina Faso Project for the Renovation of the Dori and Djibo Health Facilities; 10: Lesotho Rural Health Services IV; 11: Chad Primary Health Care Strengthening Project; 12: Uganda Second Health Services Rehabilitation Project Rating Scale: 4 = Highly Satisfactory: Project achieved or expected to achieve, or exceeded all its major relevant objectives including its institutional development objectives with likely sustainable outcomes and results; 3 = Satisfactory: Project achieved or expected to achieve its major relevant objectives including its institutional development objectives with minor shortcomings or sustainability issues; 2 = Unsatisfactory: Project failed to achieve most of its relevant objectives with minor shortcomings or sustainability issues; 1 = Highly Unsatisfactory: Project failed to achieve any of its relevant objectives.

Annex 2 Page 8 of 9

Table A5.6: Some indicators of the effects of health projects supported by the Bank Project 1 2 3 4 5 6 7 8 9 10 Country Mali Egypt Lesotho Ivory coast Uganda 1 Mali Burkina Lesotho 2 Chad Uganda Year of Approval 1987 1989 1990 1990 1990 1991 1991 1992 1993 1993 Year of PCR 2000 2000 1997 2001 2003 2000 2001 2004 2005 2001 Period of Effect 1998 1997-98 1997-02 1996-98 1996-98 1998-02 2000-03 1998-00 Population coverage by the Project 441,572 4,500,000 316,000 3,540,000 450,745 750,000 Number of consultations 212,354

Outpatients attendance 14458-18796 30% 15%

(1998-99) 14,504-26,323 81%

Inpatient admissions 3,378-5,189 54%

Total surgical operations carried out 399 10,296 324-1155 256%

Increase in forward vaccinations 1,740-6,977 300% c.100%

Increase in anti-tetanus vaccination 5,066-7,195 40%

Vaccination coverage BCG (1997-98) 38.6%-12.2%

Vaccination coverage DTCoq3 (1997-98) 12.3%-4.7% Prenatal coverage 28%-46%

Antenatal attendance first visits 3,916-3,762 -4%

Growth in assisted deliveries 35% 616-1,069 74% 300% 8,630-18,579

115% 836-1,402

68% Gynaeco-obstetrical operations 100 1,532

Child care attendance 15,480-20,897 35%

Family Planning and Antenatal Care 17,128 2,983-3,939 32% 600% 9,064-12,709

40%

Family planning first time acceptor 4,071-6,046 49%

Contraceptive coverage rate 0.2%-0.48% Decline in incidence of Bilharzias < 10% Number of patients treated for Bilharzias 4,500,000

Referral from peripheral units to the facility 910-280 -69% 187-750

301% Referral made to other hospital from the facility 129-358

178% 1 The figures relate to Budadiri Health Centre, one of the three health centres rehabilitated under the project. 2 Data from Berea and Mokhotlong district hospitals. Data from Qacha hospital are not included are they are not consistently available. Project Key: 1: Mali Health Facilities Strengthening Project in Koulikoro, Nara and Niafunke; 2: Egypt Bilharzia Control Project III; 3: Lesotho Rural Health Services Project III; 4: Ivory Coast Hospital Infrastructure Rehabilitation and Basic Health Support; 5: Uganda Health Services Rehabilitation Project; 6: Mali Renovation of Four Health Centres; 7: Burkina Faso Project for the Renovation of the Dori and Djibo Health Facilities; 8: Lesotho Rural Health Services IV; 9: Chad Primary Health Care Strengthening Project; 10: Uganda Second Health Services Rehabilitation Project

Annex 2 Page 9 of 9

Table A5.7: Borrower performance: problems faced at difference stages of project cycle Number of Projects Sr.

No. Generic Problems (Government Centred) W (29)

C (5)

S (10)

E (6)

N (6)

Total (56)

%

1 Procurement Delays (all types) 16 3 4 4 5 32 57.14 2 Low Management Capacity of Executing Agency 14 3 4 1 5 27 48.21 3 Non-adherence to Implementation Schedule 15 3 5 2 2 27 48.21

4 Delays in Fulfilment of Loan / Grant Conditions Leading to Delay in Effectiveness 12 4 5 2 3 26 46.43

5 Counterpart Funds not Made Available 9 2 1 3 15 26.79 6 Irregular Submission of Audit Reports 4 3 1 1 3 12 21.43

7 Non-adherence to Bank Rules and Procedures for Procurement Leading to Delay 3 2 2 1 3 11 19.64

8 Irregular Transmission of Quarterly Reports 4 2 1 2 9 16.07 9 Non-adherence to Bank Specifications on Quality of Works 3 1 1 2 7 12.50

10 Not Fulfilling "Other" Conditions 3 1 1 1 6 10.71

11 Bank Sanctions to the Country for Non-repayment of Arrears Leading to Delay 4 1 1 6 10.71

Source: Compiled from Country Portfolio Reports since 1987. Note: W, C, S, E and N stand for Western, Central, Southern, Eastern and Northern regions of Africa; figures in parentheses denote total number of projects reviewed from that region.

Annex 3 Page 1 of 7

LIST OF PROJECTS IN THE HEALTH SECTOR PORTFOLIO SINCE 1987

Name Project Code Status Name of Project S-Sector Year Net Loan Project Cost Supervision PCR Rating Western Region 1 Benin P-BJ-IB0-006 APVD DEVELOPPEMENT SYSTEME SANTE III ICD 2005 22.00 24.00 2 Benin P-BJ-IBZ-001 APVD PROJET D'APPUI LA LUTTE CONTRE VIH/SIDA HIV 2004 2.70 2.84 3 Benin P-BJ-I00-001 COMP CONST. INST. REG. DE SANTE PUB. DE COTONOU THC 1991 8.65 10.25 Satisfactory 4 Benin P-BJ-IB0-002 COMP PROJET SANTE II PHC 1993 5.74 8.60 Unsat 5 Burkina Faso P-BF-IBZ-003 APVD APPUI AU DEV SANIT REG CEN -EST ET NORD DC 2005 25.00 28.00 6 Burkina Faso P-BF-IBD-002 COMP RENOVATION ETABLIS.SANITAIRES DORI - DJ. SHC 1991 8.10 12.09 Unsat 7 Burkina Faso P-BF-IBD-003 COMP ETUDES SECTEUR SANTE Study 1990 0.62 0.65 8 Burkina Faso P-BF-IC0-001 COMP ETUDE DANS LE SECTEUR DE LA POPULATION Study 1991 0.75 0.80 9 Burkina Faso P-BF-IBZ-001 OnGo SANTE II PHC 1999 10.00 11.11 Satisfactory

