Health and Population Project (Loan 1316-RMI[SF]) in the Marshall Islands

Performance Evaluation Report PPE: RMI 26322 Health and Population Project (Loan 1316-RMI[SF]) in the Marshall Islands December 2005 Operations Evaluation Department Asian Development Bank ABBREVIATIONS ADB – Asian Development Bank BPHC – Bureau of Primary Health Care CHC – community health council DHSHP – Division of Human Services and Health Promotion DMC – developing member country DPH – Division of Public Health EA – Executing Agency HA – health assistant HC – health center HMIS – health management information system LA – Loan Agreement MCH – maternal and child health care MDG – Millennium Development Goal MMR – measles, mumps, and rubella MOH – Ministry of Health NGO – nongovernment organization OED – Operations Evaluation Department OEM – Operations Evaluation Mission OIHCS – Outer Island Health Care System PAM – Project Administration Manual PAT – Policy Advisory Team for Economic Management PCR – Project Completion Report PHC – primary health care PIU – Project Implementation Unit PSC – Public Service Commission RMI – Republic of the Marshall Islands STD – sexually transmitted disease TA – technical assistance TB – tuberculosis TBA – traditional birth attendant TOR – terms of reference UNDP – United Nations Development Programme UNFPA – United Nations Fund for Population Activities US – United States WUTMI – Women United Together Marshall Islands YTYIH – Youth to Youth in Health NOTE In this report, "$" refers to US dollars. Director General B. Murray, Operations Evaluation Department (OED) Director R. K. Leonard, Operations Evaluation Division 1, OED Team Leader J. Tubadeza, Senior Evalua tion Officer, Office of the Director General, OED Team Member C. J. Mongcopa, Senior Operatio ns Evaluation Assistant Operations Evaluation Division 1, OED Operations Evaluation Department, PE-676 CONTENTS Page BASIC DATA ii EXECUTIVE SUMMARY iii MAP v I. INTRODUCTION 1 A. Evaluation Purpose and Process 1 B. Project Objectives 2 II. DESIGN AND IMPLEMENTATION 2 A. Formulation 2 B. Rationale 3 C. Cost, Financing, and Executing Arrangements 4 D. Procurement, Scheduling, and Construction 5 E. Design Changes 5 F. Outputs 6 G. Consultants 9 H. Loan Covenants 10 I. Policy Setting 11 III. PERFORMANCE ASSESSMENT 11 A. Overall Assessment 11 B. Other Assessments 17 IV. ISSUES, LESSONS, AND FOLLOW-UP ACTIONS 20 A. Issues 20 B. Lessons 21 C. Follow-Up Actions 22 APPENDIXES 1. Project Results/Achievements as per Project Completion Report 24 2. Primary Health Care Issues in the Republic of the Marshall Islands 30 3. Appraisal and Actual Costs 39 4. Results of a Survey of Special Provisions to Support Primary Health Care in the Outer Islands 40 5. Outer Islands Health Centers Built Under the Project 42 6. Assessment of Project Overall Performance 50 7. Vision 2018 Health Targets 52 8. Health Indicators Pre- and Post- Project, 1993 and 2004 53 9. Utilization of Outer Islands Health Centers Built Under the Project 58 10. Accomplished Outer Island Trips 59 The guidelines formally adopted by the Operations Evaluation Department (OED) on avoiding conflict of interest in its independent evaluations were observed in the preparation of this report. Penelope Schoeffel (health and population specialist) and Ellia Sablan-Zebedy (social development specialist) were the consultants collaborating with the OED evaluation team. To the knowledge of the management of OED, there were no conflicts of interest of the persons preparing, reviewing, or approving this report. BASIC DATA Health and Population Project (Loan 1316-RMI[SF]) PROJECT PREPARATION/INSTITUTION BUILDING Person- Amount Approval TA No. TA Name Type Months ($) Date 1833 Preparation of Health and PPTA 10.0 250,000 31 Dec 1992 Population Project 2164 Health Management ADTA 15.0 465,000a 22 Sep 1994 Information System and Health Planning As per ADB KEY PROJECT DATA ($ million) Loan Documents Actual Total Project Cost $7.12 $5.90 ADB Loan Amount/Utilizationb $5.70 $5.23 ADB Loan Amount/Cancellation $0.00 $0.07 KEY DATES Expected Actual Fact-Finding 2–17 Dec 1993 Appraisal 21 Apr–13 May 1994 Loan Negotiations 8–31 Aug 1994 Board Approval 22 Sep 1994 Loan Signing 24 Feb 1995 Loan Effectiveness 25 May 1995 14 Mar 1995 First Disbursement — 4 May 1995 Project Completion 30 Nov 1999 31 Oct 2001 Loan Closing 31 May 2000 30 Jul 2002 Months (Effectiveness to Completion) 54.2 79.7 BORROWER Republic of the Marshall Islands EXECUTING AGENCY Ministry of Health and Environment MISSION DATA Type of Mission No. of Missions No. of Person-Days Fact-Finding 1 60 Appraisal 1 92 Project Administration Inception 1 11 Review 8 131 Country Program 4 74 Special Project Administration 2 18 Project Completion 1 28 Operations Evaluation 1 42 — = not available, ADTA = advisory and operational technical