AFRICAN DEVELOPMENT BANK GROUP

UGANDA

MBALE HOSPITAL REHABILITATION PROJECT

Project Performance Evaluation Report (PPER)

OPERATIONS EVALUATION DEPARTMENT (OPEV)

3 January, 1997 TABLE OF CONTENTS

1. Project Background and Formulation 1 2. Goal and Objectives 1 3. Implementation Performance 2 4. Performance of Borrower, Executing Agency and the Fund 5. Sustainability of the Project 6. Assessment of Performances and Achievements 7. Conclusions, Lessons and Recommendations

Annexes Number of Pages

I. Selected Basic Data 1 II. Project Matrix 1 III. Performance Ratings 5 1. PROJECT BACKGROUND AND FORMULATION

1.1 The present abridged project performance audit report (PPAR) is a post-evaluation of the Hospital,Rehabilitation project in . The project was in keeping with the Uganda Government’s 1996-1989’Investment Programme, whose main objective was to meet the urgent demand of the population for health services which had seriously deteriorated during the civil war. The project was identified by the Government itself. In 1986, the ADF carried out only one mission, to prepare and appraise the project. In March 1987, the Fund approved a loan of UA 3.52 million for its financing. The total project cost amounted to UA 3.90 million. The,loan agreement signed in June 1987, became effective in December 1987. The project was completed in December 1992.

1.2 The Project Completion Report (PCR) was prepared in March 1995. The quality of the PCR was deemed satisfactory. It dealt satisfactorily with all the aspects concerning the project cycle and the assessment of its performance. The’ abridged PPAR is based on the review of the PCR and the archives’ documents on the project, including the Project Appraisal Report. The PPAR completes and upda& the information contained in the PCR, especially with regard to the internal efficiency of the health system and the sustainability of the project.

2. GOti, OBJECTIVES AND RESULTS

Goal and Objectives

2.1 The project aimed at rehabilitating and improving the health care delivery system in Uganda. The country’s specific objective was to improve primary and secondary health care for both the peripheral areas as well as in the catchment area of the through the rehabilitation of the health infrastructure and training institutions.

Results

2.2 The project’s outputs are operational since July 1992. Two hundred agents from the Ministry of Health were trained in various disciplines under the project. The rehabilitation and furnishing of the Masaba Wing concerned the administration, out- patient and in-patient services, general services, the drainage system and uncovered walkways covering an area of 3069 m2 instead of 2189 m2 projected at appraisal. This major modification was implemented without cost overrun thanks to the following factors: (a) good project management by the Implementation Unit, (b) domestic and international rates of inflation much lower than could have been forecast, (c) the filling of the post of Project Coordinator by a regular member of staff of the Ministry of Health, instead of a technical assistant, and (d) the inclusion; as Government counterpart item, of the operating cost related to the Project Implementation Unit (PIU) into the Ministry of Health’s budget (PCR para. 4.2.3). Equipment and furniture purchased are modern and of good quality. The savings of UA 0.30 million realized from project implementation was used to do additional construction and equipment works, namely: an additional emergency room, a room for physiotherapy, a 2 mortuary, a kitchen, a laundry room, toilets, fences, a drainage system, covered walkways, an additional administration unit to the Masaba Wing, and a medical equipment maintenance unit.

2.3 The lack of detailed data on the health system at the time of appraisal was a barrier to the precise assessment of the project impact in the affected area. Nevertheless, the only basic health indicators available for the country in 1987 and 1994 show an improvement in the status of health care of the population. If the major causes of death and morbidity remain largely the same as at the project appraisal time, infant mortality however, has declined from 120 to 110 per thousand live births, and life expectancy at birth has increased from 43 to 47 years. Since the levels of these indicators in the’ are similar to those of the country as a whole for recent years, it is reasonable to assume that the same was the case at the time of the project appraisal, and therefore that the state of health care of Mbale District population has equally improved.

3. IMPLEMENTATION PERFORMANCE

3.1 All the conditions prior to first disbursement were fulfilled within the scheduled timetable. The procurement of goods and services was done in accordance with the applicable ADF procedures, without any particular difficulty. The major modifications requested and obtained by the Government were for the extension of the construction perimeters and the transfer of a qualified staff member of the Ministry of Health to the post of Project Coordinator instead of recruiting a technical assistant. The latter contributed substantially to the realization of savings mentioned above (PCR para. 4.5.3). Delays encountered with regard to disbursements were mainly due to incorrect information provided on the disbursement request applications and/or to the latter being sent to the wrong destination.

3.2 Construction works started with an eighteen-month delay, mainly due to an underestimation of the initial implementation schedule, notably with regard to the dates of assumption of duties by the Project Coordinator and the launching of the tender documents that the latter was responsible for organizing.