10 Burkina Faso P-BF-IBZ-002 OnGo Appui au plan multi-sectoriel VIH/SIDA HIV 2003 5.00 5.27 Unsat 11 Côte D'Ivoire P-CI-IBD-001 COMP REH.INFRAST.HOSPIT.- APPUI AUX SOINS DEB PHC 1990 4.05 14.53 Unsat Unsat 12 Gambia P-GM-IB0-001 COMP REHABILIT.OF HEALTH TRAINING FACILITIES THC 1992 5.47 7.91 Satisfactory 13 Gambia P-GM-IB0-002 OnGo HELTH SERVICES DEVELOPMENT PROJECT II SHC 1997 7.00 7.77 Unsat 14 Ghana P-GH-IB0-001 COMP HEALTH SERVICES REHABILITATION I THC 1990 12.53 16.88 Satisfactory 15 Ghana P-GH-IB0-002 COMP HEALTH SERVICES REHABILITATION II THC 1991 12.15 16.62 Satisfactory 16 Ghana P-GH-IBD-001 OnGo HEALTH SERVICES REHABILITATION III SHC 2002 18.64 29.73 17 Guinea P-GN-IBD-002 COMP REH.INFRASTRUCTURES SANITAIRES CONAKRY SHC 1987 7.56 9.52 18 Guinea P-GN-IBD-003 COMP REHABILITATION SECTEUR PHARMACEUTIQUE Phar. 1989 9.46 10.54 Unsat 19 Guinea P-GN-IB0-001 OnGo SANTE III ICD 2000 7.10 7.89 Satisfactory 20 G-Bissau P-GW-IB0-001 COMP ETUDE SECTEUR SANTE ET POPULATION Study 1993 0.11 1.06 21 G-Bissau P-GW-IBD-001 COMP REHABIL.HOPITAL NATIONAL SIMAO MENDES THC 1987 0.69 5.96 22 G-Bissau P-GW-IB0-002 OnGo APPUI AU PROG. DE DEVELOPPEMENT SANITAIRE ICD 1997 10.00 11.11 Unsat 23 Mali P-ML-IBZ-001 APVD PROJET D'APPUI A lA LUTTE CONTREVIH/SID HIV 2004 8.29 9.20 24 Mali P-ML-IB0-001 COMP ETUDES - RENFORCEMENT INST.MINIST.SANTE Study 1988 1.32 1.94 25 Mali P-ML-IB0-002 COMP RENOVATION 4 ETATBLISSEMENTS SANITAIRES SHC 1991 9.63 12.78 Unsat 26 Mali P-ML-IBD-003 COMP RENFORCEMENT INFRAST.SANITAIRES K.N.N. PHC 1987 8.88 11.95 Unsat 27 Mali P-ML-IB0-003 OnGo PROJET D'APPUI AU PRODESS (SANTE IV) ICD 2001 15.00 17.00 Unsat 28 Niger P-NE-IB0-006 APVD RENFORCEMENT DE L'EQUITE EN MATIERE DE G P&N 2004 3.00 3.16 29 Niger P-NE-IBD-001 COMP RENFORC. SECTEUR SANTE DEP. MARADI & DIFFA ICD 1993 9.17 10.25 Unsat 30 Niger P-NE-IB0-002 OnGo PROJ.D'AMELIOR.QUALITE DS SOINS(SANTE II SHC 2001 16.35 18.14 Unsat 31 Nigeria P-NG-IB0-001 COMP HEALTH SERVICES REHABILITATION PROJECT PHC 1992 48.17 78.11 Satisfactory 32 Nigeria P-NG-IB0-002 COMP KWARA STATE HEALTH PROJECT PHC 1990 12.28 14.95 Unsat 33 Nigeria P-NG-IB0-003 COMP BAUCHI STATE HEALTH THC 1990 22.55 28.83 34 Nigeria P-NG-KB0-001 COMP INVEST.PROPOSAL ABUJA INT. DIAGNOSTIC CEN THC 1996 3.00 2.09 35 Nigeria P-NG-IB0-006 OnGo HEALTH SYSTEMS DEVELOPEMENT PROJ.(IV) ICD 2002 34.74 163.93 Satisfactory 36 Senegal P-SN-IC0-001 COMP ETUDE DANS LE SECTEUR DE LA POPULATION Study 1993 0.51 1.01 37 Senegal P-SN-IB0-002 OnGo PROJET SANTE I PHC 1997 10.00 11.11 Satisfactory 38 Senegal P-SN-IB0-003 OnGo SANTE II PHC 2003 11.35 14.85 39 Sierra Leone P-SL-IB0-001 COMP HEALTH SECTOR STUDY Study 1989 1.02 1.09 40 Sierra Leone P-SL-IB0-002 OnGo HEALTH SERVICES REHABILITATION PROJECT PHC 1997 10.50 11.72 Unsat 41 Togo P-TG-IB0-001 COMP RENFORCEMENT PHARMACIE CENTRALE Phar. 1991 5.74 22.07 42 Togo P-TG-IC0-001 COMP ETUDE DANS LE SECTEUR DE LA POPULATION Study 1997 0.97 1.00 Satisfactory Central Region

