Document ofThe World Bank

FOR OFFICIAL USE ONLY

Report No.: 20713

IMPLEMENTATION COMPLETION REPORT(33260)

ON A

LOAN

IN THE AMOUNT OF US$ 54 MILLION

TO THE

FEDERAL REPUBLIC OF NIGERIA

FOR A HEALTH SYSTEM FUND PROJECT

JUNE 30, 2000

Human Development 3Africa Region

This document has a restricted distribution and may be used by recipients only in the performance of theirofficial duties. Its contents may not otherwise be disclosed without World Bank authorization.

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CURRENCY EQUIVALENTS

(Exchange Rate Effective June 16, 2000)

Currency Unit = NairaNaira 1.00 = US$ .00966184

US$ 1.00 = 100.3 Naira

FISCAL YEARJanuary 1 - December 31

ABBREVIATIONS AND ACRONYMSCBN - Central Bank of NigeriaDPRS - Department of Planning, Research and StatisticsEDL - Essential Drug ListEDP - Essential Drug PolicyEDRF - Essential Drug Revolving FundFCT - Federal Capital TerritoryFGN - Federal Government of NigeriaFMF - Federal Ministry of FinanceFP - Family PlanningFMHSS - Federal Ministry of Health and Social Services (Formerly FMOH - Federal Ministry of Health)HIF - Health Infrastructure FundHMB - Hospital Management BoardHMIS - Health Management Information SystemHR - Human Resource PolicyHSF - Health System FundIBRD - International Bank for Reconstruction and DevelopmentIEC - Information, Education and CommunicationLGA - Local Government AuthoritiesMCH - Maternal and Child HealthMTR - Mid-Term ReviewNGO - Non-Govemmental OrganizationPFI - Participating Financial IntermediariesPHC - Primary Health CarePHN - Public Health & NutritionPIU - Project Implementation UnitPTF - Petroleum Trust FundSAR - Staff Appraisal ReportSHC - Secondary Health FacilitiesSLA - Subloan AgrreementsSMF - State Ministry of FinanceSMOH - State Ministry of HealthSOE - Statement of ExpenditureTA - Technical AssistanceUNICEF - United Nations Children's FundWHO - World Health Organization

Vice President: Callisto E. Madavo (AFR)Country Manager/Director: Yaw Ansu (AFC 12)

Sector Manager/Director: Rosemary Bellew (AFTH3)Task Team Leader/Task Manager: Elizabeth Morris-Hughes (AFTH3)

FOR OFFICLAL USE ONLY

IMPLEMENTATION COMPLETION REPORTFEDERAL GOVERNMENT OF NIGERIA

HEALTH SYSTEM FUND PROJECTLn 2106-UNI

CONTENTS

Page No.1. Project Data 12. Principal Performance Ratings 13. Assessment of Development Objective and Design, and of Quality at Entry 14. Achievement of Objective and Outputs 55. Major Factors Affecting Implementation and Outcome 106. Sustainability 127. Bank and Borrower Performance 138. Lessons Learned 149. Partner Comments 1510. Additional Information 16Annex 1. Key Perfonnance Indicators/Log Frame Matrix 22Annex 2. Project Costs and Financing 28Annex 3. Economic Costs and Benefits 30Annex 4. Bank Inputs 31Annex 5. Ratings for Achievement of Objectives/Outputs of Components 33Annex 6. Ratings of Bank and Borrower Performance 34Annex 7. List of Supporting Documents 35

IThis document has a restricted distribution and may be used by recipients only in theperfonmance of their official duties. Its contents may not otherwise be disclosed withoutWorld Bank authorization.

Project ID: P002106 Project Name: Health System FundTeam Leader: Elizabeth M. Morris-Hughes TL Unit: AFTH3ICR Type: Core ICR Report Date: June 30, 2000

1. Project Data

Name: Health System Fund L/C/TFNumber: 33260Country/Department: NIGERIA Region: Africa Regional Office

Sector/subsector: HB - Basic Health

KEY DATESOriginal Revised/Actual

PCD: 01/28/88 Effective: 01/06/91 03/13/92Appraisal: 01/03/91 MTR: 03/13/94 11/01/93Approval: 05/21/91 Closing: 12/31/99 12/31/99

Borrower/lmplementing Agency: GOVERNMENT OF NIGERIAIFMOHIPARTICIPANT STATESOther Partners: Government of Japan.

STAFF Current At AppraisalVice President: Callisto E. Madavo Kim JaycoxCountry Manager: Yaw Ansu Edwin LimSector Manager: Rosemary Bellew Janet de MerodeTeam Leader at ICR: Elizabeth M. Morris-Hughes V.SrinivasanICR Primary Author: Elizabeth M. Morris-Hughes

2. Principal Performance Ratings

(HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=HighlyUnlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible)

Outcome: S

Sustainability: L

Institutional Development Impact: H

Bank Performance: S

Borrower Performance: S

QAG (if available) ICRQuality at Entry: S

Project at Risk at Any Time: Yes

3. Assessment of Development Objective and Design, and of Quality at Entry

3.1 Original Objective:

The primary objective of the proposed project was to improve health services for a wider base ofNigeria's population by creating a wholesaling mechanism, called the Health System Fund (HSF), tofinance health system improvements in a larger number of States than would be possible through individualState projects. The objectives of these improvements were, however, to be similar to those of the earliersingle State health projects, i.e., to: (a) improve the quality, coverage and efficiency of State and LGA

health and family planning; (b) promote the development of populations programs, and (c) strengthen theinstitutional and financial capacity of States and LGA's to plan, implement, monitor and evaluate theirhealth, nutrition and family planning programs. Private 'Participating' Financial Institutions' (PFIs) were tobe used to both cofinance and provide technical assistance on appraisal and implementation.

The primary objective was clear but ambitious, given the increasingly precarious state of Nigeria'sbanking sector. The objectives for the improvements in State and LGA health systems were responsive tothe borrower's development priorities for the provision of basic health, nutrition and family planningservices, but the project was risky given the range of sectoral policies and programs involved, theinvolvement of all 3 levels of Federal, State and Local Government, the potential number of participantStates, 12 at the time of Project Identification and 20 at Effectiveness, and the involvement of the PFls.These risks were recognized, although underestimated by the Bank during Project appraisal.

3.2 Revised Objective:

The restructuring of the project at the Mid-Term Review (MTR) in November 1993 resulted in anagreement to cancel the uncommitted portion of the IBRD Loan (US$16 million). The original role of boththe Fund and the PFI's changed. The PFI's responsibilities for the provision of technical assistance andfinancial resources were in future to be assumed by the FMHSS and the Project States. Regarding theobjectives for the improvements in State and LGA health systems, the restructuring reduced the range ofproject activities by dropping the population and nutrition programs, while adding provision for secondaryhealth care services and expanding the technical assistance and monitoring role of the FMHSS's ProjectImplementation Unit.

3.3 Original Components:

The project consisted of three Parts: Part A: State Health Sub-Projects; Part B: Assistance to theFederal Ministry of Health and Social Services (FMHSS); and Part C: Federal support to the States. Eachof these three Parts were divided into sub-components.

Part A: State Health Sub-Projects - Assisting Project States to carry out health and family planningsub-projects, including the extension of a line of credit to the Project States for the following:

(a) Institutional Development Sub-Projects designed to strengthen the capacity of State and localgovernment authorities to plan, carry out and monitor community-based health, family planningand nutrition programs and to improve resource mobilization and financial management including:

(i) in service training in supervisory methods, acquisition of equipment, vehicles, trainingmaterials and other logistical support items and installation of a management informationsystem;(ii) improving coordination between State ministries of health (SMOHs) and local governmentauthorities;(iii) assisting each SMOH to strengthen its financial management planning and managementcapability through the development of an annual financing plan for the health services,including cost recovery from drugs and medical services, an annual work plan, and;(iv) provision to the SMOH's of technical assistance, staff training, office equipment and fundsfor operational research.

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(b) Health Services Improvement Sub-Projects, including:

(i) upgrading, renovation and construction of primary health care (PHC) facilities;

(ii) support for provision of basic health services including pre-and post-natal maternal healthcare (MCH), family planning (FP) services immunizations, and health and nutrition education;

(iii) improvement of drug supply and distribution, including support for essential drugprograms developed by Project States with FMHSS's assistance, renovation of pharmaceuticalstores of hospitals, States and the local government authorities, and acquisition of essentialdrugs and vaccines;

(iv) establishment of disease surveillance and diagnostic services including the renovation orconstruction of facilities for public health laboratories and the provision of technicalassistance, staff training, equipment and supplies;

(v) improvement of MCH and FP services, including strengthening of the MCH/FP Units inthe Public Health Divisions of the SMOH's of the SMOHs, acquisition by the said Units ofvehicles, equipment and provision of staff training; and the development of FP services in theprivate sector;

(vi) information, education and communication (IEC) activities, including the development ofan integrated IEC plan to increase: (a) the practice of preventive health care, family planningand better nutrition in the home; (b) demand for MCH services; and (c) awareness of anddemand for family planning;

(vii) nutrition activities including: (a) promotion of nutrition education to improve infantfeeding practices; (b) testing of pilot feeding programs for vulnerable groups; (c) developmentof regular nutrition surveillance systems for monitoring and evaluating nutrition activities, and;(d) the development of improved weaning foods and their distribution, and;

(viii) support for non-governmental organizations (NGOs) including: (a) promotion of theinvolvement of the NGOs in the health care system, and; (b) establishment of a nodal point ingovernment for financial marketing and procedural assistance to NGOs.