4. PERFORMANCE OF BORROWER, EXECUTING AGENCY AND THE FUND

4.1 There was no Government policy decision that had an adverse effect on project implementation. The Project Implementation Unit managed the project in a very effective manner, despite a somewhat slow project start-up, owing to its inexperience with the ADF rules and procedures and project implementation. (PCR para. 9.2.2).

4.2 ADF performances were considered satisfactory. However, project preparation was inadequate to the extent that it was not possible to assess, at the appraisal time, available health facilities in the catchment area and to define patient referral services required to strengthen the health care system. ADF undertook 5 supervision missions during the 7 years of project execution, which thus enabled the resolution of some problems that emerged during the period of intense activities of the project. However, ADF responses were slower when problems arose that were to be resolved from the Bank Headquarters. 5. SUSTAINABILITY OF THE PROJECT

The Government is a signatory to the Alma Ata Declaration on primary health care which it adopted as a strategy for providing health care for all by the year 2000. It put in place a management committee at the Masaba Wing aimed at designing and making operational a ‘system of cost recovery with the view to cover shortfalls in the Government budget With regard to recurrent expenditures. The rate of utilization of the hospital health care: services, in particular the bed occupancy rate at .the Masaba Wing, should improve to this end. The project was consistent with the Government’s Three-Year Health Care Development Plan (1993-95), which had put an emphasis on the necessity for increased decentralization of health care services at the district level and the increased availability of financial resources to provide efficient health care services, up to the country’s most remote rural health facilities. In the area of drugs, the Government plans, though the new organ, the ” National Drug Authority”, to promote the permanent availability of essential, efficient and affordable drugs for the population throughout the country. The Ministry of Health personnel in charge of the project is competent and therefore capable of ensuring the project’s technical viability. The construction, at Mb+ of a unit. for the maintenance of hospital equipment and medical infrastructure for the regions surrounding the project areas will also contribute to ensuring the sustainability of the project.achievements. The constructions and equipment are of very good quality and their maintenance was up to now well provided for. Finally, Phase II of the Mbale Regional Hospital project was approved in 1993. The Government intends, furthermore, to put in place an efficient health care information system throughout the country starting from 1996.

6. ASSESSMENT OF PERFORMANCES AND ACHIEVEMENTS

6.1 The project is deemed of good quality overall, in view of the fact that the health care system had broken down at the time of appraisal. It was generally well appraised and met, to a large extent, the requirements of the Government of Uganda. with respect to the improvement of health care services through the rehabilitation of the Mbale Hospital. In spite of a slow start-up, the project was implemented very well because of the good quality of communication between the Borrower, ADF and the other partners of the project, but also because of, the adherence to ADF rules and procedures and the competence of the PIU personnel.

6.2 The effort at the decentralization of resources at -the level of the Districts and the Project Implementation Unit’s good management provided satisfactory environment for the implementation of the project. The experience gained by the PIU in the areas of project design and supervision from the consultant has enabled it to install alone an equipment maintenance unit. Staff training and the procurement of medical equipment of international standard have also contributed to a satisfactory transfer of technology. However, efforts should be made to correct the bias that exists in the distribution of health care personnel in favour of urban areas and hospitals.

6.3 The prospects for sustainability are good as indicated in paragraph 5.1, but a doubt still exists with respect to the low rate of ,utilization of health care services put in place. The revenue generated by the project achievements, in particular the Masaba Wing, is still inadequate in relation to projections. 4 7. CONCLUSIONS, LESSONS AND RECOMMENDATIONS

4 Conclusion

7.1 The project is thus considered generally to be satisfactory. It has achieved its specific objectives within the estimated budget allocation limits, with savings that were used for the execution of additional activities, of which the medical equipment maintenance unit. Constructions carried out and equipment purchased were of good quality. The project has contributed to the improvement of the Mbale District health care system through the rehabilitation of health infrastructure that was run down following the civil war, the establishment of a maintenance unit and of the’training of health care staff.

b) Lessons

7.2 The PCR lessons dealt with : i) the project’s success and the availabiIity of competent personnel at the Ministry of Health; ii) the reduction in the number of issues during the execution of the project and the sustained number of missions; iii) the resolution of problems related to recurrent budget expenditures and the introduction of a cost recovery mechanism in the health system; and iv) the difficulty in assessing the impact of the project on the health care system and the absence of adequate project preparation.