Annex 3 Page 2 of 7

Name Project Code Status Name of Project S-Sector Year Net Loan Project Cost Supervision PCR Rating 1 Angola P-AO-IBD-002 COMP PROJET MEDICAMENT ESSENTIELS PRET SUPPLE ICD 1991 2.95 35.80 2 Angola P-AO-IBD-004 COMP ETUDE DE PRE-INVEST. - RENFOR.INST.SANTE Study 1989 0.43 1.68 3 Angola P-AO-IB0-002 OnGo PROGRAMME REHABILITATION SERVICES SANTE PHC 2002 6.50 7.22 Unsat 4 Burundi P-BI-IBD-001 COMP INST.NATIONAL DE SANTE PUBLIQUE DU BURU. ICD 1989 3.08 8.07 Unsat 5 Cameroon P-CM-IBD-004 APVD APPUI AU PROGRAMME SANTE REPRODUCTION P&N 2004 12.13 13.64 6 Cameroon P-CM-IBD-001 COMP ETUDE TECHNIQUE SECTEUR SANTE (DON) Study 1989 1.21 1.41 Unsat 7 Cameroon P-CM-IBD-002 COMP EQUIPEMENT 6 FORMATIONS SANITAIRES ICD 1988 6.73 6.91 8 Cameroon P-CM-IBD-003 OnGo PROJET SANTE I :DEVE. DU SYSTEME DE SANTE PHC 2000 8.05 8.97 Satisfactory 9 Centrafrique P-CF-IBD-001 COMP ETUDE SECTEUR PHARMACEUTIQUE Study 1988 1.54 1.85

10 Chad P-TD-IBA-001 COMP RENFORCEMENT DES SOINS DE SANTE PRIMAIRE PHC 1993 8.26 10.23 Satisfactory Satisfactory 11 Chad P-TD-IBD-001 COMP ETUDE DU SECTEUR SANITAIRE Study 1987 0.49 1.67 12 Chad P-TD-IBA-002 OnGo RENFORCEMENT SYS.SANTE ET LUTTE VIH/SIDA HIV 2001 6.00 13.03 Unsat 13 DRC P-CD-IBD-001 OnGo Sante I Appui au PDDS en Prov. Orientale PHC 2004 25.00 27.49 14 Eq Guinea P-GQ-IBD-001 COMP HEALTH STUDY Study 1991 1.00 1.19 Unsat 15 Eq Guinea P-GQ-IBD-002 OnGo SANTE I PHC 1998 2.20 2.57 Unsat 16 Gabon P-GA-IB0-001 OnGo PROJET DE DEV. DES SERVICES DE SANTE PHC 1994 5.49 16.91 Unsat 17 Rwanda P-RW-IB0-003 COMP PROJET D'URGENCE DE REHAB. INFRA. SANIT. PHC 1996 4.40 5.28 Unsat 18 Rwanda P-RW-IBE-001 OnGo APPUI AU PNM DE LUTTE CONTRE LE SIDA HIV 2003 2.00 2.10 Unsat Eastern Region 1 Djibouti P-DJ-IBE-001 OnGo RENFORCEMENT SERVICES SANTE BASE-SANTE I PHC 2002 4.00 6.68 2 Ethiopia P-ET-IBA-001 OnGo RURAL HEALTH SERVICES PROJECT I PHC 1998 29.72 32.97 Unsat 3 Kenya P-KE-IB0-001 APVD RURAL HEALTH PROJECT III PHC 2004 23.18 31.48 4 Kenya P-KE-IBZ-002 COMP REHABILITATION OF HEALTH FACILITIES Study 1993 1.48 1.61 Satisfactory 5 Kenya P-KE-IBA-001 OnGo RURAL HEALTH SERVICES PROJECT II PHC 1998 8.00 9.16 Unsat 6 Madagascar P-MG-IBE-001 APVD LUTTE CONTRE MALADIES TRANSMISSIBLES DC 2004 6.00 11.60 7 Madagascar P-MG-IBA-001 OnGo PROJET SANTE II SHC 1999 13.19 14.61 Satisfactory 8 Mauritius P-MU-IB0-001 OnGo SUPPORT TO NATIONAL HEALTH PLAN PROJECT THC 2001 20.60 20.10 Unsat 9 Seychelles P-SC-IBA-001 COMP HEALTH II PROJECT PHC 1997 0.37 10.80 Unsat

10 Tanzania P-TZ-IBC-001 COMP STUDY-MUHIMBILI REFERRAL TEACHING HOSPIT Study 1989 0.47 0.67 11 Tanzania P-TZ-IBD-001 COMP ZANZIBAR HEALTH DEV. REQUIREMENTS STUDY Study 1997 0.90 1.01 Satisfactory 12 Tanzania P-TZ-IBD-002 OnGo THREE REGIONS HEALTH STUDY Study 1999 1.75 1.83 Satisfactory 13 Tanzania P-TZ-IBZ-001 OnGo FIRST HEALTH REHABILITATION PROJECT PHC 1997 15.00 29.50 Satisfactory 14 Uganda P-UG-IBB-001 COMP SECOND HEALTH SERVICES REHABILITION PROJECT SHC 1993 19.13 25.14 Satisfactory Satisfactory 15 Uganda P-UG-IBC-001 COMP THE MBALE HOSPITAL REHABILITATION PROJEC SHC 1987 3.51 3.90 16 Uganda P-UG-IBC-002 COMP MULAGO HOSPITAL REHABILITATION STUDY Study 1987 0.59 17 Uganda P-UG-IBC-003 COMP HEALTH SERVICES REHABILITATION PROJECT SHC 1990 29.57 37.28 Satisfactory Satisfactory 18 Uganda P-UG-IBD-001 COMP HEALTH SECTOR STUDIES Study 1993 1.71 2.95 Satisfactory 19 Uganda P-UG-IBA-001 OnGo SUPPORT TO HEALTH SECTOR STRATEGIC PLAN PHC 2000 32.50 35.97 Satisfactory Northern Region 1 Egypt P-EG-IBE-001 COMP BILHARZIA CONTROL III DC 1989 5.91 7.93 Satisfactory Satisfactory 2 Egypt P-EG-IBZ-001 OnGo HEALTH SECTOR REFORM PROGRAMME Reform 1998 12.00 300.90 Unsat 3 Mauritania P-MR-IBA-001 COMP RENFORCEMENT DES SOINS DE SANTE PRIM. PHC 1992 6.91 11.30 Satisfactory 4 Mauritania P-MR-IBZ-003 OnGo PROGRAMME D'APPUI AU SECTEUR DE LA SANTE ICD 1999 10.11 11.25 Satisfactory 5 Morocco P-MA-IBA-001 COMP RENFORC. SOINS SANTE ZONE RUR. 10 PROVINCES PHC 1992 12.34 43.14 Satisfactory 6 Morocco P-MA-IBD-001 OnGo APPUI A REFORME COUVERTURE MED.(PARCOUM) Reform 2002 110.00 131.78 Satisfactory 7 Sudan P-SD-IBA-003 COMP RUTAL HEALTH IN THE N.- E.REGIONS(GRANT) PHC 1991 1.33 1.41 Unsat