(c) Future Sub-Projects Preparation Activities, including:

(i) facility mapping and planning from renovation and upgrading;

(ii) facility utilization studies;

(iii) staffing norms studies;

(iv) studies on SMOH organization and the State health delivery system, and;

(v) epidemiological studies, and

(vi) other feasibility studies.

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Part B: Assistance to the Federal Ministry of Health and Social Services (FMHSS)

(i) Strengthening of FMHSS's Department of Planning, Research and Statistics (DPRS) including:(a) the assignment to DPRS of a Project officer exclusively for the Health System Fund (HSF)activities; (b) acquisition by DPRS of office equipment, materials and vehicles; (c) appointment toDPRS of a local Project Advisor, and; (d) the appointment of an internationally recruited adviser topromote local consultancy and work with local firns employed to assist the Project States.

(ii) Establishment of a Health Management Information System (HMIS) including the provision ofthe services of an internationally recruited HMIS advisor assisted by adequate staff, hardware,equipment and materials for FMIHSS and the Project States.

(iii) Technical assistance, training and studies including: (a) a project performance audit; (b)studies to examine the Health System Fund Policy Statement of the Borrower, project and creditguidelines and project preparation procedures; (c) studies into ways of strengthening localconsultancy skills, and; (d) a local and/or overseas training program which emphasizes projectdevelopment skills, management and project implementation.

Part C: Federal Support to the States - Provision by the Borrower to the Project States of technicalassistance and other support for:

(i) the training of health planners and other key officials employed by the Project States tostrengthen their health agencies; and

(ii) the preparation by the Project States of their three year rolling plans, annual implementationplans, and first phase sub-projects.

3.4 Revised Components:

Consequent to the agreements at the MTR on an expanded role for the FMHSS, Parts B and Cwere merged into one part as follows:

Part B: Support to the Federal Ministry of Health and Social Services

(1) Strengthening the HSF Project Implementation Unit (PIU) of the FMHSS's Department ofPlanning, Research and Statistics (DPRS) and Project States through provision of technicalassistance, vehicles and equipment, materials, incremental operating costs and training to: (a)appraise new State sub-projects, including the appraisal of equipment and maintenance needs ofsecondary health care facilities; (b) conduct two supervision visits per year to each of the ProjectStates; (c) conduct four zonal meetings per year for eligible States; (d) conduct annual reviewmeetings; (e) provide regular communication with Project States, and; (f) produce and distributeproject implementation libraries for the Project States.

(2) Strengthening the Planning Division of the DPRS and Project States through provision oftechnical assistance, vehicles and equipment, materials, operating costs and training to: (a) developand distribute guidelines for national and State health planning; (b) develop and distributemanagement manuals for Federal and State program managers, including a journal for healthplanning and management; (c) develop and distribute guidelines for monitoring and evaluation of

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State health plans; (d) conduct workshops for State health planners to use the planning, managementand monitoring guidelines, and; (e) on-site assistance to States to develop three-year health rollingplans and the annual implementation plans, including the development of annual work plans for HSFsub-projects, in collaboration with the PIU.

(3) Strengthening the Research and Statistics Division of the DPRS, through provision of technicalassistance, equipment, materials and operating costs to: (a) establish a national health managementinformation system (HMIS), including the appointment of an internationally recruited HMIS advisorand (b) sponsor key research in the following areas: (i) assessment of primary health care (PHC)financing, including public, private and household sources; (ii) a practical guide to efficient resourceallocation in the health sector; (iii) cost structure analysis for health care services at primary andsecondary health care facilities; (iv) an inventory of personnel, facilities and equipment, andorganizational structures of secondary health care institutions; (v) a descriptive study of privatehealth care practices and financing, and (vi) a pilot population-based survey to assess levels andtypes of mental illness in Nigeria.

3.5 Quality at Entry:NA

4. Achievement of Objective and Outputs

4.1 Outcome/achievement of objective.

Annex 1 includes the ratings, by component and by objective/outcome of the results achieved bythe individual states. Most ratings are "satisfactory". However, six of the 20 states achieved a highlysatisfactory rating for the preparation of state health plans and for staff training.

The over-arching project objective was improvement of the quality and efficiency of health servicesof participant States and LGA's. The financial mechanism adopted was the "wholesaling" of the loanproceeds to the PFIs, which would on-lend to the participating states. The interest rate spread wouldcontribute to the creation of a rolling fund to finance priority state projects. The main objective wasfinally eventually achieved because the International Bank for Reconstruction and Development (IBRD)and the Federal Government of Nigeria (FGN) agreed to redesign the project at mid-term, dropping theinitial financing approach.

The Loan. The FGN requested IBRD assistance in establishing a wholesale mechanism forfinancing improvements in state health systems in order to attain a more even distribution of sectorresources and thus serve a wider base of the population than possible in the past. The project, patterned onthe Infrastructure Development Fund (IDF) project (Loan 2925-UNI), was to utilize PFIs to appraise,supervise and co-finance state health subprojects and to assist the states in improving health systeminvestment planning. The Bank loan (US$70 million) provided a line of credit to FGN for financing thehealth subprojects in various states and their local government administrations (LGAs). Total project costswere estimated at US$94.5 million, of which state governments would finance US$13.5 million, PFIsUS$9.0 million, FGN US$0.7 million and a Japanese grant US$1.3 million. The proposed Bank loan ofUS$70 million was to cover 74% of the total required financing and 99% of total foreign exchange. Theproject consisted of three main activities: (i) line of credit for State health and family planning subprojects;(ii) assistance to the Federal Ministry of Health and Social Services; and (iii) training and technicalassistance support to the State Ministries of Health. The line-of-credit approach sought to respond quickly

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to small, relatively low cost projects, well within their capacity to implement, typically in the range ofUS$1 to 5 million, to be completed within 18 months for such activities as institutional development,improvement of existing PHC facilities - though not civil works for new facilities, an essential drugsprogram, and preparation for a follow-on project. Specific criteria were established for subprojectselection, appraisal and implementation.

The PFIs and the Fund. It was proposed that the PFIs help the States appraise priority projectsand participate in their financing, via on-lending of the IBRD loan. Part of the interest spread betweenprivate on-lending and the IBRD loan was to replenish the central bank account and contribute to newlending. The original premise that the PFIs would take the lead did not prove successful. Few PFIs hadskills in appraisal and experience in procurement of goods and civil works and implementation. Thesedeficiencies were recognized at appraisal. However, the operational difficulties of the PFIs branching outinto a new line of business and recruiting ad hoc expertise were not fully appreciated and the approach hadnot been field tested during the three years of preparation. In the end, only four states made sucharrangements, but there is no evidence as to the effectiveness of the arrangements. Some of the PFIs billedfor services rendered for which no supporting documentation could be produced and the expenditures weredeclared ineligible. On the one hand, the states found it difficult to put together viable projects, leading tothe PFIs' reluctance to take new staff on board in the absence of a pipeline. On the other hand, the highinterest rates put forward by PFIs caused the states to hesitate. Consequently, mutual distrust workedagainst partnerships. This innovative partnership with the private banks probably seemed feasible duringthe rapid expansion of the banking sector after the second oil boom. But by 1993 - two years aftereffectiveness - an internal Bank report identified serious problems in the sector due to weak portfolios,non-performing loans, foreign exchange difficulties and the overall decline in the economy. By 1994, thefour states working with the PFIs found difficulties in accessing their project funds and their bankstatements. This prompted a rapid re-appraisal in 1995 of the nine PFIs initially selected. The findingswere that the PFIs' head offices in Lagos had become almost skeleton operations in some cases, whilemost branches in major cities outside Lagos were nothing more than post boxes, neither able norauthorized to handle foreign exchange or project lending. By the time of the Mid-Term Review (1993) onlyUS$3 million of the US$70 million IBRD loan had been committed.

New Roles for States and FMHSS. The project was redesigned and the IBRD loan was reducedto US$54 million. Implementation now became the responsibility of the States, with success dependent onrapid enhancement of their capacity in the areas of appraisal, budgeting, financial management,procurement and local supervision and reporting. The Bank recognized that the new strategy's successwould depend on intensive capacity-building at the federal and state levels in key areas such as projectappraisal, budgeting, financial management, procurement and local supervision and reporting.Consequently, the Bank increased its supervision coefficient for the project, allocating both more RM andHQ time of staff with strong operational experience, in order to backstop the "implementation clinics"organized by the FMHSS. Addressing small, compatible groups of States, these clinics created theconditions for self-help networking to solve current problems. Additionally, the RM took a proactivestance, encouraging State PIU staff to "walk in" with their operational problems. By April 1996, there wasmuch improved assistance by the FMHSS to the States despite an increase in the number of participatingStates. By October 1997, procurement was seen as generally under control and the States were providingcounterpart funds for their sub-project on a more timely basis. By June 1998 financial management andcounterpart funding in all States had improved. The FMHSS, however, lost ground in terms of institutionalcapacity, due in large part to the frequent changes in senior staff. This was amply compensated for by thenew strength of the States in implementation which began to match the earlier devolution of power in thehealth sector from the federal to the state and LGA levels. The States now had overall responsibility, with

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delegation of PHC to the LGAs, while the FMHSS retained a role in national policy formulation andtechnical advisory services. Six additional states signed subsidiary loans - Benue, Enugu, Katsina, Kogi,Ondo, Osun in 1994 and three newly created states -Bayelsa, Ebonyi and Ekiti- joined the project in 1997,increasing coverage to 44% of Nigeria's 36 States. This was followed by a continued improvement inimplementation at the state level, particularly in the area of procurement.

