Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank Report No: ICR0000527 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-28080 NETH-20884 SIDA-20883) Human Development Sector Unit East Asia and Pacific Region ON A CREDIT IN THE AMOUNT OF SDR 68.0 MILLION (US$ 101.2 MILLION EQUIVALENT) TO THE SOCIAL REPUBLIC OF VIETNAM FOR A NATIONAL HEALTH SUPPORT PROJECT August 9, 2007
CURRENCY EQUIVALENTS (Exchange Rate Effective April 2, 2007) Currency Unit =Vietnamese Dong (VND) US$ 1.00 = VND 16,025 VND10,000 = US$0.62 FISCAL YEAR July 1 to June 30 ABBREVIATIONS AND ACRONYMS ADB Asian Development Bank IMR Infant Mortality Rate ARI Acute Respiratory Infections ISR Implementation Status Results and Report CAS Country Assistance Strategy M&E Monitoring and Evaluation CHC Commune Health Center MCH-FP Maternal Child Health Family Planning DCA Development Credit Agreement MDR-TB Multi-drug Resistant Tuberculosis DHC District Health Center MMR Maternal Mortality Rate DO Development Objective MOH Ministry of Health DOTS Directly-observed Treatment, NHSP National Health Support Project Short-course GDP Gross Domestic Product OOP Out-of-Pocket GNP Gross National Product PAD Project Appraisal Document HCMC Ho Chi Minh City PDO Project Development Objective HIV/AIDS Human Immunodeficiency PHC Primary Health Care Virus/Acquired Immune Deficiency Syndrome IBRD International Bank for PMU Project Management Unit Reconstruction and Development ICP Inter-communal Polyclinics SAR Staff Appraisal Report IDA International Development SIDA Swedish International IEC Association Information, Education, and Communication TB Development Cooperation Agency Tuberculosis Vice President: Country Director: Sector Manager: Project Team Leader: ICR Team Leader James W. Adams Ajay Chhibber Fadia Saadah Samuel S. Lieberman Samuel S. Lieberman
VIETNAM National Health Support Project CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design... 1 2. Key Factors Affecting Implementation and Outcomes... 7 3. Assessment of Outcomes... 12 4. Assessment of Risk to Development Outcome... 18 5. Assessment of Bank and Borrower Performance... 19 6. Lessons Learned... 22 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners... 23 Annex 1. Project Costs and Financing... 24 Annex 2. Outputs by Component... 25 Annex 3. Economic and Financial Analysis... 30 Annex 4. Bank Lending and Implementation Support/Supervision Processes... 31 Annex 5. Beneficiary Survey Results... 34 Annex 6. Stakeholder Workshop Report and Results... 38 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR... 39 Annex 8. Comments of Co-financiers and Other Partners/Stakeholders... 44 Annex 9. List of Supporting Documents... 45 MAP IBRD 33511R
A. Basic Information Country: Vietnam Project Name: National Health Support Project ID: P004838 L/C/TF Number(s): IDA-28080,JPN- 53273,NETH- 20884,SIDA-20883 ICR Date: 09/07/2007 ICR Type: Core ICR Lending Instrument: SIL Borrower: Original Total Commitment: Environmental Category: C Implementing Agencies: Ministry of Health Cofinanciers and Other External Partners: SIDA Government of Netherlands B. Key Dates SOCIALIST REPUBLIC OF VIET NAM XDR 68.0M Disbursed Amount: XDR 56.5M Process Date Process Original Date Revised / Actual Date(s) Concept Review: 10/01/1991 Effectiveness: 05/24/1996 05/24/1996 Appraisal: 06/27/1995 Restructuring(s): 06/29/1999 10/31/2005 Approval: 01/16/1996 Mid-term Review: 04/12/1999 Closing: 09/30/2003 10/31/2006 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Borrower Performance: Moderately Satisfactory Moderate Moderately Unsatisfactory Moderately Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Moderately Quality at Entry: Moderately Satisfactory Government: Unsatisfactory Quality of Supervision: Moderately Implementing Moderately Unsatisfactory Agency/Agencies: Unsatisfactory i
Overall Bank Performance: Moderately Unsatisfactory Overall Borrower Performance: Moderately Unsatisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Performance (if any) Potential Problem Project No at any time (Yes/No): Problem Project at any time (Yes/No): DO rating before Closing/Inactive status: Yes Satisfactory Quality at Entry (QEA): Quality of Supervision (QSA): None Satisfactory Rating D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 3 2 Health 97 98 Theme Code (Primary/Secondary) Health system performance Secondary Secondary Other communicable diseases Primary Primary Population and reproductive health Primary Secondary Rural services and infrastructure Primary Primary E. Bank Staff Positions At ICR At Approval Vice President: James W. Adams Callisto E. Madavo Country Director: Ajay Chhibber Bradley O. Babson Sector Manager: Fadia M. Saadah Sven Burmester Project Team Leader: Samuel S. Lieberman L. Richard Meyers ICR Team Leader: ICR Primary Author: Samuel S. Lieberman Kelechi O. Ohiri F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The objective of the Project is to assist the Borrower in improving the health status of the rural population in the poorer areas of Viet Nam by (i) providing high quality, reliable primary health care on a sustainable basis in 15 of the poorer provinces; (ii) reducing ii
mortality and morbidity due to malaria, tuberculosis and acute respiratory infections (diseases that disproportionately afflict the poor) as well as the adverse socioeconomic impact associated with these diseases; and (iii) Strengthening the capacity of the MOH in policy-formulation, planning and management in order to better achieve the above objectives, with a particular focus on improving the capacity to ensure that the basic health needs of the poor are met. Revised Project Development Objectives (as approved by original approving authority) The Project Development Objectives were not revised in the course of project implementation. (a) PDO Indicator(s) Indicator Indicator 1 : Value quantitative or Qualitative) Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Number of improved Commune Health Centers (CHCs)/Total targeted CHCs Number 2819 CHCs for 2070 CHCs or revised to No baseline improvement at 71.4% were 2056 CHCs at project start improved. mid-term Date achieved 05/24/1996 05/24/1996 04/12/1999 09/30/2003 Comments No baseline information was collected. It could be inferred that all the target (incl. % CHCs needed the investments to improve quality. achievement) Indicator 2 : Number of improved District Health Centers (DHCs)/Total targeted DHCs Value quantitative or Qualitative) No baseline 155 DHCs 163 DHCs (105% of original and 90% 181 with the of revised targets) addition of 26 were improved in DHCs for two terms of facility new provinces upgrade and equipment Date achieved 05/24/1996 05/24/1996 04/12/1999 09/30/2003 No baseline information was collected, since it could be assumed that the entire Comments target DHCs needed investments to improve quality. (incl. % achievement) Indicator 3 : Value quantitative or Qualitative) Utilization of CHCs 1997: 37,576,681 consultations at 9,806 CHCs in whole country or average of 3,832 consultations per CHC per year or 319 consultations per month 2002: 149,753,737 consultations at 10,293 CHCs in whole country or average of 14,549 consultations per CHC per year or 1,212 consultations iii