Southern Region 1 Lesotho P-LS-IB0-001 COMP RURAL HEALTH SERVICE PROJECT SHC 1992 11.04 13.22 Satisfactory Unsat

Annex 3 Page 3 of 7

Name Project Code Status Name of Project S-Sector Year Net Loan Project Cost Supervision PCR Rating 2 Lesotho P-LS-IB0-003 COMP HEALTH STUDY Study 1997 0.80 0.88 Unsat 3 Lesotho P-LS-IBD-001 COMP RURAL HEALTH III SHC 1990 6.98 10.39 Satisfactory 4 Lesotho P-LS-IBD-003 COMP RURAL HEALTH SERVICES PROJECT II SHC 1987 11.70 13.13 5 Lesotho P-LS-I00-001 OnGo SUPPORT TO HEALTH REFORMS PROGRAMME Reform 2002 7.40 10.69 Satisfactory 6 Malawi P-MW-IB0-001 COMP HEALTH STUDY Study 1997 0.73 1.05 Satisfactory 7 Malawi P-MW-IB0-003 COMP SUPPORT TO NATIONAL AIDS CONTROL PROG. HIV 1999 0.86 1.07 Satisfactory 8 Malawi P-MW-IB0-004 OnGo RURAL HEALTH CARE PROJECT III PHC 2000 10.00 11.12 Satisfactory 9 Mozambique P-MZ-IBD-003 COMP HEALTH STUDY Study 1991 0.20 0.50 Unsat

10 Mozambique P-MZ-IB0-001 OnGo HEALTH II PROJECT PHC 2000 9.60 10.69 Satisfactory 11 Mozambique P-MZ-IB0-004 OnGo BEIRA CORRIDOR HEALTH PROJECT PHC 1996 7.71 8.57 Satisfactory 12 Swaziland P-SZ-IBD-002 COMP HEALTH SECTOR STRATEGY AND PLAN OF ACTION Study 1993 0.46 0.57 Unsat 13 Zambia P-ZM-IBD-001 COMP RURAL HEALTH SERVICE THC 1989 6.41 0.54 Unsat Unsat 14 Zambia P-ZM-IB0-003 OnGo HEALTH II (HEALTH SECTOR SUPPORT PROJECT) PHC 1999 8.92 10.20 Satisfactory 15 Zambia P-ZM-IB0-004 OnGo SUPPORT TO THE NATIONAL AIDS CONTROL PROG. HIV 2001 1.00 1.08 Satisfactory Multinational 1 Multinational P-Z1-IBE-001 APVD INITIATIVE VIH/SIDA DE LA COI HIV 2004 6.00 10.00 2 Multinational P-Z1-IB0-002 COMP PROG. AFRICAIN DE LUTTE CONTRE L'ONCHO. DC 2000 2.00 114.32 3 Multinational P-Z1-IB0-003 COMP ETUDES SANTE LIPTAKO-GOURMA Study 1988 1.47 1.90 4 Multinational P-Z1-IB0-001 OnGo CAPACITY BUILDING FOR DISABILITY REHAB. Disab. 2000 0.93 1.02 Unsat 5 Multinational P-Z1-IB0-005 OnGo APOC PHASE II DC 2002 2.00 85.00 Satisfactory 6 Multinational P-Z1-IB0-006 OnGo INIT. PAYS RIVERAINS CONGO OUBANGUI CHARI HIV 2003 6.00 6.55 Satisfactory 7 Multinational P-Z1-IBZ-001 OnGo Support to Mano-River HIV/AIDS Control HIV 2004 5.00 22.82

Sub-sector Key: PHC = Primary Health Care; SHC = Secondary Health Care; THC = Tertiary Health Care; DC = Disease Control; HIV = HIV/AIDS; Phar. = pharmaceutical; ICD = Institutional Capacity Development; Dis. = Disability Rehabilitation; P&N = Population and Nutrition

Annex 3 Page 4 of 7

Table 1: Net Loan Approved during 1975-2005 – All Sources of Finance (Amounts in million UA)