The LGAs. The achievements in building State capacity were not mirrored at the LGA level forseveral reasons. To a large extent, state capacity building was and is a prerequisite for outreach to theLGAs. The outreach potential of the States toward LGAs was limited by their capacity, the large number(770) of LGAs and the difficult security and travel conditions, which also impinged on IBRD supervision* The LGAs and their PHC network had been starved of funds and there had been little occasion orincentive for them to be proactive. The strong grassroots organizations, such as the NGOs and women'scooperative movement, laid low during the military dictatorship, avoiding official circles.

The good news is that Nigeria's vibrant civic society is now reclaiming a more active role, withNGOs eager to participate in project planning at the State level, as they have done in the current processof preparation of the second Health Systems Loan.

Recurrent Costs. The new design required states to incorporate incremental recurrent costs intheir three-year rolling plans and annual budgets. Essentially, the burden of recurrent costs had beentransferred from the Health Fund to the individual state budgets. Initially, the states had two options forassuring counterpart funds - deduction at source from the quarterly Federal Statutory Warrants (federaltransfers to the states), or ad hoc allocations by the Secretaries to the State Government.

By 1997 twelve of the sixteen HSF states had opted for the first and more favorable option.Federal allocations to the states were continually delayed or paid only in part. The HSF states applied tothe newly established Petroleum Trust Fund (PTF) as a complementary source of counterpart financing.Only Akwa-Ibom State was successful. Unpredictable funding continued to plague implementation duringthe year of transition to civilian rule (June 1998 to May 1999). However, the inauguration of civiliangovermnent (mid-1999) resulted in immediate improvement in release of funds to 14 of the 16 states.Timely provision of counterpart funds remains a challenge and is identified as such in the state proposalssubmitted during preparation of HSF II. Actual budget allocations for both capital and recurrentexpenditures are still well below authorizations, with a disruptive effect on recurrent expenditures, andhence on crucial health services, as well as on state-funded capital projects with construction andprocurement interrupted and out of phase.

Access and Utilization. Achievement of the objective to expand access to health services wassatisfactory but utilization rates are more difficult to assess. Coverage of health care facilities expandedfaster than originally foreseen. By closing, all 16 of the HSF states (44% of all the states) had improvedaccess and utilization, including three states which had only been established in 1996. Primary health careservices are now available closer to home. Access is no longer a problem in the cities - with the exceptionof metropolitan Lagos - and distances are down to a range of 2 - 10 kms. Utilization has been difficult tomeasure because the monitoring systems at the grassroots designed to provide data for the new HealthManagement Information System (HMIS) only came on stream in 1998. Qualified observers documentincreased utilization in the two states where data collection has been in place longest - Bomo and Kwara.This has implications for HSF II since utilization rates of facilities/services are key to guiding futureinvestment.

Enhanced State Capacity for Planning. Achievement of the capacity building objectives is

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satisfactory. Good progress was made in developing planning capacity. States now have a reasonablyclear assessment of the incidence of disease through improved health statistics and a clearer grasp offinancing needs, as evidenced by the state proposals for HSF II. For example, one state graphs mostconvincingly the increase of malaria cases against the decline in the associated budgets. As the MIUSbecomes operational, planners will have much improved data.

Human Resource planning also improved. During the period 1993-98, the instability of the stategovernments and the frequent, often arbitrary dismissal or transfer of staff made systematic planning ofhuman resources difficult. However, the HSF annual work plans have highlighted the need for projection ofthe skill mix and associated recruitment, to meet attrition and expansion of services. The groundwork is inplace for annual updating of staffing needs which will become an integral part of the HMIS. A specificrelated objective was to improve the retention of newly trained staff in the areas of planning,pharmaceuticals and MIS where competition from the private sector is acute. Staff in all three fields whoreceived training/upgrading have so far been retained. However, paying salaries on time and maintainingcompetitive salaries and work conditions relative to the private sector will be essential to their continuity.

4.2 Outputs by components.

Health Fund. This component was not implemented beyond four states where it provedunsatisfactory. The retro-fitting of the project at the mid-term review placed the loan proceeds directly atthe disposition of the states, transferring the burden of recurrent cost financing, which the health fund wasto have financed, directly on the budgets of the individual states.

Primary Health Care (PHC) Facilities. The 1988 National Health Policy and Strategy spelledout the roles and functions of the local governnent authorities with regard to the provision andmaintenance of primary health services and environmental sanitation. The challenge was to meet the WHOobjective of I PHC center per 10,000 population. Shortly after loan effectiveness, a system of directfederal payments to LGAs was established. Originally, it was foreseen that States and the 452 LGAswould collaborate in preparing project proposals for PFI review, financing and implementation. After themid-term review, with the plan for the PFIs to provide technical assistance to the LGAs no longer on thetable, many states took back the responsibility for PHC, in the face of weak planning and implementationcapacity at the LGA level, and the results varied from state to state. The following states can be singledout for their performance: Enugu worked with all of its 17 LGAs; Ebonyi built a new center andrenovated another in each of its 11 LGAs: in the Delta, Rivers worked with 21 of its 23 LGA's and Bayelsabuilt! renovated 44 facilities/sites for 32 LGAs. Overall, a total of 204 PHC centers were assisted by theloan.

Secondary Health Care (SHC). This project component was rated satisfactory. Initially, theloan provided exclusively for strengthening PHC. By the mid-term review, states had been given theresponsibility for SHC. The loan agreement was amended to finance SHC facilities on the basis ofspecific operational guidelines. The National Health Policy commits each State to providing at least oneSHC facility in each LGA. Seven of the 16 states financed renovation of SHC facilities. Additionally,all States except Bayelsa completed construction and/or renovation of selected tertiary facilities - QualityAssurance Facilities and Health Training Schools (Annex 1).

All new and renovated PHC and SHC facilities were equipped, as were the tertiary facilities.Additionally, other facilities were re-equipped on the basis of need. The systematic programming ofmaintenance and repairs was introduced, with involvement of the local communities in security measures.

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State-specific facilities. Although outside the original scope of the project, these works meet thecriteria for increased quality of basic services as foreseen by the revised project. Some of the states hadurgent specific needs. For example, Lagos' maternal care facilities were under severe population pressureas were its trauma center and pharmaceutical testing laboratory. Ebonyi faces endemic sleeping sicknesswhile Ondo has a high leprosy case load. Given increased implementation capacity, these states were ableto draw down on the loan to expand or renovate relevant facilities.

Related Staff Training and Upgrading. Outputs of this component are rated as satisfactory.Despite the difficult climate of governance including arbitrary dismissals and transfers of personnel, andthe lack of any systematic state-level human resource planning, the HSF annual work programs provided auseful framework for analyzing staffing needs and implementing training. By 1996, training plans becamea standard feature of the annual work program. Training was conducted at the community, state andfederal levels (1203 trainees) and overseas (302 trainees). Priority at the state and community levels wasgiven to training the staff of new or renovated facilities and the staff of key state-wide services such asessential drug supply and the HMIS, either overseas or at the federal, state and community levels. Therewas a good deal of sharing of ideas and approaches between states. One example was training themembers of local theatrical groups to help get key health messages across to communities. Yet anothertrained health personnel in advocacy techniques to enable them to deal more effectively with localgovernment.

Capacity Building. The project had a significant impact on capacity building as demonstrated byprogress in six areas - reporting, annual work plans, implementation and supervision, preparation of statehealth plans, improved state health data bases, preparation of investment proposals for the proposed HSFII and in the area of audits. By 1994 participant States were successfully providing timely progressreports. By the end of 1996, all states but one (Akwa-Ibom which was suspended for financialmismanagement) presented annual work plans in time for the annual project review, with good overallquality. The capacity of the state PIUs in implementation, procurement and supervision had significantlyimproved by 1998 due to implementation clinics convened by the FMNHSS, direct TA by IBRD andincreased retention of key staff. The collection of standardized health data in line with HMISspecifications improved significantly. By 1998 all audits were received on schedule and outstanding auditscompleted.

Capacity building was most successful at the federal level in the areas of implementation and theHMIS. The FMHSS ran workshops on implementation which helped the PIUs become operational and by1995, the FMHSS's capacity to manage the HMIS and to provide technical assistance to the sixparticipating pilot states had been significantly strengthened. As a result, standardized and computerizeddata collection formats were designed and tested at the state level, and LGA, and private health careproviders were trained in the collection and processing of key HMIS data. Additionally, states updatedand published disease status information which had been unavailable for some time. The implementation ofthe HMIS also enabled half of the states to develop State Health Profiles which provided importantcontextual information for the HFS II investment proposals. Less successful were the FMHSS's efforts todevelop capacity for supervising/monitoring the state work programs and a capacity in research. In termsof supervision, the FMHSS was hampered by the lack of counterpart funding, by staffing problems and tosome degree by the increasing independence of the states which resented the FMIHSS looking over theirshoulders. Finally, only 10 % of the research agenda was implemented. The quality of the products is notclear.

