Findings Good Infobrief Practice Africa Region Number 127 · · August 2006 Findings Infobriefs reports on Good Practice in ongoing operational, economic and sector work carried out by the World Bank and its member governments in the Africa Region. It is published monthly by the Operations Results and Learning Unit on behalf of the Region. The views expressed in Findings are those of the author/s and should not be attributed to the World Bank Group. Mozambique: Health Sector Recovery Program TheHealthSectorRecoveryProgram(HSRP)­1996-2003-wasthefirstBank-assistedprojectinMozambique tomovetowardsasector-wideapproach.ItsobjectivewastosupporttheMozambicanNationalHealthStrategy, i.e. «the improvement of the health status of the population, in general, and a decrease in infant and child mortality in particular.» The HSRP helped bring together the Ministry of Health ( MOH ) and 16 other donors to supportonecoherentstrategy.IDA'sshareofthetotalassistanceofUS$355.7millionwasestimatedatUS$98.7 million over a period of 5 years. While improvements in health outcomes during the period are the result of the total investment program, the following refers only to those components funded by IDA, i.e. Health Services Delivery,InstitutionalSupportandHumanResourcesDevelopment Impact on the ground · During the program period, infant mortality decreased from 162 per 1,000 to 101 in 2003. · The intra-hospital maternal mortality rate fell from 186 per 100,000 live births in 1995 to 160 in 2002. · The rural hospital network was expanded through the building of one rural hospital at Muxungue ( Sofala province ) and the rehabilitation and expansion of two rural hospitals ( Gurue in Zambezia province and Mueda in Cabo Delgado province ). This represents 25% of the rural hospitals built by the government during the concerned time period and corresponds to reductions, in some instances, of up to 200 km in the distance that a critically ill person has to travel to reach a hospital. · The expanded hospitals were 90% staffed by 2003 and preliminary data from Gurue at project-end indicated that its patient load had tripled. · A kindergarten for low-level female staff was built at the Maputo Central Hospital. · Ninety-four percent of the planned health centers were completed and determined to be satisfactory ­ this represents an increase of 74% over the baseline figures in 1995. These centres were built in 7 provinces chosen for their poor health indicators or a rapid population increase. · Through Bank and other donor involvement, the MOH's ability to manage its drug supply has increased dramatically. A common fund, which uses international tendering, helped to attain economies of scale. There have been improvements in the adequacy and predictability of medical supplies ­ the country has had no stock-out of chloroquine in 5 years and no stock-out of Fancidar in 3 years. · IDA financing was used to purchase tools and spare parts and to train workers through government mainte- nance training centers. The National Maintenance Program has helped the government: (i) formulate a national maintenance policy; (ii) develop a standard equipment list; (iii) install an equipment inventory and The Good Practice Infobrief» series is edited by P.C. Mohan, mail stop J-8-811, Operations Results and Learning Unit, World Bank, 1818 H Street NW, Washington D.C., 20433. Tel. (202) 473-4114; e-mail: pmohan@worldbank.org maintenance information system; and (iv ) install a Local Area Network of computers with internet access that hosts the equipment databases and has improved communication with the provinces. · Maintenance has been decentralized with the creation of provincial and rural hospital maintenance ser- vices. Mid-level engineers have been added to rural hospitals and 3-5 equipment technicians have been added per province. MOH capacity to undertake repairs at the local level has been enhanced and this has reduced equipment downtime. · The network of warehouses for drugs and pharmaceutical supplies was improved through the building or rehabilitation of warehouses in Beira, Pemba and Lichinga; each warehouse has computers linked to a countrywide network that tracks shipments and inventory. · A total of 2,543 professionals were trained by MOH through 84 health professional courses, exceeding the goal of 48 courses. · The MOH rehabilitated, expanded and outfitted 3 high-level training institutes and 2 medium-level training centres. The project helped train 14% of all the current clinical staff and greatly improved the quantity and quality of human resources for health in the country. · The Program Management Unit ( GACOPI ) has corrected its financial management problems, established 2 regional offices for better monitoring of contracts, and out-sourced procurement. · Over the program period, GACOPI has been providing services to 9 other projects supported by 7 financiers; as a result, it has developed economies of scale and its operating costs represent 4.75% of total investment costs, an excellent performance compared to similar organizations. Lessons learned · In post-conflict situations, the difficulty of ensuring full government ownership, combined with support from multiple donors should not be under-estimated ; adequate time and resources should be allocated during project preparation to meet this challenge. · Sector-wide approaches increase the efficiency and speed of implementation for the government through the harmonization of procurement, supervision and reporting procedures. · The movement from projects to SWAps creates new requirements in monitoring and evaluation. Careful attention should be paid to the design of monitoring and evaluation systems, including the choice of appro- priate indicators, the establishment of a baseline, the balance between routine data collection and periodic surveys and the inclusion of M&E specialists in the program management team. This Infobrief has been excerpted from Implementation Completion Report No. 26963. For more information, please e-mail Jean-Jacques De St. Antoine: Jdestantoine@worldbank.org. Persons accessing the Bank's external and internal website can get more information on Health, Nutrition and Population by clicking on Topics.