The World Bank Report No: ISR4593 Implementation Status & Results Liberia Liberia Health Systems Reconstruction (P105282) Public Disclosure Copy Operation Name: Liberia Health Systems Reconstruction (P105282) Project Stage: Implementation Seq.No: 11 Status: ARCHIVED Archive Date: Country: Liberia Approval FY: 2007 Product Line: IBRD/IDA Region: AFRICA Lending Instrument: Emergency Recovery Loan Implementing Agency(ies): Ministry of Health and Social Welfare Key Dates Board Approval Date 14-Jun-2007 Original Closing Date 01-Oct-2010 Planned Mid Term Review Date Last Archived ISR Date 27-Aug-2011 Effectiveness Date 09-Jul-2007 Revised Closing Date 01-Oct-2011 Actual Mid Term Review Date 13-Feb-2009 Project Development Objectives Project Development Objective (from Project Appraisal Document) The revised Project Development Objectives are to: (i) strengthen the policy framework and selected management functions of the Ministry of Health and Social Welfare (MOHSW); and (ii) improve pre-service training and selected components of the basic package of health services. Has the Project Development Objective been changed since Board Approval of the Project? � Yes No Component(s) Component Name Component Cost Support Systems 2.40 Human Resources 2.80 Infrastructure and Equipment 3.30 Overall Ratings Public Disclosure Copy Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Satisfactory Moderately Satisfactory Overall Risk Rating Implementation Status Overview ***This is the last ISR that captures the overall project implementation. The current ratings in the ISR, thus, reflect the overall project implementation and its outcomes, except for Component ratings.*** [Background] Page 1 of 7 The World Bank Report No: ISR4593 Following a 14-year civil war in 2003, Liberia's basic health systems were in ruins, resulting in abysmal population health outcomes. The people and the government of Liberia have made impressive strides since then in consolidating peace and strengthening national authority, yet the challenges for rebuilding the health system continue to be numerous and diverse. For example, as of June 2008, only 32 percent of existing health facilities were providing basic package of health services. A freeze on user fees has reportedly increased access and utilization of services, but coverage of many health services remains low and inequitable, with a concentration of resources in the capital city. This is due mainly to Public Disclosure Copy profound shortages in human resources, lack of support systems, including equipments, supplies and essential drugs, and limited management and planning capacity of the MOHSW. The Health Systems Reconstruction Project (HSRP) sought to provide emergency support to reduce sector's financing gap, which remained even after commitments from the other major donors. Because these donors focus primarily on delivering the basic package of health service (BPHS), the Project intended to address the remaining three pillars of the National Health Policy and Plan (NHPP): support systems; human resources for health; and infrastructure development. The goal was to enable a transition from a post-conflict emergency health delivery system dependent mostly on humanitarian support to a regular health service delivery system through rebuilding the policy framework and key essential management functions of the MOHSW as well as improving pre-service training and selected components of the BPHS. [Implementation Status and Outcomes] While there were some implementation delays initially due partly to limited institutional and management capacity including that of the Bank operations, the pace and quality of project implementation has substantially improved, since the mid-term review and restructuring of the project mainly thanks to streamlined implementation arrangements, better management capacity, and intensive implementation support from the Bank task team. Even though it was the first emergency project supported by the Bank after a long and destructive war, as of September 8, 2011, nearly all planned activities under the Project have been completed and are near completion. a. Policy framework: The key sub-sector policies - in the areas of health financing, human resources for health, and decentralization - have been developed and thereby creating enabling environments to implement the NHPP more effectively and efficiently. The Project has also supported the annual health conferences which bring key stakeholders to evaluate the implementation status of NHPP and to plan the following year's program of work. b. Management function: The project has strengthened two key management functions of the Ministry - procurement and Health Management Information System (HMIS). The project has trained 8 procurement officers including two at the master's level. While further training is required to reinforce their basic trainings and to improve contract management, preparation and updating of procurement plans as well as quality of procurement activities have become much better. Installation of IT and communication equipment as well as training of 5 IT specialists responsible for HMIS and networking have enabled all 15 counties to use computerized ICT system in the production of HMIS reports. c. Pre-service training: The Project has supported various activities of pre-service training such as recruitment of pre-clinical and clinical teachers, procurement of text-books, teaching aids, as well as IT and laboratory equipment, rehabilitation/construction of laboratories and other infrastructure at A.M. Dogliotti College of Medicine, and provision of stipends to students at the Tubman National Institute of Medical Arts (TNIMA). As a result, two certificate programs to train clinical staff of critical shortage (i.e., nurse anesthetist and radiographer) have been re-instituted. Also, annual student enrollment at the College of Medicine and the TNIMA has more than tripled and students at both institutions have benefited from better quality education (e.g., courses with an activity laboratory component and clinical practicum, etc). d. In-service: The Project has supplied medical and laboratory equipment to more than 200 health facilities throughout the country. Also, the Project has recruited about 50 clinical Public Disclosure Copy teachers and staff in areas of critical shortage and placed them to targeted areas. Both ac tivities (along with support from other DPs) have contributed to the availability of the BPHS, which has increased from 32% in 2008 to 84% in 2011. Also, the