per month Date achieved 04/30/1997 04/30/2002 Comments An independent project evaluation report (2003) reported an average 10% higher (incl. % in the utilization rate (both inpatient and outpatient) of the supported CHCs achievement) compared with matched non-project CHCs Indicator 4 : Infant mortality rate Value quantitative or Qualitative) National IMR for 1997: 34.8 per 1,000 live births (DHS) IMR for 2002 was 24.8 per 1,000 live births (DHS) Date achieved 04/30/1997 04/30/2002 Comments The IMR has continued on a downward trend and 2004 MOH report put the (incl. % estimate at 18.1 per 1000 live births achievement) Indicator 5 : Maternal mortality rate Value quantitative or Qualitative) National MMR was 110 per 100,000 live births in 1996 MMR was 91 per 100,000 live births in 2002 Date achieved 04/25/1996 04/25/2002 The MMR estimates vary significantly by region and province. Given the Comments inclusion of some of the poorest provinces in the project, which tend to have (incl. % worse health outcomes, these national level data might not reflect the trend in the achievement) project Indicator 6 : Malaria prevalence rate Value quantitative or Qualitative) Baseline data of 15 project provinces as of 1997:-Prevalence rate (PR) is 10.17/1000 -Parasite positive rate (PPR) is 1.52/1000-5 outbreaks As of Dec. 2002: -Prevalence rate is 4.28/1000 -Parasite positive rate is 1.04/1000 -No outbreaks Date achieved 04/30/1997 04/30/2002 These values apply to the 15 project provinces. By Dec. 2002, reductions in Comments prevalence (by 57.9%); PPR (by 31.6%) and in outbreaks were observed. PR (incl. % was reduced in all 15 provinces, six had reduction of more than 60%; 4 provinces achievement) had increased PPR. Indicator 7 : Malaria case fatality rate Value quantitative or Qualitative) Mortality rate in 15 project provinces as of 1997 is 0.24 per 100,000 As of 2002 mortality rate in 15 project provinces is 0.09 per 100,000 Date achieved 04/30/1997 04/30/2002 Comments Figures apply to the 15 target provinces. Mortality rate had been reduced by (incl. % 62.5% achievement) Indicator 8 : TB case finding rate Value quantitative or 78% Target (WHO) was to achieve a Case finding rate reached about 89% iv
Qualitative) case finding rate of as of 2004 70% of new infectious patients Date achieved 04/30/1997 04/25/1996 04/30/2004 Comments (incl. % achievement) Indicator 9 : Value quantitative or Qualitative) The case finding rate had already exceeded the WHO targets by the first year of project implementation, however the support to this project ensured that this success was sustained and surpassed with rates as high as 89% by 2004 TB cure rate 85% Target was 85% of all patients enrolled in chemotherapy The combined cure and treatment completion rate achieved 92.1% as of 2001 Date achieved 04/30/1997 04/25/1996 04/30/2004 Comments The target had been reached in 1997, but the support ensured this was maintained (incl. % and even surpassed. By 2004, levels had reached 93% achievement) Indicator 10 : Access to primary health care services Value quantitative or Qualitative) No baseline No data collected on this Date achieved 04/25/1996 09/30/2003 Access was defined as the proportion of the population within 1 hr s normal Comments travel time to a health facility with the capacity for providing safe delivery, (incl. % adequate treatment of malaria and ARI, and dispensing essential drugs free. This achievement) was not measured Indicator 11 : Public funding to Commune and District level primary health care services Value quantitative or Qualitative) No baseline indicators No data collected on this Date achieved 04/25/1996 09/30/2003 Comments Data for this indicator was neither collected at baseline nor at the end of the (incl. % project, hence project performance could not be determined in this regard. achievement) Actions in key policy areas: 1) Pricing of Government Health Facilities, (2) Indicator 12 : Incentives and regulations for more effective private sector provision of health care. Value quantitative or Qualitative) No baseline No data collected. Date achieved 04/25/1996 09/30/2003 Comments (incl. % achievement) The initial outcome measure was the actual endorsement of the Public Investment Plan and promulgation of specific policies recommended by the project. Revisions to the result indicators were not made. v
(b) Intermediate Outcome Indicator(s) Indicator Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Indicator 1 : No intermediate outcome indicators were used Value No baseline intermediate (quantitative No indicators indicators or Qualitative) Date achieved 04/25/1996 09/30/2003 Comments (incl. % Intermediate indicators were not used in monitoring and evaluation achievement) Indicator 2 : As mentioned above, no intermediate outcome indicators were used Value No baseline intermediate No intermediate (quantitative outcome indicators outcome indicators or Qualitative) Date achieved 04/25/1996 09/30/2003 Comments (incl. % achievement) G. Ratings of Project Performance in ISRs No. Date ISR Archived DO IP Actual Disbursements (USD millions) 1 03/12/1996 Satisfactory Satisfactory 0.00 2 06/11/1996 Satisfactory Satisfactory 0.00 3 09/30/1996 Satisfactory Satisfactory 0.00 4 03/31/1997 Satisfactory Satisfactory 1.50 5 10/28/1997 Satisfactory Satisfactory 2.22 6 04/22/1998 Unsatisfactory Unsatisfactory 8.23 7 11/18/1998 Unsatisfactory Unsatisfactory 12.71 8 05/26/1999 Unsatisfactory Unsatisfactory 15.57 9 06/29/1999 Satisfactory Satisfactory 15.77 10 08/19/1999 Satisfactory Satisfactory 17.03 11 12/02/1999 Satisfactory Satisfactory 21.99 12 06/06/2000 Satisfactory Satisfactory 24.16 13 08/16/2000 Satisfactory Satisfactory 24.16 14 11/09/2000 Satisfactory Satisfactory 25.14 15 03/12/2001 Satisfactory Satisfactory 27.41 16 11/14/2001 Satisfactory Satisfactory 36.36 17 06/04/2002 Satisfactory Satisfactory 39.93 18 12/18/2002 Satisfactory Satisfactory 47.78 19 06/25/2003 Satisfactory Satisfactory 54.54 vi
