Rapport de fin d'exécution - Premier projet de santé

Docurnent of The World Bank FOR OFFICIAL USE ONLY Report No: 22720 IMPLEMENTATION COMPLETION REPORT (IDA-20850) ON A CREDIT IN THE AMOUNT OF SDR 22.2 MILLION US$ 28.2 MILLION EQUIVALENT TO THE REPUBLIC OF HAITI FOR HT- FIRST HEALTH PROJECT 09/06/2001 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized CURRENCY EQUIVALENTS (Exchange Rate Effective ) Currency Unit = Gourdes I G = US$ 0.04 US$ 1.00 = 23.35 G FISCAL YEAR October 1 September 30 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immunodeficiency Syndrome CIDA Canadian International Development Agency DOTS Directly Observed Treatment, Short Course Strategy HIV Human Immunodeficiency Virus ICC International Child Care IDA International Development Association IEC Information Education and Communication Material IMR International Mortality Rate MSPP Ministry of Health and Population (Ministere de la Sante Publique et de la Population) MEF Ministry of Economy and Finance (Ministere de l'Economie et des Finances) NGO Non-governmental Organization PAHO Pan American Health Organization PMU Project Management Unit PNLT National Tuberculosis Program (Programme National de Lutte contre la Tuberculose) SAR Staff Appraisal Report STD Sexually Transmitted Disease STI Sexually Transmitted Infection TB Tuberculosis UNAIDS Joint United Nations Programm on HIV/AIDS WDI Word Development Indicator WHO World Health Organization Vice President: David de Ferranti Country Manager/Director: Orsalia Kalantzopoulos Sector Manager/Director: Charles Griffin Task Team Leader/Task Manager: Girindre Beeharry FOR OFFICIAL USE ONLY HAITI HT- FIRST HEALTH PROJECT CONTENTS Page No. 1. Project Data 1 2. Principal Performance Ratings 1 3. Assessment of Development Objective and Design, and of Quality at Entry 1 4. Achievement of Objective and Outputs 6 5. Major Factors Affecting Implementation and Outcome 10 6. Sustainability 11 7. Bank and Borrower Performance 11 8. Lessons Leamed 8 9. Partner Comments 12 10. Additional Information 12 Annex 1. Key Performance Indicators/Log Frame Matrix 13 Annex 2. Project Costs and Financing 14 Annex 3. Economic Costs and Benefits 15 Annex 4. Bank Inputs 16 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 18 Annex 6. Ratings of Bank and Borrower Performance 19 Annex 7. List of Supporting Documents 20 Annex 8. Borrower's Report 23 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. Project ID: P007311 Project Name: HT- FIRST HEALTH PROJECT Team Leader: Ruth E. Levine TL Unit: LCSHH ICR Type: Core ICR Report Date: January 31, 2002 1. Project Data Name: HT- FIRST HEALTH PROJECT L/C/TF Number: IDA-20850 Country/Department: HAITI Region: Latin America and Caribbean Region Sector/subsector: HC -Primary Health, Including Reproductive Health, Chi KEY DATES Original Revised/Actual PCD: 10/15/1987 Effective: 06/20/1990 08/02/1990 Appraisal: 11/28/1989 MTR: 02/20/1998 02/20/1998 Approval: 01/16/1990 Closing: 06/30/1996 03/31/2001 Borrower/Implementing Agency: GOVERNMENT OF HAITI/MINISTRY OF HEALTH Other Partners: CANADLIN INTERNATIONAL DEVELOPMENT AGENCY (CIDA) STAFF Current At Appraisal Vice President: David De Ferranti Shahid Husein Country Manager: Orsalia Kalantzopoulos Sector Manager: Charles Griffin Team Leader at ICR: Ruth Levine Xavier E. Coll ICR Primary Author: Ruth Levine; Joelle Dehasse; Girindre K. Beeharry 2. Principal Performance Ratings (HS=Highly Satisfactory, S=Satisfactory, U-Unsatisfactory, HL-Highly Likely, L=Likely, UN=Unlikely, HUN=Highly Unlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible) Outcome: U Sustainability: UJN Institutional Development Impact: M Bank Perfornance: U Borrower Performance: U QAG (if available) ICR Quality at Entry: S Project at Risk at Any Time: Yes 3. Assessment of Development Objective and Design, and of Quality at Entry 3.1 Original Objective: The original objectives of the US$33.7 million project were to (a) reduce central administration expenditures of the Ministry of Health (Ministere de la Sant6 Publique et de la Population, or MSPP); (b) reduce the current ratio of salaries to operating expenditures; (c) improve collection of patient contribution to the cost of medical services and drugs; (d) strengthen key management and technical functions of the MSPP; (e) reduce maternal and child mortality rates; and (f) counter the potentially devastating effects of AIDS and tuberculosis epidemics (Development Credit Agreement, February 2, 1990). The project's objectives-and particularly those that emphasized structural and budgetary changes at the MSPP (objectives a, b, c and d)-were based on a 1987 IDA sector review. That review revealed that the MSPP had grown to be one of the largest government ministries, accounting for 16 percent of government expenditures by the latter half of the 1980s. Central administration expenditures, including salaries, absorbed nearly one-quarter of the budget; overall, salaries accounted for up to 90 percent of the MSPP budget, crowding out virtually all complementary inputs. Ministry staffing was top-heavy, with a critical shortage of nurses, technicians and auxiliaries. Health personnel were concentrated in Port-au-Prince and other urban areas, while in rural areas there was less than 1 physician per 10,000 inhabitants. The sector review concluded that the deteriorating health conditions in Haiti could be countered most effectively by addressing underlying financial, organizational and managerial imbalances that characterized the health system. The review called for reallocating public resources in favor of primary health care through increased financing of non-salary operating expenditures; decentralization of management, including delegation of operational responsibility to the district level; and greater participation of non-governmental organizations in primary health care. Additional objectives that were more directly related to health outcomes (objectives e and f) reflected a recognition that Haiti's health conditions were by far the worst in the hemisphere. It was decided that the Bank had a role to play in improving basic MCH services by providing badly needed financing for non-salary inputs (both capital and recurrent), and in strengthening the government's ability to address the threat of AIDS and TB. The objectives were based on the analysis of sector priorities, and were consistent with the Bank's overall country strategy. At the same time, the objectives reflected optimistic assessments of the quality of governance, readiness for organizational change, future political stability, and institutional capacity. They were overly ambitious, given Haiti's weak track record in implementation. 3.2 Revised Objective: The project objectives and closing date were revised three times. Overall, the changes resulted in a major increase in the duration of the project, and a shift in emphasis away from large-scale institutional change toward a strengthening of specific, high-impact elements of public health and basic health service delivery. In September 1991, about a year after implementation began, Haiti experienced a coup d'etat, a subsequent three-year international embargo and suspension of all IDA activities. When the project resumed in March 1995, the Credit Agreement was amended (effective November 1995) to streamline project implementation, set up a Special Account, and update provisions for disbursement and procurement. The closing date was extended by two years, to June 30, 1998. In February 1998, after three consecutive years of operation, a midterm review concluded that the -2 - development objectives were unrealistic, given the Haitian context. The closing date was extended by 18 months, to December 31, 1999. The objectives and targets were simplified to reflect what had been attained to date, and what-in the view of the Bank-could be achieved during the remaining life of the project. The modifications also took into account the activities of other development organizations, including U.S., Canadian and other bilateral donors. The revised objectives de-emphasized large-scale changes in Ministry organization and budgeting, and were to: (a) contribute to strengthening of the MSPP's cost recovery mechanisms and service delivery strategies and standards; (b) improve access to and utilization of basic health services, with particular emphasis on maternal and child health care; and (c) support interventions to increase utilization of tuberculosis treatment services and expand awareness of the AIDS epidemic. In December 1999, within days of the project closing, the objectives and closing date were once again revised. At the time, Bank staff and management recognized that it would be desirable to close the project and initiate design of a new operation. However, the political context of the time-and particularly the absence of a functioning Parliament-made it impossible to foresee negotiation and ratification of a new loan. Therefore, the Bank decided to extend the project to maintain a presence in the sector, and to address critical health needs-particularly in the area of TB-that required some bridge financing until new donor relationships could be established. Bank management extended the project for 15 months, to March 31, 2001, on the understanding that the remaining funds (roughly US$4 million) would be used for essential drugs, maternal and child health, and preventive and treatment activities related to tuberculosis, HIV/AIDS and other sexually-transmitted infections (STIs). It was agreed that the project would no long finance civil works. Reflecting areas in which the project had demonstrated some successes, revised objectives were to: (a) improve maternal and child health; (b) reduce infections related to AIDS/STIs and TB; and (c) improve the administration and supply of essential drugs. 3.3 Original Components: Originally, the project consisted of three components: (a) Institutional Development; (b) Health Services Delivery; and (b) Epidemic Prevention and Control. Project activities were to be implemented by a Project Management Unit (PMU), which operated outside of the rules and procedures of the Ministry, and was physically separate from the Ministry. Institutional Development (estimated at US$4.1 million). This component sought to provide support for restructuring the MSPP to rationalize and decentralize staff. It promoted the development of simple budget allocation indicators to monitor and improve the effectiveness of the use of public resources. Health personnel-most of whom were in Port-au-Prince-were to be redeployed to rural areas in the Western Health Region, covering 2.1 million people in four districts (Port-au-Prince, Croix des Bouquets, Jacmel and Petit Goave). This component also was designed to strengthen the Ministry's capacities to recover costs for medical services ard drugs, manage civil works, and procure and distribute drugs. Most of the inputs financed under this component fell into the category of technical assistance. Services Delivery (estimated at US$21.2 million). This component was designed to improve the delivery of health services at the local level, under a decentralized regime in the Western Health Region. The four-part strategy included: (a) creating 30 commune-based local health systems; (b) supporting 7 priority service delivery areas (maternal and child health care, family planning, nutrition, immunizations, control of diarrheal diseases, TB prevention and treatment, malaria control, and HIV/AIDS prevention); (c) promoting the delivery of standard, basic health services in periodic community gatherings; and (d) integrating the private sector in basic health service delivery. Inputs financed included upgrading of the -3 - health center/dispensary network, medical equipment and supplies, vehicles, training, essential drugs, per diem for sanitary officers and technical assistance. Epidemic Prevention and Control (estimated at US$8.5 Million). This component, implemented on a nationwide basis, focused exclusively on the development of an integrated tuberculosis control program, and support for HIV/AIDS prevention activities. The TB control program comprised: (a) conversion of the treatment regime to a multiple-drug short course; (b) expansion of treatment coverage; (c) maintenance of BCG immunization at a 60 percent rate; (d) expansion of profesional and para-professional training; and (e) provision of expert supervision and evaluation. Major inputs included drugs, training, and diagnostic materials and equipment Inputs financed to sUppott to HIV/AIDS prevention included laboratory testing equipment; information, education and communication materials; protective equipment and supplies for health personnel; and an AIDS-TB conference. Many of the aims of the project were in line with the then-government's goals and capacities, and thus had a reasonable chance for success, given the initial knowledge base. The largest share of project investments-for improvement of basic health services-closely followed the stated government programmatic intentions, supporting the basic services that were identified by the Ministry as high pnority. In contrast, the institutional strengthening activities, although seen by the Bank as essential to long-term effectiveness and sustainability of public health work in Haiti, did not fit well with the underlying capacity or political will. Many of the fiscal reforms, for example, depeded not on the Ministry of Health but also on the Ministry of Economy and Finance, which did not have the commitment to follow through. 