project has supported the rehabilitation of the 2nd and 3rd floor of East Wing at JFK Medical Center (which is to be completed by end of September) to improve MCH service capacity of JFK Medical Center. Locations Country First Administrative Division Location Planned Actual Liberia Montserrado County University of Liberia Liberia Montserrado County Kennedy Memorial Hospital Page 2 of 7 The World Bank Report No: ISR4593 Results Project Development Objective Indicators Public Disclosure Copy Indicator Name Core Unit of Measure Baseline Current End Target Policy in the area of human resources for Text Value None Submitted for Cabinet Policies submitted to Cabinet: health, health financing, and decentralization of consideration - Human resources for health health services, respectively, submitted to - Decentralization of health Cabinet services - Health financing Date 02-Jul-2007 08-Sep-2011 01-Oct-2011 Comments (Source: Dept of PRD) Number of county health offices using fully Number Value 0.00 15.00 15.00 computerized ICT systems in the production of their quarterly HMIS reports Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Comments (Source: June 2011 QPR, PCU) Annual student enrollment for the school year Number Value 166.00 647.00 550.00 at: (a) TNIMA & (b) A.M. Dogliotti Date 02-Jul-2007 08-Sep-2011 01-Oct-2011 Comments (Source: QPR update from PCU) Annual student enrollment for the school year Number Value 42.00 210.00 200.00 at (b) A.M. Dogliotti Sub Type Date 02-Jul-2007 08-Sep-2011 01-Oct-2011 Breakdown Comments (Source: QPR update from PCU) Annual student enrollment for the school year Number Value 124.00 437.00 350.00 at (a) TNIMA Sub Type Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Breakdown Comments (Source: June 2011 QPR, PCU) Public Disclosure Copy Number of courses offered at A.M. Dogliotti Number Value 0.00 4.00 4.00 with an active laboratory component Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Comments - Anatomy, Biochemistry physiology and Microbiology (Source: June 2011 QPR, PCU) Page 3 of 7 The World Bank Report No: ISR4593 Indicator Name Core Unit of Measure Baseline Current End Target Proportion of targeted health facilities which Percentage Value 0.00 66.00 50.00 improved at least 10 percentage point in Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Public Disclosure Copy equipment scores according to the accreditation criteria Comments - Proxy data used: 66% of all health facilities have improved equipment scores at least 10% points (Source: 2009 & 2011 Accreditation Reports) Intermediate Results Indicators Indicator Name Core Unit of Measure Baseline Current End Target Health facilities constructed, renovated, and/or Number Value 0.00 212.00 222.00 equipped Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Comments - 212 facilities have received at least 1 equipment (data from 1 county still missing) (Source: PCU) Health personnel receiving training Number Value 0.00 895.00 300.00 Date 02-Jul-2007 08-Sep-2011 01-Oct-2011 Comments - Approximately 200 health personnel attended the health conferences from 2008 to 2011. - IT (5); project mgt/FM (2); procurement (8); nurse anesthetist (30); radiography (42); digital x-ray (8) (Source: June 2011 QPR, Public Disclosure Copy PCU) Policy in the area of human resources for Text Value None Draft policies available Draft policy available for: - health, health financing, and decentralization of Human resources for health - health services, respectively, drafted Decentralization of health services - Health financing Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Comments (Source: June 2011 QPR, PCU) Page 4 of 7 The World Bank Report No: ISR4593 Indicator Name Core Unit of Measure Baseline Current End Target Number of county health offices supplied with Number Value 0.00 15.00 15.00 ICT equipment for HMIS Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Public Disclosure Copy Comments (Source: June 2011 QPR, PCU) Number of procurement officers in MOHSW Number Value 0.00 8.00 5.00 fully trained in accordance with the Public Procurement and Concessions Act Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Comments - 2 procurement officers currently enrolled in a master's program with 6 additional officers completed procurement courses at LIPA.10 staff from MOHSW participated in hands-on training (Source: June 2011 QPR, PCU) Cumulative number of students who received Number Value 0.00 605.00 545.00 stipends at TNIMA Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Comments (Source: June 2011 QPR, PCU) Number of teaching laboratories at A.M. Number Value 0.00 3.00 4.00 Dogliotti renovated and equipped Date 02-Jul-2007 08-Sep-2011 01-Oct-2011 Comments - Renovation of 3 teaching laboratories, fence and administrative building completed; construction of additional lab near completion - Equipment installed Public Disclosure Copy (Source: PCU) Number of clinical teachers and staff recruited Number Value 0.00 50.00 45.00 in areas of critical shortage (doctors, nurses, midwives, and other allied health workers) Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Comments -One staff recruited, but didn't serve, and thus the number reduced from 51 to 50 (Source: June 2011 QPR, PCU) Page 5 of 7 The World Bank Report No: ISR4593 Number of targeted health facilities supplied Number Value 0.00 212.00 222.00 with medical and laboratory equipment Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Comments - 212 facilities have received 200 health clinics; 15 health Public Disclosure Copy at least 1 equipment (data centers; and 7 referrals from 1 county still missing) hospitals (Source: PCU) Number of targeted wards at JFK Medical Number Value 0.00 0.00 2.00 Center fully renovated Date 02-Jul-2007 22-Jul-2011 01-Oct-2011 Comments - Rehabilitation ongoing (Source: June 2011 QPR, PCU) Data on Financial Performance (as of 19-Jul-2011) Financial Agreement(s) Key Dates Project Loan No. Status Approval Date Signing Date Effectiveness Date Closing Date P105282 IDA-H3040 Effective 14-Jun-2007 15-Jun-2007 09-Jul-2007 01-Oct-2011 Disbursements (in Millions) Project Loan No. Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P105282 IDA-H3040 Effective XDR 5.60 5.60 0.00 5.02 0.58 90.00 Disbursement Graph Public Disclosure Copy Page 6 of 7 The World Bank Report No: ISR4593 Public Disclosure Copy Key Decisions Regarding Implementation n/a Restructuring History Level one Approved on 28-Jan-2010 Related Projects There are no related projects. 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