20 12/16/2003 Satisfactory Satisfactory 63.33 21 06/16/2004 Satisfactory Satisfactory 72.02 22 12/22/2004 Satisfactory Satisfactory 72.02 23 03/25/2005 Satisfactory Moderately Satisfactory 72.27 24 02/14/2006 Satisfactory Satisfactory 76.91 25 02/03/2007 Satisfactory Satisfactory 77.25 H. Restructuring (if any) Restructuring Date(s) ISR Ratings at Restructuring Board Approved PDO Change DO IP Amount Disbursed at Restructuring in USD millions 06/29/1999 N S S 15.77 10/31/2005 N S MS 73.48 Reason for Restructuring & Key Changes Made Changes made to activities but no formal restructuring Project extended on exceptional basis to address Avian flu epidemic, but no formal restructuring of project. I. Disbursement Profile vii
1. Project Context, Development Objectives and Design 1.1 Context at Appraisal At the time of project preparation, Vietnam was undergoing a major transition from a centrally planned economy to a market economy. In the early 1990s, the Vietnam economy was just beginning to stabilize, following decades of economic crises in the 1970s and 1980s - a period characterized by the vestiges of a protracted war, weak government policies, a less supportive international environment and the collapse of the Soviet Union and with it, financial support from former countries of the communist bloc. Pivotal change in economic reforms started with the initiation of the Doi Moi reforms, in 1986, which culminated in significant achievements in economic growth in the ensuing decades. Annual GDP growth averaged 7% in the 1989-92 adjustment periods, driven by strong exports and fiscal discipline that reduced inflation from 400% in 1988 to 5.2% by 1993. However, challenges remained. The per capita GNP was below US$200 in 1993; poverty incidence was high (average poverty rate in 1993 was 58.1%) and disparities persisted. Poverty was largely concentrated in rural areas (66.4% in rural versus 25.1% in urban areas), among ethnic minorities, and had a regional dimension (poverty rates were highest in mountainous areas). In recognition of these inequalities, the government developed an extensive system of social programs and safety nets. However, since the 1980s, the quality and quantity of the programs rapidly deteriorated and health was no exception. Significant improvements in health outcomes were achieved, with gains realized in most health status indicators. Occurring in parallel to these changes in the macroeconomic environment, Vietnam experienced significant and impressive improvements in health status. Life expectancy at birth had increased, total fertility rate dropped from about 6.0 per woman in 1975-80 to near replacement levels today. Infant and maternal mortality rates also declined. These improvements in health outcomes were attributed to strong political commitment at all levels, relatively high literacy rates among women, a vast network of primary health care services (in particular at the commune levels, managed by cooperatives) and focused programming on preventable diseases (such as malaria, vaccine-preventable diseases) through targeted vertical programs. However, significant public health challenges persisted. Malnutrition rates were still among the highest in the region. Unmet needs for family planning 1 were estimated at 44% of women, and modern methods of family planning were largely unavailable. Resurgence in infectious diseases such as Malaria, Tuberculosis, and the emergence of new infectious diseases such as HIV/AIDS, SARS and Avian Influenza were being observed. Akin to trends in poverty, the improvements in health outcomes had not progressed uniformly. Most indices, such as MMR and IMR were worse among ethnic minorities, in remote areas, and within certain geographical regions. 1 This refers to the proportion of married or in union women who are sexually active who would prefer to avoid becoming pregnant, but are not using any method of contraception. 1
Reduction in investments in the health sector led to a deterioration in quality of care and decline in utilization, mostly of the CHCs. The dismantling of the community cooperative networks, sharply diminished external support to the sector, macroeconomic instability and fiscal crises of the mid-1980s all contributed to this. Many CHCs had deplorable infrastructure, lacked very basic equipment and were inadequately staffed. Unsurprisingly, the quality of services deteriorated, and utilization of such facilities declined over the years. The poor were disproportionately affected, because, whereas CHCs were more likely to be utilized by the poor (0.24 contact rate vs. 0.12 for the richest quintile), the better off tended to utilize other public facilities and private clinics. Rationale for Bank investment. The Investment in the Health Sector at this time was consistent with the 1995 Country Assistance Strategy for Vietnam which cited the improvement of health and education for human resource development as key activities under one of the pillars of the CAS Poverty Alleviation. In addition, the Sector Work Vietnam: Population, Health and Nutrition Sector Review of 1992, supported by the Bank, identified the key issues in the health sector and laid down the foundation upon which Bank assistance to the sector was subsequently built. This project was the first health sector project supported by the World Bank in Vietnam. At the same time, this project complemented the Population and Family Health Project, which addressed a lot of demand side issues. The Bank investment was very timely, given the rapidly deteriorating state of the health infrastructure, in particular, of the commune and district level facilities which primarily served the poor. The Bank s comparative advantage in its convening power was also leveraged as other key donors SIDA and the Netherlands participated in this project. Finally, the project also built on the Bank s knowledge of the sector and experience in similar countries around the world. 