3.4 Revised Components: Revisions across all components genermally represented a scaling-down of the project's ambitions, in light of political turbulence and weak governance; an increasing recogition of the institutional limitations of the Ministry of Health; and a reorientation toward core public health activities. In November 1995, the first amendment to the Credit Agreement specified the following revisions: The Institutional Development component was narrowed to reinforce a set of specific capacities within the MSPP, including: (a) developing and implementing policies for public health, public safety, health emergencies and health technology; (b) setting priorities for health spending and research; (c) determining standards for service delivery and ensuring compliance; (d) maintaining a national health information system; and (e) setting norms for the training and licensing of health workers (Credit Agreement, Amendment 2). In November 1998, the second amendment to the Credit Agreement specified the following revisions: In Institutional Development, the component was further narrowed to strengthen the MSPP's capabilities in the design and implementation of (a) cost recovery stategies, stating with basic analytic work on health service financing and costs; and (b) service delivery strategies and standards for essential drugs, quality control of pharmaceutical products, medical emergencies and control of TB and AIDS/STIs. Inputs include technical assistance, staff training and establishrment of norms and protocols. In Services Deltvery, support remained similar to the original conception, but was more highly specified under six objectives and several sub-objectives. For most of hese, the objectives were expressed in terms of the inputs to be provided rather than as objectives in the traditional sense (e.g., the provision of medical equipment, radio communications systems and related training to health personnel and community representatives in the South-Eastern Health Region). -4 - Under Epidemic Disease Prevention and Control, the component was modified to take advantage of up-to-date global knowledge, and support the MSPP's (a) Integrated National Tuberculosis Control Program, including the introduction of the Direct Observed Therapy Short-term (DOTS) strategy, following the WHO protocol; and (b) AIDS/STIs Program through implementation of social marketing and information, education and communication (IE&C) strategies. In December 1999, the third amendment was issued, with the agreement that, as of January 2000, the remaining project funds (roughly US$4 million) would be used for public health programs of the highest priority for the sector: essential drugs, maternal and child health (including immunization campaigns), TB and AIDS/STIs. No civil works were to be financed. The closing date was extended to March 2001. 3.5 Quality at Entry: Mardnallv satisfactory. While the project objectives fit well with the prevailing understanding of issues in the Haitian health sector, and the Bank's emphasis on social sector investments in very poor countries, several shortcomings in the design can be identified. First, as noted earlier, there was insufficient national commitment to institutional restructuring. The Ministry of Economy and Finance, whose cooperation was essential for reorganizing the budget, did not have a sense of ownership of the program. Second, the design assumed that certain changes in personnel changes could be made within the sector, when they in fact required a government-wide transformation. Third, the Ministry's capacity to implement multiple activities was overestimated. Fourth, the design reflected a conceptual confusion between inputs and objectives. Fifth, judged by current standards, the project was excessively supply-oriented, with little attention to dimensions of demand and community participation. 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: Unsatisfactory. The project failed to achieve most of its major relevant objectives. Overall, public health in Haiti today cannot be said to have improved over the course of the past ten years, and there is no evidence that the project ameliorated a significant share of the health problems associated with general political, economic and social upheaval. If measured by the original health outcomes that the project sought to achieve (per the Staff Appraisal Report)-reducing mnaternal, infant and child mortality by 40 percent by 1995-then the project was unsatisfactory. In addition, virtually all the institutional development objectives were abandoned during implementation. However, the project did have some important successes after design revisions were made to strengthen core public health functions, particularly in provision of essential drugs and in certain elements of Epidemic Prevention and Control (see details in Section 4.2). 4.2 Outputs by components: Institutional Development: Unsattsfac.orv. Failures are seen in each of the major elements of this component, as it was originally conceptualized. First, at the start the project sought to promote the reallocation of the MSPP budget away from salaries, and toward complementary inputs-correcting a distortion of long-standing. Soon after the project's launch, political events in fact led to an increase in spending on salaries. By 1998, the likelihood of achieving a better balance between spending among administration, personnel and other inputs within the health sector was seen as so remote that a covenant calling for reduced salary ratios and central administration expenses was dropped from the Credit Agreement. It is interesting to note, however, that in 1999, staff salaries were brought down to 79 percent of the budget (from 90 percent in 1987), when the government launched a national public sector reform program. This implies that the transformation required government-wide action, and could not be realized -5- within the health sector alone. Second, although a study was conducted on cost recovery options, the recommendations were found to be overly ambitious. Several additional minor steps were taken to strengthen cost recovery, such as some consultancies, but there is no evidence of impact. Third, redeployment of personnel to rural areas was never stimulated by the project, despite the original intentions. Recognizing the low probability of success, the covenant related to salary expenditures for staff at health centers outside of Port-au-Prince was later dropped. Although the institutional restructuring component was reduced in scale and scope during the multiple project revisions, the reorientation toward core public health functions did have positive spill-over effects at the institutional level. For example, progress was made in applying standardized therapeutic protocols in the national tuberculosis program, and in introducing drug treatment protocols for the essential drugs program. The public-private partnerships developed under the TB program increased institutional capacity to participate in contractual relationships. Modest improvements were also ultimately made in the Ministry's introduction of cost recovery measures. The essential drugs program relied on revenues generated at the health facility level to finance the availability of drugs at the peripheral level. Services Delivery. Unsatisfactory. Crudely, the project can be judged by comparing its original outcome targets with current health conditions reported in the 2001 World Development Indicators and elsewhere. While changes in indicators such as infant mortality are the result of many factors outside the health system, and cannot be attributed to the successes or failures of the project, it is clear that health conditions have not consistently improved (and that measurement problems continue to exist). For infant mortality, the SAR target was a decrease by 15 percent by the end of the third year of the project; and 35 percent by the end of the sixth year (i.e., from 119 per 1,000 live births in 1987 to 78 per 1,000 by 1995). Haiti's IMR was estimated at 70 per 1,000 in 1999, suggesting that improvements have been made. For child mortality, the story is quite different. The project was to contribute to a reduction by 15 percent by the end of the third year; and 40 percent by the end of the sixth year (from 22 per 1,000 in 1987 to 14 per 1,000). Haiti's under-five mortality was estimated in 1999 at 118 per 1,000, indicating either a very rapid deterioration in health conditions or very poor measurement, or both. For maternal mortality, the project was designed to contribute to a reduction of maternal mortality by 15 percent by the end of the third year; and 40 percent by the end of the sixth year (from 267 per 10,000 live births to 220 per 10,000). The rate of maternal mortality in 2000 is estimated by the MSPP at 523 per 10,000. Again, this implies some combination of worsening health conditions and measurement error. Looking at output measures, which can be more directly attributed to project implementation, results are disappointing. Of the 28 health facilities to be constructed (5 health centers and 6 dispensaries) and rehabilitated (16 health centers and 1 dispensary), 3 health centers were constructed and 2 were rehabilitated. Three of the seven planned shelters/housing were completed. Half of the 10,000 planned latrines were built; however, 3,250 additional latrines were built in areas for which they had not originally been planned. Thus, including both planned and unplanned works, construction of latrines reached an 83 percent completion level relative to the original figures. The rehabilitation of 10 drug warehouses and 4 community centers not originally planned brings the total of completed civil works to 8,272 out of the 10,036 originally planned (or 82 percent of the works). The quantity of civil works fell short of expectations primarily because per-facility costs were higher than expected. Facilities were found to be in worse shape than anticipated at appraisal (about six years earlier), and in several cases had to be replaced instead of rehabilitated. -6 - Whether the physical improvements supported by the project had a health impact remains an open question. A 1999 evaluation study found that upgraded facilities were not utilized more than other facilities. In spite of commitments made to the Bank, the MSPP had difficulties recruiting and retaining staff to work in remote areas, and thus the facilities often operated below capacity. Bank supervision missions attempted to persuade Ministry authorities to delegate responsibility for the management of these facilities to non-governmental organizations, which have a better track record in operating health centers, but these efforts were unsuccessful. Procurement and distribution of drugs and medical supplies was unsatisfactory during much of the project's implementation. Chronically, Hlaiti has suffered (and continues to suffer) fiom a lack of coordination and poor assessment of health centers' needs, resulting in inadequate distribution and wastage. In some instances, inexperienced health staff simply do not know how to use the materials; in other instances, a lack of storage space and/or missing installation equipment has meant that drugs or equipment have not been put into service. The project did not successfully address these systemic problems. The project can take credit for some notable improvements in the essential drug supply after the design revisions, however. There is documentary evidence of: (i) increased availability of drugs at affordable prices; (ii) improved management of patient care at the peripheral level; and (iii) introduction of basic cost recovery measures. An external evaluation conducted in 1999 found that essential drugs were available in a high percentage of health facilities (95 percent of dispensaries; 80-90 percent of health centers; and all hospitals). Field visits conducted during supervision missions confirmed that drugs were available even in remote areas. Similarly, spot checks confirmed that prices of essential drugs distributed through the national program (PROMESS) were dramatically lower than in private pharmnacies (i.e., two- to seven-fold differentials). The achievements in the essential drugs program, which was essentially managed as a project of PAHO, were found