Document of The World Bank Report No: 30701 IMPLEMENTATION COMPLETION REPORT (SCL-42720 TF-29364 PPFB-P3100 PPFB-P3101 TF-28730) ON A LOAN IN THE AMOUNT OF US$30 MILLION TO THE DOMINICAN REPUBLIC FOR A PROVINCIAL HEALTH SERVICES PROJECT December 23, 2004 CURRENCY EQUIVALENTS (Exchange Rate Effective December 2004) Currency Unit = Dominican Peso RD$ 1 = US$ 28.5 US$ 1 = 0.035 RD$ FISCAL YEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS AMD Asociacion Medica Dominicana (Dominican Medical Association) CAS Country Assistance Strategy CENCET Centro de Control de Enfermedades Tropicales (Centre for the Control of Tropical Diseases) CERSS Comision Ejecutiva de Reforma del Sector Salud (Executive Commission for Health Sector Reform) CNS Consejo Nacional de Salud (National Health Council) CONEP Consejo Nacional de Empresas Privadas (National Council of Private Companies) DPS Direcciones Provinciales de Salud (Provincial Health Departments) DRS Direcciones Regionales de Salud (Regional Health Departments) DR The Dominican Republic ENDESA Demographic and Health Survey HNP Health, Nutrition and Population IADB Inter-American Development Bank IBRD International Bank for Reconstruction and Development ICB International Competitive Bidding IDSS Instituto Dominicano de Seguridad Social (Dominican Social Security Institute) IMCI Integrated Management of Childhood Ilness INAPA Instituto Nacional de Agua Potable y Alcantarillado (National Institute of Drinkable Water and Sewerage) MIS Management Information System (Sistema de Informacion Gerencial) NBC National Competitive Bidding NGO Non-Governmental Organizations NBF Non-Bank Financed OECD Organization for Economic Cooperation and Development PAD Project Appraisal Report PAHO Pan American Health Organization PCU Project Coordination Unit POA Plan Operativo Anual (Annual Operational Plan) SESPAS Secretaria de Estado de Salud Publica y Asistencia Social State Health Secretariat (Ministry of Health) STP Technical Secretariat of the Presidency UEP Unidad Ejecutora Provincial (Provincial Executing Unit) UNDP United Nations Development Program UNICEF United Nations Children's Fund Vice President: David De Ferranti Country Director: Caroline D. Anstey Sector Manager: Ana Maria Arriagada Task Team Leader/Task Manager: Andréa C. Guedes DOMINICAN REPUBLIC DO Provincial Health Services 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 2 4. Achievement of Objective and Outputs 4 5. Major Factors Affecting Implementation and Outcome 15 6. Sustainability 17 7. Bank and Borrower Performance 19 8. Lessons Learned 21 9. Partner Comments 22 10. Additional Information 22 Annex 1. Key Performance Indicators/Log Frame Matrix 24 Annex 2. Project Costs and Financing 27 Annex 3. Economic Costs and Benefits 29 Annex 4. Bank Inputs 30 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 32 Annex 6. Ratings of Bank and Borrower Performance 33 Annex 7. List of Supporting Documents 34 Annex 8. Borrower's Contribution to the ICR 35 Annex 9. Legislation Supporting the Implementation of the General Health Law 39 Project ID: P007015 Project Name: DO Provincial Health Serv. Project Team Leader: Andrea C. Guedes TL Unit: LCSHE ICR Type: Core ICR Report Date: December 23, 2004 1. Project Data Name: DO Provincial Health Serv. Project L/C/TF Number: SCL-42720; TF-29364; PPFB-P3100; PPFB-P3101; TF-28730 Country/Department: DOMINICAN REPUBLIC Region: Latin America and the Caribbean Region Sector/subsector: Health (94%); Central government administration (6%) Theme: Child health (P); Health system performance (P); Population and reproductive health (P); Participation and civic engagement (S); Decentralization (S) KEY DATES Original Revised/Actual PCD: 02/15/1996 Effective: 11/30/1998 09/04/1998 Appraisal: 10/02/1997 MTR: 11/30/2001 10/17/2001 Approval: 01/15/1998 Closing: 06/30/2004 06/30/2004 Borrower/Implementing Agency: Dominican Republic/Technical Secretariat of the Presidency; Dominican Republic/State Secretariat of Health; Dominican Republic/Executive Commission for Health Sector Reform Other Partners: United Nations Development Program (UNDP) STAFF Current At Appraisal Vice President: David de Ferranti Shahid Javed Burki Country Director: Caroline D. Anstey Orsalia Kalantzopoulos Sector Manager: Evangeline Javier Charles Griffin Team Leader at ICR: Andréa C. Guedes Patricio Marquez ICR Primary Author: Rosa Puech; Andréa Guedes 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: S Sustainability: L Institutional Development Impact: SU Bank Performance: S Borrower Performance: S QAG (if available) ICR Quality at Entry: S Project at Risk at Any Time: No 3. Assessment of Development Objective and Design, and of Quality at Entry 3.1 Original Objective: The overall objective of the Provincial Health Services Project was to improve the health status of the population of the Dominican Republic, particularly the poor, pregnant, and lactating women and children under 5 years of age, in selected peri-urban and rural areas of participating provinces. These provinces were selected because of their overall low income level and because 48 percent of the country's population lives there . To this end, the Project would assist in: (i) expanding health care coverage to reach the poorest 1 population groups, focusing on mother and child health care, by developing new health care organization, financial, and managerial models at the provincial level; (ii) improving the quality of existing health care services to the poor; (iii) strengthening policy-making and management capacity of provincial health units that work in coordination with the Provincial Development Councils (PDC) under the State Health Secretariat (SESPAS), as well as of participating health facilities; and (iv) fostering community participation in the health system. 