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) The objective of the project is to assist the borrower in improving the health status of the rural population in the poorer areas of Viet Nam by (i) Providing high quality, reliable primary health care on a sustainable basis in 15 of the poorer provinces; (ii) Reducing mortality and morbidity due to malaria, tuberculosis and acute respiratory infections (diseases that disproportionately afflict the poor) as well as the adverse socioeconomic impact associated with these diseases; and (iii) Strengthening the capacity of the MOH in policy-formulation, planning and management in order to better achieve the above objectives, with a particular focus on improving the capacity to ensure that the basic health needs of the poor are met. About 14 key performance indicators targeted at the specific objectives/components of the project were approved. They include in order: (A) For the first objective, (1) Proportion of total targeted CHCs that have been improved, (2) Proportion of improved DHCs of the targeted total, (3) Utilization of CHCs, (4) Infant Mortality Rate, and (5) Maternal Mortality Rate. (B) For the second objective, (6) Malaria Prevalence rate, (7) Malarial case fatality rate, (8) TB Case Finding rate, and (9) TB Cure rate. 2
(C) For the third objective, (10) Access to primary health care services, (11) Public funding to commune and district level facilities, (12) Progress on project disbursement, (13) Progress on credit disbursement, and (14) Actions in key policy areas. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification. The PDO/indicators were not formally revised in the course of project implementation. The project, within its stated objectives, allowed for enough flexibility to respond to the changes that fitted within the overall development objectives during implementation. 1.4 Main Beneficiaries The project was designed to benefit the entire population, particularly with respect to the national priority programs for Malaria, TB, and Acute Respiratory Infection (ARI), and by better management of the health system through the enhancement of the policymaking capacity of the MOH. The primary target groups of this project as identified in the SAR were (i) Rural population in the poorer areas of the country, in particular poor residents of the 15 poorest provinces who would benefit from improved quality of services at the CHCs, ICPs and DHCs, and (ii) The poor and other vulnerable groups disproportionately affected by infectious diseases (Malaria, TB and ARIs). The intermediate beneficiaries identified were the health care workers delivering these services who would benefit from training, and better working conditions; and the MOH staff responsible for policy formulation and management who would also benefit from capacity-building activities. 1.5 Original Components (as approved) The key components of the project and indicative costs were as follows: Component 1: Assistance to Commune and District Health Centers (US$60.1 million equivalent to SDR 40.4 million estimated base cost, of which US$52 million or SDR 35 million was spent). Disbursed World Bank Government Netherlands SIDA SDR 34,973,575 SDR 28,873,626 SDR 3,559,962 SDR 2,539,987 SDR 0 US$ 52,040,680 US$ 42,963,956 US$ 5,297,223 US$ 3,779,501 $0 This component aimed to improve essential public health services at the primary (CHC) and first-referral level (DHC) facilities in 15 provinces selected according to specific criteria outlined in the SAR. The subcomponents were: (1) A package of civil works to upgrade or build new health facilities to meet certain minimum standards for service delivery; (2) Provision of essential drugs, basic equipment and supplies to the CHCs and DHCs; and (3) In-service training of health personnel to build capacity. Component 2: Assistance to Three National Priority Programs (US$51.4 million equivalent estimated base cost, of which US$39.8 million was spent). 3
Disbursed World Bank Government Netherlands SIDA SDR 26,747,929 SDR 23,470,108 SDR 3,277,821 SDR 0 SDR 0 US$ 39,800,918 US$ 34,923,521 US$ 4,877,397 $0 $0 This component aimed to support three already established national health programs for malaria, tuberculosis, and ARI respectively. (1) The National Malarial Control Program subcomponent aimed at protecting populations at risk of malaria through locally effective anti-vector measures, improved program management and epidemiological services. The project financed inputs such as insecticides, equipment, transportation, training, and technical assistance. Disbursed World Bank Government Netherlands SIDA SDR 10,898,647 SDR 9,503,920 SDR 1,394,726 SDR 0 SDR 0 US$ 16,217,187 US$ 14,141,834 US$ 2,075,353 $0 $0 (2) The National Tuberculosis Program aimed at reducing the TB incidence within the general population as well as curing infected patients, through the attainment of a case finding rate of 70% of new infectious patients and cure rate of 85% of all patients enrolled in treatment. The project provided drugs, equipment, transportation, training and operations support. Disbursed World Bank Government Netherlands SIDA SDR 13957439 SDR 12247306 SDR 1710132 SDR 0 SDR 0 US$ 20,768,669 US$ 18,223,992 US$ 2,544,677 $0 $0 (3) The ARI Program aimed to extend coverage of ARI treatments services to 100 percent of children under-five years of age by the year 1999 through the provision of inputs such as the training of workers, financing of drug treatment costs, and the largescale implementation of a case management approach. Disbursed World Bank Government Netherlands SIDA SDR 1,891,843 SDR 1,718,881 SDR 172961 SDR 0 SDR 0 US$ 2,815,062 US$ 2,557,695 US$ 257,367 $0 $0 Component 3: Strengthening Institutional Health Planning and Management in the Ministry of Health (US$4.7 million equivalent estimated base cost, of which everything was spent including an additional US$0.8 million, resulting in a total of about US$5.5 million). Disbursed World Bank Government Netherlands SIDA SDR 3,710,081 SDR 0 SDR 0 SDR 0 SDR 3,710,081 US$ 5,520,601 $0 $0 $0 US$ 5,520,601 4
