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Evaluation of the Primary Health Care Project in the Lao People's

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Evaluation of the Primary Health Care Project in the Lao People's ASIAN DEVELOPMENT BANK Operations Evaluation Department PROJECT PERFORMANCE EVALUATION REPORT IN THE LAO PEOPLE’S DEMOCRATIC REPUBLIC In this electronic file, the report is followed by Management’s response. Performance Evaluation Report Project Number: PPE: LAO 25109 Loan Number: 1348-LAO(SF) May 2006 Lao People’s Democratic Republic: Primary Health Care Project Operations Evaluation Department Asian Development Bank CURRENCY EQUIVALENTS Currency Unit – kip (KN) At Appraisal At Project Completion At Operations Evaluation (August 1994) (October 2000) (April 2005) KN1.00 = $0.0014 $0.0001262 $0.0000952 $1.00 = KN715.00 KN7,920.00 KN10,500.00 ABBREVIATIONS ADB – Asian Development Bank BME – benefit monitoring and evaluation EIRR – economic internal rate of return IMR – infant mortality rate Lao PDR – Lao People’s Democratic Republic MDG – Millennium Development Goal MMR – maternal mortality rate MOPH – Ministry of Public Health NGO – nongovernment organization OEM – Operations Evaluation Mission PCR – project completion report PCU – project coordinating unit PHC – primary health care PHCEP – Primary Health Care Expansion Project PIO – project implementation office PPTA – project preparatory technical assistance RDF – revolving drug fund TA – technical assistance TB – tuberculosis U5MR – under-5 mortality rate UNDP – United Nations Development Programme NOTE In this report, “$” refers to US dollars. Director General B. Murray, Operations Evaluation Department (OED) Director R.K. Leonard, Operations Evaluation Division 1, OED Team leader S. Tamondong, Evaluation Specialist, Operations Evaluation Division 1, OED Team members C. Infantado, Portfolio Evaluation Officer, Operations Evaluation Division 1, OED I. de Guzman, Senior Evaluation Assistant, Operations Evaluation Division 1, OED B. Cafirma, Evaluation Assistant, Operations Evaluation Division 1, OED Operations Evaluation Department, PE-683 CONTENTS Page BASIC DATA iii EXECUTIVE SUMMARY v MAP ix I. INTRODUCTION 1 A. Evaluation Purpose and Process 1 B. Project Objectives 1 II. DESIGN AND IMPLEMENTATION 3 A. Formulation 3 B. Rationale 3 C. Cost, Financing, and Executing Arrangements 4 D. Procurement, Construction, and Scheduling 5 E. Design Changes 5 F. Outputs 5 G. Loan Covenants 8 III. PERFORMANCE ASSESSMENT 8 A. Overall Assessment 8 B. Relevance 8 C. Effectiveness 8 D. Efficiency 10 E. Sustainability 10 IV. OTHER ASSESSMENTS 12 A. Impact 12 B. ADB and Borrower Performance 14 C. Technical Assistance 15 V. ISSUES, LESSONS, AND FOLLOW-UP ACTIONS 16 A. Issues 16 B. Lessons 16 C. Follow-Up Actions 18 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. A local team with three consultants Sounthoune Nanthavongdouangsay, Siphone Sitthavongseng, and Kongkheo Darasavong assisted during field work, and staff health consultant Stanley Zankel worked for 10 days. Marjelou Realuyo-Castillo assisted with survey analysis at the headquarters. To the knowledge of the management of OED, there were no conflicts of interest of the persons preparing, reviewing, or approving this report. APPENDIXES 1 Operations Evaluation Mission Survey Information 19 2 General Profile of Primary Health Care Centers in Xieng Khouang and Oudomxay 20 3 Matrix of Survey Results 24 4 Detailed Rating 34 5 Economic Evaluation 49 6 Household Survey 1996, and National Health Survey 2001 54 7 Progress on the Achievement of Millennium Development Goals 55 8 Outcomes and Delivery 58 9 Primary Health Care Centers in Oudomxay 59 Attachment: Management Response BASIC DATA Primary Health Care Project (Loan 1348-LAO[SF]) Project Preparation/Institution Building Person- TA No. TA Project Name Type Months Amount Approval Date 1947 Essential Drugs Project PPTA 8 $250,000 9 Sep 1993 2291 Strengthening the ADTA 36 $800,000 19 Jan 1995 Ministry of Public Health 5692a Facilitating Capacity RETA – $300,000 19 Jul 1996 Building and Participation Activities As Per ADB Loan Key Project Data ($ million) Documents Actual Total Project Cost 6.25 5.32 Foreign Currency Cost 3.68 3.20 Local Currency Cost 2.57 2.12 ADB Loan Amount/Utilizationb 5.00 4.48 ADB Loan Amount/Cancellation 0.22 Key Dates Expected Actual Management Review Meeting 20 Jun 1994 Appraisal 5–23 Jul 1994 Loan Negotiations 17–18 Nov 1994 Board Approval 19 Jan 1995 Loan Agreement 17 Feb 1995 Loan Effectiveness 18 May 1995 4 May 1995 Project Completion Apr 2000 Dec 2000 Loan Closing 31 Oct 2000 6 Dec 2001 Months (effectiveness to completion) 59 68 Borrower Lao People’s Democratic Republic Executing Agency Ministry of Public Health Mission Data Type of Mission No. of Missions Person-Days Fact-Finding 1 76 Appraisal 