3.2 Revised Objective: The Project's objectives remained unchanged throughout its implementation. 3.3 Original Components: The total project costs were estimated at US$42 million (US$30 million loan and US$12 million Borrower's contribution). The project comprised the following components: Component 1. Provincial Subprojects (US$33.5 million, 80 percent of project costs). This component sought to improve the quality and coverage of health care services in selected areas. This was to be achieved by transforming health care delivery systems from isolated providers into provincial integrated delivery systems. The selected areas of intervention had large concentrations of low-income and underserved population groups. The subprojects were designed to be sponsored by Provincial Development Councils (PDC) and to include: (i) essential maternal and child care health care interventions; (ii) 2 development of new health care organization, financing, and managerial models to create provincial delivery systems; (iii) institutional strengthening to reorganize and enhance the planning, implementation, and monitoring capacity of the provincial health offices of the SESPAS, and other health facilities; (iv) training and continuing education of health personnel; and (v) monitoring, evaluation, and dissemination of local level experiences. Subprojects would finance rehabilitation of infrastructure, equipment, training, technical assistance, and incremental recurrent costs. Component 2. Policy Development and Studies (US$2.7 million, 6.4 percent of project costs). This component was intended to support the design of policies and institutional reforms to further decentralize health care management and delivery of health services. Approximately eight studies were to be carried out on topics that were to be agreed between the Project Coordinating Unit (PCU) and the Bank. Several workshops, seminars, study tours, and feasibility studies were also to be carried out. These activities were to be coordinated with the Inter-American Development Bank-financed project . 3 Additionally, this component was to provide technical cooperation on the possibilities for utilization of an unfinished medical campus (inside the high complexity hospital Plaza de la Salud located in Santo Domingo), including reviewing options to optimize its use, to integrate it within the provincial network, and to guarantee access to its services by the poor. - 2 - Component 3. Project Administration (US$2.2 million, 5.2 percent of project costs). This component was designed to finance the Project Coordinating Unit's (PCU) administrative and operating costs for carrying out the overall project implementation by national, provincial, and area units. This included financing for: (i) PCU consultants; (ii) provincial subproject preparation; (iii) travel; (iv) training; and (v) other administrative expenses. 3.4 Revised Components: In September 1998, the Dominican Republic was hit by Hurricane George, which caused severe damage in 24 of the country's 29 provinces. Total hurricane damages were estimated at US$2 billion. The Government requested the Bank's help, as well as that of other donors, to prepare a Contingency Plan that would address hurricane damage to the health sector. This assistance was in line with the Project's broad Development Objective of improving the health status of the Domican Republic's population. On October of 1998, the Loan Agreement was modified to include a new component to finance emergency-related rehabilitation, repair and equipment of affected health facilities, basic water and sanitation systems, and provision of needed medicines and medical supplies. A total of US$3 million (10 percent of the loan) was reallocated to finance these activities. The Project's targeting area was expanded to cover all of the hurricane affected provinces and the Santo Domingo National District. In November 1999, about US$852 thousand of unused funds under the category for financing the Project Preparation Facility were reallocated to the Emergency Subprojects, raising the total amount allocated to the emergency to about US$3.85 million. In 2000 the Dominican Republic faced outbreaks of polio and measles that threatened to undermine the achievement of the Project's Development Objective. As a result, the Bank agreed to provide support under the project to increase the extent, efficiency, and effectivenes of the Government's five-year immunization program to control outbreaks of polio and measles. This was carried out in coordination with PAHO and other international agencies. A total of US$3 million of loan resources were used to finance activities to control these outbreaks, including the acquisition of vaccines to cover the entire targeted population, and information campaigns at the national level. 