DATA SHEET TEMPLATE FOR PROJECT PAPER

GEORGIA: PRIMARY HEALTH CARE DEVELOPMENT PROJECT (Credit No.3702)

Borrower: Republic o f Georgia Responsible agency: Ministry o f Labor, Health and Social Affairs Revised estimated disbursements (Bank FY/US$m) -based on current US/SDR exchange rate

P

FY 1 2003 1 2004 1 2005 1 2006 1 2007 1 2008 I 2009/2010

Current closing date: 12/3 1/2009 Revised closing date: proposed to extend until 12/3 1/2010 Indicate if the restructuring is:

Board approved -a RVP approved -

Does the restructured project require any exceptions to Bank policies? Have these been approved by Bank management? I s approval for any policy exception sought from the Board?

- Yes W N o Yes -No Yes H N o

Revised project development objective/outcomes: (i) (ii)

to improve coverage, utilization and quality o f health care services, and; to strengthen Government stewardship functions in the health sector

Does the restructured project trigger any new safeguard policies? NO

Revised Financing Plan (US$m.) Source Local Foreign Total

Borrower IBRD/IDA Total

4.46 0 14.40 9.1 18.86 9.1

4.46 23.5

27.96

2

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PROJECT PAPER

PROPOSAL TO RESTRUCTURE

GEORGIA PRIMARY HEALTH CARE DEVELOPMENT PROJECT (Project ID P040555)

A. Introductory Statement

1. This Project Paper seeks Board approval to introduce changes in the Georgia Primary Health Care Development Project (PHCD), Credit No.3702, Project ID PO40555 and the related amendments to the project’s Development Credit Agreement. The proposed changes include: (i) changing the project development objectives and key performance indicators to better reflect priorities o f Georgia’s current health sector reform program; (ii) revision o f project components, with added emphasis on sector stewardship activities; (iii) changing the project name to “Health Sector Development Project” to better reflect the nature o f the proposed project restructuring; (iv) amending Schedule 1 o f the Development Credit Agreement to allow the percentage o f expenditures to be financed at 100 percent under a single new category combining works, goods, technical assistance, training, and incremental operating costs; (v) reallocation o f Credit proceeds among the current expenditure categories to accommodate the proposed changes; (vi) changing the project procurement plan and prior review thresholds to reflect the October 2006 updated World Bank Procurement and Consultant Guidelines; and (vii) extending the project Closing Date by 12 months to December 31,2010.

B. Background and Reasons for Restructuring

2. The SDR 16 mil l ion Credit (US$20.34) for this Project was approved on August 1, 2002 and became effective on May 6, 2003. The Project Development Objective, as stated in the Development Credit Agreement, i s “to improve coverage and utilization o f quality primary health care (PHC), in the territory o f the Borrower, based on a model o f Family Medicine/General Practice.” The Project includes three components:

+ Component I (US$16.2 million total costs): PHC Service Delivery: the overall objective o f the component was to support development o f PHC services in urban and rural areas o f Georgia through rehabilitation o f the facilities and provision o f basic medical and office equipment. This component has three sub-components: (i) establishing PHC clinics and referral laboratories; (ii) PHC Referral Pilot at Kutaisi M C H Center; and (iii) Community-based Information, Education and Communication (IEC).

+ Component I1 (US$7.10 million total costs): Institutional Development: the objective o f this component was to support institutional development and the capacity building in Family Medicine for the sustainable delivery o f the PHC services through: (i) Capacity building for PHC Training; (ii) Capacity building in the management o f PHC services; (iii) Strengthening Health Management Information Systems for PHC; and (iv) Support for PHC Financing Reforms.

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+ Component I11 (USU.5 million total costs): Project Management Support. The objective o f this component i s to support project implementation by supporting the development and functioning o f the Health and Social Implementation Center.