Essential Drugs. All states except one (Kogi) adopted essential drugs policies while all statesestablished essential drugs lists, with provision for regular updating. Success was largely due to the

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cooperation between the State Pharmaceutical Officers who established a mutual support network,particularly helpful to the newer participant states. Initially, under the aegis of the National EssentialDrugs Loan, the FMHSS had been expected to be a source of technical assistance in this area but it did notdevelop the necessary outreach capacity and finally the Federal component of this Loan was canceled. Theestablishment of new state essential drug funds and the re-vitalization of existing funds proved much morechallenging. The National Essential Drugs Loan which had financed the states' purchase of essential drugsclosed in 1997. Also, the LGAs now became responsible for the purchase, storage, distribution andpricing of drugs for the PHC centers. Some worked with state funds while others participated in theUNICEF-funded Bamako Initiative. Finally, the Petroleum Trust Fund began to bypass the state funds bydirectly purchasing and distributing drugs, albeit with little planning, resulting in the delivery of quantitiesin excess of demand, creating storage problems, or in qualities and types which did not meet therequirements of the essential drugs list. Consequently, developing effective procurement, distribution andpricing policies for essential drugs at the state level, remains a task for the proposed HSF II.

4.3 Net Present Value/Economic rate of return.N/A

4.4 Financial rate of return:N/A

4.5 Institutional development impact:

The HSF Loan had significant institutional development impact.

Community impact. The project had marked impact on the mindset of beneficiary communities.In addition to their appreciation of the Government's provision of accessible and adequate PHC services,communities took on more responsibility for security of facilities and equipment and for oversight offinancial aspects.

State impact. The State's significantly developed their capacity to plan, implement, manage andmonitor public health services at the state and LGA levels. The technical capacity of the states wasgreatly strengthened in the areas of HMIS, health planning, management of pharmaceutical Supplies and inresearch.

FMHSS impact. The FMHSS developed an increased technical capacity in HMIS and benefitedfrom in-service training. However, the frequent changes in leadership (five ministers during the projectperiod) and related changes at the director level meant that training/upgrading did not achieve its fullimpact since staff were frequently re-assigned or inappropriately placed.

5. Major Factors Affecting Implementation and Outcome

5.1 Factors outside the control of government or implementing agency:

Political Instability. The disruptive and unstable political environment, substantially andnegatively affected all stages of the project at both the State and Federal level. The military regime,launched in 1988 under Head of State Babaginda, gave way in 1991-1992 to civilian government at Statelevel with Senate and House of Representatives in place at the national level, but the military heads ofstates remained. The June 12th annulment of the 1993 Presidential elections led to six months of civil strifein many parts of Nigeria. An interim civilian Head of State, Sonekan, took office August 1993, and was

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toppled by General Abacha who led a military regime from November 1993 until his death June 1998.During this time, state military administrators were changed every 18 months. There was also areoccurrence of civil strife in the Southwest of Nigeria following the death in July 1998 of Abiola, winnerof the 1993 election. Project implementation activities ground to a halt during such periods of politicalinstability and physical danger to citizens. Moreover, the international technical assistance identifiedduring appraisal as an important element in implementation became unavailable as firms closed theirNigerian branches and ceased to do business in the country.

5.2 Factors generally subject to government control:

Macroeconomic factors. Frequent changes in the exchange rate and the policy of "official" ratesand controls favored selected individuals and firms and affected the performance of suppliers andcontractors. Many of these suppliers and contractors went bankrupt having become dependent on importedinputs, which were subject to frequent price adjustments. The serious deterioration of the financial sectorultimately eliminated the role of the PFls while continuing to impact negatively on project accounts.

Administrative governance. Frequent changes in the military administration and in state healthcommissions had adverse effects on the continuity of state PIU staff. This serious problem was corrected in1995 when the Federal Ministry of Finance (FMF) decided that staff changes in future would requireclearance from both the Minister of Finance and the Bank, thus ensuring increased stabilization of thePIUs for the remaining years of implementation.

5.3 Factors generally subject to implementing agency control:

Bureaucratic procedural requirements. The cumbersome multi-level clearances required by thestate health ministries delayed implementation, particularly during the first six years. These bureaucraticobstacles diminished over time as the PIUs developed more managerial capacity and as a result ofpersistent follow-up by Bank missions at the level of the military administrators and state commissioners.

Procurement Capacity. The fact that neither the States nor the FMHSS/PIU had any previousexperience with regard to Bank procurement procedures was a substantial obstacle to implementation.Similarly, the states lacked experience in project identification and preparation. The implementation clinicsand Bank technical assistance solved these problems.

Financial Management. Initially, there was no capacity in financial management at the state andfederal levels. This problem was alleviated through training and the assistance of the resident missionfinancial management specialist. As soon as state PIUs acquired basic computer skills, a tailor-madesoftware was developed to enable their financial officers to effectively monitor the loan and counterpartfunds. The financial officers also received short term training overseas. Capacity remained an obstacle atthe federal level. The FMHSS/PIU, although only managing two loan categories, did not developcomparable competence, nor did the FMF maintain accurate records of the unallocated funds.

5.4 Costs andfinancing:

The total cost was projected as US$94.50 million at appraisal. It was planned that the Bank wouldfinance US$70.00 million, the State Governments US$13.50 million, the PFI's US$9.00 million, theFederal Government US$0.7 million and the Japanese Grant facility US$1.30 million. However, both thetotal projected cost and the financing plan changed early into implementation. States were unwilling toborrow from the PFIs due to their high interest rates and due to their lack of capacity to appraise projects.At re-structuring projected costs were re-estimated at US$68.8 million, with the Bank's loan amount set atUS$ 54.00 million. At Loan closure the total project cost was estimated at US$74.77 of which the Bank

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financed US$52.76 million, the States and the Federal Government US$20.71 million and the JapaneseGrant US$1.30. In the period CY 1994 through second quarter 1996, quarterly disbursements averagedUS$ 0.5 million; from the third quarter 1996 through 1997, US$ 1.6 millions and through the first twoquarters of 1998, US $ 2.35 millions. The 97 percent disbursement (est. US$ 52.4 million) achieved by thethird quarter of FY 2000 reversed a disbursement lag which had stood -at 89 per cent at the time of themid-term review.

6. Sustainability

6.1 Rationale for sustainability rating:

The sustainability of the project is rated as "likely" on the basis of the following rationale:

Government commitment During the year of transition to civilian rule, all the 16 HSF Stateteams were specifically consulted by the government-elect as to the recurrent budget requirements forsustaining activities assisted by the loan. All 36 governors-elect have now confirmed their intention toparticipate in a follow-on project, aiming at national coverage.

Policy environment. The Federal government's emphasis on poverty alleviation and investment inthe social sectors, the first visit in 10 years by a Minister of Health of Nigeria to the World Bank inFebruary 2000, together with the recent formal passage of the federal government's anti-corruption bill bythe legislature are important indicators of the continued improvement in the policy and governanceenvironment.

Institutional and management effectiveness. Sixteen (44 %) of the 36 States of Nigeria nowhave a core team of technically sound, well trained and motivated health professionals, with competency inplanning and management of basic health services at State and local community level and experience inproviding technical assistance to neighboring States. At the Federal level the national HMIS program iswell established and well managed. In October 1999 the FMHSS convened its first consultation with otherhealth care providers and development partners to discuss the main sectoral reform issues to be tackled.

Social Impact and participation. The steps taken by the state teams to ensure a community senseof responsibility for the newly accessible health services and facilities will be an important factor inensuring sustained accountability by the LGA's and SMOH for the maintenance of such services.

A persistent issue is that of recurrent funding. In the event of a follow-up project it will beimportant to make firm arrangements, reflected in the Credit Agreement, relative to the timely provision ofcounterpart funds as agreed by IBRD and the borrower states. To the extent possible, availability of thesefunds should be an annual trigger for IBRD disbursements or as a trigger for proceeding with the next"tranche" of procurement since works and goods would likely be phased in a project of national scope.

6.2 Transition arrangement to regular operations:

Given the most recent transition to civilian rule and the long term efforts require to reverse theeffects of the past decades of economic and political instability, the Federal and State Governments haverecognised that the most effective way to ensure the mainstreaming of the programs and capacitiesstrengthened with the assistance of HSF I is for all States to participate in a second program of comparableassistance. For the HSF I States, with their State Health Plans and results of their Phase 2 studies, initialpreparatory discussions were held June 1999, and HSF Phase 2 Preparatory activities involving the

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participation of all States and FMHSS began January 2000, shortly after Loan closure.

