ICRR 14190 Report Number : ICRR14190 IEG ICR Review Independent Evaluation Group 1. Project Data: Date Posted : 01/31/2013 Country : Tanzania Project ID : P082335 Appraisal Actual Project Name : Second Health Sector US$M ): Project Costs (US$M): 963.0 4,200.0 Development Project L/C Number : C3841; CH071 Loan/ US$M ): Loan /Credit (US$M): 65.0 165.0 Sector Board : Health, Nutrition and US$M): Cofinancing (US$M ): 548.0 986.0 Population Cofinanciers : GTZ, UNDP, UNFPA, Board Approval Date : 12/16/2003 UNICEF, World Health Closing Date : 12/31/2007 06/30/2011 Organization, Swiss, DFID, CIDA, Denmark, Netherlands, Norway, AfDB Sector (s): Health (80%); Central government administration (10%); Non-compulsory health finance (10%) Theme (s): Health system performance (29% - P); Child health (29% - P); Malaria (14% - S); Nutrition and food security (14% - S); Decentralization (14% - S) Prepared by : Reviewed by : ICR Review Group : Coordinator : Judith Hahn Gaubatz Judyth L. Twigg Soniya Carvalho IEGPS1 2. Project Objectives and Components: a. Objectives: According to the Project Appraisal Document (PAD, page 4), the project objective was: to achieve improvements in the provision of quality health services through continuing to support reforms, capacity development and improved management of resources, while placing a greater emphasis on quality. The project was the second part of a three -phase Adaptable Program Loan (APL), covering the period 2000-2011. The long-term objective of the Program was to improve access, utilization, quality, and financing of health services through increased efficiency and effectiveness in use and allocation of resources, to maximize impacts on health outcomes, especially among the poor, women, and children . The first phase of the APL focused on sector reforms and institutional capacity building, through changing the way the sector was managed and financed, and by shifting roles and responsibilities . According to the Development Financing Agreement (page 17), the project objectives were : to assist the Borrower in continuing to improve the quality of health services and to improve management of resources allocated to the health sector , both of which were to be achieved through the expansion of the health sector policy and institutional capacity building reforms carried out during the first phase of the program . As the Financing Agreement included a second objective to "improve management of resources allocated to the health sector," which is consistent with the APL objective and the project activities, it is used for the purposes of this review. b.Were the project objectives/key associated outcome targets revised during implementation? No c. Components: The Ministry of Health and Social Welfare (MOHSW) was directly responsible for national /referral or specialized hospitals, medical training schools, and national health programs (i.e. "vertical programs" such as malaria or nutrition), as well as overall technical responsibility on health matters . The "President's Office: Regional Administration and Local Government " (PORALG) administered regional and district hospitals, with each local government authority (LGA) operating health centers and dispensaries . The majority of the project funds would be "pooled" with other donors into a basket fund to be used for the activities identified below; the remaining funds were to be used for the national vertical programs and for central -level capacity building. (Note: Data on project costs at appraisal are taken from Annex 5 of the PAD. However, there is no appraised cost for Component 3, and the appraised costs for Components 1 and 2 add up to the entire project cost of US$ 963.0 million. According to the project team, the actual costs per component were not available due to the programmatic nature of the project .) 1: Improving District Level Health Services (Appraisal: US$573.5 million; Actual:not available ):This component aimed to improve the quality of health services; reduce the financing gap in the health sector; improve equity of access to health services; and improve equity of resource allocation . The project funds would support the implementation of Community Council Health Plans, which included the provision of a minimum package of essential health services . Activities also included: implementation of quality assurance initiatives, integration of HIV/AIDS activities into service delivery, advocacy for healthy household and community behaviors, implementation of staff incentive and staff training plans, publication of annual district health budgets and performance data, and strengthening of management user fees, community health funds, and exemption systems for the poor. 2: Strengthening the Management of Secondary and Tertiary Hospital Care (Appraisal: US$389.1 million; Actual: not available): This component aimed to strengthen human resources; improve management systems; and improve the quality of service delivery and facilities . Activities included: development of a cadre of hospital managers, establishment of hospital boards and hospital strategic plans, development of an efficient cost management system, performance audits, delivery of a package of quality services (as defined by national norms and standards), support for HIV/AIDS patients, and infrastructure rehabilitation and maintenance . 