Approval Year Education Health Social Agriculture Communi-cations

Enviro-nment Finance

Industry / Mining /

Quarrying Power Transport

Urban Develo-pment

Water Supply /

SanitationMulti-Sector Total

1975 4.6 11.9 16.5 32.1 3.9 2.0 12.0 12.0 48.1 29.4 156.11976 7.6 1.6 9.2 20.0 5.9 13.6 8.2 14.8 28.8 31.4 131.81977 14.7 9.9 24.7 53.4 8.3 16.5 4.1 22.6 81.2 39.5 250.31978 20.3 12.4 32.7 85.4 28.5 9.9 17.3 22.7 75.2 32.2 303.91979 21.5 21.5 112.0 16.4 15.0 52.5 69.2 40.3 0.7 327.41980 18.9 7.4 26.3 157.3 12.7 50.1 28.9 31.7 103.4 32.7 443.11981 26.3 29.1 55.4 142.4 30.4 53.1 9.5 24.5 107.9 46.5 469.71982 52.8 28.5 81.4 175.4 10.0 50.2 8.0 68.8 113.2 97.1 10.7 614.91983 51.4 40.5 91.9 158.6 32.4 54.8 26.0 101.7 177.5 56.6 28.1 727.71984 50.3 9.6 59.9 132.1 55.3 146.5 25.2 53.6 166.2 41.5 1.0 681.31985 72.4 19.2 91.5 195.3 33.5 91.6 12.3 48.7 241.3 98.2 1.0 813.51986 99.4 25.1 124.4 232.9 33.4 236.8 114.8 233.6 94.7 58.3 9.2 1,138.21987 57.7 34.4 92.1 469.4 11.6 128.7 111.6 34.9 188.4 37.3 290.9 1,364.81988 34.7 11.5 46.3 290.8 3.1 116.6 168.8 390.1 243.1 107.6 167.8 1,534.21989 193.9 33.5 227.5 277.3 140.2 111.5 134.9 235.3 110.4 447.4 1,684.41990 73.1 91.3 166.6 272.5 20.5 214.1 279.9 176.0 210.2 185.5 268.3 1,793.51991 92.3 55.5 154.0 445.4 27.8 292.1 118.2 72.8 247.2 204.7 357.4 1,919.71992 162.9 84.6 263.8 272.0 63.3 1.6 120.0 23.7 91.1 209.7 200.2 499.7 1,745.11993 54.3 46.6 115.9 228.6 41.9 125.4 46.0 41.6 231.2 11.2 197.8 1,039.61994 0.0 5.5 5.6 11.5 75.6 111.9 54.8 94.4 15.8 182.5 552.21995 3.1 0.0 3.1 8.3 0.0 11.4 71.3 150.0 244.11996 12.0 15.1 29.1 179.2 1.3 0.0 26.6 46.7 29.1 157.4 469.41997 112.8 66.3 224.9 134.6 0.0 0.7 196.0 44.0 1.1 179.5 38.0 421.4 1,240.21998 158.5 51.9 261.5 125.4 95.1 472.1 34.3 134.9 108.2 0.6 65.2 300.4 1,597.61999 39.9 44.8 123.9 323.9 673.5 0.9 67.8 203.3 37.0 174.7 1,605.02000 138.0 70.2 257.2 187.8 2.3 243.4 5.8 38.3 112.0 1.9 119.8 170.6 1,139.22001 61.2 59.0 163.5 251.1 100.0 15.4 406.9 33.2 57.6 723.5 68.6 429.7 2,249.42002 42.6 189.4 244.1 368.5 3.9 484.7 20.5 196.2 296.0 44.0 1,308.4 2,966.42003 156.6 25.9 196.0 363.2 16.9 286.6 1,140.0 106.1 637.0 307.5 237.4 3,290.62004 37.4 97.1 154.8 461.5 1.7 537.5 5.4 50.7 613.3 131.0 553.8 2,509.62005 93.8 77.5 196.5 210.9 22.8 393.8 50.1 315.8 212.1 173.1 212.7 1,787.8Total 1,965.1 1,255.3 3,561.7 6,378.8 621.5 61.2 5,650.3 2,598.4 2,678.5 6,168.8 2.6 2,489.8 6,579.1 36,790.6

Annex 3 Page 5 of 7

Table 2: Number of Projects Approved during 1975-2005 (All sources of finance)

Approval Year Education Health Social Agriculture Communi-

cations Enviro-nment Finance

Industry / Mining /

Quarrying Power Transport

Urban Develo-pment

Water Supply /

SanitationMulti-Sector Total

1975 1 3 4 8 2 1 4 3 17 7 46 1976 2 3 5 4 2 6 1 3 8 9 38 1977 4 2 6 13 2 5 2 6 12 8 54 1978 4 2 6 21 4 2 4 6 16 8 67 1979 3 3 19 5 4 8 13 8 1 61 1980 3 1 4 18 2 8 2 5 14 6 59 1981 4 4 8 23 4 9 1 3 13 7 68 1982 5 4 9 18 1 8 1 6 11 8 1 63 1983 5 7 12 21 3 3 1 6 16 8 1 71 1984 6 4 10 21 3 7 2 6 23 5 1 78 1985 11 9 20 22 1 8 3 6 17 8 1 86 1986 8 2 10 21 8 11 4 9 9 9 1 82 1987 7 7 14 28 2 10 4 6 14 4 7 89 1988 5 5 10 14 1 10 5 3 14 6 8 71 1989 10 8 18 28 8 7 6 18 12 16 113 1990 8 8 17 32 5 6 10 6 15 9 20 120 1991 11 10 24 37 2 17 5 9 18 9 22 143 1992 14 5 21 33 2 1 3 14 6 19 10 17 126 1993 7 10 20 49 6 6 14 14 19 5 6 139 1994 0 2 3 3 7 6 2 5 2 4 32 1995 1 0 1 1 1 5 3 1 12 1996 1 3 5 9 1 4 2 5 2 2 30 1997 9 10 26 19 2 1 1 5 5 11 9 18 97 1998 8 5 19 40 1 3 2 5 7 1 8 27 113 1999 5 6 14 18 9 1 2 13 4 10 71 2000 5 7 17 33 1 6 2 6 11 1 6 12 95 2001 9 5 19 32 1 1 6 2 4 13 5 20 103 2002 8 9 22 26 1 13 2 7 9 6 21 107 2003 10 7 21 32 3 9 4 6 14 7 16 112 2004 7 12 23 34 1 4 1 4 10 8 27 112 2005 4 12 18 24 3 6 1 4 8 7 16 87 Total 185 172 409 701 55 11 199 123 164 395 2 210 276 2,545

Annex 3 Page 6 of 7

Table 3: Average Sizes of Project (Amounts in million UA)