7.3 The review of the PCR made it possible to draw the following additional lessons : i) the introduction of a good tariff system for cost recovery can generate adequate revenue to cover the basic requirements such drugs, transport, food and thus provide a solution to budget difficulties related to recurrent costs; ii) the project impact assessment is difficult when detailed statistical data on the health care system is not available at the time of the project appraisal; iii) the financial capacity of contractors is one of the key factors in meeting the project implementation schedule; and iv) project execution is without hinderance when ADF rules and procedures are adhered to by the various project partners and communication between all parties is fine.

d Recommendations

7.4 The PCR’s recommendations are of interest to the Bank Group which should : i) encourage Governments to introduce a cost recovery mechanism in the health care systems, with the view to forestall recurrent budgetary expenditures difficulties; ii) provide technical assistance to member countries during the start-up phase of projects in order to avoid implementation delays; iii) put an emphasis on the preparatory stage of the projects’ cycle before their appraisal ; and iv) ensure the dispatch of a minimum of two supervision missions per year during the implementation of projects.

7.5 Additional recommendations relate to the Government of Uganda which should : i) review the tariff system regarding the provision of medical services with the view to putting it at the disposal of the entire population concerned, by introducing affordable prices for all or differentiated prices according to incomes; and ii) develop a health care information system throughout the country with the view to improving health care management and the rationality of related decision making. . Annex 1 . Page 1 of 1

SELECTED BASIC DATA Country . UGANDA Project . Mbale Hospital Rehabilitation Project Loan Number : ‘F/CS/UG/H/87/20 Borrower . The Government of the Republic of Uganda Executing Agency : Project Implementation Unit, MOH

A LOAN APPRAISAL ESTIMATE ACTUAL Amount: (UA/Million) 3.52 3.52 Approval Date 23103187 Signature Date 11/06/87 Date of Entry into Force 16112187 Date of First Disbursemeht 30/06/88 31/12/88 Date of Last Disbursement 3 l/12/90 30/06/95

B. PROJECT

Total Cost (UA million) . 3.90 3.60 Source of Financing (UA million) :

Source ADF . 3.52 3.52 Gvt. . 0.38 0.08

Imnlementation Period . 32 months 98 months

&I& Reference

Date and Reference of PCR . March 1995i

C. PERFORMANCE INDICATORS

Cost Overrun . Savings :UA 0.30 million 2 Time Overrun . 66 months Overall Project Performance . Satisfactory Implementation Performance . Satisfactory Performance of ADF . Unsatisfactory

c$ISET-kg-OUGAPARE

’ The PCR was prepared but has not yet been presented to the Boards.

2 Including 38 months of additional works . Annex 2 Page 1 of 1

Project : Mbale Hospital Rehabilitation, Uganda PROJECT MATRIX

Narrative Description (WI) ObJecUvely Verlflable IndIaton (OW Meana of Valf!-mUon 0 MaJor Awmpllon~

ProJccl ObJectlve: I. To tnpmn, primary WI f.cadnry hcnllh care sclviae in Uw catdvlrn areas of Mtak Hospital (apptmimalcly 7CKl,@Kl inbnbilanla)

Achlcwmenlr: I. Renovation nnd cvrsmxtion of Mbals Hospital : lk Mn&e wii

2.1 ef,. lii~ in Anwx VI of tk Appmisal Report 2. Efftiivc 2. Pmgmas, Sqxtiicm ani Canpktica Rqwrb Programmc of Hoepiti E&d- F.cpair. 3.1 -do- 3. _ d0 - 3. mckti Pmgraznms for lhz MaintiM of Fumi&-e atxl Gaxal Equiporfl 4.1 Project mmdirwtor 4. - d0 . 4. tnamix Policks dMuSuMilI Favour of Staff. 5.1 xl0 tmid slaa 5. -dO- 5. ENeaivc UIiliilka of tminri hcsllb staff.

Actlrllles: Resou~a: 1.1 ScniMn nrd lclraining cswmcd 1. Pmgnss, supcl-vkiorl Pmgluu supcNi8ias ard I. Adbzrnre to ACTUAL PROJECT COSTWA millim): Canpklim Reinlu, Gmnl Cmdiliau of .%xninm 0.019 ADF De.+0 & Suporviaion 0.386 2.1 Conocption and Supxvision Con3wcticm 2.407 Medico) Quipnu 0.680 2. Rsgukr l3cm-d Equipmcrl end Lwpplicd 0.037 Reiibwcnxa of Tsclmicnl hsistnra . rkbl contnacd from op.mlillg Erpaae3 0.074 ADF 3.1 Ramvalion sod anrtim -- worb T&al C-1 3.602 3. Tiiiy Rccndvo~nl of 4.1 Proawc~t and butallatioo of Compclc~ Tc-zhnial Hmpiul Equipncnt ACTUAL FINANCING PLAN : Apsislancc DEV. LOC. CUR. TOTAL 5.1 ProaJrc*ti of fumilwm awl ADF 3,538 3.518 4. Tii1y gcrwal equipflr,N m-r 0.084 0.084 Rccnrilmcn~ of T& 3.518 0.084 3.6ot Canpclc”l 6.1 Provision of Tccludcal As&tans conlmaon amI COnrldraaU