3. Progress to date: After initial delays, the implementation accelerated in 2006. Sixty one percent o f IDA funds (SDR9.87 mill ion or US$14.68 million) have been disbursed and an additional U S $ l . l mil l ion (4 percent) i s committed. In terms o f activities, the project has financed the rehabilitation o f 103 primary health care centers, regional family medicine training centers, as well as the Kutaisi M C H Center under Component 1. Training o f family medicine staff has also been supported. Under Component 2, an informatiodcommunication strategy has been developed and a Master plan for the PHC has been prepared. In addition, the capacity o f the Health Policy Unit and the Center for Medical Statistics and Information has been strengthened. The project has made progress towards the achievement o f i t s development objectives as measured by key performance indicators. About 71 percent o f rural population have access to the PHC clinic within 15 minutes in project target areas (Imereti, Adjara, Shida Kartl i regions) and national average utilization o f PHC services increased from 1.4 (2003) to 1.85 (2006) visitskapita (3/capita target). A ten percent increase nationwide in the proportion o f infants that receive timely immunization (DPT3) was observed amounting to an 86.8 percent coverage rate (2006). There has been a 7.5 percent increase (30 percent increase targeted) in the proportion o f pregnant women to have had at least 4 perinatal visi ts compared to the baseline.

4. Reasons for Restructuring: In the mid-l990s, Georgia embarked on a series o f reforms in the healthcare sector. These sought to improve the mobilization, allocation, and management o f public funds and to shift the healthcare delivery system away from the heavy emphasis on tertiary care to primary health care. Most recently, in 2006, the government launched a further major reform o f the health sector, which composes four main areas: (i) increasing the private sector role in health financing and service provision by privatizing public health facilities; (ii) prioritizing public funds to finance health care for the poor and other vulnerable groups; (iii) channeling public health financing through private health insurance companies; and (iv) strengthening the regulatory role o f the Ministry o f Labor, Health and Social Affairs (MOLHSA). Given these policy changes, the Government requested that Bank support under the Primary Health Care Development Project be revised to reflect the new priorities. The government has decided not to continue to rehabilitate primary health care clinics, because these would be privatized, but rather to increase funds for additional training on family medicine, to revise family medicine guidelines, to strengthen the stewardship functions o f the MOLHSA, and to develop a modernized public health information management system covering the entire health system rather than just PHC as was originally envisaged. To meet the new reform requirements in a dynamic policy environment in Georgia, the Bank agreed to restructure the project. I t should be noted that this project was a core project under the 2003 Country Assistance Strategy and the key element under the Country Partnership Strategy Progress Report for FY2006-2009. This Project also complements the Poverty Reduction Support Operation (PRSO), which provided policy-based credits to the Government for a range o f policy reforms including the reform in the health sector. In parallel to the PRSO, this Project finances a health management information system and provides technical assistance to the Government for better monitoring service provision by the private sector. The Project i s conducting an impact evaluation o f the Medical Assistance Program for the Poor, which i s a key program under the

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health sector reform. This kind o f support i s very critical to the success o f the health reform in Georgia.

Project Development Objective Improve Access

C. Proposed Changes

Revised PDO Indicators % o f population covered w i th re-trained family medicine providers Percentage o f rural population wi th access to a PHC clinic within 30 minutes of transportation/ walking Increased immunization rate of (DPT3).

5 . During the restructuring mission in July 2008, the project was re-appraised and re-costed in order to reflect changes in Government priorities. As a result o f the restructuring mission, i t was proposed to revise the original project objectives, the project name, project components, and key indicators in the Results Framework. It should be noted that following the restructuring mission, the process was interrupted by the Russo-Georgia military conflict in August 2008. As a result, the project lost time for the implementation. In the letter to the Bank on October 20, 2008, the Government o f Georgia requested formally project restructuring as well as the second extension o f the project Closing Date from December 3 1,2009 to December 3 1 , 201 0 in order to fully utilize the IDA credit and achieve the revised project development objectives. This letter reconfirms the proposed restructuring in order to meet the changing needs under the health sector reform program. The proposed changes are as follows:

Increase Utilization

Enhance Quality

6. Revised PDO, project name, and outcome indicators: The proposed revised PDO includes a new objective relating to the strengthening o f the stewardship functions o f the MOLHSA. The revised PDOs are to: (i) improve coverage, utilization and quality o f health care services in the territory o f the Recipient, and (ii) strengthen the Government’s stewardship functions in the health sector. In order to better reflect the revised objectives, the project name would change to the Health Sector Development Project. In l ine with the proposed revisions in the PDO, the results framework i s revised. During the course o f the implementation, some indicators in the results framework became irrelevant and have been modified informally. A thorough assessment was made o f all outcome and output indicators in the results framework during the restructuring mission and a set o f new indicators have been proposed to ensure that the results framework more closely reflects the project activities. In total, 9 out o f 17 indicators were modified, 7 were dropped and another 17 indicators were added. This restructuring allows indicators under the results framework to be formally changed (see Annex 1 for details on the original outcome and intermediate outcome indicators in the Project Appraisal Document and the proposed changes to the original indicators and the targets as well as the new indicators). Annex 2 provides the revised Results Framework with the baseline data and targets. The main outcome indicators to measure the success o f the restructured project are as follows:

Increased health care service utilization as measured by number of out- patient visits per capita (by poor and by general population) (threshold score for accessing M A P - 70,000) Increased satisfaction of population wi th PHC services in target areas, as measured by the utilization survey % of trained rural physicians who manage cases according to nationally approved treatment guidelines in project target areas Proportion of TB patients managed at the PHC level according to the

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Project Development Objective I Revised PDO Indicators I DOT stratew,

Component 2: Institutional Development Sub-component 2.1: Capacity Building for PHC Training

Strengthen Stewardship Functions I % o f health budget earmarked to program for poor I Key health laws revised & passed (health care, medical practice)

Component 2: Support for Health Sector Reform Sub-component 2.1: Information and Communication Campaign

I I Increased awareness o f population on health care reforms I

Sub-component 2.2: Capacity Building in the Management o f PHC Services

Sub-component 2.3: Strengthening Health Management Information Systems for PHC

7 . Revised project components: The project design would be changed as follows: (i) the original sub-components 1.1 and 1.2 would be merged; (ii) sub-component 2.1 would be moved under Component 1 , now renamed “Strengthening the PHC System”. This would consolidate all PHC related activities under Component 1, Additionally, Component 2 would be renamed “Support for Health Sector Reform” and the original sub-component 1.3 would be moved under this component. Also, the original sub-components 2.2 and 2.4 would be merged under a new sub-component 2.2. Component 3 on Project Management would remain unchanged. The table below shows comparisons o f the original and revised project structure.

Sub-component 2.2: Capacity Building for M O L H S A in Policy, Regulation, Financing and M&E Sub-component 2.3: Strengthening Health Management Information Systems

Sub-component 2.4: Support for PHC Health Care Financing Reforms I

I Component 3: Project Management I Component 3: Project Management

8. The total estimated costs in US$ are based on the current SDWUS$ exchange rate o f SDRl/US$1.48 (February 17, 2009). Hence the total Bank financing i s estimated at US$23.5 million, The revised project description would be as follows:

COMPONENT 1: Strengthening PHC System (US$17.8 million Bank financing)

+ Sub-component 1.1 : Upgrading Health Clinics: The objective o f this sub-component i s to increase access to critical primary health care services. This sub-component would finance the following activities: (i) rehabilitation o f health clinics, including 1 reference laboratory; (ii) provision o f equipment for clinics and family doctors; (iii) rehabilitation

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and equipment o f Kutaisi M C H Center; and (iv) equipment for Avian flu resuscitation units and anti-viral drugs for avian flu.

+ Sub-component 1.2: PHC Training: The objective o f this sub-component i s to strengthen capacity in PHC and improve the quality o f care, through the: (i) rehabilitation and equipment o f 5 regional Family Medicine Training Centers; (ii) establishment o f Family Medicine Faculty; (iii) development o f clinical guidelines and undergraduate nursing education curriculum; (iv) provision o f training for PHC providers in family medicine, on clinical guidelines, and contract negotiatiodmanagement skills; and (v) provision o f training on maternal and child care and health management to health practitioners and managers.

COMPONENT 2: Support for Health Sector Reform (US$4.1 million Bank financing)

+ Sub-component 2.1 : Information and Communication (IC): The objective o f this sub- component i s to increase awareness and understanding by the population o f the Government’s health reform program. Specifically, this includes information on programs for the poor, privatization o f health facilities, contracting with private insurance, content o f the benefit package, etc. The sub-component would finance the design and implementation o f the I C campaign throughout Georgia.

+ Sub-component 2.2: Capacity Building in MOLHSA in Policy. Regulation, Financing and Monitoring and Evaluation. The objective i s to support the development o f capacity o f the MOLHSA to analyze, monitor the sector as a basis for ‘steering’ rather than ‘rowing’ stewardship role. This sub-component would finance the following activities: (i) Strengthening the capacity o f Health Policy Division in MOLHSA; (ii) institutionalization o f M&E; (iii) support for development o f regulatory capacity; (iv) the development and institutionalization o f National Health Accounts; (v) carrying out a Health Sector Performance Assessment; (vi) technical assistance on health financing reforms; and (vii) conducting the Impact Evaluation o f the Medical Assistance Program for the Poor.