7. Bank and Borrower Performance

Bank7.1 Lending:

Given the innovative nature of the proposed HSF financial mechanism, and the complexity of theenvisaged coordination between the PFI's, the Central Bank, the State and Federal Ministries, and theprivate sector consulting resources, the Bank played a leading role in guiding project preparation andappraisal. During the first identification mission, consultations were held with all the concerned financialand consulting agencies and the FMHSS. The three subsequent missions helped thirteen of the 20 Statesdevelopment their sub-projects. The Bank also carried out a detailed assessment of the banking sectorduring preparation to determine the feasibility of involving the private sector.The range of technical skills,mix and continuity of the Bank team were generally appropriate. However, the presence of a healthspecialist with skills in M&E would have been desirable in retrospect.

7.2 Supervision:

Early missions in the period 1992-94 were clearly not adequately nor consistently staffed with therequired range of technical and operational skills. Nor was the Resident Mission able to provide adequateprocurement and financial management advice at that time. The latter would perhaps have permittedearlier identification of the rapid structural and financial deterioration of the PFIs. From 1995 onwards, allmissions included the full range of technical skills required and the Resident Mission was strengthened inthe areas of physical implementation,procurement and fnancial management. Also, decision-making waslargely decentralized. The period of proactive supervision, also began at this point. Annual reviewsconducted by HQ staff, encompassing all states over a period of up to three months, were backstopped byad hoc, "on call" missions by field staff who also held "on demand" implementation clinics. Thissupervision approach, though successful, was expensive in staff time and budget, while security and travelconditions placed great stress on staff. This was also a period in which supervision was hampered byinadequate access to reliable and timely pouch and electronic mail. Finally, the excessive demand on thetime of disbursement staff should be recognized. The loan included 94 expenditure categories, specialaccounts were frequently blocked by banks or by officials and cases of financial mismanagement had to beinvestigated (Akwa-Ibom).

7.3 Overall Bank performance:

The Bank's overall performance was satisfactory although uneven. Supervision can be rated highlysatisfactory from 1995 onward.

Borrower7.4 Preparation:

The performance of the Borrower at all levels and with all agencies was satisfactory duringpreparation. The FGN was fully committed to minimizing the social costs of recent macroeconomicmeasures by supporting the preparation of the HSF as additional to the National Essential Drugs Projectand the National Population Project. Thirteen of twenty states participated actively in the three workshopson the preparation of project proposals.

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7.5 Government implementation performance.

Throughout implementation both at the Federal and State levels, the project was plagued bypolitical instability and governance problems. The frequent changes at the federal ministerial level alsoresulted in lack of consistency in sectoral policy and dialogue. At the state level, the frequent changes inmilitary administrators and health commissioners led to interference with the agreed practices andprocedures with regard to procurement, consultancies and the use of vehicles and equipment. It is notablethat HFS state PIUs consistently rate political interference in the procurement process and arbitrary staffpolicies as major factors hindering implementation. However, as noted above (capacity building), the PIUsgradually gained in competence, to the point of executing their responsibilities in a timely and satisfactorymanner. The PlUs also became better integrated in their ministries and developed sound working relationswith the key services of the ministries, avoiding the isolation and jealousies which have sometimescharacterized "PIUs."

7.6 Implementing Agency:

In the early years of the Loan, the FMHSS was most successful in the area of provision of supportfor the states in implementation and after 1995 in the development of the HMIS and development of StateHealth Plans. The FMHSS ran workshops on implementation which helped the PIUs become operational.By 1995, the FMHSS's capacity to manage the HMIS and to provide technical assistance to the sixparticipating pilot states had been significantly strengthened. As a result, standardised and computeriseddata collection formats were designed and tested at the state level and state, LGA, and private health careproviders were trained in the collection and processing of key HMIS data. Consequently, states were ableto update and publish disease status information which had been unavailable for some time. In 1996-1998the FMHSS assisted the states to develop their State Health Plans. Progressively, however, the statesassumed the responsibility for implementation. This is the most positive feature of the Borrower'sperformance. None of the HSF States had borrowed from the Bank for health before. Nonetheless, theydemonstrated a rapid learning curve in response to Bank technical assistance and training. By 1997 theirPIUs had mainly become proficient in procurement of works, goods and services and the state planningdepartments were generating annual plans and timely progress reports.

7.7 Overall Borrower performance:

Like the Bank's performance, the Borrower's performance was uneven but satisfactory despite avery difficult implementation climate. The momentous political events of the decade directly impacted notonly implementation and the govemance of all the agencies involved but also the livelihood and physicalsecurity of their staff.

8. Lessons Learned

Restructuring

* Working closely with the client was an essential ingredient in successful restructuring. The IDA teamspent up to three months in the field, holding implementation clinics for the state PIU staff and theResident Mission operated a walk-in trouble-shooting service in areas such as procurement andfinancial management.

* The development of self-help support networks between, for example, the more experienced and lessexperienced PIUs can be an effective method of capacity-building.

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* Strengthening the Resident Mission through the appointment of well-qualified sector and procurementspecialists who were able to organize implementation clinics and provide clearance on procurementand financial matters greatly facilitated implementation.

Supervision

* In the context of an eventual follow-on project, possibly broader in scope, the supervisionarrangements adopted by IDA would likely require new approaches, given Bank budget constraints.A possible strategy would be to contract local firms to train and deploy supervision support teams -sector specialists, architects/engineers, accountants, quantity surveyors - to provide technicalassistance to the state PIUs and to carry out site supervision.

Project Design

* Operationally complex arrangements, such as those for retailing project financing through the PFIsshould be field-tested. This would have been possible during the two years of project preparation withPPF or grant financing.

* It is important to design and implement monitoring and evaluation early and to ensure that measurableindicators are established and that staff are trained in data collection procedures. These issues weretackled only in the last two years of the project.

* Where significant expansion of physical infrastructure for health service coverage is planned, areliable "health map" or an adhoc survey is indispensable for appraising investment. Coverage shouldinclude, inter alia: existing facilities to be renovated/repaired, proposed sites for new facilities, publicutility availability, location relative to target populations clients and the relative location of privatesector facilities.

9. Partner Comments

(a) Borrower/implementing agency:

The main conclusions of the ICR have been discussed with the Federal Minister of Health who hasconfirmned his agreement for us to proceed on that basis. Each of the participant states provided their ownevaluation reports on the implementation of HSF and have already incorporated the "lessons learned" at thestate level in their draft PCDs for the second Health Systems loan which have already been reviewed by theBank.

(b) Cofinanciers:

A copy of the draft ICR was sent to the Government of Japan for their review.

(c) Other partners (NGOs/private sector):

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10. Additional Information

Studies Included/Undertaken by the Proiect

S/N State Study Purpose of Study Status1. Akwa-lbom Implementing the Minimum Local Government To achieve implementation of the Completed

Health for all package (1997-2005) PHC programmes

2. Bavelsa Prototype State Health Plan To develop a health plan motivating Completedthe LGAs to think along the samelines

3. Implementing the Minimum Local Government To improve health plan status CompletedHealth for all package (1997-2005)

4. Benue Implementing the Minimum Local Government Discussions aimed to improve health CompletedArea Health for all Package plans status

5. Development of Local Government Health Plans To develop appropriate health Completedfor: packages for local governmentsGboko; Agatu; Ado; Vandeikya; Ushongo; Ukum;Tarkar;Okpokwu; Otukpo; Oju; Ohimini; Ogbadibo; Obi;Makurdi; Apa; Katsina-Ala; Gwer; Gwer-West;Guma; Buruku; Logo; Kwande; Konshisha (June1999)

6. Health Human Resource Survey Reports for the To determine and obtain manpower Completed20 LGAs: Public & Private: Production, Training, distribution and training needs perDistribution & Utilization facility(March, 1999)

7. Health Profile (November 1997) To attain the diseases profile of the CompletedState

8. Borno Health Plan of Action for Implementing the To harmonize roles and activities to CompletedMinimum Local Government Area for all package achieve implementation of the PHC(1997-2005) programmes

9. Ebonvi Prototype of State Health Plan To obtain implementation of health Completed(1997-2005) plan

10. Study On Essential Drugs To detect problems in DRF Completedsustainability

I. Ekiti Health Information Digest (Ist edition, Vol. 1, To serve as information about Health Completed1998) Institutions at both levels

12. Enu2u Survey of Health Facilities to Receive HSF Drugs To determine the readiness of the Completedand Medical Equipment designated facilities

13. Kaduna Prototype State Health Plan To obtain statistics planning of health Completed(1997-2005) services

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S/N State Study Purpose of Study Status14. Kaduna(cont) Implementing the Minimum Local To improve health plans status Completed

Government Health for all package(1997-2005)

15. Integrating and Strengthening Kaduna State To establish a national health CompletedHealth Management Information System information system by governments of

the Federation

16. Katsina Health Profile (1992-1996) To obtain statistics planning of health Completedservices

17. Health Profile (1997-2005) To obtain statistics planning of health Completedservices

18. Prototype State Health Plan To improve health plan status Completed(1997-2005

19. Implementing the Minimum Local CompletedGovernment Area Health for all package(1997-2005)

20. Kot-i Health Statistical Bulletin (1992-1997) To stimulate improvement of health Completedplan

21. Implementing the Minimum Local Workplan to strengthen the CompletedGovernment Health for all package implementation of PHC(1997-2005)

22. Kwara Inventory of health Institutions & Personnel To determine and obtain manpower Completeddistribution and training needs perfacility