3. Strengthening the Central Level Stewardship Role (Appraisal: not provided ; Actual: not available): At the regional level, this component aimed to improve service delivery and stewardship responsibilities . Activities included: technical support to districts on quality service provision, performance audits, strengthening of data collection and management, support for improved inspectorate functions, and analyses of skills and human resources needs. At the central level, this component aimed to improve health financing, budgeting and resource allocation; address human resource shortages; improve the quality of service delivery; strengthen monitoring and evaluation; and further implement sector policy reforms . Activities included: support for improved resource allocation, improvement of the budget process through pooling of external financing (the basket fund), addressing of motivation and distribution issues in human resources, rolling out of national quality standards and protocols, definition of service agreements with private sector providers, periodic assessments of health sector performance, harmonization of MOHSW and PORALG planning, and strengthening of MOHSW capacity . Additional Financing (AF): According to the ICR (page 7), the introduction of the new activities below was a result of MOHSW's request for specific funds to meet new and emerging demands that could not be adequately addressed through the original financing arrangements. The first AF (US$60 million) was approved for the period December 31, 2007 to December 31, 2009, to focus on implementation of malaria prevention and treatment activities . The second AF (US$40 million) was approved for the period December 31, 2009 to December 31, 2010, to focus on implementation of food fortification activities and the purchase of emergency obstetric equipment . d. Comments on Project Cost, Financing, Borrower Contribution, and Dates: Project cost : The estimated project cost, which includes all sources of financing such as the Bank, the government, and other donors, was US$963 million. With the additional financing by the Bank, other donors and the government, the final project cost was US$ 4.2 billion. The significantly increased cost was due in part to the addition of malaria, food fortification, and emergency obstetric activities; it was also due to the decision to provide continued support to the health sector through additional financing, rather than through a third phase of the APL or a Poverty Reduction Support Credit (PRSC), as originally envisaged. Financing : The original amount of Bank financing was US$ 65 million, of which US$40 million was drawn from an IDA credit and US$25 million from an IDA grant. There were two Additional Financings (AF): In 2007-09, US$60 million was approved; in 2009-10, US$40 million was approved. A number of donor partners provided US$ 986.0 million in co-financing, compared to the planned amount of US$548.0 million. Borrower contribution No problems were reported regarding the fulfillment of counterpart obligations . US$350.0 million was the planned amount, while the actual contribution amounted to US$ 2.8 billion. Dates : The project was first extended from December 2007 to December 2009, in parallel with the first AF. The project was extended a second time from December 2009 to December 2010, in parallel with the second AF, as well as to ensure completion of the project activities . The project was extended a third time from January 2011 to June 2011, in order to complete procurement of the emergency obstetric equipment . 3. Relevance of Objectives & Design: a. Relevance of Objectives: High. High Given the stagnation, and even worsening, of health outcomes indicators during the 1990s, the relevance of the objective to achieve improvements in the provision of quality health services was high . The government's Health Sector Development Program for 2000-2011 focused on implementing the essential and most cost-effective health interventions, as well as transforming financing, management and delivery roles of the public sector. The Bank's Country Assistance Strategy for 2012-2015, current at project closing, clearly identifies improved access to and quality of health services as a key outcome . The objective was also highly relevant to the Bank's corporate priorities of achieving the Millennium Development Goals (MDGs). b. Relevance of Design: Substantial . The project design appropriately focused on intermediate outcomes (such as treatment coverage ) given the time frame of the project, while also noting health status outcomes (such as mortality rates) that were expected to be impacted over the course of the three -phase Program. The means through which the outcomes were to be achieved (sector reform, capacity building, management support ) were likely to lead to improved provision of services. A critical role was given to local level agencies, although many lacked adequate capacity and the human resource situation, in general, was marked with a severe shortage of qualified workers in the health sector. 4. Achievement of Objectives (Efficacy): The program supported the implementation of the government's health sector support strategy and the 133 Comprehensive Council Health Plans (CCHPs). These Plans covered all district hospitals and health centers (thereby potentially reaching 100 percent of the population). (Note: The majority of the Bank project's funds (US$125 million, or 76%) was pooled with other donors into a basket fund; this US$ 125 million comprised 19% of the total funds available in the donor basket fund . The non-pooled Bank project funds were used for central level government support and malaria and nutrition activities .) Objective : To achieve improvements in the provision of quality health services . Substantial , due to evidence of improved intermediate outcomes . The project team reported that increases in coverage levels took place during a period of significant population growth (the population grew from 33.7 million to 43.2 million, or 28.1 percent). Baseline data coinciding with the s tart of the project period would