nationwide, and were not limited to the project areas. At least in quantitative terms, training and technical assistance was satisfactory, with more than 800 health care staff taking training in medical and administrative topics. Epidemic Prevention and Control. Satisfactorv. The success of this component is due to the partnerships between the public sector and non-governmental organizations (NGOs) that implemented the activities, even under difficult circumstances. In addition, this component benefited from constructive coordination with PAHO/WHO, CIDA and USAID, all of whom were involved in various ways and agreed to support the interventions after project closing. The TB Control component had a very satisfactory outcome. As planned in the SAR, the project contributed to the establisit .,ent of a renewed National TB Control Program, based on the WHO-recommended DOTE ,iodel. The program successfully involved various partners and operated within the primary health c a infrastructure. Detection of smear-positive cases increased from 5,493 cases in 1997 to 6,828 in 1999. fie proportion of smear-positive cases treated under DOTS rose from 0 in 1996 to more than 30 perce-. in 2000. Treatment success for smear-positive cases detected in 1998 reached 79 percent for those treated under DOTS, compared to 63 percent in non-DOTS areas. Even in areas where the DOTS strategy is not yet used, success rates have improved. In addition, a quality control system has been established for laboratories that diagnose TB. Despite progress, the TB control results are relatively fragile. More than 50 percent of estimated TB cases are not detected, reported and treated, and the epidemic is worsening due to its association with HIV/AIDS. The success to date has resulted in large part from the formal collaboration among MSPP staff, facilities -7 - and NGOs. This relationship was complicated by the short contract periods provided under the project between the NGOs and the MSPP, the delays frequently experienced in renewing the contracts during the course of the project, and long delays in obtaining reimbursement for expenses. Due to limited access to vehicles provided to departmental-level authorities during the project, adequate field supervision was inhibited. On the positive side, the objectives, work products and indicators utilized in the contracts improved over time, and technical staff in the Ministry and PMU staff worked closely in communicating with NGO partners. The public-private collaboration supported by the project offers a useful model for future public health interventions. Under Haiti's difficult conditions, developing the necessary administrative and personal relationships to generate successful collaboration was and will continue to be time- and resource-intensive. With respect to AIDS/STI prevention activities, results are more difficult to quantify and have not been formnally evaluated, but are generally viewed positively. NGOs conducted wide-ranging awareness-raising activities (conferences, seminars, workshops, outreach to youth, caravans, community meetings, condom distribution and so forth), testing and counseling. Observers note that the project contributed to enhanced HIV screening capabilities, with the establishment of five departmental screening centers; and improved access of vulnerable groups to condoms through the social marketing program. 4.3 Net Present Value/Economic rate of return: N/A 4.4 Financial rate of return: N/A 4.5 Institutional development impact: Modest. While some 800 health care personmel received project-funded training, there is little evidence that the new skills were applied systematically. The strong management skills of the PMU, though invaluable for the implementation of the project, were not formally transferred to the MSPP. NGOs participating in the TB control and HIV/AIDS activities under the project were able to increase their capacity as contractors, in both technical and administrative terms. Although NGOs have for many years played a critical role in operation of health facilities-and often have outperformed the government in this area-the project further strengthened their ability to contribute to sectoral goals. 5. Major Factors Affecting Implementation and Outcome 5.1 Factors outside the control of government or implementing agency: This project-as the whole Haiti portfolio-was strongly affected by instability, civil unrest and political crises. Project implementation was brought to a halt about a year after implementation began, following the September 1991 coup d'etat, which was followed by an international embargo and a three-year suspension of the IDA program. The coup and embargo devastated the economy, with grave repercussions throughout society-from households to government agencies. In 1997, two years after the project resumed, the resignation of the Prime Minister further strained the political climate and distracted the administration's attention from development issues. The political crisis became still more pronounced after the May 2000 elections, when procedures for establishing winners of legislative and local elections were seen by many as unconstitutional and fraudulent. Presidential elections went ahead in November 2000, despite an opposition boycott; a new administration came into power in February 2001, headed by President Jean Bertrand Aristide and Prime Minister Jean Marie Cherestal. The political crisis persisted and new international assistance to Haiti remained on hold. -8 - Throughout these events, the government has proven unable to fulfill core public health functions, not adequately financing the provision of public goods (e.g., vector control) and goods with externalities (e.g., immunizations). The breakdown of the health system, coupled with the high level of poverty, has made the Haitian population extremely vulnerable to the emergence, re-emergence and rapid spread of infectious diseases. Haiti has become an incubator of diseases for the region; the situation is especially worrisome for vaccine-preventable diseases, HIV/AIDS, and multi-drug-resistant TB. 5.2 Factors generally subject to government control: A lack of commitment on the part of the Government, in particular the successive Ministers of Health and Ministers of Finance, undermined the project from the outset. This factor, coupled with the high turnover of administrations and ministers (3 administrations, 4 Ministers of Health), meant that priorities were frequently being reevaluated. The First Health Project was unable to gamer full ownership of successive administrations. During project implementation, the culture and institutional incentives present in the MSPP were rarely conducive to efficient execution. Ministry officials faced a series of natural and human-made emergencies (e.g., measles epidemics, drug shortages, hurricanes, strikes), and viewed the project as a pot of money to be used to resolve some of these problems. In such a context, insufficient attention was devoted to systemic issues affecting implementation, and to the long-term goals of the project. This situation was exacerbated by a lack of a tradition of programming and monitoring project activities. On several occasions, the Government of Haiti failed to fulfill basic responsibilities. For example, during calendar year 2000, the government frequently fell into arrears with IDA repayment, resulting in several suspensions of IDA disbursements. These portfolio-wide suspensions permitted exceptions for the procurement of drugs for maternal and child health, TB and AIDS/STIs. From November 2000 through February 2001, an overdue audit report-largely the result of lack of performance by a private auditing firm-led to the suspension of disbursements for activities under the project, causing several activities to stall. As a result, many of the potential benefits of the final extension were not realized. 5.3 Factors generally subject to implementing agency control: In the midst of the political turmoil affecting Haiti, the PMU was able to maintain a relatively high degree of efficiency and effectiveness. Strong management skills and remarkable continuity in key personnel insulated the project, to some degree, from a general envirornment of chaos during several periods. The PMU Coordinator proved able to work across political divisions, which benefited implementation tremendously. And, by working with NGOs, the PMU was able to achieve impressive successes in TB prevention and control activities. The PMU was isolated physically and institutionally from the Ministry-a situation that simultaneously helped and hindered its effectiveness--and therefore had limited capacity to ensure that the project was integrated into the Ministry's core functions. 5.4 Costs andfinancing: The total cost of the project was estimated to be US$33.7 million, of which US$28.2 million equivalent (SDRs 22.2 million) would be financed by the IDA credit; the govemnment was to allocate the equivalent of US$3.1 million (in salaries). CIDA was to co-finance on a parallel basis the equivalent of US$2.4 million. The base costs to be supported by the project were estimated at US$28.7 million, with contingencies of US$5 million. The foreign exchange component (for imported materials) were estimated at US$22.4 million, or 66 percent of total project cost. The costs also included the refinancing of a project preparation -9- facility of US$560,000, approved in October 1987; and increases of US$190,000, approved in April 1989, and of US$150,000, approved in November 1989. The original allocation of project resources was modified along with the changes in project content. The Institutional Development component, originally programmed to absorb US$4.1 million, eventually used about US$1 million. The Services Delivery component was originally budgeted at US$21.1 million, and ultimately used about US$17 million. For the Epidemic Prevention and Control component, which was budgeted at US$8.5 million, approximately US$10 million was expended by the close of the project. Final disbursements under the project amounted to US$29.1 million equivalent (SDRs 21.1 million), resulting in a cancellation of US$1.3 million undisbursed. (Due to a chance in the US$/SDR exchange rate, the total disbursed amount in US$ exceeds the commitment amount.) Thus, in the end, 11 years after the start of the project, the project had disbursed 95.2 percent of the original credit amount. 6. Sustainability 6.1 Rationale for sustainability rating: Unlikely. The many activities that were initiated under the project-and particularly the institutional development interventions, civil works, stocking of health centers-are not sustainable without government support. That support is unlikely due to both the government's on-going fiscal crisis, and lack of institutional commitment. 6.2 Transition arrangement to regular operations: Several of the project activities constituted one-time investments that can be appropriated by the government with no further outlays. Others, which require maintenance, additional salary support, and other recurrent expenditures, are currently on shaky ground. There are no plans for project activities to be part of the Ministry's regular operation. However, certain project components-in particular, the TB and AIDS work-are expected to continue at some level with external support. IDA currently is disengaged from Haiti and will likely remain so until the pending issues related to governance and arrears have been resolved. The Bank is processing a number of grants that will allow it to capitalize on the achievements of the First Health Project despite the current IDA disengagement. A first grant of US$50,000 from the Japanese government has been approved. This grant will serve to assist the preparation of the National HIV/AIDS Strategic Plan, which will provide the framework for all future donor operations in HIV/AIDS in Haiti. A second grant of US$250,000 from the World Bank's Post-Conflict Fund also has been approved. This grant will assist the efforts of several agencies to contain the recent polio outbreak in Haiti. A third grant request (for an approximate amount of US$1 million) in support of HIV/AIDS prevention and related activities that will be implemented by NGOs will be submitted shortly to the Post-Conflict Fund. In addition to these grants, the Bank has sought to maximize the benefits of the First Health Project by seeking alternative sources of financing to maintain the key activities. In collaboration with WHO, the Bank has thus successfully negotiated relay financing from other donor agencies to maintain support to the National Tuberculosis Program .The U.S. Agency for International Development and the Canadian Government have developed projects to support the Tuberculosis Program beginning this year. All fundamental functions of the Program that were formerly financed from the First Health Project, including drug supply, will be maintained and/or further developed. It is expected that the Tuberculosis Program will continue to expand its tuberculosis case detection and its improvements in cure rates. 