23. Health Manpower Survey To determine areas requiring skill and Completedequipment procurement

24. Survey of Health Facilities To obtain inventory of health Completed(September 1995) facilities, equipment and health

manpower resources

25. Strengthening of the schools Of Nursing and To design health care system: skills CompletedSchool of health technology and health service improvement

26. Annual Health Statistical Bulletin Completed(1998-1992) andHealth Statistical Bulletin (1993-1996)

27. Study on Problems of the Handicapped and Completedthe Nomadic

28. Lagos Survey of Schools of health Services in Lagos To obtain inventory of schools of CompletedState: Public/Private health facilities in the state

29. Comprehensive health Manpower/Facility To obtain inventory of health facilities CompletedSurvey in Public/Private health facilities in to determine what is available andLagos State obtainable

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SiN State Study Purpose of Study Status30. Lagos( cont) Medical Equipment Survey of 23 Selected To provide baseline data to determine Completed

health care Facilities in Lagos State equipment requirements

31. Established Functions and Complementary To determine equipment requirements CompletedEquipment Required in 23 Selected health in the selected facilities forcare facilities in Lagos State procurement under the project

32. Review of Existing Primary Health Care To establish priority renovations to be Completedfacilities in Lagos State for carried out under the projectRenovation/Rehabilitation/Completion

33. Comprehensive Survey Of Drugs Sources & To determine affordability of drugs CompletedDistribution in Lagos and track sources of fake drugs

34. Preparation of Operational Workplan for For the design of a Management CompletedImplementing the National Health Information SystemManagement Information System in LagosState

35. Establishment of A WHO medium Size Drug To provide documentation for the CompletedQuality Control Laboratory establishment of a public health

laboratory

36. Prototype State Health Plan To obtain statistics planning of health Completed(1997-2005) services

37. Implementing the Minimum LocalGovernment Area Health for all package To improve health status Completed

38. Ondo Health Statistical Bulletin (1997) To stimulate improvement of health Completedplans

39. Implementing the Minimum Local To improve health status CompletedGovernment Area Health for all Package

40. Prototype State Health Plan To obtain statistics planning of health Completed(1997-2005) services

41. Osun Osun Health Bulletin, draft Draft(1991-1998)

42. Health manpower Survey of Public/private To obtain inventory of health Completedhealth Institutions facilities, equipment to determine(March 1999) what is available and obtainableEquipment Survey and specifications for 22Secondary health care facilities (March 1999)

43. Training Needs Assessment for health Skills and Health service CompletedWorkers and Health Training Institutions improvement

44. Geo-Physical Survey of 6 Zonal Hospitals for Completeda sinking of Boreholes To provide the data for the

I construction of boreholes

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S/N State Study Purpose of Study Status45. Osun (cont.) Prototype State Health Plan (1997-2005) To obtain statistics planning of health Completed

services

46. OYO Implementing the Minimum Local To improve health plan status CompletedGovernment Area Health for all package

47. Detailed Cost Analysis Of Selected health To determine cost of the inputs CompletedFacilities Oyo (September 1996)

48. Issues and Options for health Care Financing To provide requisite data to develop Completedin Oyo State guidelines to determine appropriate(November 1996) fees to be charged at government

facilities

49. Inventory & health facilities and mapping In To obtain inventory CompletedOyo State of facilities(November 1996)

50. Deployment of Health personnel in Oyo State To know what types of personnel are Completedhealth Facilities required by cadre

51. Prototype State Health Plan To obtain statistics planning of health Completed(1997-2005) services

52. Rivers Implementing the Minimum Local To improve health plan status CompletedGovernment Health for all package

53. Prototype State Health Plan To obtain statistics planning of health Completed(1997-2005) services

54. State Health Plan To improve health services Completed

55. Integrating and Strengthening Rivers State To establish a national health CompletedHealth Management Information System information system by govemments of

the Federation56. Rivers State Health Bulletin Completed

(1988-1992)

57. Rivers State Health Profile Completed(1993-1996)

58. Baseline/Needs Assessment Survey on Health To obtain requisite data CompletedFacilities, Manpower and Equipment

59. Administrative Management Problems in six Completedselected Secondary Facilities in Rivers State

60. Knowledge Attitude Practice of FP by To establish the level of immunization Completedmothers attending immunization centers in coverage and awarenessPort-Harcourt

61. AIDS incidence and trend in Rivers State To determine approximate prevalence Completedwith Special reference to Screening Center rate and use of screening centers

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S/N State Study Purpose of Study Status

62. Rivers(cont.) Three year study on Trend on Non CompletedCommunicable Diseases in three selectedHealth Facilities in Port-Harcourt(1999)

63. Other States Prototype State Health Plan To obtain statistics planning of health Completed(1997-2005) services

Abia64. Prototype State Health Plan To obtain statistics planning of health Completed

(1997-2005) servicesAdamawa

65. Prototype State Health Plan To obtain statistics planning of health Completed(1997-2005) services

Anambra66. Prototype State Health Plan (1997-2005) To improve health plan status Completed

Cross River67. Implementing the Minimum Local Completed

Government Health for all packageEdo (1997-2005)

68. Integrating and Straightening Edo State To establish a national health CompletedHealth Management Information System information system by governments of

the Federation

69. Prototype State Health Plan To obtain statistics planning of health Completed(1997-2005) services

Yobe70. Integrating and Strengthening Yobe State To establish a national health Completed

Health Management Information System information system by govemments ofthe Federation

71. Prototype State Health Plan To obtain statistics planning of health Completed(1997-2005) services

Zamfara72. Nigeria Country Plan of Action for Completed

implementing Minimum District Health forFederal all package (1995-2000)

73. Inventory of Health Research & Workers in To obtain inventory of research and Completedthe Universities, Medical Research Institute medical schools manpower& Centre of Excellence (March 1996)

74. National Health Management Information To revise NHMIS forms CompletedSystem (NHMS)

75. NHMS-Forms Instruction and Operational CompletedReference Ma'nual (June 1997)

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S/N Study Purpose of Study Status

76. Policy, Programme, Strategic Plan of Action To obtain new health data information Completedsystem

77. Health in Nigeria 1994-1995 To report on the state health services Completed(June 1996) and population health

78. Handbook of Planning and Managerial To expand discussion of health CompletedProcess for National Health Development planning

79. Handbook on Monitoring and Evaluation of To help monitoring and controlling of CompletedHealth Development Programmes and health plansProjects (April 1997)

80. Accounting System for DRF Scheme in all To effective implementation of the CompletedHSF Participating States DRF scheme(April 1997

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Annex 1. Key Performance Indicators/Log Frame Matrix

Outcome / Impact Indicators:

Indlcatolat$ ;r*Ject~t 0 Iin0|u007 0 7 0 t.ti PR AMt stlmateObjective ia)Establishment and financing ofan Health System Fund.( HSF)

-Incorporation of post-project recurrent costs -3/16 States (Katsina, Kwara, and Lagos) by -9/16 States historical Health Sector Budgetin States 3 year Rolling Plan. 12/98, have already provided for post -project allocation data, as % of total State budget.(

recurrent costs in their respective Rolling 9498) and as an indicator of managementPlans. All 16 State HSF Loan Teams had capacity for recurrent cost coverage is nowbeen consulted on this issue by their State available. Ondo and Lagos are stable ranging'Transition Teams" prior to the 6/99 6.6%-9.3% and 5.6- 7.3% respectively;

handover to civilian rule. Kwara uniquely consistently above 10%ranging 13.7-21.0%;all others eitherdeclining to below 10% or changes range3-15%. Two States only received 100% ofallocation (Ebonyi and Lagos) all othersreceived 20-60% of the allocated funds

Objective ib) Improve the quality andefficiency of Health Services of participantStates and local governments(LGA's).

-Documented new/increased user rates of -Only 2/16 States have documented Increased accessibility to health care;the health services of such facilities. utilization of completed site-specific distance for user population now ranges from

facilities;todate(Borno PHC's utilization less than 2km to 1 Okms (Oyo andincrease ranges 16-60%; Kwara SHC's Akwa-lbom)increase 40-80%)

Objective iia) Strengthen capacity ofparticipant States to plan, carry out,monitorand evaluate their PH programs.

-Retention of Trained staff in Health -all trained staff retained to date; in light of -the previous 20 years has witnessed thePlanning/Pharmaceutical/HMIS. the 3/99 minimum wage increase, the 6/99 collapse of Nigeria's management of training

civilian State govemments management of and deployment of all levels/cadres of HealthBudget % allocations to Health Sector, will be Care professionals. Oyo and Bomo Statesone determining factor of trained staff are the exception with 200+Medicalremaining in the public sector health Practitioners and 30+ Pharmacists(Privateservices. and Public); majority of remaining States

have less then 50 General Practitioners andless than 20 Pharmacists;only 2/16 todate have qualifiedEpidemiologists. All States overwhelminglydepend on various nursing cadres tomaintain health services.

-State Plans for Training/ -The 9/16 HSF State Health Plans (plus 7/20 -The State Health Plans provide theRetraining required Health personnel. non HSF States) & 10/16 States Phase Two framework for addressing the status of

studies now provide a robust information heafth service staffing noted above, and nowbase for SMOH's to adopt formal need to be presented and formally approvedRecruitment/Career development HR Plans by civilian State Assembly

Objective iib) Strengthen the institutional andfinancial capacity of the participant States.