This component aimed to improve the beneficial impact of policies affecting the health sector by enhancing the capacity of the MOH to use several health sector planning and management tools. The subcomponents included: (1) Improving the planning and management of public expenditures for health by (a) Improving the budgeting, accounting, and operational reporting systems of the central MOH hospitals and institutes, provincial health departments, and the central MOH; and (b) Preparing a public investment plan for the health sector; (2) Assisting the government in better mobilizing private financing for health by improving the system of setting, charging and collecting prices for publicly provided health services to better protect the poor and increase revenues available to enhance the quality and quantity of these services; and preparing proposals for further expanding private production of health services; (3) Generating population-based household data and analysis for health sector planning. 1.6 Revised Components The project was not formally restructured. Hence, no major revisions to the components occurred. However, notably, there were some modifications to planned activities as outlined below. 1.7 Other significant changes The project was extended three times. The first extension (18 months from October 2003 to March 2005) was in order to support some of the activities under the TB subcomponent such as the procurement of drugs and equipment. The implementation of this sub-component had only picked up steam after the mid term review. It was important to maintain Bank support for this sound program, as the drugs financed under the project were at that point absolutely critical to program performance and alternative financing sources were not immediately available. Global Fund financing only became available years after that. The second extension (7 months, from March 31 2005 to October 31, 2005) was to allow for completion of the unfinished procurement of TB equipment. Unfortunately the changes in the management slowed down the procurement process and the lengthy review and approval procedures of MOH attributed to further delays. The third extension (1 year from October 2005 to October 2006) was to assist in the Avian Influenza emergency response. The urgent need for a large amount of medical equipment in the hospitals of the affected provinces could only be met by external financial supports. Upon the request of the government, Bank management agreed on an exceptional basis to allow a third extension so that remaining project funds could be used to support preparation of a national plan and the purchase of critical equipment. The national plan was prepared but the procurement of equipment was stalled because of unacceptable technical specifications. The funds were then cancelled and the government eventually purchased the needed equipment using their own funds. A new Avian Flu operation which was better designed to respond to the emergency nature of the disease was later prepared with Bank support. 5
National Health Support Project Loan Utilization (in SDR Million) Loan Canceled on 10/03: 1,679,842.00 New Loan Amount: 66,320,158 68 17.5 13.0 10.1 Loan Canceled: 9,736,836.38 New Loan Amount: 56,583,321.62.2 Loan Canceled on 11/06: 74,926.91 New Loan Amount: 56,508,394.71 48.8 53.3 56.2 56.3 56.5 Board Approval 01/96 Original closing date 09/03 03/05 10/05 08/06 Actual Loan Used at Closure 10/06 1 st Extension (18 months): To continue support for National TB Program 2 nd Extension (7 months): To complete procurement of X-ray equipment under the National TB program 3 rd Extension (12 months): To respond to Avian flu Undisbursed Disbursed Cancelled Other specific changes made to the various components in the project included: 6
Component 1: Number of beneficiary provinces changed from the original 15 at appraisal, to 18 at the end of the project. One of the provinces (Ha Bac) was split in two, Bac Giang and Bac Ninh; In addition, a decision was made in 2001 to expand investments to two new provinces. Construction of 55 Inter-commune Polyclinics (ICPs) in mountainous areas, with very limited access to DHs, was added to the project, based on the borrower s request. Some modifications were made in this component that included (i) a reduction in the civil works at commune level and an increase in civil works at district level; (ii) decreased investments in essential drugs (list decreased from 33 drugs to 7); and (iii) an increase in the number of training modules from 5 to 9. Component 2: In addition to the extension for supporting implementation of the national TB program, there were changes in implementation arrangements, with the procurement management responsibilities transferred from the PMU to National TB Program. Component 3: The activities under subcomponent 3.2 were replaced by three sets of activities the hospital inventory survey, a review on the health card for the poor program, and training in health economics. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry The rapid transition and economic growth following the introduction of the Doi Moi reforms in 1986 had an impact on the health sector. Vietnam had a good support for health, with strong political commitment from the government, an extensive primary health care network supported and financed by the rural cooperative system, and Central Government support for National Target Programs that were performing well. The period immediately preceding the project was characterized by a shift from collective to familybased agriculture and, with that, an end of the collective revenue generation system of the rural cooperatives, with the defunct status of the latter. This led to the depletion of funds available for health at the commune level. Many services were either withdrawn or scaled back, especially within CHCs in poorer areas. The widening quality gap that ensued was compounded by the introduction of user fees and the legalization of the private sector in 1989. The program benefited from the availability of sound analytical work such as the Population, Health and Nutrition Sector Review 1992, the World Development Report 1993: Investing in Health, and the 1993 Vietnam Living Standards Survey. This Sector Review among other things underscored the need to address access to health services at the community-level. It also prioritized addressing diseases of public health concern such as malaria, TB and ARI which disproportionately affect the poor. The project was fully aligned with the national priorities of the Government and with the Country Assistance Strategy which outlined investments in health and education as one of the key 7