Approval Year Education Health Social Agriculture Communi-

cations Enviro-nment Finance

Industry / Mining /

QuarryingPower Transport

Urban Develo-pment

Water Supply /

SanitationMulti-Sector Total

1975 4.6 4.0 4.1 4.0 1.9 0.0 2.0 3.0 4.0 2.8 0.0 4.2 0.0 3.41976 3.8 0.5 1.8 5.0 3.0 0.0 2.3 8.2 4.9 3.6 0.0 3.5 0.0 3.51977 3.7 5.0 4.1 4.1 4.2 0.0 3.3 2.1 3.8 6.8 0.0 4.9 0.0 4.61978 5.1 6.2 5.4 4.1 7.1 0.0 5.0 4.3 3.8 4.7 0.0 4.0 0.0 4.51979 7.2 0.0 7.2 5.9 0.0 0.0 3.3 3.7 6.6 5.3 0.0 5.0 0.7 5.41980 6.3 7.4 6.6 8.7 6.3 0.0 6.3 14.5 6.3 7.4 0.0 5.5 0.0 7.51981 6.6 7.3 6.9 6.2 7.6 0.0 5.9 9.5 8.2 8.3 0.0 6.6 0.0 6.91982 10.6 7.1 9.0 9.7 10.0 0.0 6.3 8.0 11.5 10.3 0.0 12.1 10.7 9.81983 10.3 5.8 7.7 7.6 10.8 0.0 18.3 26.0 17.0 11.1 0.0 7.1 28.1 10.21984 8.4 2.4 6.0 6.3 18.4 0.0 20.9 12.6 8.9 7.2 0.0 8.3 1.0 8.71985 6.6 2.1 4.6 8.9 33.5 0.0 11.5 4.1 8.1 14.2 0.0 12.3 1.0 9.51986 12.4 12.5 12.4 11.1 4.2 0.0 21.5 28.7 26.0 10.5 0.0 6.5 9.2 13.91987 8.2 4.9 6.6 16.8 5.8 0.0 12.9 27.9 5.8 13.5 0.0 9.3 41.6 15.31988 6.9 2.3 4.6 20.8 3.1 0.0 11.7 33.8 130.0 17.4 0.0 17.9 21.0 21.61989 19.4 4.2 12.6 9.9 0.0 0.0 17.5 15.9 22.5 13.1 0.0 9.2 28.0 14.91990 9.1 11.4 9.8 8.5 4.1 0.0 35.7 28.0 29.3 14.0 0.0 20.6 13.4 14.91991 8.4 5.5 6.4 12.0 13.9 0.0 17.2 23.6 8.1 13.7 0.0 22.7 16.2 13.41992 11.6 16.9 12.6 8.2 31.6 1.6 40.0 1.7 15.2 11.0 0.0 20.0 29.4 13.81993 7.8 4.7 5.8 4.7 7.0 0.0 20.9 3.3 3.0 12.2 0.0 2.2 33.0 7.51994 0.0 2.7 1.9 3.8 0.0 0.0 10.8 18.6 27.4 18.9 0.0 7.9 45.6 17.31995 3.1 0.0 3.1 8.3 0.0 0.0 0.0 2.3 0.0 23.8 0.0 0.0 150.0 20.31996 12.0 5.0 5.8 19.9 0.0 0.0 1.3 0.0 13.3 9.3 0.0 14.6 78.7 15.61997 12.5 6.6 8.7 7.1 0.0 0.7 196.0 8.8 0.2 16.3 0.0 4.2 23.4 12.81998 19.8 10.4 13.8 3.1 95.1 0.0 157.4 17.1 27.0 15.5 0.6 8.1 11.1 14.11999 8.0 7.5 8.9 18.0 0.0 0.0 74.8 0.9 33.9 15.6 0.0 9.2 17.5 22.62000 27.6 10.0 15.1 5.7 0.0 2.3 40.6 2.9 6.4 10.2 1.9 20.0 14.2 12.02001 6.8 11.8 8.6 7.8 100 15.4 67.8 16.6 14.4 55.7 0.0 13.7 21.5 21.82002 5.3 21.0 11.1 14.2 3.9 0.0 37.3 10.3 28.0 32.9 0.0 7.3 62.3 27.72003 15.7 3.7 9.3 11.3 0.0 5.6 31.8 285.0 17.7 45.5 0.0 43.9 14.8 29.42004 5.3 8.1 6.7 13.6 0.0 1.7 134.4 5.4 12.7 61.3 0.0 16.4 20.5 22.42005 23.5 6.5 10.9 8.8 0.0 7.6 65.6 50.1 79.0 26.5 0.0 24.7 13.3 20.5Total 10.6 7.3 8.7 9.1 11.3 5.6 28.4 21.1 16.3 15.6 1.3 11.9 23.8 14.5

Annex 3 Page 7 of 7

Table 4: International Assistance to African Health and Population sectors (Million of US$)

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004ALL Donors –Total 828,06 1060,60 947,95 924,20 925,34 1181,81 1010,27 960,22 1604,99 1353,95 1907,79 1920,71 2226,52 2846,91 3202,89

Australia 2,96 0,00 0,28 3,47 2,41 9,32 9,30 5,51 6,94 1,79 6,72 0,32 0,03 51,22 1,13

Austria 11,43 1,08 0,00 0,00 0,00 0,00 3,83 2,22 2,87 2,07 20,87 2,05 3,46 2,13 4,05

Belgium 2,51 1,64 0,00 0,00 18,80 19,39 30,64 28,43 28,49 30,31 36,56 32,94 75,77 42,85 34,10

Canada 22,12 6,13 8,01 3,96 42,27 60,03 23,47 15,39 8,33 11,32 46,49 33,86 67,54 146,37 171,26

Denmark 14,89 60,32 86,77 69,08 25,91 77,79 130,04 2,55 3,33 80,21 18,40 23,33 56,38 53,42 128,64

Finland 4,57 27,87 15,07 2,75 14,26 14,14 5,12 3,69 18,50 3,42 3,10 8,44 16,13 7,48 9,56

France 30,21 45,35 41,18 32,15 45,36 34,08 28,26 74,57 79,58 48,64 49,76 75,30 73,96 89,72 139,24

Germany 23,15 2,35 8,34 12,69 33,73 51,65 32,10 49,82 89,12 40,14 44,56 63,01 44,96 111,71 67,94

Greece 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 6,00 1,05

Ireland 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 14,39 22,20 40,21 59,66 71,77

Italy 57,51 64,72 50,45 31,17 0,72 10,21 32,31 10,50 6,95 21,44 31,27 13,03 28,91 30,66 42,12

Japan 16,91 16,06 47,55 41,66 47,02 61,48 43,19 40,18 41,28 9,90 14,00 39,51 43,71 74,94 77,63

Luxembourg 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 19,14 6,85 7,71 13,97