-Retention of State support for improvedprograms in HMIS, Health Planning, -All incoming State Govemors-elect and -16/16 States have signalled their strongResearch and EDP. State Health Commissioners confirmed their intention to continue to support HMIS, Health

intention to continue support for the Planning, Research and EDP through formalstrengthened State capacity in these 4 confirmation of their participation in the HS2domaines at 6/99 Seminar. at the 10/99 National Council of Health.

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Output Indicators:

I~~~~~~~~~~~~Poce _ t'" Is,P.-tPSR,= ,.Objective ia) Establishment and financing ofan Heaflth System Fund.

-Adequate, regular provision of counterpart -the % of counterpart funds received -imrmediate improvement following June 99Funds for States HeaHth Services/HSF. todate(6/99) ranged from FMHSS 5% only, handover to civilian administration ranging

to 9/16 States at less than 50%,with 2 over from 5 States at 1 000h-4 others above 50%,90%. Duing the year of transition to civilian but still 2 below 20%.rule, FY99, Benue, Ebonyi, Kogi and LagosStates Loan assisted activities wereparticularly slowed by the delay incounterpart fund provision.

Objective ib) Improve the quality andefficiency of Health Services in participantStates and LGA's.

-Number of renovatedlextendedlupgraded -149 PHC facilities/sites -Completion of 55 outstanding works giving aconstructed Primary Health Care Facility (13/16 States to complete outstanding works total of 204 PHC facilities/sitessites (PHC) 12/99)

-Number of renovated/ extended/upgraded -9 CMS, 2Public Health Labs, 2 Drug Quality -outstanding works completed: adding 1constructed Secondary Health Care Facility Control Labs, 51 Hospitals/SHC's, 8 State Drug Quality Control Labs,sites (SHC's). Training Schools, 3 HMIS Units, 1 Medical 14 Hospitals, 1 HMIS Unit and 5 Boreholes

Equipment Maintenance Workshop. Three to 6/99 totalSMOH,2 PIU's, 35 Boreholes (for PHC/SHCfacilities), 32 Generators/Connection toNational Grid.

-As of 6/99 these have included completion-Range and category of Location-specific of Upgrading Matemity -as per 6/99.needs. Hospital/establishment of Trauma

Emergency Centrel Drug Quality Control Lab(Lagos State); X-Ray Theatre & Isolationward for TB/Leprosy Referral Centre (Ondo State);Health Centres to provide full range(curative & preventive) of services, due tophysical riverine isolation of large deltapopulations (Bayelsa State)"sleepingsickness" wards (Ebonyi State); PublicHealth Labs (Kogi and Lagos)

-All 225 PHC/SHC Health facilitiescompleted todate, comissioned and in use.

-Number of PHC/SHC Facilities re-equipped, An additional 104 PHC/SHC Faclities have -55 outstanding facities/ sites commissionedcommissioned and in use. been equipped, partially re- equipped. 12/99; equipment distribution

continued-4/2000.-10,600 staff received new/upgrading

-Number/categories of staff from/for such training through workshops, seminars etcfacilities received upgrading training. (LGA councillors, LGA/PHC Coordinators, -as per 6/99

Pharmacy Techni-ians,HMIS Officers,General Practitioners, Paramedics, Nurses,Environmental Health officers, TBA's) withlocal communities and NGOs.

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Objective iia) Strengthen the capacity ofparticipant States to plan, carry out, monitorand evaluate their PH programs.

-Timely completion of Annual Progress -As of 12/95, all participant States have -as per 6/99Reports. provided timely Annual Progress reports

-Timely formulation of realistic coherent -As of 12/96, all participant States have -as per 6/99Calendar- Year Workplans/Budgets provided realistic coherent Calendar-Year

Workplans/Budgets.

-Formulation of State/LGA Plans. -9/16 State Health Plans and 1/16 -as per 6/99completed LGA Health Plans (Benue)

-Formulation of State Essential Drug Policy -15/16 have EDP's (Kogi); 16/16 have EDL's; -as per 6/99(EDP) & Essential Drug List(EDL). 5/16 already reviewed EDL's.

-EDP & EDL formal statutory approval by -14/16 formally approved. -as per 6/99State Executive Council

-Establishment/upgrading of Essential Drugs -16/16 have one/combination DRFs; -as per 6/99Revolving Fund.

-Establishment/upgrading of State/Federal -16/16 have HMIS (8/16 established since -as per 6/99Health Management Information System '97)(HMIS).

-No/Categories of Staff trained/upgraded to -312 staff completed Overseas Training, -as per 6/99-ensure maintenance of these activities by 1203 completed NationaV State level skillsStates and FMHSS. training: all State HSF/PIU stafft candidates

from each of the SMOH departments; othersectoral ministries implicated inHSF(Finance, Public Works, Justice). HMIStechnical capacty strengthened with FMHSSand broad but unsystematic inservice trainingfor members of PIU and staff of otherFMHSS departments

-Specification/completion of Phase 2 studies. -9/16 completed Phase 2 Studies. - 10/16 completed Phase 2 Studies

-% Completion of Annual Work Plan.-(96-98)15/16 completed(Akwa-lbom); as of - as per 6/9998, Workplans 100% completed by midyear

-% Completion of respective activitles of -Facilities renewaV equipping,and staffAnnual Work Plan. training and HMIS 100% completed; Phase 2 - as per 6/99

studies 62% completion.

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Objective iib) strengthen the institutional andfinancial capacity of the participant States.

-Maintenance of regular quality supervisionamd monioring visits to HSF participant -(94-97) biannual monitoring State visits -as per 6/99States by FMHSS/PIU. were completed by FMHSS/PIU.

Discontinued thereafter due to lack of fundsand capacity.

-Implementation Clinics and Pre Annual -(94-97) Clinics and prep workshopsReview preparatory workshops convened by organised by FMHSS; thereafter States did -as per 6/99FMHSS/PIU not need prep workshops and specific needsas appropriate. based clinics organised by IBRD

in Abuja.-Timely coherent realistic Anuual Workplan -Timely Annual Workplansfrom FMHSS/PIU including all Components (i.e. by Dec of preceding year) was never -as per 6/99for State outreach from Research/Health achieved. Coherence and realism achievedPlanning/ HMIS. after several revisions.

-% Completion of such Workplans. -(97-98) Health Planning & (97-99) HMISwere 100%; -as per 6/99Research never exceeded 10%.

-Timely provision of all State and -by 6/98 for the first time all Audits wereFMHSS/PIU Audits. received on schedule, and two outstanding -by 6/30/2000,17/17 Audits received

Audits completed. 6/99 Five months civilservants strike/transition to civiliangovemment delayed finalization of 10 StateAudits.

-Provision of EDP/TA on matching funds -Not achievedbasis with States. (Calendar 97 onwards) -as per 6/99

End of project

- 25 -

Federal Ministry of Health

Objective ii a)Strengthen capacity of participant States to plan, carry out,monitor and evaluate their PH programsOutputs SFormulation of State / LGA PlansFormulation of State Essential Drug Policy (EDP) and USEssential Drug List (EDL)Establishment / upgrading of State / Federal Health HSManagement Information SystemNo / Categories of Staff trained / upgraded to insure Smaintenance of these activities

Objective ii b)Strengthen the institutional and financial capacity of theparticipant statesOutputs LSMaintenance of regular quality supervisionamd monitoring visits to HSF participant States byFMHSS/PIU.

Implementation Clinics and Pre Annual Review preparatory LSworkshops convened by FMHSS/PIUas appropriate.

Timely coherent realistic Annual Work plan from USFMHSS/PIU including all Components for State outreachfrom Research/Health Planning/ HMIS.

% Completion of such Work plans. LS

Timely provision of all State and FMHSS/PIU Audits. S

Provision of EDP/TA on matching funds basis with States. US(Calendar 97 onwards)

Code: US - UnsatisfactoryLS - Less Satisfactory

S - SatisfactoryHS - Highly Satisfactory

-26 -

Health Svstem Fund Project: Participant States

Objective Outcome. Obiective ib) Outcome: Obiective it a) Outcome: Outcome Objective ii b} Outcome:ii Post-project Improve the Documented Strengthen Retention of Status of Strengthen the Retention ofEstablish procurement quality and new/user capacity of Trained Staff State Plans for institutional / State support

Ca gpot A, ment / costs efficiency of H. rates of the participating in Health Training,' financial for improvedfinancing incorporated Services of health States to plan, Planning / Retraining capacity of the programsof Health in States 3 participating services of carry out, Pharnaceuti required participant HMIS I HealthSystem year Rolling States and local such monitor and cal Health states Planning /Fund Plan gov. LGSs facilities evaluate their Personnel Research &

_ ___rrr FDP

___ _ __ S S.. _ , * _ ______Akwa-lbom LS S _S LSSBorno S Li HS S S.S

Kaduna LS S .S LS SKwara HS- HS -_S_ _ HS S

Oy_ S S S HS S711 5 _ _ _ _ _ _ _ _ _ _ S SH -

.___.__ _________ s _Benue S S _ S S .SEnugu LS _ S S LS SKatsina HS S S HS S

_agos - S S _ _ S HS SOlndo S S HS S

OSU S_ _ HS _

. _ _ _ _ _ _ _ _ _ _ _ _ _ S S...... . _ _ _ _ _ _ _ _ _ _....... Bayeba S _ S S S SEbonvi s S SSSEkiti S _SS