7. Bank and Borrower Performance -10- Bank 7.1 Lending: Satisfactory. After more than 11 years, in the light of sweeping changes in Haiti's political landscape, it is extremely difficult to judge the Bank's lending performance in health. It met the minimum criteria of identifying priority issues for the sector. However, the Bank overestimated institutional capacity for financial management and procurement. In addition, in retrospect it is clear that the political risks were far greater than had been anticipated during project design. 7.2 Supervision: Unsatisfactor. Projects in high-risk countries such as Haiti require intense supervision, yet unrest or political upheavals frequently prevent timely supervision missions and/or field visits. As shown in Annex 4, there were several significant gaps in supervision due to security concems; those supervision missions that did occur often were restricted to Port-au-Prince. Thus, judging supervision performance against a "gold standard" for timeliness is difficult, but it is clear that the Bank supervision teams made every effort to conduct missions as regularly as possible.. Supervision missions adequately reported on project implementation progress, made impressive efforts to mobilize technical collaboration from other agencies (WHO, UNAIDS and PAHO), and quickly pointed out design flaws and implementation problems. On occasion, follow-up on recommendations was weak, due in part to frequent changes in ministerial leadership, as well as the lack of integration of the PMU into the Ministry. In addition, there were several changes in project task managers (six), sector managers, resident representatives and country directors-as well as the Bank's project management structure and processes-over the life of the project. Despite the supervision teams' satisfactory performance in the face of very difficult country conditions, questions can be raised about the wisdom of the decisions taken by the Bank regarding the orientation and extension of the project. Specifically, several observers question whether the decision to focus project resources on public health activities, and to minimize attention to institutional reforms, was a correct one. If it was clear that the political will for institutional change was absent, then even the most pro-poor and urgently needed public health activities-such as those supported by the project in its later phases-could not be expected to be sustained. In addition, given that Bank management was aware of the lack of Borrower commitment and the low probability of sustainability, it is reasonable to ask whether an extension to the closing date should have been granted. 7.3 Overall Bankperformance: Unsatisfactory. The Bank made a concerted effort to design and supervise the project well, in the face of severe limitations. However, the Bank demonstrated questionable judgment the change in orientation of the project and the extension of the closing date. Borrower 7.4 Preparation: Satisfactory. Documents indicate a relatively high degree of Borrower involvement during the design phase. 7.5 Government implementation performance: Unsatisfactorv. Throughout the project, political turbulence, lack of continuity among key personnel within the Ministry, uneven commitment to project aims, and isolation of the PMU from the Ministry's line operations contributed to the operation's poor performance. 7.6 Implementing Agency: Hi0hlv Satisfacton. The PMU possessed strong management capabilities, had a strong commitment to the aims of the project, and was responsive to Bank rules and regulations. Within the Haitian context, the PMU stood out as a remarkably effective management team. While compliance with substantive covenants was poor-and, in fact, many of the key covenants related to institutional strengthening were dropped as the project was revised-compliance with most routine administrative covenants was adequate. 7.7 Overall Borrowerperformnance: Unsatisfactory. Many positive aspects of the implementing agency's performance were dwarfed by the overwhelming constraints associated with the political and economic upheaval affecting Haiti during the 1990s. Table 1: Histry of Status of Legal Covenants Agreement Covenant Present Original Revised Description of Covenant Comments ISection Type Status FuMilment FuMfilmlent Date Date 2.03 5 After Delay 06/30196 03131101 Closing Date Requested for Haig's Compiled with Pubic Health needs 2.06 2 Partially 01115191 To be Commitment and Services Charges Lack of payment and Complied wfith doterminded arriers occasioned during projecrs implementation 3.01 (b) 5 After Delay 09120/2000 06/08/2001 Project Management Unit Completion Delay due to data Complied with Report colebtion within the PMU 3.01(c) (i) 10 Complied with 08/02/1990 CoordInating unit 3.01 (e) 3 Complied with 6/20/1990 Maitbin an account in Gourdes and make adequate deposits In the Project Account, so as to maintain an average quaterly balance not less than the equivalent of $250,000 or such other balance as agreed upon between the Borrower and the Association 3.03 (a) 12 After Delay 04/30/1991 12/31/1997 Undertake a study for purposes of Due to the 1991 Complied with Pert A.2 of the Project and ensure that suspension of all IDA!s such study is completed in a timely activities in Hait fashion 3.03 (b) 12 Not Complied 09/30/1991 01/31/1999 Put into effect recommendations of Due to 1991 suspenslon with the above study as agreed upon with of all IDA's activities In the Association Haiti, and subsequente change in project focus 3.04 11 Partially 06/1/1991 07/18/1997 SubmHttotho Associaton the public Dueto the 1991 Complied with sector health budget and the plan of suspension of all IDA's Project expendiures for the following actities in Hait .year 4.01 (a) 01 Complied with 09/01/1991 The Borower shal have the Records and Accounts Onduding Special Accounts) for each fiscal year audited by hidependent auditors acceptable to the Assodation 4.01 (b) ('') 01 Complied wIth 03101/1991 The Borrower shall fumish to the Assodation no later than 6 months after the end of each fiscal year, a certfled copy of the audit by said auditors 6.02 5 After Delay 06/20/1990 08/02/1990 Effective Date Due to delays In Complied with establishing Special Account and because of change of authorities due to charnge of Governmenit -12 - Covenant Type: 1: Accounts/audft; 2: Financial perfbrmance/generate revenue from benefidaries; 3: Flow and utilization of Project Funds; 4:Conterpart Funding; 5: Management aspects of the Project or of its executing agency; 6: Environmental covenants; 7: Involuntary resettiement; 8: Indigenous people; 9: Montiing, review and reportng; 10: Implementation; 11: Sectoral or cross-sectoral budgetary or other resource allocation; 12: Sectoral or cross-sectoral regulatorymsutional action; 13: Other 8. Lessons Learned 8.1 Under the right conditions. public-private partnerships can help to mitigate institutional constraints. The TB program owes much of its singular success to the structured partnership between the public sector and committed non-governmental organizations, which were contracted to carry out well specified tasks. Through partnership with the NGO sector, the program was able to engender rapid change and scale-up to a more effective model of TB prevention and control. Key elements of this success were (a) the development of contracts with outputs that could be monitored well, and verified; (b) recognition and reinforcement of the role of the Ministry of Health in managing national programs; and (c) continuity and stability of funding for NGO activities. 8.2 Supply-driven public sector projects cannot overcome systemic constraints. Time and again, investments made under this project failed to yield the expected benefits because of the limited management and financing capacity of the public sector. Specifically, the physical improvements in the primary health facilities were never matched by additional or better trained personnel, and thus the ultimate benefits on health conditions had little chance of being realized. In retrospect, it might have made more sense to promote demand-side financing, which would permit use of health care providers outside of the public system. 8.3 Basic implementation capacity is essential. Throughout its implementation, the project suffered from the lack of fundamental management skills within the public sector. Baseline data were not collected; targets often were not set, or not set appropriately; activities were not programmed in a consistent manner, and sound monitoring systems were not established. Development and maintenance of these skills, which requires time, financial resources and institutional commitment, is a basic prerequisite to successful lending. 8.4 Governance of acceptable quality and basic implementation capacitv are essential for the success of a Bank oNeration. Throughout its implementation, the project suffered from the lack of fundamental management skills and rules of accountability within the public sector. Baseline data were not collected; targets often were not set, or not set appropriately; activities were not programmed in a consistent manner; and sound monitoring systems were not established. Prerequisites for future lending should include: (a) at least a minimally acceptable quality of governance; and (b) a commitment to developing and maintaining project implementation skills. 8.5 Small, simple and well-defined operations will work better than more wide-ranging proiects. Given Haiti's well known human resource constraints, the persistent budgetary shortages, and the political and other risks, future lending should focus on well-defined operations, perhaps of a pilot nature. 8.6 Changes in the nature of public sector employment may only be realized on a govemment-wide basis, rather than within one sector. In Haiti, as in most other countries, the "rules of the game" under which health workers are employed are set by government-wide civil service laws and regulations, and cannot be modified only within the sector. Making changes in the size, distribution and/or remuneration of public sector workers requires the participation and commitment of a wide range of actors outside of the -13 - health sector, and may not be best addressed through health sector operations. 8.7 Supply-driven public sector projects cannot overcome systemic constraints. Several times, investments made under this project failed to yield the expected benefits because of the limited management and financing capacity of the public sector. Specifically, the physical improvements in the primary health facilities were never matched by additional or better trained personnel, and thus the ultimate benefits on health conditions had little chance of being realized. In retrospect, it might have made more sense to promote demand-side financing, which would permit use of health care providers outside of the public system. 9. Partner Comments (a) Borrower/implementing agency: The Borrower was given the opportunity to comment on two versions of this report. With respect to the first version, the Borrower stated that the Government agreed with the substance of the report. The second version differed from the first only in the overall ratings of Bank and Borrower performance -- downgraded from "Satisfactory" to "Unsatisfactory." The Borrower provided no additional comments on that version, after a four-month comment period. (b) Cofinanciers: N/A (c) Other partners (NGOs/private sector): World Bank consultation with the non-governmental organizations that worked in partnership with the government under this project to itnplement TB and HIV/AIDS prevention and control programs yielded the following insights: (a) Shortcomings in the capacity of NGOs cannot be faulted for relative lack of success in implementing HIV/AIDS prevention programs, because the same NGOs implemented TB program successfully. (b) NGO success in TB prevention and control (compared to HIV/AIDS) can be traced to (i) strong leadership in the national TB program; (ii) better contract specification and ability to monitor results. A key element of success in the TB programs was the relative ease of monitoring performance and identifying specific output measures. (c) NGOs became frustrated because payments took a long time to materialize, and often arrived after activities were completed, reports remitted and all expenditures justified. NGOs would have preferred a pure output/performance-based contract, rather than the existing arrangement of a contract that included both output-based elements and a requirements that all expenditures be justified. (d) For planning purposes, NGOs prefer that the term of the contract be at least one-year, on a renewable basis. (e) Some NGOs reported that the contracts with the project tended to be too small; others that they do not have (and do not have the means to hire) the human resources to implement the activities for which they were contracted. -14 - (f) NGOs are strongly interested in future partnerships, particularly if the suggestions for improvements in the terms of the contract are taken into consideration. 