have better substantiated the overall health status outcomes, as well as more details on the actual services and outputs, or coverage levels, provided by the districts through the minimum essential health package . In addition, the impact of external factors such as economic growth (and subsequent declines in poverty ) or other projects or donors not participating in the basket fund (i.e. Bank's Multi-Country HIV/AIDS Project implemented in the country from 2003-2010 or the Global Fund or PEPFAR) is not discussed in the ICR. Outputs Budget support was provided to implement Comprehensive Council Health Plans, which focused on providing a minimum package of essential health services (such as antenatal care, contraception, childhood illness management, promotion of exclusive breast -feeding, and treatment for tuberculosis and HIV ). The ICR does not report on any increase in the proportion of the population with access to the minimum package . The following specific outputs were reported : 6.6 million children received Vitamin A supplementation, achieving the target of 6.5 million. Regarding micronutrient fortification, the ICR notes (page 37) that there were some disagreements on modalities of implementation (i.e. fortification processes, types of fortificants to be allowed, micronutrients premixes to be used), and thus the procurement process experienced delays . 2.4 million bed nets were purchased and /or distributed, achieving the target . 63,364 patients were treated for tuberculosis in 2010, falling slightly short of the target of 66,000. HIV services (counseling and treatment) were established in all districts . The integrated management of childhood illness (IMCI) approach was implemented in all districts . Emergency obstetric equipment was provided, although specific information on outputs is not provided in the ICR. Policy guidelines for malaria, tuberculosis, HIV /AIDS, childhood illnesses, and nutrition were developed . A Quality Assurance Framework Program was developed according to an accreditation system for service providers. Initiatives to improve quality included accreditation of facilities (no data on the number of type of facilities receiving accreditation provided ), establishment of quality assurance units, and inclusion of quality assurance concepts in the training curriculum . 13,000 health personnel received training on health management and /or technical skills (i.e. management of childhood illness), surpassing the target of 3,600. The ICR (page 19) reports that there were 42,553 health personnel in 2009/2010. The number of health workers enrolled in pre -service training to meet minimum qualifications and certifications increased from 899 in 2004 to 6,450 in 2010, although falling short of the target of 8,599. There are no data on the proportion that completed the training and met qualifications . Outcomes Intermediate outcomes The proportion of children under five receiving Vitamin A supplementation increased from 12.5% in 1999 to 60.8% in 2010, achieving the target of 50%. Baseline data did not match the start of the project period (2004), and therefore the extent to which this outcome is attributable to the project is unclear . The proportion of households that owned insecticide -treated bed nets increased from 39.2% in 2007/08 to 63.5% in 2010. The utilization of bed nets in households with children under five years old increased from 25.7% in 2007/08 to 64.1% in 2009/10. The utilization of bed nets in households with pregnant women increased from 26.7% in 2007/08 to 56.1% in 2009/10. The ICR (page 35) reports that Bank support for the national malaria program (which began with the Additional Financing in 2006) was intended to meet a specific need for improving the availability of bed nets, while other donors provided broader program support . The tuberculosis treatment completion rate increased from 80% in 2003 to 87.5% in 2010, falling short of the target of 90%. The extent to which this outcome is attributable to the project activities is unclear given the activities of other donors such as the Global Fund . The proportion of births attended by a skilled health worker increased from 43% in 2005 to 51% in 2010, falling short of the target of 57%. The ICR reports (page iv of the Data Sheet) that "inadequate emergency obstetric units and staff shortages contributed greatly to the non -attainment of this target." The percentage of pregnant women who received at least one antenatal care visit increased from 94% in 2004 to 95.9% in 2010. The proportion of women aged 15-49 reporting the use of modern contraceptive methods increased from 26.4% in 2005 to 34% in 2010. The coverage of the DPT3 childhood immunization increased from 83% in 2007 to 88% in 2009/10, falling short of the target of 90%. No earlier baseline year data are provided . Coverage of anti-retroviral treatment for people with advanced HIV infection increased from 14% in 2006 to 80% in 2010. The proportion of pregnant women tested for HIV during an antenatal visit increased from 27% in 2004/05 to 79% in 2008. The extent to which this outcome is attributable to the project activities is unclear given the activities of other projects such as the Bank's Multi -country HIV/AIDS Project (2003-2010) or other donors such as the Global Fund or PEPFAR . Health status outcomes The proportion of children under five suffering from malnutrition decreased from 37.7% in 2004/05 to 35.4% in 2010 according to the height-for-age index, and from 21.8% to 20.7% according to the weight-for-age index. As nutritional status can be affected by many different factors within and outside the health sector, it is unclear the extent to which these results can be attributed to the program . The Infant