7.1 Annex 3 Page 1 of 5

PROJECT : REHABILITATION OF MBALE HOSPITAL

PERFORMANCE RATINGS

FORM IP 1 IMPLEMENTATION PERFORMANCE

I I I / Adherence to Time 1 T&e 18-month delay in the start-up of I Schedule construction works was due to wrong estimate of the initial implementation schedule. Additional works extended the implementation schedule ,by 38 additional months. 2 Adherence to Cost 4 Savings was generated on the cost of the Schedule major components. 3 Compliance with 3 Compliance with conditions and Covenants agreements was generally satisfactory. No Government policy decision hindered the execution of the project. 4 Adequacy of 3 The Borrower provided most of the Supervision and status reports. The frequehcy and Status Reports composition of ADF supervision missions enabled the resolution of most of the problems that occurred during ’ project execution.

5 I Satisfactory Operation I 3 I The quality of outputs is satisfactory. 1 (if applicable) 1 I I Overall Assessment of 2.8 The overall Implementation performance Implementation is satisfactory, except;‘ however for Performance delays on the implementation schedule. Annex 3 Page 2 of 5

FORM BP1 PERFORMANCE OF ADF

1 At Project 1 ADF did not actually participate in the Identification identification of the project carried out by Stage the Government. 2 At Preparation 2 A better project preparation would have enabled a better assessment of the implementation schedule, costs and data related to Mbale’s health care system .

3 At Appraisal 2 The project implementation schedule was I I wrongly estimated. The verifiable indicators were not all specified in the appraisal report due to inadequate project preparation. 4 At Supervision 3 The frequency and composition of supervision missions were satisfactory; however a large number of these missions would have enabled to improve the implementation schedule. Overall 2.0 The performance of ADF was generally Assessment of the unsatisfactory. Fund’s Performance Annex 3 Page 3 of 5

FORM PO 1 PROJECT ACHIEVEMENTS

Relevance and Achievement of Objectives 0 Macroeconomic n.a. The macroeconomic objectives do. not appear Policy ex@icitly in the project appraisal and completion reports, but strong links exist with the social objectives: improvement of the quality of work with the‘ ;iew to raising work productivity, etc. ii) Sector Policy Satisfactory Social Project which meet the need to strengthen the country’secondary health care system in line with the Government’s health care policy . iii) Physical ,Physical implementation was made in a Achievements (incl. satisfactory manner, despite major modifications. production) iv) Financial Results 3 Financial agreements were adhered to. The financial management of the project did not pose any particular problem. The Government introduced. a cost recovery system which seems pro&ising.for the sustainability of the project achievements. v> Poverty Alleviation, 3 The achievements of the project contribute to the Social aspects and good’health of the population, hence to the Women in alleviation of poverty. The training of the female development medical personnel was provided for during project implementation. The Masaba wing offers comfortable conditions for delivery, improved pre and post natal services and ‘family planning. vi) Environment The quality of achievements offers a healthy environment for the uatients. vii) Private Sector The project was essentially designed to renovate Development the Masaba private Wing in which patients would pay for medical seryices received: . . . Vlll Other (Specify) : n.a Annex 3 Page 4 of 5 c .

2 Institutional Development

0 Institutional 3 Efforts at decentralizing resources at the district Framework, including level, good management on the part of the Restructuring Project Implementation Unit have provided a satisfactory institutional framework for project implementation.

ii) Financial & 3 The .PCR does not mention any particular Management problem in this area, with the exception of the’ Information Systems, non availability of statistical data at appraisal due including Audit to civil war. Systems iii) Transfer of 3 The experience acquired by the Project Technology Implementation Unit in the area of design and supervision from the consultant allowed it to install alone an equipment maintenance unit. The training of personnel and the procurement of medical equipment of international standard have also contributed to a satisfactory transfer of technology . iv) Staffing by qualified 3 The Project Implementation Unit staff was staff (incl. turnover, competent during the implementation of the training and project. Its efficiency made it possible to achieve counterpart staff) the project without excessive delays and with savings over the initial project cost. 3 Sustainability i)Continued Borrower 3 The Government is signatory to the Alma Ata Commitment Declaration on primary health care which it adopted as a strategy for the pursuit of health for all by the year 2000. It put in place a cost recovery system to counter Government budget shortfalls , ii) Policy Environment 3 No Government decision is unfavorable to the environment . iii) Institutional 3 The institutional framework was satisfactory with Framework regard to the sustainability of the project outcomes. iv) Technical Viability & 3 The Ministry of Health personnel in charge of Staff Training the project is competent and thus capable of ensuring the technical viability of the project.