10. Additional Information N/A -15 - Annex 1. Key Performance Indicators/Log Frame Matrix Outcome/lmpact Indicators Infant Mortality: Decrease of 15% of the current rate (11 19/1,000) by the end of N/A 70/1,000 the third year of the project, and of 35% of the current rate by the end of the sixth year of the project to achieve a rate of at most 78/1,000 in the project area Child Mortality: Decrease of 15% of the current rate (22/1,000) by the end of the N/A 118/1,000 third year of the project and of 40% of the current rate by the end of the sixth year of the project to achieve a rate of 1411,000 in the project area Matemal Mortality: Decrease of 15% of the current rate (367/100,000) by the N/A 523/100,000 end of the third year of the project and of 40% by the end of the sixth year to achieve a rate of at most 220/100,000 in the project area Output Indicators IndicatorlMatrix P it d In hst ActuaULatest t ''4SR Esfdht From Staff Appraisal Report Number of pregnant women to be seen at least three times per year by N/A N/A trained personnel Number of pregnant women to be immunized against TB N/A N/A Number of all recorded births to be attended by nurse midwife or physician N/A N/A Number of sterilizations performed on (a) men and (b) women N/A N/A Number of women in reproductive age immunized against tetanus N/A N/A Number of families with children to receive informaton about oral rehydration N/A N/A Number of preschool children to be complete vaccinated N/A N/A Number of preschool children to be surveyed for nutritonal status (weight/age) N/A N/A Number of preschool children identified to be at risk of xerophthalmia to receive N/A N/A vitamin A Number of persons (a) screened; and (b) treated for TB N/A N/A Number of persons (a) screened; and (b) treated for malaria N/A N/A Number of blood donors screened for HIV infection N/A N/A Number of persons at risk to be screened for HIV infection N/A N/A Number of latrines built N/A Approx. 8,250 Number of water sources sanitized N/A N/A From other sources (aide-memoires, PSRs) Availability of essental drugs Greater than 60% nationally Health facilities constructed or rehabilitated 5 Health facilities equipped 38 Staff trained in medical and administrative topics 800 Smear-positve TB cases detected 6,828 Proportion of detected cases treated under DOTS 63-79% Note: The lack of information about process indicators reflects incomplete monitoring systems -16 - Annex 2. Project Costs and Financing Project Cost by Component (in US$ million equivalent) Project Cost by Appraisal Estimate (US$ Actual/Latest Estimate Percentage of Appraisal Component million) (US$ million) Institutional Development 3.6 1 28% Service Delivery 17.6 17 97% Epidemic Control 7.5 10 133% Total Baseline Cost 28.7 37 129% Physical Contingencies 1.1 Price Contingencies 3.9 Total Project Costs 33.7 37 Total Financing Required 28.2 26.3 93% Note: CIDA was to provide US$2.4 million. The Govemment of Haiti was to provide US$3.1 million. Note: Due to the change in the US$1SDR exchange rate, the total disbursed amount in US$ exceeds the commitment amount Project Costs by Procurement Arrangements (Appraisal Estimate) (US$ million equivalent) Expenditure Category Procunement Method Total Cost iICBlS NCB Other NBF Works 0.0 3.5 0.0 0.0 3.5 (0.0) (3.5) (0.0) (0.0) (3.5) Equipment, Fumiture, Medical Supplies, 10.3 0.6 0.1 0.0 11.0 Drukqs (10.3) (0.6) (0.1) (0.0) (11.0) Vehicles, Motorcycles 3.5 0.0 0.0 0.0 3.5 (3.5) (0.0) (0.0) (0.0) (3.5) Technical Assistance 0.0 0.0 1.9 0.0 1.9 (0.0) (0.0) (1.9) (0.0) (1.9) Training 0.0 0.0 4.3 0.0 4.3 (0.0) (0.0) (1.9) (0.0) (1.9) Salaries and Operational Costs (including 0.0 0.0 4.5 4.1 8.6 PMU) (0.0) (0.0) (4.5) (1.0) (4.5) PPF refinancing 0.0 0.0 0.0 0.9 0.9 (0.0) (0.0) (0.0) (0.9) (0.0) Total 13.8 4.1 10.8 5.0 33.7 (13.8) (4.1) (8.4) (1.9) (28.2) Project Costs Financed by IDA (Appraisal Compared to Actual/Latest Estimate) (US$ million equivalent) Expenditure Category Appraisal Disbursed Disbursed/Appraisal (US$ million) (USS million) Estimate Works 3.5 5.7 162.9 Equipment, Furniture, Medical Supplies, Drugs 11.0 10.0 90.9 Vehicles, Motorcycles 3.5 1.1 31.4 Technical Assistance 1.9 2.7 142.1 Training 1.9 1.9 100.0 Salaries and Operational Costs (including PMU) 5.5 4.1 74.5 PPF refinancing 0.9 0.8 Total 28.2 26.3 93.3 -17- Annex 3. Economic Costs and Benefits N/A -18 - Annex 4. Bank Inputs (a) Missions: Stage of Project Cycle No. of Persons and Specialty Performance Rating (e.g. 2 Economists, 1 FMS, etc.) Implementation Development Month/Year Count Specialty Progress Objective Identification/Preparation June 1987 N/A N/A November 1987 N/A N/A Appraisal/Negotiation June 89 6 Health Specialists, Family Planning Specialist, Operation Assistant, Procurement Specialist, Consultants November 1989 3 Health Specialist, Lawyer Supervision May 1990 2 Health Specialist, Financial S Analyst June 1990 4 Health Specialist, Financial S HS 1 Analyst November 1990 2 Financial Analyst, Project S HS Assistant March 1991 2 Financial Analyst, Health S HS Specialist October 1993 2 Operations Assistant, Division S Chief S S January 1995 3 Economists, PAHO S Representative June 1995 3 Economist, Consultants S S August 1995 4 Portfolio Analyst, Operation S S Analyst, Public Health Specialist, Consultant October 1995 5 Public Health Specialists, S S Economist, Procurement Analists March 1996 2 Public Health Specialist, Public S U Health Consultant July 1996 3 Health Specialist, Lead Health S U Specialist, Public Health Consultant Fevrier 1997 1 Health Specialist S U April 1997 3 Project Coordinator, S Procurement Coordinator Administrative Assistante February 1998 3 Two Health Specialists, Project S S Advisor June 1998 6 Two Health Specialist, S -19 - Nutritionist, Project Advisor, Project Assistant, USAID Specialist October 1998 5 Project Adivisor, Health S Specialist, Pharmaceutical Specialist, Sector Leader, World Bank Resident Mission Representative, 10/2000 6 Economist, Health Specialists, Resident Mission Representative, Procurement Specialist, ONUSIDA Advisors ICR April 2001 4 Economist, Health Specialists, Operation Analyst June 2001 4 Econornist, Operation Analyst, Health Specialist, ONUSIDA Specialist (b) Staff Stage of Project Cycle Actual/Latest Estimate No. Staff weeks US$ ('000) Identification/Preparation 115.5 523,000.00 Appraisal/Negotiation 56.3 115,900.00 Supervision 114.76 869,698.27 ICR 13.12 38,689.20 Total 299.68 1,508,598.27 -20- Annex 5. Ratings for Achievement of Objectives/Outputs of Components (H=High, SU=Substantial, M=Modest, N=Negligible, NA=Not Applicable) Rating D Macro policies O H OSUOM O N * NA D Sector Policies OH OSUOM ON O NA DG Physical O H OSUOM O N O NA O Financial O H OSUOM O N O NA I Institutional Development O H O SUO M O N 0 NA a Environmental O H OSUOM O N * NA Social a Poverty Reduction O H OSUOM * N O NA El Gender O H OSUOM O N * NA El Other (Please specify) O H OSUOM O N * NA El Private sector development 0 H O SU 0 M 0 N 0 NA O Public sector management 0 H O SU O M 0 N 0 NA El Other (Please specify) OH OSUOM ON * NA -21 - Annex 6. Ratings of Bank and Borrower Performance (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HU=Highly Unsatisfactory) 6.1 Bankperformance Rating OI Lending OHS*S OfU OHU El Supervision OHS OS *U OHU D] Overall OHS OS * U O HU 6.2 Borrowerperformance Rating M Preparation OHS OS OU 0 HU O Government implementation performance O HS OS O U 0 HU Ol Implementation agency performance OHS OS O U 0 HU O Overall OHS OS O5*U 0 HU -22 - Annex 7. List of Supporting Documents Staff Appraisal report: Haiti First Health Project (November 28, 1989) Development Credit Agreement (February 2, 1990) Rapport de Cl6ture-Premier Projet Sante, MSPP/IDA (MSPP, June 2001) Reflexions: Premier Projet de Sante (Daniel Henrys, June 2001) Aide-Memoire (1989-2001) Project Status Reports (1989-2001) Amendments to the Credit Agreement Citation: 'Evaluation du Projet MSPP/IDA,' vol. 1 & 2. Institut Haltien de l'Enfance. December 1999 -23 - Additional Annex 8. Borrower's Report Rapport de C18ture-Premier Projet Sante MSPP/IDA I. Introduction Le pr6sent rapport contient une analyse finale du Premier Projet de Sante MSPP/IDA. II r6pond a l'obligation de pr6senter un rapport de cl6ture de projet devant servir a 6valuer les ecarts eventuels entre les resultats escomptes et ceux qui ont ete obtenus par cet effort conjoint du Gouvernement HaYtien (GH) et des bailleurs de fonds, dont principalement la Banque Mondiale (BM). L'analyse couvre -d'une part-les modalit6s et strategies d'ex6cution du projet, en mettant en perspective les difficultes rencontr6es vers I'accomplissement de son objectif principal et de ses objectifs specifiques. A ce titre, les hypotheses de base portant sur les contextes politique, et socio-6conomique peuvent revetir une importance toute particuliere par rapport A certains objectifs initiaux du projet. D'autre part, une 6valuation des ressources humaines, et financieres disponibles au projet par rapport aux resultats obtenus, permettra d'appr6cier l'efficacite des depenses consenties. Le rapport est ainsi structure. La section II trace un bref historique du projet, et s'inspire d'un c6te des documents d'elaboration du projet, et de l'autre c6te des diff6rents rapports et aide-memoire, de meme que des documents d'amendement du projet. La section III se penche sur l'6valuation du projet le placant dans sa perspective historique. A la lumiere des aspects saillants qui se d6gagent de la section precedente, la section IV offre une appreciation generale du projet, de meme que des appreciations particulieres portant sur les diverses composantes du projet Celles-ci utilisent les indicateurs de performance retenus lors de l'6laboration du projet tout en tenant compte des objectifs r6vises. C'est aussi dans cette quatrieme section que le rapport aborde de facon synthetique le theme des facteurs cles ayant influenc6s le deroulement et les resultats du projet. Ceci se fait obligatoirement A partir d'une convergence d'informations, incluant l'analyse des objectifs et moyens du projet. Une demiere et cinquieme section comprend des recommandations susceptibles de ben6ficier A I'6laboration d'autres projets dans le secteur. I. Analyse Rtbrospective En prelude de I'evaluation A suivre, cette sous-section tente de retracer l'historique du projet a la lueur des risques emanant du contexte difficile de sa mise en couvre, et les changements d'objectifs et d'orientation que de tels d6veloppements ont pu occasionner. L'instabilite politique comptait parmi un des risques majeurs identifi6s dans le SAR. Les repercussions de cette instabilit6 sur le projet devaient provenir des remaniements minist6riels eventuels, puisque de nouveaux responsables prendraient du temps A assimiler, et a s'engager dans la voie des profondes r6formes propos6es par le projet. Le projet a en effet subi plusieurs secousses politiques depuis son articulation initiale. Son lancement a eu lieu sous le Gouvemement Pascal-Trouillot en juillet 1990. Est venu en fevrier 1991, un nouveau gouvernement, celui de Jean-Bertrand Aristide, puis est survenu le coup d'etat de septembre 1991. Le projet devait red6marrer en mars 1995 a la faveur du retour de Jean-Bertrand Aristide, et 11 mois avant l'installation d'un nouveau president, Ren6 Garcia Pr6val. -24 - Chacun de ces d6veloppements politiques impliquait un nouveau gouvemement avec de nouvelles urgences et de nouvelles priorites, un nouveau cabinet ministeriel, et donc un nouveau Ministre de la sante, un nouveau Directeur General, et potentiellement un remue-menage au niveau meme des cadres impliques directement dans le projet. Durant la periode d'ex6cution effective du projet, le MSPP a connu jusqu'a six ministres, et autant de Directeurs Generaux. II est opportun de signaler ici que Bijou (avril, 1993) a rapporte que la ostandardisation et le red6ploiement du personnel debutes A la fin de 1989.. .ont e discontinues au depart du Ministre Pintro ... des techniciens transfer6s a des postes importants sont automatiquement retournes a leurs anciens postes )). De plus, quelques six annees plus tard l'IHE (decembre, 1999) a pu compter (< Les changements frequents des directeurs departementaux>> parmi les contraintes importantes ayant peses lourdement sur l'execution du projet. L'Unite de Gestion du Projet (UGP) etabli en 1990 constituait, 1'element de stabilit6 essentiel pour la continuation du projet. Cette demiere a survecu jusqu'en 1992, bien apres la suspension du financement de l'IDA en 1991, et a joue un role d6terminant dans la coordination des activit6s