3.5 Quality at Entry: ICR rating: Satisfactory The Project was the first health operation financed by the Bank in the Dominican Republic. The Project was consistent with the Country Assistance Strategy's (CAS-Report 14260-DO) objectives of reducing poverty and improving the country's human capital base. The Project was also consistent with the Bank's Health, Nutrition and Population (HNP Strategy Paper of September 1997), and supported the Government's health sector priorities, as set out in the Health Sector Reform and Modernization Program (contained in a policy letter of August 1997). Since this was the first Bank-financed operation in the Dominican Republic's health sector, the Bank team sought to coordinate closely with the Inter-American Development Bank (IADB) in designing an assistance package that supported country priorities of restructuring the sector, promoting the integration of the public and private sectors, and targeting basic health care expenditures on the poor. Additionally, the Bank team sought to provide complementarity in assistance provision by USAID, UNDP, PAHO/WHO, and the European Union. The Project's Development Objective was fully consistent with the Government's own objectives. The administration that took office in August of 1996 had embarked on an effort to modernize the State for which it had created a Commission for the Reform and Modernization of the State. Subsequently, an - 3 - Executive Commission for Health Sector Reform (CERSS) was established (1997) as the body responsible for leading reform efforts, providing political support, and coordinating external support for the health sector. The Project's implementation arrangements were well conceived and detailed in the PAD and in the Project's operational manual. Nevertheless, part of the institutional arrangements for the first component (subprojects) required adjustment in the project's early implementation. This was due to their complexity, as further explained in Section 4.2 below. Because of the State Health Secretariat's (SESPAS) poor track record in implementing a 1995 IDF grant, project design placed implementation responsibility on a Project Coordinating Unit (PCU) under CERSS. CERSS was to act on behalf of SESPAS and the Technical Secretariat of the Presidency. This allowed for CERSS to coordinate and include SESPAS in all project activities while including other key actors of the sector, as well. The Project's flexibility allowed it to respond to the changing needs and uncertainties of the health sector transformation process. Its flexible design was based on broadly defined areas of intervention instead of specific pre-defined numeric targets. It emphasized piloting and testing, but did not set implementation targets up-front. While this approach created difficulties for the monitoring of project implementation and preparation of this ICR, it also proved to be the Project's greatest stength: the flexibility to adapt to the changing sector realities and to use differentiated implementation strategies in different geographical areas supported under the Project. This flexibility proved to be particularly important for responding to the emergencies created by Hurricane George and by the later outbreaks of polio and measles. Still, the Project Appraisal Document (PAD) lacked easily monitorable output indicators, as well as a baseline for outcome and output indicators. As a result, ENDESA and SESPAS data were used to provide an approximation evaluation of the Project's Impact. 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: The Project mostly achieved its overall development objective of reducing infant, under 5 and maternal mortality by 30 percent in project areas. According to the national health statistics , between 1996 and 4 2002, infant mortality was reduced by an average of 35 percent in project-supported regions (Regions 0, III, IV, and VII). However, there are still significant gaps across regions. Under 5 mortality was reduced by 34 percent on average in regions targeted by the project, also surpassing the Project's target. At the national level, the maternal mortality rate decreased by 22 percent, from 229 maternal deaths for each 100,000 children born in 1996, to 178 in 2002. However, regionally disaggregated data on maternal mortality is not available to determine the Project's impact in the targeted areas. In addition to the Project's positive impact on maternal and child health in participating regions, it had a substantial impact on the development and implementation of the Dominican Republic health reform process. While these accomplishments were not explicitly listed by outcome indicators in the Project Appraisal Document (PAD), they are substantial and noteworthy, and include: · Revision, improvement, and approval of a new legal framework for the health sector in the country. In 2001, the General Health Law (Ley General de Salud) and the Social Security Law (Ley de la Seguridad Social) were approved with significant support from the project. The CERSS' legal team played a key role in revising the law proposals and in bringing together a large group of stakeholders to discuss the amendments to the draft legal text then under analysis in the Senate. - 4 - Through an effective lobby and advisory role, CERSS supported the approval of both laws and their dissemination at the national level. The General Health Law created the National Health Council, an entity that, with CERSS support, regulated the content of the new Health Law to make it operative. Together with the National Health Council, the CERSS contributed to modernizing the health sector through the preparation and approval of key regulations governing the General Health Law, the elaboration and approval of protocols and quality standards for service delivery in over 27 medical areas, including maternal and child health, and the establishment of norms to govern the provision of health services and health centers. These norms provided