Code LS - Less SatisfactoryS - Satisfactory

HiS - Highly Satisfactory

- 27 -

Annex 2. Project Costs and Financing

Proect Cost by Component (in US$ million equivalent)

Component A.State Health Sub-Projects 90.30 58.81 0.65Component B.Assistance to the Federal Ministry 1.90 5.54 1.31of HealthComponent C.Federal support to the States( this 2.30component was combined with Component B at MTR)

Total Baseline Cost 94.50 64.35

Total Project Costs 94.50 64.35Total Financing Required 94.50 64.35

Project Costs by Procurement Arrangements (Appraisal Estimate) (US$ million equivalent) ___

1. Works 0.00 41.60 4.00 0.00 45.60(0.00) (27.00) (2.60) (0.00) (29.60)

2. Goods 22.30 16.20 2.00 0.27 40.77(21.70) (9.80) (2.00) (0.27) (33.77)

3. Services 0.00 0.00 7.10 0.80 7.90(0.00) (0.00) (6.90) (0.80) (7.70)

4. Miscellaneous 0.00 0.00 0.00 0.23 0.23(0.00) (0.00) (0.00) (0.23) (0.23)

5. Miscellaneous 0.00 0.00 0.00 0.00 0.00(0.00) (0.00) (0.00) (0.00) (0.00)

6. Miscellaneous 0.00 0.00 0.00 0.00 0.00(0.00) (0.00) (0.00) (0.00) (0.00)

Total 22.30 57.80 13.10 1.30 94.50(21.70) (36.80) (11.50) (1.30) (71.30)

Project Costs by Procurement Arrangements (Actual/Latest Estimate) (US$ million equivalent)

1. Works 0.00 4.31 0.37 0.00 4.68(0.00) (17.25) (1.50) (0.00) (18.75)

2. Goods 0.00 2.49 1.36 0.51 4.36(4.00) (9.99) (5.45) (0.51) (19.95)

3. Services 0.00 0.00 11.82 0.79 12.61(0.00) (0.00) (11.82) (0.79) (12.61)

-28 -

4. Miscellaneous 0.00 0.00 0.36 0.00 0.36(0.00) (0.00) (1.45) (0.00) (1.45)

5. Miscellaneous 0.00 0.00 0.00 0.00 0.00(0.00) (0.00) (0.00) (0.00) (0.00)

6. Miscellaneous 0.00 0.00 0.00 0.00 0.00_ (0.00) (0.00) (0.00) (0.00) (0.00)

Total 0.00 6.80 13.91 1.30 22.01(4.00) (27.24) (20.22) (1.30) (52.76)

" Figures in parenthesis are the amounts to be financed by the Bank Loan. All costs include contingencies.2'Includes civil works and goods to be procured through national shopping, consulting services, services of contracted

staff of the project management office, training, technical assistance services, and incremental operating costs related to(i) managing the project, and (ii) re-lending project funds to local government units.

Project Financing by Component (in US$ million equivalent)

:r .. .e v_k'igL__ t=u'....iCE !-._'

State Health Sub-Projects 49.90 30.73 9.67 0.0 0.0 0.0Assistance to Federal 1.20 0.07 0.63 0.0 0.0 0.0Ministry of HealthFederal Support to the 1.10 1.20 0.00 0.0 0.0 0.0StatesPost MTR: 48.65 19.47 0.00 0.0 0.0 0.0State Health Sub-Projects

Assistance to Federal 4.11 1.24 1.30 0.0 0.0 0.0Ministry of Health andFederal Support to States

-29 -

Annex 3: Economic Costs and Benefits

- 30 -

Annex 4. Bank Inputs

(a) Missions:Stage of PrqiectCycle No. of Persons and Sp0cialt Performance Rating

(eg. Economists, I NS, etc.) implementation DevelopmentMonear Count Specilt y Progress Objective

Identification/Preparation11/87 2 ML/SOO,PH S S04-5/89 8 ML/HP,HFI,SOO,PH, S S

4CON(1Inst,lFin,2PH)

Appraisal/Negotiation06-7/89 8 ML/HP,SOO,FM,PH,4 S S

CON(l Inst, lFin,2PH)10/89 8 ML/HFI,PH,CO,DO,CON(HP) S S

Supervision06/91 1 ML S S06/92 2 CON(PS) S S03/93 2 ML/PH,CON(PS) S S09/93 3 ML/PH,OO,FM S S12/93 7 ML/DV,PH,ECON,OO,PS S S09/94 3 ML/PH,OO,PS S S06/95 4 ML/PH,OA,SOO,CON(AR) S S12/95 6 SOO,OO,PS,PA,CON(AR), S S

FM(INT)12/96 5 ML/PH,OO,DA,PA,CON(AR) S S09/97 5 MLIPH,FA,OO,PA,DA, S S

CON(AR)12/97 6 ML/PH,FA,OO,PA,DA, S S

CON(AR)07/98 6 ML/PH,OO,FA,PA,DA S S

CON(AR)06/99 6 ML/PH,OO,FA,PA,DA, S S

CON(AR)

ICR05 5 ML/PH,OO,PA,FA,CON S S

(AR)

AR=Architect,BA=Banking,CO=Counsel,CON=Consultant,DV=Division Chief,ECON=Economist,DA=Disbursement Assistant,DO=DisbursementOfficer,FM=Financial Management,FI=Finance,HFI=Heaith Financing/lnstitutions,HP-Health Planner,HS=HealthSpecialist,INST=Institutional,INT=Intem,ML=Mission Leader,OA=Operations Assistant,OO=Operations Officer,OS=Operations Specialist,PA=Procurement Analyst,PS=Procurement Specialist,PH=Public Health,SOO=Senior Operation Officer

-31 -

(b) Staff3?

Stage of Pro c Cycle ___ __ 777____a____________

________________ No. Staf~weeksus$ (,OM)Identification/Preparation 47.95 124.11AppraisaVNegotiation 23.25 46.20Supervision 500.06 1,017.79ICR 12.03 29.12Total 583.29 1,217.22

- 32 -

Annex 5. Ratings for Achievement of Objectives/Outputs of Components

(H=High, SU=Substantial, M=Modest, N=Negligible, NA=Not Applicable)Rating

Macro policies O H OSUOM O N * NASector Policies O H *SUOM O N o NA

3 Physical O H *SUOM O N O NA3 Financial O H OSUOM O N * NA

Z Institutional Development 0 H O SU O M 0 N 0 NAZ Environmental O H OSUOM O N * NA

Social3 Poverty Reduction O H OSU*M O N O NA

•ZGender O H OSUOM O N O NAO Other (Please specify) 0 H O SU O M O N 0 NA

F Private sector development 0 H O SU 0 M 0 N 0 NAF Public sector management 0 H O SUO M 0 N 0 NAO Other (Please specify) O H OSUOM O N O NA

- 33 -

Annex 6. Ratings of Bank and Borrower Performance

(HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HU=Highly Unsatisfactory)

6.1 Bank performance Rating

I Lending OHS OS OU OHUC Supervision O HS * S OU OHUO Overall OHS OS O U O HU

6.2 Borrower performance Rating

O Preparation O HS * S O U O HUO Government implementation performance 0 HS O S 0 U 0 HUE Implementation agency performance O HS * S O U O HUL Overall OHS OS OU O HU

- 34 -

Annex 7. List of Supporting Documents

1. Maps IBRD 20709R and 30707.2. Staff Appraisal Report No. 8080-UNI dated April 3, 1991.3. Loan Agreement dated August 6, 1991.4. Report of Mid-Term Review dated December 23, 1993.5. Aide-memoires of Bank supervision missions Jun/19/91; Jun/30/92; Mar/01/93; Sept/24/93;

Dec/23/93; Sept/16/94; Jun/29/95; Apr/24/96; Jun/19/97; Oct/29/97; Feb/27/98; Jun/30/99;12/30/99 and 05/10/00.

6. List of Studies undertaken during Loan implementation (Section 10.).7. Borrower's Completion Reports from all 16 HSF States , received February 2000.8. "Lessons Learned from HSF 1" (Section from proposals by all 16 HSF prepared for participation

in a second Health Systems Credit); reviewed May-June 2000.9. Technical summaries of implementation issues/lessons learned from World Bank Procurement

Specialist, Financial Management Specialist and Consultant Architect.( May and June 2000).10. The National Health Policy and Strategy to Achieve Health for All Nigerians, October, 1988.11. Impact of World Bank Assisted Projects in Nigeria 1958-1998.Volume V; September 98, Report

on Health Sector; BIFEX Consultants Ltd., Lagos, Nigeria for Federal Ministry of Finance.12. Evaluation Study of World Bank assisted Health Sector Projects in Nigeria 1984-1998 Study

conducted by COLNIG (NIG) Ltd. Health Care Financing and Management Consultants, October2nd 1998; for the Federal Ministry of Finance.

- 35 -

MAP SECTION

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