components in its poverty reduction strategy. The project was designed to be pro-poor, and help improve basic social services that had deteriorated from years of fiscal crises. The design of the Project focused on key areas that needed support and by doing so contributed to the improvements of health outcomes, especially for the poor. The project design responded to pertinent supply-side constraints in the health care system that stemmed from years of underinvestment and deterioration of quality of care. Through its focus on basic services for poor areas in particular to the CHCs, and activities that largely benefit the poor as well as the three priority diseases, the project made important contributions towards better health outcomes, especially for the poor. When taken together with the Population and Family Health Project that was implemented in parallel and which focused on demand side issues and reproductive health, the package provided Vietnam with important investments for the health sector. The project could have paid more attention to demand side interventions, especially those geared towards overcoming financial barriers and changing the health-seeking behaviors of selected target groups. Some of this was left to the Population and Family Health Project which was designed around the same time and focused on demand side factors and social mobilization that influenced health seeking behavior. Despite the complementarities of the two operations, the project could have done more on demand side issues such as improving financial access for the poor. Despite the important focus areas, the design was complex and MOH faced important challenges, especially in the area of procurement. The unfamiliarity of MOH with Bank procedures and the complexity in design contributed to implementation delays. The project design reflects three different approaches to supporting the health system: the provision of specific inputs (supplies, drugs, equipment, civil works, and training) to the health system; the support of Vertical National Targeted Programs; and building capacity. It also included several financing sources. The MOH faced important challenges, especially with procurement. As the first Bank financed project in the health sector, the MOH was unfamiliar with ICB procedures for procurement of drugs and medical equipment. Proficiency with such procedures is typically acquired by practice, and usually only after about one or two ICB cycles have been completed. In spite of the limited capacity, international TA on procurement was not included as it was not considered an option in the country then, a situation that later changed with the realization of the value of such TA in expediting procurement procedures and building capacity. The project eventually served as a training ground for procurement staff who subsequently worked in future donor-financed projects or in private sector. The discrepancies between national procurement regulations and the Bank's procurement guidelines contributed to the delays of large amount of procurement of equipment, suppliers, and civil works. For instance, the National Competitive Bidding and Shopping procedures contained seventeen discrepancies. It was therefore challenging to stay in compliance with the international best practice. Adding to the delays, was the poor communication and coordination among relevant departments, agencies, and institutions, and the lengthy internal procedures for review and approval of procurement related documentation at each stage of the cycle, e.g. planning, drafting, advertising, evaluation, and contracting. 8
Over time, MOH made improvements as regards bidding document reviews, but procurement planning, in particular cost estimations, remained a major obstacle. It was not uncommon to have the annual procurement plan approved by mid-year. Although the intention was to spend borrowed funds with care, the laborious process did not always add value. In summary, this project shared most of the challenges faced by first generation projects in the country, and provided valuable lessons to future projects in design, capacity building, and procurement execution. 2.2 Implementation The project was declared effective on May 24, 1996 and closed on October 31, 2006. Overall, the project implemented key activities and was flexible in terms of meeting client's changing demands over the ten-year period. The leadership in MOH provided important policy support that aided the implementation process. However, frequent delays in implementation were encountered due to limited capacity at national and provincial levels and large amount of procurement involved for drugs, medical equipment, and civil works. ICB and NCB procedures were new to the project staff as well as the national bidders and contractors. Some of these constraints were project specific and others were generic as also pointed out by the CPPR. The key implementation constraints for this project include: (i) Limited capacity at various levels especially the PMU in a relatively complex project - At the national level, there was the PMU in place, managed by a Vice Minister as Project Director. Lead persons were appointed for components 1 and 3, who in turn coordinated with respective departments responsible for implementation of various activities. Component 2 was implemented directly by the national institutes implementing the national programs and overseen by the PMU. At the provincial level, a Project Manager was appointed in each project province responsible for activities in their respective provinces. Coordination became more challenging than expected especially given that project managers and most of the staff were working only part-time on the project. There were no provisions to hire consultants at that time, therefore only civil servants could be contracted, with minimal financial incentives for the additional workload. Most of the positions in the PMU were vacant at the initial stage of implementation. In later years, the project faced a high turnover of project staff and had to continuously train new staff throughout the project lifetime. Severe shortage of qualified staff plagued most of the projects in the country. Although having a vice minister as project director showed strong commitment of the MOH to the project, this often proved counterproductive, as the director could not give time to day-to-day operations, but had to sign all contracts and key communications to the Bank, resulting in frequent delays in getting documents signed. Delegation of signing was not a common practice. Lessons learned by the MOH were reflected in subsequent projects, whereby either the project director or the deputy director now have to be full-time managers, supported by civil servants, contracted staff and consultants, especially on procurement and disbursement. Government counterpart funds provide salary supplements to the civil servants, and consultants are paid at market prices. Same arrangements are made for 9