Mortality Rate (IMR) decreased from 99 (per 1000 live births) in 1999 to 51 in 2010, achieving the target of 54. Baseline data coinciding with the start of the project period (2004) are not provided and therefore the extent to which the improvement occurred during the project period is unclear . The Under-five Mortality Rate (U5MR) decreased from 146.5 (per 1000 live births) in 2003 to 81 in 2010, achieving the target of 86. The Maternal Mortality Rate (MMR) decreased from 578 (per 100,000 births) in 2004 to 454 in 2010, falling short of the target of 391. The Total Fertility Rate (TFR) decreased from 5.6 in 1999 to 5.4 in 2010, achieving the revised target of 5.4. Baseline data coinciding with the start of the project period (2004) were not provided and therefore the extent to which the improvement occurred during the project period is unclear . Objective : To improve management of resources allocated to the health sector Modest . While a number of capacity strengthening measures were implemented, there was limited evidence of actual improvements in the management of resources. There were also shortcomings in key activities related to the management information system and drug supply, as well as continued shortages in human resources . Outputs All 133 districts received capacity building support to produce Comprehensive Council Health Plans (CCHPs) and received grants for implementation of the Plans . Quarterly performance audits of the districts (based on the annual Health Plans ) were conducted. A cadre of hospital managers was established, with all government hospitals being supported by hospital management committees, hospital boards, and financial committees . All hospitals were operating under strategic plans, which were intended to provide guidance on funding and implementing hospital activities. Over 20 procurement officers were recruited to support the Ministry of Health activities, including training in financial management. 6 Zonal Training Centers were established to train district and regional health management staff . Human resource development measures were developed such as long -term manpower planning, re-distribution to the districts, motivation and retention of staff, strategic use of Zonal Training Centers, and incentives for rural facilities. However, the ICR reports (page 18) that there is still a severe shortage of human resources at all levels, with the current staff levels at "half the total number of health workers required to effectively implement health service delivery." Although a strategy for public -private partnerships was to be implemented, the only progress reported was the registration of new facilities. Outcomes Total government health funding per capita increased over the project period from $ 6.6 to $13.98, achieving the target of $14. The project design identified this as an indicator of effective advocacy by the Ministry of Health . Although the health management information system (HMIS) saw improved collection and management of data at the facility level, HMIS data "continues to be intermittent and unreliable despite considerable external support, with utilization and analysis at district level still minimal ." (ICR, page 23). The supply of medicines from the Medical Stores Department (MSD) was inconsistent, attributed to irregular disbursement of funds from the Ministry of Health and slow procurement processes . 5. Efficiency: Substantial . The project design included a focus on known cost -effective interventions such as malaria prevention through increased use of bed nets, and child and maternal health . Malaria prevention activities were implemented as planned and the intermediate outcome of increased coverage of bednets, particularly for children and pregnant women, was substantially achieved . At least US$60 million (due to the first Additional Financing ) went towards malaria activities. The ICR also estimated that about 25% of project financing (over US$1.0 billion) went directly towards strengthening the health delivery system that attended maternal and child health concerns (i.e. immunizations, nutrition, number of births taking place at health facilities, antenatal and postnatal care for mothers, neonatal care for newborns). An internal rate of return of 8% (by the year 2019) was calculated for the approximately 25% of the project that covered child and maternal health activities (benefits were based on averted productivity/illness costs for mothers and children ). The outcomes in the areas of malaria prevention, child and maternal health were substantially achieved even with a 25% growth in population over the time period . In addition, Bank resources were leveraged to secure additional co -financing for emergency obstetric equipment and achieve economies of scale in procurement . However, there were some shortcomings in implementation of maternal health activities (emergency obstetrics) and subsequent lower-than-targeted achievement of intermediate outcomes (births attended by skilled workers ). The ICR (page 24) also noted that adoption of the SWAp contributed to efficiency gains as it reduced operating costs through consolidating management of donor funds . However, there is no specific evidence provided to substantiate the claim. ERR )/Financial Rate of Return (FRR) a. If available, enter the Economic Rate of Return (ERR) FRR ) at appraisal and the re- re -estimated value at evaluation : Rate Available? Point Value Coverage/Scope* Appraisal No ICR estimate No * Refers to percent of total project cost for which ERR/FRR was calculated. 