+ Sub-component 2.3: Strengthening o f Health Management Information System (HMIS): The objective i s support the development o f the HMIS. Specifically, this includes (i) the rehabilitation and equipping o f the Center for Medical Statistics, which has been merged with the National Center for Disease Control; (ii) technical assistance to analyze the existing flows o f health related information and to develop a conceptual framework, conduct a bankable feasibility study including an implementation plan for a future system o f health information management at a national level; and (iii) the design o f the HMIS.

COMPONENT 3: Project Management (US$1.60 million Bank financing)

+ This component would continue to support effective administration and coordination o f the project. This includes managing the resources.of the project, procuring goods and services under the project, operating the financial management system, and ensuring timely and appropriate reporting.

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Other related proposed changes:

9. changes are proposed:

In order to reflect changes made in the project, as outlined above, the following additional

a new single expenditure category entitled, “Provision o f Civ i l works, Goods, Consultant Services and Training, and Incremental Operating Costs,” with an allocation o f SDR 6.6 mil l ion added to the Allocation o f Credit Proceeds in Schedule 1. This category would be financed at 100 percent in l ine with the 2005 Country Financing Parameters, which allow for such financing.

reallocations between expenditure categories to accommodate the proposed changes. The reallocations proposed are as follows:

Allocation of Credit Proceeds (SDR)

The project Closing Date would be extended by12 months to December 31, 2010 because the implementation o f the new activities under the restructured project requires a longer project time period.

The procurement thresholds under the restructured project would be based on the updated Procurement and Consultant Guidelines (2004) as revised in October 2006. The procurement plan will specify those contracts which are subject to the Bank’s prior review.

D. Analysis

I O . The government o f Georgia has taken a radical approach to change both the financing and provision o f health care services in Georgia. This approach has the potential to increase financing to the health sector through private investment and to improve management o f health

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service provision. However, the approach also bears substantial risks. One o f the major risks i s whether the government would have the capacity to regulate and monitor the provision o f health service by the private sector as well as the purchasing function performed by private insurance companies. This risk i s addressed by the proposed changes under the project by increasing support to capacity building for the Ministry o f Health to enhance i t s stewardship functions.

1 1. Another risk i s that a large proportion o f population who are poor are not eligible for the government’s Medical Assistance Program for the Poor, which covers the extremely poor, and who will have difficulties to access health care after the privatization o f the health facilities. The project supports an evaluation to assess the impact o f the government’s reform programs on the access to and utilization o f health services and will provide hard evidence to policy makers on the feasibility o f the approach being taken.

12. The proposed changes, however, do not have a major effect on the original economic, technical, institutional, environmental, and social aspects o f the project. In terms o f project implementation and financial arrangements, these would continue to be used under the restructured project. Also, the existing procurement procedures would apply for all project activities. A revised procurement plan for the restructured project has been prepared and reviewed by the Bank team. Lastly, the proposed changes to the project do not affect the environmental category o f the project or trigger new safeguard policies. The restructuring does not involve any exceptions to Bank policies.

E. Expected Outcomes

13. The proposed changes in the project’s development objectives and i ts design are reflected in a revised set o f outcome and intermediate outcome indicators o f the project that are attached to this Project Paper (see Annex 1 and Annex 2). The revised results framework, which includes ten outcome indicators as well as a set o f component-related indicators, has been discussed and agreed on with all relevant project agencies.

F. Benefits and Risks

14. The project i s expected to yield benefits in support o f Georgia’s health sector reform to improve the health status o f i t s population. As a result o f the project: (i) relevant health facilities would be rehabilitated and equipment provided; (ii) health staff would be trained and certified to provide family medicine on the basis o f new family medicine guidelines; (iii) the capacity o f the MOLHSA and related agencies would be strengthened in policy analysis, monitoring and evaluation, and in regulation. Importantly, i t i s expected that the main benefit o f the restructured project would be that it provides the support to the government at this critical time to be able to monitor and evaluate i ts health reform program and to ensure that the most vulnerable groups o f the population have access to good quality healthcare services.