Netherlands 13,58 16,36 32,54 42,54 46,25 74,10 90,50 45,26 73,84 52,99 46,55 111,69 171,58 24,98 135,57

New Zealand 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,13 0,65 1,51

Norway 15,08 6,25 28,77 3,90 27,85 46,55 33,90 28,92 14,98 61,87 24,36 107,06 86,18 70,35 63,95

Portugal 0,00 0,00 0,00 0,00 0,02 0,20 0,75 0,11 0,50 8,60 5,87 7,67 7,42 7,89 9,66

Spain 4,59 6,57 8,41 0,00 0,00 0,00 53,28 35,34 36,55 50,51 16,58 33,63 23,69 25,61 56,38

Sweden 73,84 26,39 92,36 32,65 21,67 96,72 0,73 24,65 7,19 33,23 38,94 21,32 59,33 72,52 58,67

Switzerland 27,70 22,41 7,64 13,86 19,96 5,06 17,73 32,95 17,64 25,67 27,00 5,67 30,82 24,00 21,10

United Kingdom 8,37 18,20 69,44 69,36 78,70 33,89 81,30 62,79 151,82 208,04 383,80 184,46 100,19 295,17 357,56

United States 142,53 215,16 188,65 164,31 220,21 157,27 152,39 236,14 206,85 310,64 384,89 412,39 565,87 656,58 963,33DAC Countries –Total 471,95 536,86 685,46 523,55 645,13 751,88 768,82 699,04 794,76 1000,78 1214,12 1217,01 1503,10 1861,59 2430,18

EC 6,59 5,48 115,01 128,98 42,40 115,54 92,52 25,95 243,02 235,68 219,68 210,11 30,81 219,36 225,83

AfDB 5,77 6,08 0,00 25,45 35,46 0,00 3,01 11,55 0,00 0,00 0,00 14,73 109,77 0,00 0,00EU Members –Total 244,65 270,85 404,55 292,40 285,42 412,17 488,85 339,94 498,73 579,58 710,65 618,19 708,82 837,49 1130,28

G7 –Total 300,80 367,97 413,62 355,31 468,01 408,61 393,02 489,41 583,93 650,12 954,77 821,57 925,13 1405,15 1819,08

AfDF 62,06 88,78 62,94 160,42 10,76 0,00 17,93 77,67 82,01 61,07 88,69 48,82 94,80 34,10 127,85

GFTAM 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 28,65 697,80 577,75

IBRD 172,10 167,00 0,00 0,00 0,00 0,00 68,00 0,00 116,00 0,00 0,00 0,00 0,00 45,00 0,00

IDA 109,60 256,40 84,54 85,80 191,60 314,40 60,00 146,00 369,20 44,90 316,71 286,36 332,00 487,90 338,79

UNDP 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 11,51 0,00 0,00 0,00 0,00 0,00

UNFPA 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 67,82 85,52 125,48 0,00

UNICEF 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 68,59 75,85 70,52 73,49 80,24

Multilateral -Total 356,11 523,73 262,49 400,65 280,22 429,94 241,45 261,18 810,23 353,17 693,67 703,70 723,42 985,32 772,71

Source: OECD database on international aid flows.

Annex 4 Page 1 of 3

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Annex 5 Page 1 of 3

LIST OF VARIOUS DOCUMENTS REVIEWED

List of Country Portfolio Review Reports Reviewed

No. Country Portfolio Review Report DARMS Ref. Code 1 Benin: Country Portfolio Review Report 1996 ADB/BD/WP/96/46 2 Benin: Country Portfolio Review Report 2000 ADB/BD/WP/2000/78 3 Burkina Faso: Information Note on the Portfolio Review 1995 ADB/BD/IF/95/199 4 Cameroon: Country Portfolio Review Report 1997 ADB/BD/WP/97/91 5 Cameroon: Country Portfolio Review Report 2004 ADB/BD/WP/2004/56 6 Cape Verde: Country Portfolio Review Report 1999 ADB/BD/WP/99/106 7 Chad: Country Portfolio Review Report 1998 ADF/BD/WP/98/14 8 Chad: Country Portfolio Review Report 2002 ADF/BD/WP/2002/62 9 Cote d'Ivoire: Portfolio Review Report 1996 ADF/BD/WP/96/67

10 Equatorial Guinea: Country Portfolio Review Report 1997 ADF/BD/WP/97/130 11 Equatorial Guinea: Portfolio Review Report 2002 ADF/BD/WP/2002/02 12 Equatorial Guinea: Portfolio Review Report 2004 ADF/BD/WP/2003/122 13 Ethiopia: Country Portfolio Review Report 2003 ADF/BD/WP/2003/35 14 Gabon: Portfolio Review Report 1996 ADF/BD/WP/96/110 15 Gabon: Portfolio Review Report 2000 ADF/BD/WP/2000/19 16 Gambia: Country Portfolio Review Report 1996 ADF/BD/WP/96/95 17 Ghana: Country Portfolio Review Report 1999 ADF/BD/WP/99/61 18 Guinea Bissau: Portfolio Review Report 2004 ADF/BD/WP/2004/02 19 Guinea Bissau: Portfolio Review Report 1997-2000 ADF/BD/WP/98/66 20 Guinea: Portfolio Review Report 1999 ADF/BD/WP/99/95 21 Guinea: The Bank Group's Portfolio Review Report 1996 ADF/BD/WP/96/51 22 Lesotho: Country Portfolio Restructuring Report 1995 ADF/BD/WP/95/100 23 Malawi: Country Portfolio Review Report 1997 ADF/BD/WP/98/60 24 Malawi: Portfolio Review Report 2003 ADF/BD/WP/2003/08 25 Mali: Portfolio Review Report 1999 ADF/BD/WP/99/38 26 Mali: Review Report on Bank Group Operations 1995 ADF/BD/IF/95/40 27 Mauritania: Country Portfolio Review 1998 ADF/BD/WP/98/95 28 Mauritania: Portfolio Review Report 2002 ADF/BD/WP/2001/192 29 Mauritania: Portfolio Review Report 2005 ADF/BD/WP/2005/08 30 Mauritania: The Bank Group's Portfolio Review Report 1996 ADF/BD/WP/96/39 31 Morocco: Bank Group Portfolio Review Report 2000 ADF/BD/WP/2000/92 32 Morocco: Note on the Portfolio Review 1995 ADF/BD/IF/95/132 33 Morocco: Portfolio Review Report 2002 ADF/BD/WP/2002/66 34 Mozambique: Country Portfolio Review Report 1996 ADF/BD/WP/96/66 35 Mozambique: Country Portfolio Review Report 1999 ADF/BD/WP/2000/107 36 Niger: Report on the Portfolio Restructuring 1997 ADF/BD/WP/97/02 37 Nigeria: Country Portfolio Performance Review 2004 ADF/BD/WP/2005/62 38 Nigeria: Country Portfolio Report 1996 ADF/BD/WP/96/138 39 Nigeria: Country Portfolio Review Report 1999 ADF/BD/WP/99/43 40 Rwanda: Country Portfolio Review Report 1998 ADF/BD/WP/98/03 41 Rwanda: Portfolio Review Report 2000 ADF/BD/WP/2000/26 42 Senegal: Country Portfolio Review Report 1996 ADF/BD/WP/96/71 43 Senegal: Country Portfolio Review Report 1999 ADF/BD/WP/99/9 44 Senegal: Portfolio Review Report 2003 ADF/BD/WP/2004/133