provincial PMUs. More importantly, capacity at every level has been strengthened gradually over the past ten years and MOH is in the process of decentralization, switching from execution to stewardship functions on policy and regulations. (ii) Procurement delays of ICB packages - In spite of repeated training workshops on procurement, and some improvements in capacity, preparation of technical specifications and evaluation of bids remained extremely challenging to the MOH evaluation group. Some of these challenges include: (1) Difficulty in reaching specification agreements. The review group normally consisted of doctors and medical technicians who were familiar with only one or two preferred brand names of equipment. Disagreements often ensued; resulting in several meetings, repeated bid validity extensions and up to 5 to 6 month delays for major packages; (2) The requirement in the national procurement regulation to reject bids above the ceiling price. This discrepancy between the national procurement regulation and the Bank's procurement guidelines was cited by several projects as a major obstacle in implementation, and was raised as a country issue with MPI and the Government Office in many occasions. Yet it remains unresolved; (3) Slow decision-making process. There seemed to be a tendency for making collective decisions in MOH on most of the procurement related issues a situation worsened by the PMU 18 scandal in the press. Project staff and managers at various levels began trying to avoid any misperception of corruption. The unwillingness to make decisions became one of the major factors causing procurement delays in the last few years of project implementation; (4) Drug Procurement was particularly problematic, due to the uneven quality of the products of drug suppliers from less regulated markets. Several times, the project had to return whole containers after drug inspections were carried out. The issue though related to procurement, could only be resolved at the regulatory level. In general, health sector procurement has been challenging in most of the Bank financed projects in many countries. This project does not seem to be an exception, although it could have done better if public procurement reform in Vietnam has moved faster. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization An overall results framework was not prepared in full at the preparation stage. Indicators were identified and were a mixture of overall goals and outcomes as well as some input indicators, most times with no clear linkages with the PDOs or to project performance. The vertical programs already had their own established M&E systems in place and had clearer results frameworks. For components 1 and 3, the initial design was complex and mixed in terms of what the project was trying to measure. Implementation of the M&E was equally suboptimal, with no baseline information collected for the indicators and no monitoring carried out. Two years into project 10
implementation, an effort was made, in response to a government proposal to simplify the M&E and to rely on routinely collected data from the MOH, however, this was not effectively followed up, until 2002, when the Bank mission, began outlining a plan for end of project evaluation. While the indicators were not always appropriate and better for some components than others, there was good data about the direction of the sector and the outcomes in project supported provinces. Selected surveys also provided useful indicators as did some of the project monitoring data. Still, attribution is difficult in this case as with several health projects. For example, some indicators focused on higher level impacts, hence not appropriate for determining project performance. IMR and MMR are such examples. Overall, the M&E framework was mixed in terms of quality, and efforts in implementation were insufficient. There was much room for doing more at the preparation and implementation stages in this regards. 2.4 Safeguard and Fiduciary Compliance. No safeguard issues were triggered in this project. It was determined that the project would not have any significant impact on the environment and there were no resettlement issues triggered in the project. Financial management: Throughout the life of the project, basic financial management arrangements were in place to manage, control, account and record the funds and transactions of the project and to manage the fixed assets. Internal controls such as segregation of duties, fixed assets record/reconciliation, bank and cash reconciliation, and reconciliation of funds received between the PMU s accounting software records and the Bank s records were in place and operated satisfactorily (see sections 2.1 and 2. for discussions of procurement practices and experience). There were sufficient numbers of staff assigned to finance-related tasks and at central level the such staff were experienced and adequately skilled. At the provincial level, there were financial management capacity weaknesses and the Bank FM team worked with the PMU to undertake a stock-taking of financial management capacity in the provinces and to develop and implement training programs for Provincial PMU finance staff, and to undertake regular review and monitoring of the provincial financial management activities and reports. Assistance was provided to the project to produce detailed and practical guidelines for the provincial accounting and reporting to support more timely disbursements, accounting and reporting. The major issue throughout the life of the project was the complicated hierarchy of authority within the various Departments of the Ministry of Health and the high staff turnover in such departments, which caused delays in approvals that affected disbursement progress. Delays in approvals continued to impact on the completion of the project with the selection of the independent auditor and signing of the audit contract for the final audit of the project delayed more than six months. 11