SESPAS with key tools to exert its regulatory role within the health system. · Modernization and strengthening of the State Health Secretariat (SESPAS), in particular at the regional and provincial levels. The Provincial Health Departments (Direcciones Provinciales de Salud ­DPS), created shortly before loan approval, were strengthened through staff training in the areas of management, strategic planning, and management of information systems. The DPS were also at the center of the consultation processes carried out in the 14 participating provinces. The Project contributed to the development of an accountability culture and greater service-oriented attitude in the provincial health systems. At the national level, CERSS provided support to SESPAS' Department of Primary Level Attention. This support focused on efforts to implement the service delivery model at the primary level, with the establishment of units to deliver primary care services (Unidades de Atencion Primaria), and the publication of educational guides and regulations on this matter. CERSS also supported SESPAS' Department of Norms and Protocols through the publication of key protocols to improve the quality of health services provided. · Development and testing of new health care organizational arrangements, and promotion of management and financial incentive innovations. Throughout project implementation, CERSS worked with SESPAS, stakeholders, and other relevant institutions to test new managerial models that would provide hospitals with greater autonomy to manage resources and set incentives for good performance. There was also progress in exploring and creating provider networks to better organize and deliver health services. By project completion, it had supported the elaboration of a proposal to articulate a network of health care providers, which served as the basis for the regulation governing the service delivery networks approved in December 2003. The project provided financial and technical support to implement the health delivery model chosen by SESPAS, which emphasizes reorganizing service delivery, focusing on preventive services, strengthening primary care level, and establishing health regions across the country. · Promotion of stakeholder participation in the health system through consultations for the revision and approval of new legislation, and consultations at the regional and provincial levels to prepare their Annual Operational Plans. The approval of the legal framework for the health sector emphasized civil society's participation in the management of health systems. The Project supported this new focus by including stakeholders in the bodies charged with the direction and consultation of health providers (Patronatos and hospitals' Boards of Directors). 4.2 Outputs by components: Component 1. Provincial Subprojects ICR Rating: Satisfactory This component was designed to finance subprojects sponsored by Provincial Development Councils (PDC). These subprojects sought to develop and/or strengthen: (i) essential health care interventions - 5 - centered around maternal and child care activities; (ii) new health care organizational, managerial, and financing models; (iii) the capacity of SESPAS' provincial health offices and health facilities to plan, program, implement, and monitor health programs; (iv) raise clinical and managerial capacity at provincial level, so as to assist in the improvement of quality of health care; and (v) provide monitoring and impact evaluation capacity. By project completion, this component had satisfactorily contributed to the: (i) improvement of the capacity of health centers to deliver basic health services; (ii) definition of minimum standards to increase quality of the services delivered; (iii) strengthening of the managerial and clinical capacity of health personnel; (iv) design and implementation of a management information system (MIS) as an instrument to improve management; and (v) testing of alternative organizational models to deliver health services, including proposals on the establishment of networks of health care providers. At appraisal, the project did not define specific numeric targets to measure implementation progress. Instead, targets were set yearly in the Annual Operational Plans (Planes Operativos Anuales) prepared by the Secretariat of Health's Provincial Departments (DPS). While this component was successful in achieving its objectives, implementation arrangements were different than those described in the PAD. The original Project design foresaw the creation of local implementation units, within the DPS, to lead the preparation of subprojects to be financed under the project. The PAD proposed the signature of an umbrella participation agreement between the PCU and the Provincial Governors of each of the 14 participating provinces, and the subsequent signature of "Executing Agreements" between the local implementation unit and the health care providers (hospitals, ambulatory facilities, etc). The Project's PCU would supervise and assist provincial authorities in this process. The PCU started to work with the proposed arrangement in each of the provinces, but this mechanism turned out to be too complex. As a result, the Secretariat of Health and CERSS agreed that the DPS would become the executing units, and local implementation units were never created. The DPS was given the responsibility for leading preparation of the Provinces' Annual Operation Plans which defined the year's priorities, activities to be supported by the