ICRR 10116 Report Number : ICRR10116 ICR Review Operations Evaluation Department 1. Project Data : OEDID : OEDID: L3307 Project ID : P005717 Project Name : Population and Family Health Country : Tunisia Sector : Other Population Health & Nutrition L/C Number : L3307 Partners involved : Prepared by : Charles Derek Poate, OEDST Reviewed by : Susan A. Stout Group Manager : Roger Slade Date Posted : 07/30/1998 2. Project Objectives, Financing, Costs and Components : The objectives were to increase the national contraceptive prevalence rate from 40 to 45%, and to improve the health status of the population, with particular emphasis on women and children in rural areas . The estimated total investment cost of the project was US$39.0 million of which US$26.0 million was met by a loan from the World Bank (as approved by the Bank in 1991). The total cost of the project (including recurrent costs to be met by Government) was estimated at appraisal at US$63.2 million. The project became effective on 2nd October 1991 and was closed on 31st March 1998, 12 months later than envisaged. Most of the funds were disbursed. There were no formal co-financiers, although UNICEF provided the funds for the training component and other agencies for other minor components of the project. There were four components comprising: i. Integration of Maternal and Child Health (MCH) and Family Planning (FP) centers involving a mix of recruitment/ redeployment of midwives, in-service training, establishment of a regional family planning center, monitoring of referral of pregnant women and improved neo-natal services; ii. Expansion of outreach services to increase access to MCH/FP involving redeployment of staff to inaccessible areas, re-organization of mobile teams and purchase of mobile clinics. iii. Improvement of first referral level of health care through X-ray and other services and upgraded access to ambulatory specialist care; and iv. Enhancement of the quality of health care through in-service training, improved supply of basic drugs, studies to improve performance evaluation and the introduction of a health information system. 3. Achievement of Relevant Objectives : (a) Contraceptive prevalence: the project's objective of increasing contraceptive prevalence rate (modern methods) was exceeded. It increased the rate from 40 - 50% compared to the target of 45%, although this may have been too modest. With the Government continuing to increase the access to health services in rural areas this rate is likely to improve further. (b) Health status of women and children in rural areas. The data (although incomplete) show improvements in the key indicators over the period with infant mortality falling from 45.3 to 30.6 for Tunisia as a whole, and fertility rate falling from 3.38 to 2.87. However, a wide disparity still exists between rural and urban areas, with the increase in private health services in urban areas thought to be responsible for the maintenance of the gap. 4. Significant Achievements : The most significant achievements were: — All scheduled extension, renovation and construction works in 158 health centers were completed, and 57 district hospitals were upgraded through the provisoin of additiona laboratory services, X-Ray facilities and dental offices. The integration of MCH/FP services achieved 130% of target . The objectives of increasing modern method contraceptive prevalence exceeded the target and were achieved early in the life of the project (target 45% prevalence, achieved 50%) 5. Significant Shortcomings : In spite of improving rural health services, the project did not lessen the gap between health status in urban and rural areas. The monitoring and evaluation system did not take account of existing resources and capability and fell well below expectations. 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Highly Satisfactory Highly Satisfactory Institutional Dev .: Substantial Substantial Sustainability : Likely Likely Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Borrower's evaluation is particularly thorough and shows creative use of limited available data. Quality of ICR : Satisfactory 7. Lessons of Broad Applicability : — The results of projects which are dependent on the deployment of staff to the field, especially involving re-location to remote areas, involve risks, and staff preferences and government procedures often mitigate against this. Special measures and incentives need to be incorporated into the project design. Regional and subregional analysis of health system performance and outcomes can assist in targeting resources. A tradition of 'self evaluation' within the Ministry of Health, encouraged and supported by task manager continuity and strong commitment to evaluation, facilitated incorporation of experience from previous projects, and, during this project, helped identify solutions to sectoral issues which are being employed in a new health sector process. Project objectives should be fully integrated in the Government's strategy. Even successful projects need fully effective monitoring and evaluation systems 8. Audit Recommended? Yes No 9. Comments on Quality of ICR : The ICR provided appropriate coverage, describing the achievement of the project's objectives and fully setting out the project's shortcomings. The ICR is clearly laid out and well written, and includes a useful discussion of issues in the establishment of monitoring and evaluation systems and in locating staff in rural areas.