ICRR 11127 Report Number : ICRR11127 ICR Review Operations Evaluation Department 1. Project Data: Date Posted : 02/07/2002 PROJ ID : P008253 Appraisal Actual Project Name : Health Services Project Costs 16.01 15.05 Rehabilitation US$M ) (US$M) Country : Albania Loan /Credit (US$M) Loan/ US$M ) 12.4 11.85 Sector (s): Board: HE - Health (85%), Cofinancing Central government US$M ) (US$M) administration (15%) L/C Number : C2659; CP852 Board Approval 95 FY ) (FY) Partners involved : Closing Date 03/31/2000 03/31/2001 Prepared by : Reviewed by : Group Manager : Group : Timothy A. Johnston Ronald S. Parker Alain A. Barbu OEDST 2. Project Objectives and Components a. Objectives The project sought to prevent deterioration in health status during economic transition by improving the quality of basic preventive and curative health services, including : upgrading selected primary and secondary facilities to minimum sanitary and physical standards; strengthening treatment skills of hospital physicians and nurses; and building capacity at the central and district levels to manage health resources and implement sectoral reforms . b. Components Project components included: Health services rehabilitation ($12.4 million): including rehabilitation of 100 primary health care centers in six pilot districts; rehabilitation of two major district hospitals, and development of masterplans to transform them into regional hospitals; and support for facilities maintenance; Capacity building ($3.6 million): including (a) establishing an inservice management training program for district health teams; (b) training for hospital nurses and physicians; (c) strengthen the capacity in the Ministry of Health for (i) health planning and financing; and (ii) developing a pharmaceutical policy; (d) support for the project coordination unit. c. Comments on Project Cost, Financing and Dates The project was not formally restructured, but civil unrest in 1997 and the Kosovo war contributed to delays and modifications in some activities. The project was extended one year . 3. Achievement of Relevant Objectives: The project achieved most of its relevant objectives . As the first Bank health project in a country with weak capacity, project design was kept simple . Most of the physical objectives were achieved : 99 of the planned 100 health clinics were upgraded, and the project contributed to improvements in facilities and infrastructure in the two target hospitals . The project also supported development of hospital Master Plans, which may assist in planning future investments . The capacity building component successfully established an inservice training program for district staff, supported upgrades to nurse training centers (to complement training support provided by the Swiss ), and financed physician training in emergency care and diagnostic techniques . While the project did not attempt to promote major sector reforms, some of the technical studies sponsored by the project may help inform future reforms . A drug pricing and reimbursement study was completed in 1996, but was not followed up due to outbreak of civil unrest . Subsequently, funds were reallocated to financed technical studies on : public perceptions of the health care system; hospital management; and health services financing (including development of a National Health Accounts framework ). 4. Significant Outcomes/Impacts: Support for training in management of basic health services was among the most successful outputs . Initially, 160 district health officers attended two -week management training courses, sponsored by the MOH . Retaining skilled trainers proved difficult at prevailing government wages, however . So the MOH and ministry of education jointly developed an innovative training program, which hired local and international trainers on a contract basis to teach the courses, with technical support from the University of Montreal (financed by CIDA). This model appears to be sustainable, and over 60 additional district health staff have received training so far . In addition, the study on public perceptions of the health care system played a key role in promoting the importance of patient's rights in the MOH . It is also worth noting that the project completed most of its physical objectives, and contributed to capacity building and policy development, despite a difficult institutional context and a period of civil unrest . 5. Significant Shortcomings (including non-compliance with safeguard policies): Lack of effective maintenance arrangements, plus constraints on recurrent costs (due to lack of progress in downsizing), places physical investments at risk . Although government agreed during project design to close underused rural health clinics in the pilot districts, and to downsize selected districts hospitals, this did not happen . Project design underestimated both the political and technical difficulty of downsizing . Although a Swedish firm provided quality technical assistance to strengthen hospital maintenance, due to limited interested (in one hospital) and high staff turnover (in both), the impact was limited. Developing an effective drug policy remains a priority (although USAID may provide financing ). With regard to training, the Faculty of Medicine failed to complete a planned training needs assessment . Although project design identified some key health and outcome indicators, it did not specify who was to collect and analyze these indicators, or allocate resources for undertaking M&E . As a result, there is little evidence regarding the impact on project investments on service quality, utilization, or health outcomes. 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Satisfactory Satisfactory The project achieved most of its stated objectives, but lack of progress on maintenence and downsizing poses a risk to investments. Weak M&E means there is limited evidence on impact. Institutional Dev .: Modest Modest Sustainability : Likely Likely Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Satisfactory NOTE: NOTE ICR rating values flagged with ' * ' don't comply with OP/BP 13.55, but are listed for completeness. 7. Lessons of Broad Applicability: Achieving effective rationalization /downsizing of clinics and hospitals is politically and technically difficult . Preparation of regional or national investment plans may be necessary, but require adequate "buy in" from stakeholders; Project efforts to strengthen the hospitals' capacity for maintenance management would have benefited from more extensive technical assistance, as well as integration into a more comprehensive hospital management training program; To increase the influence of technical studies, adequate time and resources need to be allocated for dissemination and discussion of findings and recommendations with government and stakeholders . The collection and analysis of project indicators often requires substantial technical support, particularly when national M&E systems are weak. 8. Assessment Recommended? Yes No 9. Comments on Quality of ICR: The ICR provides a concise summary of the project's accomplishments and shortcomings, and draws thoughtful lessons from project experience .