durant la p6riode de crise. II importe de souligner ici que la stabilit6 de l'UGP est imputable aux procedures (organisation, gestion, et supervision) 6tablies au sein de l'institution, aux liens etroits entre cette entite et la BM, et a la clart6 de ses attributions. Un fait important demeure cependant, l'UGP n'est Das un oreane d'ex6cution. Son r6le qui se limitait A la gestion des fonds du projet, et a l'6mission d'avis techniques ne pouvait lui permettre de proteger le projet completement contre les troubles sociaux et politiques, et les derapages adniinistratifs, proceduriers ou autres du Ministere charge de l'ex6cution du projet. Ce point est important puisque le SAR cite la creation de l'UGP comme un facteur d'attenuation des risques identifies. Les nombreux remous politiques n'ont pas et6 vides de consequences economiques. Lors de l'elaboration initiale du projet, le taux de change etait fix6 a cinq gourdes pour un dollar am6ricain. Deja en 1991, la Banque de la Republique d'Haiti (BRH) passait officiellement du regime de taux de change fixe (5gourdes/dollar americain) A un r6gime de taux de change flottant, et du meme coup la gourde s'echangeait A 7,5 gourdes/dollar americain, soit une decote de 50% par rapport a l'hypothese de depart. En 1995, au red6marrage du projet, la gourde s'echangeait A plus de quinze gourdes pour un dollar. Par consequent, la contribution financiere du GH au projet, evaluee A quelques trois millions de dollars en 1990 ou 15 millions de gourdes, devait passer du fait de la d6preciation de la monnaie nationale a plus de 45 millions de gourdes. De plus, des taux d'inflation se situant au-dessus de la barre de 20% causerent un des6quilibre important entre le budget pr6visionnel et les cofts de realisation des projets. Dans l'enveloppe budg6taire initiale, les contingentements ne s'elevaient qu'a 11,5% du budget previsionnel, soit US $3,9 millions d'un montant total de 33,7 millions de dollars americains, et 300/o des depenses totales du projet devaient etre executees localement. Ces changements economiques importants En 1995, le Produit Int6rieur Brut ne constituait, en termes reels, pas plus de 81% du niveau estim6 en 1991, I'anne de suspension de l'apport financier de l'IDA au projet. De plus, le taux de croissance annuelle de la population estim6e a 2.08% pour les ann6es 90 etait de 30% superieur a celui de 1.6% retenu dans le SAR de 1989. Ces changements demographiques et 6conomiques importants ont probablement occasionn6 des mouvements migratoires tout aussi importants avec des consequences immediates sur la population ciblee par le projet, et une difficulte accrue quant A l'analyse de son impact. , qui auraient pu constituer une base de remise en question et de renegociation du projet, ont occasionn6 plusieurs amendements A ce demier lors du redemarrage en mars 1995. Certains amendements apport6s au projet initial sont reproduits ci-dessous. Ces amendements font suite aux missions effectuees par la BM en Haiti aux lendemains de la resolution de la crise politique, et apres consultation avec les autorites ha7tiennes, et les responsables de la Sante. Le chemin des amendements a -25 - e pr6fere a celui de la remise en question formelle, et de la ren6gociation d'un autre accord. Amendements : objectlfs r6vises Un amendement dat6 septembre, 1995 pr6voyait la reduction des centres de sante a construire ou a r6habiliter. En effet, une des provisions de cet amendement stipulait l'annulation de I'annexe 2 de I'accord de credit. Cette annexe contenait la liste exhaustive des centres a construirm ou a rehabiliter. Le plus important amendement apporte au projet est survenu en decembre 1998. Ce demier renvoyait sa date de cloture au mois de decembre 1999, et en modifiait 1'envergure de facon substantielle. Le renforcement institutionnel ne se resumait plus qu'a deux initiatives: 1) Recouvrement des cofits de prestations de soins de sant ; 2) Appui technique au Ministere en ce qui a trait a la conceptualisation des strat6gies de prestations de soins de sant6, des standards de distributions de medicaments essentiels, et l'6tablissement de normes et standards pour les soins d'urgence, et le contrOle de la Tuberculose, du SIDA, et des maladies sexuellement transmises. Dans le volet Prestation des Soins de Sante les Medicaments Essentiels reapparaissaient, et le programme devait d6sormais s'6tendre a l'6chelle nationale. De plus, le programme de construction des centres de sant6 ne couvrait plus que 10 au lieu des 29 initialement prevus, soit une reduction de pres de 2/3 de I'effort. Les composantes structurelles du volet Contr6le et Pr6vention des Epidemies 6taient 6limin6es. II n'6tait plus question de restructuration du MSPP ou d'Unit6s Communales de Sante. De plus, l'implication des ONGs initialement pr6vue dans les seuls domaines de la Tuberculose et du SIDA 6taient d6sonnais admise pour le volet < Prestation des Soins de Sante>>. Autant dire que, par rapport aux objectifs initiaux, le projet s'est trouv6 du fait de ces changements importants, completement denature, et on pourrait m&ne aller jusqu'a penser que cet amendement constitue un constat d'6chec de la formulation du projet initial. Au moins cette mesure confrinnait la n6cessit6 ressentie par la BM d'adapter les objectifs du projet aux r6sultats juges atteignables, ou deja atteints. Cependant, on ne peut ecarter lhypothese que cet amendement reflete une tentative de mesures correctives par rapport aux defaillances conceptuelles not6es plus haut dans l'elaboration du projet. II faut remarquer que ces changements apport6s au projet sont encore compatibles avec la matrice de l'annexe 3. Toujours est-il que des contraintes 6manant de l'environnement politique instable pesaient encore lourdement sur le projet: La d6mission du Premier Ministre Rosny Smarth en juin 1997 entrainerait celle de plusieurs membres de son cabinet, et cet ev6nement a et6 suivi d'une longue p6riode de crise tant au niveau du Parlement qu'a celui de PEx6cutif. Plus particulierement, l'interimat du Ministere de la Sant6 serait pendant longtemps assur6 par le Ministre de l'Interieur. HI. Evaluation de la Performance, et Impact du Projet L'historique dresse ci-dessus permet de distinguer trois grands moments du projet. Le premier s'etend de juillet 1990 a septembre 1991, le second debute en mars 1995 pour finir en decembre 1998. Finalement, le dernier couvre l'intervalle janvier 1999-mars 2001. La structure g6nerale du projet reste inchang6e durant les deux premiers moments, alors que des changements radicaux au niveau de tous les objectifs marquent la demiere. L'evaluation de l'impact et de la performance suit ces trois moments. 111.1 Les r6sultats interm6dialres : Juilet 1990-Septembre 1991 A ce stade (seulement un peu plus d'an d'execution) du d6roulement du projet, il serait pr6mature de baser l'6valuation sur l'objectif principal ou meme les objectifs specifiques. Par contre, il sied de tenir compte des r6sultats escomptes, et des activites prevues selon l'6ch6ancier retenu dans l'Accord de Cr6dit, et le -26- SAR. Le rapport de la Directrice de l'UGP de l'epoque, le Docteur Josette Bijou, renseigne valablement sur les realisations de cette periode. 111.1.1 Resultats Escomptes Au niveau des resultats escomptes, un derapage majeur touchant l'augmentation de la ponderation de la masse salariale dans les depenses totales du MSPP (hausse a 95.5/5.5 du ratio salaires/depenses de fonctionnement au lieu de la reduction a 84.5/15.5) devait aboutir a une suspension du financement de 1'IDA, en novembre 1990, seulement trois mois apres le lancement du projet. La suspension ne devait etre levee qu'en decembre 1990, apres certaines assurances de la part du GH. II est bon ici de rappeler que dans la structure d'un (< cadre logique >>, les resultats escomptes constituent une assise ou un intrant pour les objectifs specifiques qui a leurs tours determinent l'accomplissement de l'objectif principal. La restructuration du MSPP, rappelons-le ici, representait un resultat escompte d'une grande importance. Ici le projet se heurte de plein fouet aux problemes conceptuels: l'insistance de la BM sur un intrant qui n'etait pas necessairement determinant pour l'objectif principal, et les objectifs sp6cifiques. Par contre, bien que quelques delais aient ete enregistres et quelques ajustements encore necessaires, des progres avaient et realis6s en ce qui a trait a d'autres aspects. Plusieurs cadres, et techniciens avaient requ une formation en gestion, et d'autres avaient beneficie d'une formation sur le contr6le des infections. Par ailleurs, les outils de gestion, et le processus de diagnostic vers la mise en place des AP avait ete acheve, et le regime de traitement courte-duree contre la tuberculose avait ete introduit. L'etude pour la mise en oeuvre du processus de rationalisation des cofits allait aussi bon train. 111.1.2 Activites Le projet avait, a ce stade, finalise le processus d'appel d'offres pour 47 vehicules, et des contrats avaient ete signes pour la rehabilitation de trois centres de sante, et la construction de trois autres. De plus, des dossiers d'etude etaient bien avances pour sept autres centres. II faut encore mentionner que dans le cadre des volets Tuberculose et SIDA, plusieurs centres de traitement avaient ete approvisionnes en medicaments, que les processus de procuration du mat6riel de laboratoire et d'acquisition de vehicules etaient tres avances. L'analyse des d6penses consenties (voir annexe 4) montre que -hormis salaires et cofits operationnels- les deux plus fortes ponderations (exprim&es en pourcentage du budget previsionnel correspondant par poste) sont imputables a l'assistance technique, et a la formation: 13,31%, 10,72%, respectivement. A ce stade, seulement 8,24% du budget global avait ete depense. 111.1.3 Synthese: Objectif principal et objectifs specifiques En resume, ce premier moment du projet se distingue surtout par la preponderance des activites de formation, de realisations d'etudes, et de mise en place des structures prealables aux prochaines etapes. Avant meme le coup d'etat de septembre 1991, un evenement significatif devait remettre tous ces acquis en question. ll s'agit de la reforme administrative du MSPP introduite en juillet 1991 et qui aboutit a la fermeture des structures administratives du Ministere. Cette demiere crea des mouvements de personnel, -27 - nefastes au projet, et des cadres importants pour le suivi, la gestion, et la planification etaient depIaces. Cet &venement, A l'avant veille de celui de septembre 1991, jetait le doute sur l'engagement r6el de l'Etat dans la voie du type de reformes (administration centrale) pr6nees par le projet. Jusqu'ici donc, le projet etait encore loin (volet Tuberculose mis a part) des objectifs specifiques, et de l'objectif principal. I1 est opportun de repeter ici que les r6sultats touchant les allocations budg6taires du MSPP semblaient deja hors des capacites du projet. Le derapage enregistr6 plus haut le demontre d'ailleurs. Cette initiative ne pourrait etre menee a bon port-surtout dans un contexte d'urgence budgetaire, et d!instabilit6. La remise en question formelle de la provision de l'Accord de Credit portant sur les allocations budgetaires du MSPP viendra sous la forme d'une r6forme administrative generale administr6e par la cr6ation du Conseil National pour la Reforme Administrative (CNRA). Cette entite etait chargee d'analyser, de valider, et d'harmoniser tous les plans sectoriels de r6formes administratives. Ce n'est quen aofit 1999 que la reforme administrative de I'administration publique dans son entier fut lancee. I1.2 Les resultats intermediaires : Mars 1995-Decembre 1998 A l'encontre de la periode precedente, cet intervalle (trois annees d'ex&eution) est suffisamment grand pour meriter que l'evaluation prenne compte de l'objectif principal et les objectifs specifiques du projet. Dans les circonstances difficiles dejA decrites, le projet devait donc redemarrer en mars 1995, et il fallait au prealable dresser un etat des lieux. Cet etat des lieux devait rev6ler la necessite de rendre l'UGP operationnel, d'activer la mise en place des UCS, la rehabilitation des infrastructures et l'acquisition d'equipements, le besoin de dresser un inventaire des ressources humaines du projet et de relancer les programmes de formation, et de financer l'obtention des m6dicaments essentiels. En mars 1995, une programmation sur tous ces points avait et6 faite couvrant 9 mois: avril-decembre 1995. HaYti est A ce jour en pleine periode 6lectorale, un nouveau gouvemrnement sera install6 le 7 fevrier 1996.. .'histoire se repete. A ce titre, il faut prendre note des commentaires d'une mission de la BM ayant sejourne A Port-au-Prince entre les 11 et 15 mars, 1996: "les progris r6alises [depuis octobre, 1995] ont et plus modestes que prevues. Ceci est dfi surtout [A ] la non-reconduction des contrats de I'6quipe de I'UGP et aussi [A] la non-approbation par la nouvelle administration