15 . The main risk o f the project not being able to achieve i t s development objective i s the unstable political environment and the frequent change o f policy makers and policy decisions. The relatively low capacity o f the implementing agency to carry out the project activities in a very dynamic and a complex political environment i s another risk. The latter risk i s o f particular

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concern given the project’s ambitious nature, a relatively short remaining implementation period, and a set o f activities which tend to be highly labor intensive, such as the provision o f training to a large number o f medical staff. On the positive side, the project implementation unit i s highly competent with excellent staff and management, which benefits from continued support from high Government levels. Also, to further mitigate this risk, technical assistance will be provided to MOLHSA and other government agencies to assist policy makers in overseeing the reform progress.

16. Policy environment in Georgia, especially in the health sector i s very dynamic. I t imposes high risk for this operation. However, it also provides opportunities for high gain because i t allows the Bank to stay engaged in the health sector to influence important policy development in Georgia.

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Annex 1. Proposed Changes in the Results Framework

Original (from PAD)

Original Indicators (from PAD)

Approximately 50% o f the population with access to a PHC clinic within 30 mins of wal kinglother transportation Population with access to PHC services completing at least three visits per capita per year

Revised or New

20% increase in the proportion of infants in the population that receive immunization (DPT3) on time

20% increase from 78% in 2004

90%

90%

5

At least 50% of population enrolled with certified family medicine practitioners by 2008 90% of providers trained in family medicine actually practicing family medicine 90% of rehabilitated facil i t ies have trained family medicine doctors, nurses and basic equipment Regional Family Medicine Training Centers operational

PHC norms and standards and master plan translated and

2.6fpclyr for poor; 2.3lpclyr for gen. population

90% of DPT3 coverage

50%

50%

90%

5

Laws passed

IC campaign carried out

implemented as laws Basic health information systems for PHC developed and implemented

Indicators

Revised or New Indicators (in Project Paper)

YO of rural population with access to PHC clinic within 30 mins of transportatiodwalking

Increased healthcare service utilization as measured by number of out-patient visits per capita (by poor and by general population) (threshold score for accessing the MAP - 70,000) Increased immunization rate of (DPT3)

YO population covered with retrained family medicine providers

YO of PHC providers trained in family medicine (country- wide)

Regional Family Medicine Training Centers rehabilitated and equipped (operational)

Key health norms revised and passed (healthcare, medical practice)

IC campaign designed and implemented

Proposed Changes

This indicator i s revised to add “rural”, because the project finances only rural clinics.

Revised to better define the indicator.

Revised to better define the indicator.

Revised to better define the indicator.

Revised to make this indicator measurable.

Kept as original.

Revised to better define the indicator.

Revised to better define the indicator.

Revised to include expanded scope of the campaign.

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Analytical studies and Analytical studies and I Revised to better evaluations needed for developing healthcare financing reforms for PHC completed and used to revisehedefine implementable strategies for healthcare financing

I Studies and

% o f trained rural physicians who manage cases according to nationally approved treatment guidelines in project

evaluations needed for developing healthcare financing reforms complete and used to reviselredefine strategies

New

Health sector performance evaluation completed

HMIS system developed

target areas Increased awareness of population on healthcare

define the indicator.

New 70

Number of rural practices New equipped

analysis carried out

I 98

HSPE report produced

System designed and implemented for PHC 30

40

30

Number of new, rehabilitated and equipped health clinics

Increased satisfaction of population with PHC services in target areas, as measured by the utilization survey Number of physicians trained in new clinical guidelines

Kutaisi center rehabilitated, equipped and staff trained

Increased satisfaction (70%)

New

550

Center rehabilitated, equipped and staff trained

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established, equipped, curriculum developed

I Master plan developed and used

Laws revised (healthcare, medical practice)

Policy and decision-making capacity strengthened as measured by number of health policy staff trained, improved policy analysis, regular reports on health reform implementation and institutionalized M&E

30% increase in the number o f ARI/DD cases managed at the PHC level

30% increase in the proportion o f pregnant women who have had at least 4 prenatal visits

I

50% increase in the proportion of adult patients seen in refurbished PHC clinics for whom blood pressure i s recorded in patients medical records Improved knowledge and practice o f practices related to healthy lifestyles (smoking, diet, wellbeing check-ups)

New

New

New

New

New

New

This indicator i s dropped because no disaggregated data reported for this indicator. Dropped. The project has no direct inference on this indicator. It i s not appropriate indicator to monitor project performance. Dropped due to lack o f data.