assistance, PPTA = project preparatory technical assistance, SDR = special drawing rights. a Including supplementary technical assistance amounting to $65,000, approved on 23 July 1997. b The original loan amount of SDR3.911 million ($5.7 million) was equivalent to $5.23 million as at loan closing date. EXECUTIVE SUMMARY This report details the findings of an evaluation of the Health and Population Project in the Republic of the Marshall Islands (RMI). This was the first Asian Development Bank (ADB) support for the health sector in the RMI. The RMI comprises 31 atolls dispersed over a vast span of ocean, with a total land area of just under 110 square kilometers. It has a population of 50,840 of whom 70% live in two crowded urban locations (Majuro and Ebeye) and 30% live on small, scattered outer islands. The Marshall Islands was formerly part of the United States (US) Trust Territory of the Pacific Islands (1945–1986), under a United Nations trusteeship agreement. In 1986, the RMI entered into a Compact of Free Association with the US, which expired in 2001. A new 20-year Compact was subsequently negotiated, effective from October 2003. Dependence of the RMI on aid is unusually high among ADB’s Pacific developing member countries (DMCs). The rationale for the project was the poor development results of the high per-capita expenditure on health in the RMI, by Pacific DMC standards ($100 in 1991), despite which the country ranked comparatively low on health indicators. Epidemiological evidence showed that the RMI had a high prevalence of both infectious and chronic diseases. At the time of project formulation (1992–1994), the health and population sector was confronted by four major problems: quality of health services, equity of access to health services, sustainability of health services, and rapid population growth. There was a need to shift the emphasis of health service provision from expensive curative services to preventive services based on a primary health care (PHC) approach. The Project aimed to develop a PHC approach and more effective PHC services in the Ministry of Health (MOH, formerly the Ministry of Health and Environment). This was to be achieved by providing (i) technical support for establishing PHC models and for improving the institutional capacity of MOH; (ii) physical infrastructure for new outer island health centers and specialized health centers on Majuro, plus equipment; and (iii) support for project implementation. Associated technical assistance (TA) was provided to establish a health management information system (HMIS) and to support health planning. The objectives were grounded in the Government’s health and population policies; ADB’s policies for the health and population sector, and its country strategy for the RMI; and the results of the project preparatory TA, which included a health sector study. In formulating the Project, there was insufficient recognition of the likely barriers to success posed by staff shortages in MOH. It was known that the Public Service Commission might not approve the appointment of essential counterpart staff, but it was assumed, incorrectly, that this obstacle could be overcome by attaching covenants to the loan requiring cooperation among government agencies. An overlapping ADB TA and program loan for public sector reform provided policy advice to the Government to reduce public service employment, advice that was not coordinated with the implementation needs of the Project. The project design was based on an overoptimistic assessment of what might realistically be achieved, given the magnitude of the challenges. There were too many objectives and components for the size of the loan, the scope of consulting services, the duration of the project, and local institutional capacity. The Project lacked adequate leadership, and there were weaknesses in implementation. The performance of the consultants was variable, and the contracted consulting companies iv performed below expectation. The attached TA for the HMIS was unsuccessful. The physical infrastructure and equipment components were successfully implemented, although maintenance provisions were unsuccessful. The project provided 26 new outer island health centers and 4 specialized health centers on Majuro, which have improved access to PHC services. The technical support components and provisions for health promotion and population awareness activities achieved few of the expected outcomes and impacts. Although trends in population growth, life expectancy, and infant mortality rates improved in the intercensus period 1988–1999, it is unlikely that these were due to the Project, as most of its components were not completed until 1998–1999 or later. Although public health education and outreach programs encouraged by

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