6. Outcome: Moderately Satisfactory , due to moderate shortcomings in achievement of the objectives . The relevance of the project objectives was High, and the relevance of the design was Substantial . Achievement of the objective to improve the provision of quality health services was rated Substantial . Achievement of the objective to improve management of resources was rated Modest due to limited evidence of outcomes . Efficiency was rated Substantial . a. Outcome Rating : Moderately Satisfactory 7. Rationale for Risk to Development Outcome Rating: Government commitment to continuing sector reforms is likely to be sustained, as well as donor partnerships through the sector-wide approach (SWAp). The focus on local level service delivery is being further strengthened by building governance and accountability structures at the local level (i.e. community health plan guidelines). A follow-up project is currently being prepared to continue focus on local service delivery . The potential risks that were rated Significant related to the impact of HIV /AIDS on the health work force and the potential to reverse any health gains realized from the project. However, the ICR reports (page 26) that these risks were effectively mitigated through implementation of the ongoing Multi -Country HIV/AIDS (MAP) project. a. Risk to Development Outcome Rating : Negligible to Low 8. Assessment of Bank Performance: a. Quality at entry: The project was a continuation of the first phase of support to the government's Health Sector Development Program, with lessons incorporated such as the need to address human resources shortages in addition to capacity building, the need to strengthen M&E to properly assess the impact of activities, and the need to improve hospital referral systems . The project was prepared through intensive collaborative work with governments and other donor partners . Areas of risk were, for the most part, effectively addressed through mitigation measures, although low capacity at the local level, was not identified as a significant risk and subsequently materialized. Fiduciary issues were addressed extensively in project covenants (i.e. annual audits, joint annual reviews with donor partners and government ) to ensure effective support on fiduciary and procurement issues. For example, the ICR (page 9) highlights a provision which required a Memorandum of Understanding on the basket fund among the government, the Bank, and other donor partners before any disbursements could be made. A participatory M&E process was designed to address existing inadequacies in M&E capacity. at -Entry Rating : Quality -at- Satisfactory b. Quality of supervision: Supervision of the project was intensive and proactive (as reflected by the establishment of various working committees to review different aspects of implementation, and regular reviews of financing mechanisms and district annual plans). Among other things, this led to the revision of a number of target values for key indicators, given the additional financing and extended project period . However, despite the emphasis on M&E, the management information system did not reach full functionality . There were also shortcomings in environmental management (See Section 11), although the Bank team undertook capacity building measures to address the inadequacies. Issues in financial management raised in the FY 07/08 audit were clarified and resolved . Quality of Supervision Rating : Satisfactory Overall Bank Performance Rating : Satisfactory 9. Assessment of Borrower Performance: a. Government Performance: The government demonstrated strong commitment to the reform agenda, including decentralization of service delivery and inclusion of health interventions in the broader development agenda . Legal covenants, including the Memorandum of Understanding related to the basket fund, were implemented with full compliance . The overall allocation to the health sector has increased annually, with overall per capital health expenditure increasing as well. However, the total percentage for health sector spending has remained almost the same, if not decreasing, and thus the prerequisite for shifting Bank financing from sector -specific projects to budgetary support was not met (along with other conditions to improve procurement performance and to include discussion of the waste management plan at annual reviews ). Government Performance Rating Moderately Satisfactory b. Implementing Agency Performance: The Ministry of Health and Social Welfare actively and effectively participated in the sector -wide approach (SWAp), as evidenced by the establishment of the Health Reform Secretariat and Sector -Wide Approach Committee to ensure coordination of all donor -assisted programs. The ICR (page 28) notes that the Ministry continued to ensure that all recommendations from donor partners through the various committees were addressed, including improving the level of compliance with legal covenants especially with regard to financial management. However, there remained procurement difficulties throughout the project period (See Section 11), and the key management information system never became fully functional . There is limited information provided on the performance of the Prime Minister's Office for Regional Offices or the Local Government Agencies (LGAs), which oversaw all district-based health activities (including delivering health services and providing health data ). The project team reports that while there were some challenges with the newly introduced decentralization process, the project funds were overall disbursed and utilized as planned . The Medical Stores Department (MSD) faced difficulties in providing a consistent supply of drugs . The ICR reports (page 21) that the Department attributed this to a number of factors, of which "irregular and inconsistent disbursement of funds from the Ministry of Health