du MSPP des activit6s prevues, lies en partie A la decision de restructurer le Ministere et de reevaluer les strategies." HII.2.1 Activit6s Si la periode pr6cedente avait et marquee par la pr6pond6rance du programme de formation et de l'assistance technique, celle-ci s'etait revelee etre celle des travaux d'infrastructures et du capital physique du projet (voir annexe 4). En effet, les acquisitions d'equipements medicaux et de m6dicaments essentiels, et l'achevement des chantiers de construction et de r6habilitation des centres de sant6 absorbaient pres de 77%, et 63% des allocations budgetaires prevues pour ces postes, respectivement. II importe de souligner aussi que 43% de l'enveloppe budgetaire pr6vue pour l'acquisition de v6hicules avait &6 consomme. -28- Par ailleurs, le taux de consommation du programme de formation avait A peine atteint 19%, mais celui de Passistance technique s'6tait 6leve a 40% a peu pres, soit plus du double. III.2.2 Resultats Escomptes La restructuration du secteur sante se faisait encore attendre. En particulier, meme le concept des UCS faisait encore l'objet de controverses, et des confusions quant A leurs modalites de fonctionnement persistaient. Bien que des progres aient e enregistres en ce qui a trait A l'aspect infrastructure physique et logistique de la decentralisation (construction/r6habilitation et meilleur approvisionnement de centres), des retards ou carences se faisaient encore sentir au niveau de la disponibilite des ressources humaines dans ces derniers. L'annexe 5 presente le budget execute par le MSPP entre 1997 et 1999. Une difference significative dans la pond6ration des salaires dans le total des d6penses du Ministere n'apparait qu'en 1999, alors que cet objectif ne devait plus etre poursuivi par le projet A partir de 1999. En 1999, la proportion des salaires dans le total des depenses etait passe a 79%, un changement notoire par rapport aux 84%, et 85% enregistres en 1997 et 1998, respectivement. II importe de souligner que cette reduction ne s'explique nullement par une diminution de la masse salariale. Celle-ci est passee de 310,7 millions de gourdes en 1998 A 348,3 millions de gourdes en 1999, soit une augmentation de 12% en termes nominales et, vu le taux d'inflation de 9,9% entre septembre 1998 et septembre 1999, cette montee correspond A une croissance reelle d'environ 2%. L'annexe 6 montre l'evolution de la part relative des departements sanitaires de l'Ouest et du Sud-Est dans le total des depenses du MSPP entre 1996 et 1999. II est evident, que l'evolution de l'execution du budget dans ces departements ne reflete pas une allocation prioritaire des ressources financieres du MSPP. De plus, l'annexe 6 fait ressortir que entre 1997, et 1998, les allocations salariales des departements n'ont pas augmente de facon significative, refletant trbs probablement le non-redeploiement des ressources humaines vers les centres concernes par le projet. En ce qui a trait aux realisations de travaux d'infrastructure, le point suivant merite d'etre soulignee. Alors que 77% des previsions budgetaires avaient et epuises, seulement 6 centres avaient et eriges ou rehabilites au lieu des 28 initialement identifies, et quelques cinq mille latrines avaient et6 construites, un effectif bien en decA des 10,000 envisages au debut. Cependant, plusieurs dep6ts peripheriques (10) avaient et rehabilit6s, des salles communautaires avaient ete construites, et un total de 3.250 latrines-non prevues par le projet- avaient ete erigees dans le Nord. Bien que l'on pourrait classifier toutes ces realisations de trbs positives, la concentration des resultats positifs dans deux secteurs du projet (Tuberculose, et Medicaments Essentiels) sans la decentralisation du MSPP (non-implantation des UCS, non-redeploiement des ressources humaines), faisait encourir au projet le risque de ne pas atteindre son objectif principal ou ses objectifs specifiques cles. Point n'est besoin d'etre grand clerc pour se rendre compte qu'il existe une correspondance presque parfaite entre les realisations enregistrees jusqu'a cette date, et l'amendement de decembre 1998. -29- m.2.3 Objectif specifiques Les aide-memoire et rapports prepares anterieurement montrent que les objectifs sp6cifiques les mieux satisfaits se concentrent dans le volet "Medicaments Essentiels" et "Tuberculose". L'introduction de la strategie de courte dur6e pour le traitement de la tuberculose etait effective, et avait remporte des succes tel qu'en temoigne des taux de guerison augmentes. Encore en butte A des problemes de ruptures de stock, le systeme d'approvisionnement des medicaments essentiels etait nettement amnliore, un fait dui en partie A l'implantation des dep6ts peripheriques. 111.2.4 Synthese: Objectif principal L'analyse d'impact se heurte a deux obstacles. Premierement, les statistiques permettant de discerner rimpact du projet a partir des indicateurs de performance retenus lors de l'elaboration du projet ne sont pas toujours disponibles pour les zones du projet. II semble opportun de souligner ici que la disponibilite d'une base de donn6es avait ete envisagee dans le cadre du projet, mais que cette activit6 n'a pas ete menee A bon port. Deuxiemement, il semble important de signaler dans ce contexte, que le passage du decoupage administratif en regions, puis en departements, puis A la tentative 6chouee de l'implantation des UCS n'6tait pas apte A conduire A des indicateurs de performance precis ou A des mecanismes de collecte d'information adequats. Toujours est-il que le consultant rejoint l'opinion de 1'IHE (decembre 1999) selon laquelle il n'est pas permis de penser A une amelioration sensible de la situation sanitaire en Haiti. A ce commentaire, le consultant ajoute qu'il n'est meme pas permis de cherir, dans un contexte institutionnel degrade et dans un environnement de crise economique et de constantes remises en question, l'illusion de resultats durables dans ce domaine, en conformite avec l'esprit du projet. HII.4 Dernier moment: Janvier 1999-Mars 2001 En 1998, la date d'echeance du projet avait et reculee A decembre 1999. En 1999, cette echeance fut encore repoussee A mars 2001. L'annee 1999 marque un tournant important quand on admet l'hypothese d'une remise en question tacite de certains objectifs cles du projet initial. Ainsi, il etait admis que la plupart des resultats substantiels A obtenir A travers cette initiative etaient d6jA acquis. II s'agissait donc, autant que l'on puisse en juger, de consolider les succes relatifs du projet: "Tuberculose" et "Medicaments Essentiels". Repetons-le ici, le projet ne focalisait plus sur la restructuration du MSPP, et l'emphase sur les UCS avait ete abandonnee, et la decentralisation se resumait a assurer que les quelques centres de sante, dans l'Ouest et le Sud-Est, avaient le personnel et le materiel requis pour leurs bons fonctionnements. De plus, en 2000 le projet apportait un appui financier au Programme Elargi de Vaccination (PEV), et de nouvelles initiatives etaient prises dans le cadre de la Sante reproductive. Puisque la portee du projet avait et6 reduite aux deux initiatives sus-mentionnees, le rapport MSPP-ONGs (elargi des suites de l'amendement de 1998) venait A revetir un plus haut niveau d'importance. Cette collaboration a constitue un appui logistique important accompagne d'un apport en ressources humaines necessaires. II faut ajouter A cette liste la contribution des ONGs dans les activites IEC. Parmi les realisations importantes de cette demiere etape du projet, on peut compter: 1) Le renforcement des activites de depistage de la tuberculose, -30 - 2) Le renforcement des activit6s de lutte contre le SIDA (disponibilit6 des tests) et les MST, 3) L'appui (produits pharmaceutiques) a certains centres hospitaliers (Cap-haftien, Jacmel, Gonaives, Hinche, Cite Soleil) dans le domaine de la Sante Reproductive, 4) L'amelioration sensible de la disponibilite des Medicaments Essentiels', 5) L'appui A l'ecole des << Sages Femmes )>, et 6) L'Appui au PEV. IV. Evaluation L'6valuation de la performance du projet pr6sentee ci-dessous offre d'abord une appreciation gen6rale des modalites de son ex6cution et de l'envergure de son impact. De l'avis de consultant, cette d6marche permet une mise en contexte appropriee des resultats specifiques observ6s. Une description analytique de ceux-ci fait l'objet d'une deuxieme sous-section : appreciations particulieres. IV.1 Appreciation Generale : facteurs cl6s, et vlabilWt du projet L'instabilit6 socio-politique couplee du manque d'engagement soutenu et coherent du GH dans la voie de la reforme du secteur explique en grande partie l'evolution du projet. L'objectif principal de ce dernier visait 1' amelioration durable du statut de sant6 de la population. Pour ce faire, une strategie specifique avait ete retenue dont lun des aspects cles aurait dui deboucher sur la d6centralisation effective, et le renforcement tout aussi durable des institutions ayant pour mission, de reguler le secteur, et d'offrir des services de sant6. La "durabilite" constitue un critere d'evaluation eleve, mais necessaire, puisque des notions tout aussi importantes telles la continuit6, et la coherence dans le temps, aboutissant a reffet cumule des efforts la sous-tendent. Un projet forme un tout, et il n'est pas possible (ou recommandable), pour les besoins d'une evaluation conforrne, de s'en tenir A quelques resultats positifs, aussi importants qu!ils soient ou et quels que soient leurs impacts ponctuels (voir annexe 7). Par cons6quent, dans la mesure o4 les circonstances socio-politiques difficiles sus-mentionnees ne se sont pas soldees par une amelioration sensible des capacit6s de gestion ou le redressement notoire des defaillances organisationnelles des structures du Ministere, le consultant ne peut que constater le degre de succes tres limite, dans sa globalite, du Premier Projet de Sante MSPP/IDA. Cette opinion se justifie au moins de deux manieres. Premierement, les redressements organisationnels aptes A preserver/securiser les investissements consentis dans le cadre du projet ne sont pas encore en place. Pour plus de specificite, des equipements (y compris vehicules) ont ete acquis, des batiments ont ete construits, et il nexiste pas l'ebauche d'un plan d'entretien pour ce capital physique precieux voire, des procedures ou provisions (voire disponibilites) budgetaires en visant le maintien. En ce qui a trait au caital humain. la d6pravation des cadres occasionn6e par les nombreux evenements politiques est encore a craindre. Le consultant ne possede aucune 6vidence de racceptation du principe de l'implantation des UCS ou de quelque autre modele de deploiement des ressources humaines. La viabilite du projet reposait sur la bonne comprehension de son objectif principal, et de ses objectifs specifiques, mais aussi de la strategie d'ensemble. A ce titre, il est regrettable que des instruments de suivi de projets, tel le cadre logique n'aient pas ete disponibles, d'une part, et qu'une ventilation peu judicieuse des ses composantes ait ete faite au depart, d'autre part. IV.2 Appr6ciations Particulikres La methodologie retenue pour cette section s'assied d'une part sur l'execution du budget pour chacune des composantes du projet, et sur les realisations observees d'autre part. -31 - II faut noter des le debut que le budget pr6sent6 dans le SAR ne constitue pas un instrument d'analyse. Plus specifiquement, les rubriques prisenties dams le budget pr&hlonnel se sont pas ventilees par composante programmatrice (voir annexe 4). En l'absence d'une telle programmation, il est difficile de juger (par volet) 1'ex6cution du budget par rapport aux anticipations scion le canevas de I'annexe 3. Plutot, la totalite des postes budg6taires peuvent etre regroup6s sous la rubrique ( Renforcement Institutionnel >>, ce qui ne permet qu'une appr6ciation limitee des differents aspects du progamme. Une analyse plus fine ne devient possible qu'A partir de l'ann6e 2000 quand une p on budg6taire detaill6e (voir Annexe 8) a e r6alisee couvrant l'intervalle janvier 2000 -mars 2001 pour chaque volet du projet. IV.2.1 Genie Civil (satisfaisant) Quelques 5,7 millions de dollars am6ricains auraient ete d6caiss6s au titre de cette rubrique. Ce montant represente environ 92% 1'enveloppe budg6taire pr6vue, alors que seuement 50°/e des travaux originellement programmes ( voir annexe 9) ont 6t6 ex6cut6s. Toutefois, un menu assez consistant de chantiers ont et entrepris. Ainsi, en ajoutant les travaux non ptevus (latrines dans le Nord, salles communautaires, et depots p6ripheriques) on arrive a un taux d'achWvement de 82%. La note (satisfaisant) s'explique du fait de la port6e des realisations observ6es (importance des d6p6ts p6riph6riques) en depit d'un cadre macroeconomique degrade (inflation, d6pr6ciation de la gourde). De plus, I'6cart entre les previsions et les realisations en ce qui a trait au nombre de centres construits et rehabilit6s s'explique par le