Project, and targets to monitor progress. The Plans incorporated community input and were approved by the provincial authorities. The activities listed under the Plans were then implemented by the DPS and approved by health care providers in each region. The following activities were carried out: (a) Improvement of health facilities through physical rehabilitation and equipment provision. The Project financed the improvement of health facilities in Regions 0, III, IV and VII by upgrading: health facilities, labs and service delivery units, equipment in hospitals and health centers. Physical investments under the Project succeeded in ensuring a supply of safe water and sanitation services in health facilities. Investments also strengthened the biomedical waste management systems, by financing the purchase of incinerators and training of personnel on their use. The overall impact of these activities was positive, with 60 percent of all the infrastructure needs identified under the Annual Operation Plans (prepared throughout implementation) upgraded with Project financing. However, there were variations across regions and interventions concentrated in Regions 0 and IV, where more than 85 percent of the infrastructure works identified as needing improvement were carried out. Infrastructure improvements in Regions III and VII only covered a smaller share of needs identified under the Annual Operation Plans (58 and 27 percent, respectively). This was due to insufficient counterpart funds, component resources being allocated to the prevention of malaria and polio, and the ensuing need to establish priorities among regions. According to the Government, the focus on Regions 0 and IV was due to three criteria: Region IV had been selected to pilot the National Health Insurance System and the Social Security System, Region 0 (Santo Domingo) is a highly dense populated area, and the overall epidemiological condition of the population in those areas. As project financing of civil works required the largest amount of counterpart financing (60 percent), rehabilitation activities suffered with restriction in counterpart financing. - 6 - All of the health centers (hospitals and rural clinics) were equipped, including six emergency rooms, and the operating rooms, delivery and neonatal areas of these centers. In some cases, hospitals received additional equipment such as sonogram machines and automated lab equipment. All of the laboratories were equipped in the 14 provincial and 23 municipal hospitals in the four regions targeted by the Project. Additionally, the Provincial Health Departments (DPS) and Regional Health Departments (DRS) were provided with audiovisual equipment, office furniture and computers, as part of their effort to strengthen their managerial capacity. Finally, hospitals received computers and information technology equipment to operationalize the management information system (MIS). (b) Improvement of medical care quality assurance mechanisms. The Project did not establish predefined outputs for this line of intervention, but aimed to select quality assurance systems, develop and test them, and later implement them in participating provinces. Efforts to improve the quality assurance mechanisms in health care focused on sensitization activities for health professionals, identification of problems in specific hospitals followed by the implementation of actions to address them, development and implementation of norms and protocols for service provision, and establishment of minimum standards for health centers and medical training facilities. At project onset, the Executive Commission for Health Sector Reform (CERSS) began developing and implementing a strategy to sensitize the authorities and medical personnel of the need to improve service delivery to obstetric users. The strategy consisted of training 25 doctors and nurses to become facilitators. As promoters of change, they were responsible for re-designing the delivery of obstetric services in hospitals participating under the project. They were also responsible for working with medical personnel in those hospitals to promote the implementation of change. While this experience succeeded in changing certain barriers in obstetric service delivery (such as the fragmented hours for doctor's offices), it did not have the expected impact in service delivery as a significant number of doctors and nurses were too accustomed to old practices that they did not adopt these changes. In 2000, CERSS pursued a complementary strategy, focusing its effort to improve the obstetric service delivery in four hospitals. A participatory consultation was carried out in those hospitals to identify problems and propose solutions. This resulted in several important changes (e.g., changes in doctors visit hours and improvement in basic services to female patients) in three of the four hospitals. The Project financed the design and implementation of norms and protocols for health service provision, aimed at setting quality standards for those services. In particular, the Project supported SESPAS' efforts to elaborate, review, print, and disseminate norms containing national standards for provision of services (Normas Nacionales de Atencion). A total of 27 of these were completed and disseminated. The Project also financed a set of activities to support their dissemination, including: workshops with relevant stakeholders (e.g., journalists, trade unions, and private companies), distribution of more than 10,000 copies to health