Dropped due to the project activities have been changed and does not directly affect l i festy le changes.

Family Medical Facility developed 40

20150

Master plan developed

Laws revised

Capacity strengthened

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20% increase in the number of cases managed according to internationally and nationally approved

I Dropped. More

treatment guidelines 40% increase in the number of appropriate referrals (appropriately defined according to the

number of ARI/DD cases managed at the PHC level

appropriate indicators have been introduced in this area.

I

Dropped. More appropriate indicators have been introduced.

indicator appeared twice in the PAD.

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Annex 2: Proposed Project Results Framework

Project Development Objective (PDO)

PDO Indicators

Access

Proposed Targets

Quality

Data sourceskomments

?LO of population covered with re- trained family medicine providers Percentage of rural population with access to a PHC clinic within 30 minutes o f transportation' walking

50%

50%

MOLHSA Reports

To be measured by household survey

(total rehab facilities o f

L'tilization

Kutaisi center rehabilitated, equipped and staff trained

Increased immunization rate of (DPT3). Increased health care service utilization as measured by number o f out-patient visits per capita (by poor and by general population) (threshold

Increased satisfaction

(70%) 30%

40%

30%

Laws passed

70%

120

98

Center rehabilitated equipped and trained staff

5

Baseline (original and new

indicators)/ 0.6

(2004) 20% (2008)'

78% (2004) 2lpcly

for poor 2lpcly

for G. Pop (2006) 66%

(2006) As measured by

household utilization survey

As measured by Facility Survey

National TB Center

MOLHSANHA Data

As measured by number o f laws revised

and passed As measured by public

opinion survey Actual 103 done

98 done

MCC training to be provided in 50 districts to 120 doctors and will include Kutaisi Rehabilitated and equipped 3 centers;

0% (2008)

3% (2004)

3.6% (2006)

0 (2008)

46% (2006)

0 (2003)

0 (2007)

Stew a rd s h i p functions

0 (2003)

N o family medicine faculty (2003)

project target areas Proportion of TB patients managed at the PHC level according to the DOT strategy. YO o f public health expenditure earmarked to program for poor Key health laws revised and passed (health care, medical practice)

Sub-component 1.1: Upgrading health clinics

Increased awareness of population on health care reforms Number of new, rehabilitated and equipped health clinics

Number of rural practices equipped

800 rural) 90% I NCDCPublic Health

Sub-component 1.2: PHC Capacity Strengthening

for poor household utilization survey

2.3lpclyear for G. DOD

Regional Family Medicine Training Centers rehabilitated and equipped (operational) Family Medical Faculty established, equipped, curriculum developed

I training in 4 Family I Family Medical Medical I Facility established Facility

established

The 20% i s for the total population and the data for the rural population i s been collected. I

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Sub-component 2.1: Information and Communication Sub-component 2.2: Capacity Building for M O L H S A in Policy, Regulation, Financing and M&E

Sub-component 2.3: Strengthening Health Management Inform a tio n

% of PHC providers trained in family medicine (country-wide)

90% of rehabilitated facilities have trained family medicine doctors, nurses and basic equipment % of PHC staff trained in contracting/ management

20 family medicine guidelines developed and adopted, and 50 guidelines distributed Number of physicians trained in new clinical guidelines IC campaign designed and implemented

Master Plan developed and used

Laws revised (health care, medical practice) Policy and decision-making capacity strengthened

Analytical studies and evaluations needed for developing health care financing reforms completed and used to revise/redefme strategies. Health sector performance evaluation (HSPE) completed

HMIS system developed

5 yo (2003)

0 (2003)

(2008)

0 (2003)

0 (2003) N o IC

campaign (2003) No MP (2003)

50%

90%

40%

20150

550

IC campaign carried out

Master plan developed

Laws revised

Capacity strengthened

Studies and analysis

carried out

HSPE report produced

HIMS system designed

Systems

At the beginning o f the project 105 doctors were trained by DFID. (the total doctors need for training in country i s 2,200 and 1,205 to be trained by project)

HSPIC

404 doctors to be trained out of 1,042 rural doctors Printing and distribution will be done for al l guidelines Of the 2,200 in country

Master plan developed

As measured by number of health policy staff trained, improved policy analysis, regular reports on health reform implementation, and institutionalized M&E.

Consultant assessed the current systems

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