2.5 Post-completion Operation/Next Phase Since project completion, available primary health care services have improved. The CHCs and DHCs are being utilized, health care workers have benefited from training and capacity-building activities completed. Maintenance however remains a problematic issue. The TB and Malaria programs continue to perform well. Additional financing for these programs has been successfully mobilized from other sources such as the Global Fund. ARI management is now integrated into the PHC service network. This project generated a lot of lessons, which have been applied to subsequent Bank projects such as (1) the adoption of a more focused regional approach to addressing health sector issues, (2) increased focus on supporting demand-side interventions in subsequent Bank projects; and (3) increased involvement of provincial level authorities in the design and implementation of the project. Government and Bank have adopted these lessons into the new operations. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation The project was highly relevant at the time of its design and still remains so at the time of this ICR, primarily because it addressed some of the key issues affecting the health sector. At the time of the project design, the health infrastructure in Vietnam was in rapid decline following the decrease in available financing for basic health services. Improving the quality of basic services was important to support the revitalization of the health system and improve services. The project objectives still reflect strategic priorities and vision of the government for the health system as outlined in the objectives of the Comprehensive Development Design for the Health System in Vietnam to 2010 and vision by 2020. 3.2 Achievement of Project Development Objectives Overall Rating: Moderately Satisfactory The objective of the project is to assist the borrower in improving the health status of the rural population in the poorer areas of Vietnam by (i) providing high quality, reliable primary health care on a sustainable basis; (ii) reducing mortality and morbidity due to malaria, tuberculosis and acute respiratory infections; and (iii) strengthening the institutional capacity of MOH and provincial health departments to meet the basic health care needs of the poor. Despite data limitation and the problem of attribution, based on the available information, achievement of the specific project development objectives is rated Moderately Satisfactory overall. Although not directly attributable to this health sector intervention, rural health status as outlined in the overall project objective has improved 2, as illustrated in the table below. 2 Gwatkin et al, Socioeconomic Differences in Health Nutrition and Population: Vietnam. April 2007 12
Vietnam Year IMR U5MR TFR Rural 1997 36.6 48.3 2.5 2002 26.9 35.6 2.0 The project s contribution to this was through its focus on specific provinces which are largely poor and rural. The investments at the CHC and VHW level health services, which are more pertinent in rural areas, also helped ensure that poor rural communities were the major beneficiaries of the investments. Most of the results and outcomes were achieved and some exceeded the targets. At the same time, the project faced important implementation challenges and the M & E framework could have been strengthened significantly. Thus, and as will be noted below, the overall rating of the project is Moderately Satisfactory. Given the unique nature of each individual component, independent assessments of their achievements are reflected below: Component 1: Moderately Satisfactory The project improved the quality of available primary health care services within the specific provinces in the country. The investments in the CHCs, where the poor access basic services and which serve as point of convergence for preventive and curative services for the poor, helped ensure that residents of the target communes had access to CHCs that could provide basic care. The report from beneficiary assessment supported the fact that the quality of services provided in the CHCs was perceived to have improved as a result. It is also noteworthy that the approach adopted by the project helped create a safety net against the potential collapse of primary health care services with the economic and institutional changes that were taking place in country. An evaluation of the impact of project investments using data from the NHS reported that, compared to matched nonproject provinces (which also received other investments), the CHCs in the project provinces had better quality in terms of infrastructure, staff skills and morale, and capabilities for performing basic functions. However, poor maintenance of the facilities remained a threat to long term sustainability of the improved quality of care. CHCs built by the project were often in worse state, requiring more repairs, compared to those in matching communes. The government has since introduced new measures like the health fund for the poor and increased supervision of CHCs by the Local People s Committee, to provide financial support and new financing mechanisms for basic health services as well as improved oversight of CHC management. Secondly, the project through its well-targeted focus on poor areas of the country improved the quality of health infrastructure available in some of the poorest areas of the country thus creating a more equitable coverage of quality primary health care. There was increased confidence of the local people in the quality of the commune health centers in project areas (although an evaluation survey reported that the CHCs in the minoritydominated communes fared worse in terms of quality compared to those where the Kinh ethnic group formed the majority). This led to an increased utilization of project health centers (10% more than in matched, non-project health centers, which had also received investments from other sources in the same interval). This increase however, was mostly 13