professionals, inclusion of these norms in the tertiary level curriculum, and support for the creation of a new Department within SESPAS in charge of standards. Additionally, the Project supported the elaboration of protocols for the most common pathologies for mothers and children under 5, working with two of the biggest maternity facilities in the country. These protocols were later sent to PAHO, who approved and distributed them to other hospitals in the country for implementation. During the ICR mission, it was observed that these protocols were being implemented in the hospitals visited. In all cases, health professionals and lab personnel were well aware of these efforts and deemed them key in improving the quality of their work. - 7 - Finally, the Project supported the design and establishment of minimum standards for health centers and medical training facilities. The Project supported SESPAS' efforts to define minimum standards for the opening of health centers (for outpatient and hospitalized patients), for blood banks, and for transportation, among others. Additionally, CERSS supported the elaboration of an accreditation guide for clinical laboratories. This effort was coordinated with PAHO and the Confederacion Latinoamericana de Bioquimica Clinica and was eventually adopted throughout the Latin American region. Technical assistance under the Project supported the efforts of CERSS, the Autonomous University of Santo Domingo, and the National Council for Medical Residencies to define the minimum standards for both training institutions (hospitals) and programs. In light of those standards, the content of the pre-service training for pediatrics, gynecology-obstetrics, surgery, and internal medicine was revised. As part of this effort to improve tertiary medical training, five of the eight medical practice hospitals, which train pediatricians and obstetricians, received computer equipment and training to access virtual libraries. (c) Training of medical personnel. The Project aimed to train financial and administrative personnel to enhance organization and management capacity of the provincial health systems. It also sought to improve the quality of the services delivered and patient satisfaction. For these goals, the PAD did not predefine up-front numeric targets. The project financed training in health-specific issues and management for approximately 20,000 professionals, including doctors, nurses, pharmacists and bio-analysts; administrative, financial, and support personnel; staff from the Provincial and Regional Health Departments (DPS and DRS), and SESPAS; and representatives for the health unions. Training was provided through seminars and postgraduate studies, initially abroad and later in national universities, which began offering these courses after the approval of the Health Law. One of the key innovations in the training offered was its delivery at the local level. This enabled training to reach a greater number of key hospital staff while facilitating their attendance. Areas covered by training included: l Strategic and operational planning for DPS and DRS staff to strengthen their strategic skills and help them define sector priorities at the local level. The course concentrated in needs assessment and local planning. l New service delivery model for DPS and DRS staff. The model distributed responsibilities for patients by geographical area and introduced a cultural change in the delivery of health services, placing emphasis on community level service provision. In coordination with the Pan-American Health Organization (PAHO), all rural teams in the provinces of Duarte, Samana, Sanchez Ramirez, Maria Trinidad Sanchez, Salcedo (in health Region III) and the provinces of health Regions IV and VII were trained. l Integrated services to children under 5 for doctors and nurses in the provinces of Salcedo, Pedernales and San Pedro de Macoris. This course was also delivered in collaboration with PAHO. l Basic computer skills and information systems to staff in the DPS and DRS for hospital personnel. Around 5,000 professionals were trained in 50 courses. l Strategic planning and financial management for staff in 14 out of the 24 hospitals where the MIS was implemented, leading to the preparation of a development plan. Additionally, staff in the remaining 10 hospitals received training on the uses of tools for strategic planning. l Health economics and reform for more than 100 professionals through five courses that took place in Chile and Panama. - 8 - l Management of health services and systems at the post-graduate level to 74 managers. The course had the duration of one year (400 hours) using the semi-presencial modality with tutoring at the work place. (d) Design and implementation of a Management Information System. The Project aimed to develop, test, and adopt an information system that would allow for better cost accounting and financial management, and for improving medical records. The Project supported the definition, piloting, and implementation of a management information system (MIS) as a key instrument to improve management, strategic planning, and efficiency in the delivery of health services. The MIS included the following modules: (i) patient registration; (ii) financial management; (iii) human resources; (iv) drugs and prescriptions; (v) budget; and (vi) demography and population registry. Through the actions described below, the Project succeeded in modernizing the management and operation of the 24 health facilities where the MIS was