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No. Country Portfolio Review Report DARMS Ref. Code 45 Seychelles: Country Portfolio Review Report 1998 ADF/BD/WP/98/167 46 Sierra Leone: Country Portfolio Review Report 1996 ADF/BD/IF/96/49 47 Sudan: Bank Group Portfolio Review Report 1995 ADF/BD/IF/95/47 48 Sudan: Country Portfolio Review Report 1998 ADF/BD/WP/98/130 49 Swaziland: Country Portfolio Review Report 1995 ADF/BD/IF/95/122 50 Swaziland: Country Portfolio Review Report 1998 ADF/BD/WP/99/08 51 Tanzania: Portfolio Review Report 1994 ADF/BD/IF/94/165 52 Togo: Bank Group Portfolio Review Report 1996 ADF/BD/WP/96/48 53 Togo: Portfolio Review Report 2001 ADF/BD/WP/2001/42 54 Tunisia: Information Note on the Portfolio Review 1995 ADB/BD/IF/95/249 55 Uganda: Country Portfolio Review Report 1997 ADF/BD/WP/97/07 56 Zambia: Country Portfolio Review Report 1995 ADF/BD/IF/95/158

List of Project Completion Reports Reviewed

No. Project Completion Reports DARMS Ref. Code 1 Health Facilities Strengthening Project in Koulikoro, Nara and

Niafunke ADF/BD/IF/2000/108

2 Rural Health Services Project ADF/BD/IF/97/202 3 Public Pharmaceutical Sector Rehabilitation Project ADF/BD/IF/2001/192 4 Bilharzia Control Project III ADF/BD/IF/2000/32 5 Services de Santé Rural III ADF/BD/IF/97/182 6 Hospital Infrastructure Rehabilitation and Basic Healthcare Support ADF/BD/IF/2001/50 7 Health Services Rehabilitation Project ADB/BD/IF/2003/135 8 Project de Renovation de Quatre Etablissements Sanitaires Ruraux ADF/BD/IF/2000/98 9 Project for the Renovation of the Dori and Djibo Health Facilities ADF/BD/IF/2001/46

10 Rural Health Services Project IV ADF/BD/IF/2004/159 11 Primary Health Care Strengthening Project ADF/BD/IF/2005/35 12 Second Health Service Rehabilitation Project ADF/BD/IF/2001/23

List of other Bank Documents Reviewed

No. Documents DARMS Ref. Code 1 Review of Bank’s Experience in Rural Health 1999 ADB/BD/WP/99/11 2 Bank Group Guidelines on Communicable Diseases 2004 ADB/BD/WP/2004/18/Rev.1 3 Guidelines on Development Budget Support Lending (DBSL)

2003 ADB/BD/WP/2003/145/Rev.2

4 Guidelines on Bank Group Operations Using Sector-wide Approaches 2004

ADB/BD/WP/2003/84/Rev.2

5 Guidelines on User Fees on Health and Education 2005 ADB/BD/WP/2004/144/Rev.1 6 Guidelines for the Implementation of Bank Group’s Policy on

Population 2004 ADB/BD/IF/2004/10

7 HIV/AIDS Strategy Paper for Bank Group Operations 2001 ADB/BD/WP/2001/11/Rev.3 8 Health Sector Policy Paper 1996 ADB/BD/WP/96/52 9 Strategic Plan for the Bank Group for the 2003-2007 Period ADB/BD/WP/2002/82/Rev.3 10 Ghana: Evaluation of Bank Assistance to the Health Sector ADF/BD/IF/2005/198 11 Tanzania: Evaluation of Bank Assistance to the Health Sector ADF/BD/IF/2005/199 12 Morocco: Evaluation of Bank Assistance to the Health Sector ADF/BD/IF/2005/214

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No. Documents DARMS Ref. Code 13 Independent Evaluation Study of ADF VII, VIII and IX –

Summary Record of the Proceedings of Feedback Workshop for Participants from RMCs

ADF/BD/IF/2004/141

14 Stepping up to the Future: An Independent Evaluation of ADF VII, VIII and IX – Management Response

ADF/BD/IF/2004/143

15 Tanzania: Country Strategy Paper 1999-2001 ADB/BD/IF/99/256 16 Tanzania: Country Strategy Paper 2002-2004 ADB/BD/WP/2003/48 17 Ghana: Country Strategy Paper 1999-2001 ADB/BD/WP/2000/44 18 Ghana: Country Strategy Paper 2002-2004 ADB/BD/WP/2003/20 19 Morocco: Country Strategy Paper 2000-2002 ADB/BD/WP/2000/124 20 Morocco: Country Strategy Paper 2003-2005 ADB/BD/WP/2003/123 21 Bank Group Malaria Control Strategy ADB/BD/WP/2002/25 22 Health Sector Policy Guidelines ADF/BD/WP/98/139