was noted . In addition, slow procurement processes and cumbersome donor processes could have contributed to this erratic availability of drugs at MSD ." Implementing Agency Performance Rating : Moderately Satisfactory Overall Borrower Performance Rating : Moderately Satisfactory 10. M&E Design, Implementation, & Utilization: a. M&E Design: The M&E design included a participatory monitoring and evaluation process, which required active involvement of key stakeholders. The key indicators for the first objective included both intermediate outcomes which were directly related to the project activities, as well as health status, which were expected to be impacted by the end of the three-phase Program. However, baseline data did not always match the start of the project period to ensure proper assessment. b. M&E Implementation: Regular monitoring of project implementation was carried out through the following activities : Joint Annual Reviews; Quarterly Basket Finance Committee meetings; Annual Sectoral Public Expenditure Reviews; and quarterly progress reports submitted by districts to monitor progress in the implementation of District Health Plans . Given the inadequacies of the management information system, the project supported demographic and health surveys and a malaria/HIV indicator survey to assess health outcomes instead . Shortcomings in baseline data not adequately addressed. c. M&E Utilization: The ICR (page 11) notes that Joint Annual Reviews were carried out each year to assess actual expenditures and achievements over the year, compare outputs with work plans, and review the budgets for the coming year . Annual district health performance data are published, although there were no specific examples provided of how the data was utilized to improve performance or inform decision -making. M&E Quality Rating : Modest 11. Other Issues a. Safeguards: Due to medical waste issues, the project triggered the environmental safeguard policy (O.P. 4.01) and was identified as an environmental category "B" project. A health care waste management plan was developed . Although routine implementation of the plan was carried out, a review concluded that "progress had been made but that more needed to be done especially on the training performed and on reporting of activity implementation." b. Fiduciary Compliance: Financial management: The ICR (page 12) reports that financial reports were produced regularly and that the project was in compliance with all legal covenants . Audits for the non-basket expenditures were unqualified and timely. The FY07/08 audit of the basket expenditures was qualified for the following reasons : the amount of expenditure reported was overstated by approximately US$ 2 million; payment vouchers for 0.3% of expenditures could not be located; and salary payment to one employee on unpaid leave (about US$4,400) was not refunded by the responsible staff . An action plan to address the issues was developed, with the ICR reporting (page 12) that the issues were clarified (fund transfer or filing problems) or resolved (funds returned to the Bank.) Procurement: The ICR reports (page 13) that mitigation actions to address inadequate capacity were implemented. Procurement performance improved over the project period, with regards to preparation of bid documents, bidding, evaluation, and general compliance . Although shortcomings persisted in contract management, supervision of projects, and delayed payments, the project team confirmed that all expected procurement was successfully completed without either substantiated procurement complaints or mis-procurement. . c. Unintended Impacts (positive or negative): d. Other: 12. Ratings : 12. ICR IEG Review Reason for Disagreement /Comments Outcome : Satisfactory Moderately There were moderate shortcomings in Satisfactory the achievement of objectives . Risk to Development Negligible to Low Negligible to Low Outcome : Bank Performance : Satisfactory Satisfactory Borrower Performance : Satisfactory Moderately There were shortcomings in Satisfactory environmental management performance, as well as in M&E. Quality of ICR : Satisfactory NOTES: NOTES - When insufficient information is provided by the Bank for IEG to arrive at a clear rating, IEG will downgrade the relevant ratings as warranted beginning July 1, 2006. - The "Reason for Disagreement/Comments" column could cross-reference other sections of the ICR Review, as appropriate. 13. Lessons: As reported in the ICR (page 29) and adapted by IEG: The sector-wide approach contributed to improved sector dialogue, as it helped to ensure a joint review process among donor partners and multiple Ministries . Strong government commitment to the decentralization process is critical; however, in a setting of human resource shortages, inadequate capacity at the decentralized levels can impede effectiveness of decentralization. 14. Assessment Recommended? Yes No Why? To verify outcomes, particularly the longer -term health outcomes that were to be assessed at the end of the original three-phase Program. Also, to learn lessons regarding the effectiveness of the sector -wide approach, decentralization of service delivery, and the pooled basket funding mechanism . 15. Comments on Quality of ICR: The ICR was overall satisfactory . However, the quality of the evidence had some shortcomings (baseline and final data figures not consistent with project period ) and discussion of attribution was limited . Despite the significant number of co-financiers and the emphasis on the donor -coordinated approach, there were comments reported by only one co-financier (which was not identified). The actual project costs per component were not available. a.Quality of ICR Rating : Satisfactory