1 76 Inception 1 8 Project Administration Review 9 87 Special Loan Administration 2 26 Midterm Review 1 34 Project Completion 1 24 Operations Evaluationc 1 80 – = unreported, ADB = Asian Development Bank, ADTA = advisory technical assistance, PPTA = project preparatory technical assistance, RETA = regional technical assistance. a Fifteen ADB operational activities involving 11 developing member countries, including Lao PDR, received support. Each supported activity received $16,500, on the average. b The loan amount was equivalent to SDR3,404,000 at the time of approval, and SDR3,232,426.24 at loan closing. The cancelled portion of the loan amounted to SDR171,573.76. c The Operations Evaluation Mission comprised Susan D. Tamondong, evaluation specialist (mission leader); a survey team with three local consultants (Sounthone Nanthavongdouangsy, Siphone Sitthavongseng, and Kongkheo Daravasong); and a staff consultant for 10 days. v EXECUTIVE SUMMARY The Primary Health Care Project was a $5.3 million Asian Development Fund loan approved on 19 January 1995 as the first Asian Development Bank (ADB) health intervention in the Lao People’s Democratic Republic (Lao PDR). It was aimed at supporting the Government’s health policy, adopted in 1993, to improve basic primary health care (PHC) services particularly in the villages. The Ministry of Public Health (MOPH) was the Executing Agency, and seven related institutions formed the project coordinating unit. The Project used a pilot approach in the two mountainous northern provinces of Xieng Khouang and Oudomxay, where project implementation offices (PIOs) were set up to monitor the Project. The main objective of the Project was to improve the quality of life in the rural areas of Lao PDR by reducing the mortality and morbidity caused by diseases that can be prevented or easily treated. The specific objectives were to (i) establish PHC services in the villages and thus improve access to basic curative and preventive services; (ii) improve the quality of care from both public and private sector providers; and (iii) improve the quality of drugs available to consumers. A technical assistance (TA) of $800,000 was attached to the loan during the first 2 years of the Project to (i) assist in the implementation of the Project, (ii) improve the skills of peripheral health workers through in-service training, and (iii) spread the benefits from the Project to the rest of the country. In addition, a regional capacity-building TA (5692: Strengthening the Ministry of Public Health) linked to the Project (i) studied community perceptions of health centers (overall satisfaction, use of the centers, drug prices and availability, informal payments, treatment by health workers, and suggested improvements in services); and (ii) assessed issues related to health workers (recruitment, assignment, deployment, housing and agricultural land provided, training received and planned, and supervision), as well as issues related to recording and reporting, difficulties with improvements in the health centers, the revolving drug fund, and the need for more female staff. The Project was completed in December 2000 and the $0.22 million undisbursed balance was cancelled when the loan closed in December 2001. The Project was carried out according to ADB’s operational strategy and the health policy of the Lao PDR. The design was relevant at the time of preparation and at appraisal. The involvement of other organizations in the early stages and during implementation contributed to the success of the Project and the achievement of its broad, as well as specific, objectives. The Project built 73 primary health centers and 3 district hospitals, renovated 5 other hospitals, and supported a public health school in Oudomxay. It trained close to 6,000 health workers and staff, most of whom are still in their assigned posts. The revolving fund established to maintain the supply of drugs in the health centers is functioning efficiently. Supervision by the PIOs continues, and MOPH has maintained its budget. Project outputs were completed on time and implementation went smoothly. MOPH implemented phase 2 of the Project with the help of lessons from phase 1. The Project and the two associated TAs are rated as successful. The Primary Health Care Project in Lao PDR helped improve the quality of life in the remote northern rural communities and made people more aware of modern medicine, reproductive health, the prevention of common diseases, and the importance of hygiene. Its positive impact on health conditions and practices in the target areas, as a result of easier access to basic health facilities and services, has been significant, although the benefits cannot be quantified due to a lack of benefit monitoring. However, qualitative interviews
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