changement d'orientation du projet (plus de focalisation sur le modele UCS) not6 plus haut, un d6veloppement qui n'est pas imputable a la mauvaise gestion ou l'incapacite d'ex6cution. En d'autre termes, 1'6quipe en charge des activit6s de genie civil a su r6pondre aux demandes des d6cideurs quand celles-ci ont 6te formulees. IV.2.2 Equipements & Mat6riels M6dicaux (son stsfaisant) II existe une liste assez impressionnante de tnat6riels m6dicaux (voir annexe 10) achetes mais non completement distribu6s. Cet etat de chose d6plorable s'explique par un manque de coordination d'une part, et par une mauvaise evaluation des besoins des etablissements sanitares, d'autre part. En ce qui a trait A certains mat6riels distribues, ils sont rest6s inutilises dans plusieurs cas soit parce qu'il n'y avait pas de techniciens pour les installer, soit par manque d'espace dans les centres, soit par cause d'absence du personnel qualifi6 pour les utiliser. De plus, un grand nombre de besoins en mat6riels et 6quipements ont ete formul6s par diverses institutions sanitaires alors que du materiel reste entrepose: un gaspillage inacceptable des ressources mises a disponibilit6 par le projet. Le matbriel et les 6quipements ont ete achetes sur demande des responsables du MSPP. Des 75 vehicules tout-terrain pr6vus, quarante-sept (47) ont et6 acquis et distribu6s. Ainsi, a peu pres 42% du montant prevu ete depens6 pour l'acquisition de v6hicules. II a et6 rapport6 au Consultant que ces vehicules n'ont pas toujours et6 utilis6s aux fins pour lesquels ils ont 6t6 achet6s (moyen logislique pour la supervision, et les visites de terrain). De plus des disponibilit6s budg6taires ne se sont pas mat6rialis6es au MSPP pour satisfaire aux besoins d'entretien ou de r6parations. II en a r6sult6 que l'UGP a du pourvoir A bon nombre de requetes pour combler ces lacunes. IV.23 M&iLcaments Essentiels (satisfaisant) En bute A des problemes de rupture de stock au debut du projet, ce volet du programme a su r6soudre ces problemes, et a contribu6 par l'entremise des ONG et, grace i l'implantation des depots p6ripheriques au bon approvisionnement des institutions sanitaires. -32- Le volet ME et l'acquisition d'6quipements et de materiels ont consomme pres de 91% de 1'enveloppe previsionnelle, soit $9,97 millions des $10,96 millions pr6vus. IV.2.4 Assistance Technique et Formation (satisfaisant) L'assistance technique et le programme de formation ont coWte $4,6 millions au projet. Ces deux activites visaient l'amnelioration de la qualite des ressources humaines soit par dissemination de nouvelles techniques sanitaires, soit par l'introduction de nouvelles procedures. Une bonne partie du personnel sanitaire (plus de 800) a beneficie (voir annexe 11) d'une formation. Cette formation a couvert tant le domaine medical (Tuberculose, et le SIDA) que le domaine administratif. Certaines r6serves pourraient cependant etre formul6es quand a la durabilite de tels efforts si ils ne sont pas int6gres dans la programnation du MSPP de favon continue. On se rappellera ici que la depravation des cadres formes a constitu6 un des problames dont a souffert l'execution du projet. L'assistance technique et la formation ont consomme $2,7, et $1,9 millions, respectivement. Alors que l'enveloppe prevue pour l'assistance s'6levait a S3,6 millions, celle de la formation se chiffrait a $1,1 millions. Ainsi ces deux activit6s ont consomm6 74%, et 181% de leurs allocations budgetaires respectives. IV.2.5 Renforcement Institutlonmel (non satisfaisant) Les activit6s sus-cit6es representent l'essentiel du <o Renforcement Institutiomel >>. Cet effort aura cofte un total de $21,5 millions, soit 77,4% des $27,7 millions decaisses au titre du projet. L'absence de preuves tangibles de la durabilite des effets d'un tel effort explique l'insatisfaction avec ce volet du projet, particulierement en regard des resultats pas toujours probants du cote des priorites sanitaires ciblees. Les resultats des trois priorites sanitaires sont discutes dans les sous-sections suivantes. IV.2.5 Soins de Sante de Base (Tris insatisfaisant) La sant6 matemo-infantile 6tait particulierement ciblee par le projet. Une nette deterioration du statut de sante des meres et des enfants apparait dans les statistiques presentees dans l'annexe 13. Le taux de mortalite maternelle aurait plus que doubl6 en 2000 (523/100,000 naissances vivantes) compare A celui du SAR (220/100.000). Par ailleurs, le taux de mortalit6 infantile serait passe de 77,4/1.000 a 80/1.000. L'annexe 12 montre aussi des statistiques alarmantes sur le taux de mortalite maternelle: 1.067/100.000 A l'Hbpital St. Michel de Jacmel. Parmi les raisons citees pour ce taux 6leve, on retrouve le manque de materiels adequats, et du personnel qualifie. Des trois h6pitaux identifies, seules les statistiques de l'Hopital Justinien du Cap se trouvent en dessous de la moyenne nationale. On pourrait ajouter, vu les causes de d6ces, l'insuffisance dans la fourniture de soin avant la naissance, ce qui laisse supposer un nombre insuffisant d'interactions des femmes enceintes avec le milieu medical. Compares A l'ensemble des femmes enceintes du pays, seules les femmes du Sud-Est se portent mieux, jugees au travers du taux de s6roprevalence, et de la prevalence de la Syphilis parmni les fenimes enceintes. Celles de l'Ouest ont un taux de s6ropr6valence inf6rieur A la moyenne nationale. Ces deux departements etaient cibl6s par le projet. Entre 1996 et 1999, I'annexe 12 montre une l6gere hausse du taux de seropr6valence, alors que le taux d'infection a la Syphilis s'est amrlior6 de fagon sensible. nl incombe de souligner que le groupe d'fage -33- pardielsrement A risque ed S msdtu6 par le-s moins de vingt aien milieu rural, IV.2.6 SIDA/MST (satdaisaat) Avec celui de la Tuborcuose, le volet SIDA/MST repr6sentait une composante importante de la lutte contre les end6mies majeures. Six ONG ont t6 engag6s pour aider le MSPP A mener cette lutte contre la s6ropr6valence et les MST. L'annexe 13 pr6sente a liste complete des ONG impliquees de m&ne que les actions entreprises par elbs. On notera que des rapports sont disponibles pour seulernent quatre ONG sur six. On rappelle ici quo l'apport de ces organisations a et6 considerable dans les activit6s IEC, I'approvisionnement, et le d6pistage. Pour les ONG dont les rapports sont disponibles, on peut avancer, qu'en g6n6ral, elles se sont bine acquitt6es de leurs tiches. Le volet ONG-SIDAJMST a coWte un peu moins de $100.000 au projet. Bien qu'un effort consid6rable ait 6t6 consenti (Caravane des Jeunes, formation, conferences, rencontres communautaires, distribution de preservatifs) la lutte est loin d'tre terminee. L'annexe 14 montre que la grande majorit6 de h population est sensibilis6e sur le probleme du VIH/SIDA. Toutefois, seulement 14% des hommes, et 6% des femmes ayant eu (en 1999-2000) des rapports sexuels durant les douze demiers mois rapportent avoir utilis6 des pr6servatifs, soit un taux d'utilisation effectif des pr6servatifs d'a peu pres 10%/0. IV.2.7 Tuberakose (Trbs usafabaut) Le volet Tuberculose a connu un grand succ6s. Des objectifs sp6cifiques majeurs ont et atteints: des taux de succs sup6rieurs a 70%/ ont 6 observ6s en 1999, et le d6pistage des cas frottis positifs a beaucoup augment6 (voir annexes 15 et 16). De plus le taux d'abandons serait passe de plus de 45% A moins de 20%/o, soit une r6duction de plus de 100%/. Ici encore, l'action des ONG en support d'un BPCLT dynamis6 explique ces bons resultats. Les trois ONG retenus pour mener cetet lutte sont la ICCMCAT, le CDS, et la CCH. Le financement leur a permis de mobiliser un nombre appr6ciable de ressources humaines additionnelles (voir annexe 17) pour la lutte anti-tuberculose. Hormis la formation, ces ONG ont Wt6 impliqu6es dans le depistage et le traitement. Elles ont bien rempli leurs mandats. Le financement des ONG par le projet s'est eleve A quelques 577 mille dollars americains. IV.2.8 Coit-Efficact Tenant compte des limitations d6crites ci-dessus, le calcul du ratio coft-efficacit6 se base exclusivement sur les resultats obtenus pour les programmes prioritaires : Soins de Sant6 de Base, et Endemies Majeures (ruberculose, SIDA/MST). Le calcul du ratio est expliqu6 i l'annexe 19. Selon les criteres retenus, le projet auralt ete effectdfi 47%, un resultat peu satisfaisant. V. Conchlions et Recommandadems Conform6ment & on statut, et dans un contexte strgique de "Lutte contre la Pauvrete" le secteur social repr6sente un domane prioritaire pour lIDA. En depit du mveau de succ'es peu eleve de ce projet, l'implication de 1I'DA dans le secteur ne sera pas probablement remise en question. Cependant, des leoons importantes peuvent etre tir&es de cette premiere exp6rience. -34 - Premierement, un des risques identifies lors de l'61aboration du projet etait la relative inexperience du secteur avec les programmes finances par l'IDA. Un impact positif de l'ex6cution de ce projet a e la formation de I'UGP, et a travers elle, la familiarisation avec les modalites, et proc6dures de l'IDA. Deuxiemement, l'insistance sur la restructuration de l'administration centrale du MSPP a probablement et une erreur strategique. Le projet a obtenu de meilleurs resultats pour les programmes (Tuberculose, et Medicaments Essentiels) clairs. Ce benefice peut probablement &re etendu a d'autres domaines prioritaires de la sante, si la programmation s'efforce de cibler des problemes de sante tout aussi specifiques que la Tuberculose. Troisiemement, les ONG se sont reveles etre un appui logistique important, et de plus ces entites offrent (I'experience de 1992 I'a montre, de meme que les resultats qu'elles ont pu obtenir) des opportunites pour la continuation des activites en cas de troubles politiques. Hafti n'est peut-etre pas aux lendemains de la stabilite politique, et des strategies qui tiennent compte de ce facteur determinant doivent etre envisagees. Quatriemement, II est recommande d'une part que l'IDA continue son support des domaines prioritaires specifiques a travers des centres de sante identifies. Cette initiative pourra beneficier des competences et expertises acquises par l'UGP, qui en outre de son role de gestionnaire financier, a pu au moment opportun se transmuter en organe d'execution. De l'avis du consultant, forte de son experience, l'UGP devrait jouer un role cle dans l'elaboration d'un second projet. Cependant, l'UGP devrait jouer un r6le de supervision effective, et de suivi. Pour que cette tache soit accomplie, il faudra penser a integrer une unite specialisee en collecte d'informations (incluses toutes les statistiques du projet), et en redaction de rapports de suivi. A ces fins, l'UGP pourra beneficier de l'appui technique d'une firme ou d'un groupe de professionnels. Dans ce contexte, il faudra absolument preparer des formulaires de collecte de donnees en focalisant sur les indicateurs de performance, et les conditionnalites. L'echeancier des collectes devrait servir les besoins de supervision, d'evaluation, et de prises de decisions (mesures rectificatives, decaissements, etc..). Sans des formulaires de suivi et d'evaluation etablis au prealable, la tache de supervision se reduit a une simple politique de constats. En consequence, il est fortement recommande que la partie haitienne soit appuyee techniquement par un consultant ou une firme lors de la preparation du prochain projet. Cette assistance technique devra porter sur tous les instruments de suivi. Cinquiemement, le budget devrait etre formule sous une forme analytique, tel qu'il l'a ete durant la derniere annee du projet. La presentation du budget ex6cute sous une forme autre que celle-IA, infirme l'analyse cofit-efficacite. Sixiemement, des conditionnalites specifiques, associees a des activites devant aboutir a chacun des resultats escompt6s devraient &re formules. Les moments importants du projet devraient etre specifies au prealable, et la supervision devrait permettre au projet de respecter un «( chemin critique >> pre etabli. Ces conditionnalites devraient portees seulement sur les besoins operationnels du projet, et ne pas s'aventurer dans un remaniement institutionnel de trop grande envergure. Septiemement, avant le lancement du projet, on devrait prevoir une campagne de communication pour divulguer la portee et la teneur du projet a l'ensemble de la communaute medicale, et aussi aupres des -35 - utilisateurs. Si un effort particulier est consenti ceux qui en sont responsables (meme indirectement devraient en etre informes), et les b6neficiaires eventuels devraient aussi en etre imbus. Finalement, pour plus d'efficacite dans la distribution des materiels et equipements, il est recommande que toutes les conditions soient remplies pour leurs pleines utilisations (ressources humaines, courant electrique, programmation des interventions medicales a accomplir, espace physique, etc..). Les activites d'acquisition d'equipements et de materiels ont et marquees par trop de gaspillages. -36 -