implemented. The Project financed the acquisition of equipment (hardware and software) and technical assistance to adapt applications that were already available on the market to better suit the country's needs. During 1998 and 1999, CERSS focused on defining the framework for the MIS and developing an implementation strategy. Initially, the system was to be piloted in two provinces (Salcedo y Pedernales), as were the rest of project activities. As the scope of project implementation expanded ­ due to the demand for project support - CERSS started to pilot the implementation of the MIS modules in two hospitals and two DPS (in the selected provinces). A total of 100 (out of 290) personnel were trained (including hospital directors, heads of health areas, nurses, and administrative and financial personnel). The training was focused on management of information systems and basic computer skills. After the General Health Law was approved in 2001, the MIS was implemented in participating provinces. The CERSS signed agreements with local authorities (DPS, DRS and hospital directors) to support implementation of the MIS by providing financing to overcome infrastructure problems. By project completion, all municipal and provincial hospitals in those provinces had the necessary computer infrastructure, auxiliary power systems, and qualified personnel to handle the system. Moreover, computer technology was visibly incorporated by staff as a daily working tool. During implementation, problems with hiring information technology staff for the hospitals temporarily affected the implementation of the system. Nonetheless, by project completion, this problem had been resolved and IT personnel were being financed by the participating hospitals. Additionally, by project closing, the MIS had been implemented in 24 hospitals (representing 28 percent of the total hospital capacity in the country and serving around 30 percent of the population): seven municipal, five provincial, five regional, and seven national hospitals. It should be noted that during the ICR mission, it was observed that the MIS installed in the visited hospitals was fully operational and hospital staff knew how to use it. The ICR mission observed that the MIS has been contributing to increasing the efficiency and quality of service delivery in the pilot hospitals. The implementation of electronic health records has resulted in the reduction of medication errors, enhanced attention to emergency patients, improved management of lab results, and the correct application of protocols. Furthermore, the MIS has fostered improvements in the management of prescriptions, by avoiding errors and controlling the consumption of medications. Finally, the MIS has led to better patient care by reducing the wait time for doctor visits and scheduling of surgeries, and making the patients' medical history immediately available to hospital staff. - 9 - (e) Development of new health care organization, financial and managerial models. The Project aimed to develop, test, and adopt new methods for allocating funds to providers and, in general, to explore alternative organizational and managerial models. The Project was successful in testing new organizational arrangements and in bringing about innovations in management and financial incentives. The loan provided financing for piloting a system of autonomous management in two hospitals in the Provinces of Barahona (Hospital Jaime Mota) and Herrera (Hospital Dr. Velez Santana). In February 2002, SESPAS signed a Management Agreement with Hospital Jaime Mota to pilot autonomous management. Before that agreement, the PCU had provided technical assistance to hospital staff to prepare a Strategic Action Plan defining the steps needed to attain autonomous management, including specific goals to measure achievements and improvements in the delivery of health services. The hospital management team and key clinical personnel participated in this exercise. The interventions supported include: implementation of a MIS in the hospital, preparation of a quality improvement plan that included improvements to infrastructure and equipment, and formulation of proposals to explore management arrangements. The hospital accomplished the targets established to move towards a fuller autonomous management experience. Nevertheless, by project completion, this was still pending as SESPAS ­ to whom the hospital belongs - had not yet given support to proceed with the testing of autonomous management of resources and use of incentive mechanisms. Before the inauguration of Hospital Dr. Velez Santana in January of 2003, the Project supported the preparation of the autonomous management plan and the design of the management arrangements. As a result, this hospital was already created as an autonomous institution, governed by an administrative board composed of public and private sectors, and civil society representatives. The hospital hired its own personnel and managed its resources (from the national budget and from patient payments). In the case of this hospital, the experience with autonomous management has been very successful. The hospital offers high quality services and shows outstanding productivity. This pilot experience proved that the tested model was a viable option for the public provision of health services in the Dominican Republic. Following this successful experience, the network of health service providers for the health region of West Santo Domingo was created by Presidential Decree in February 2004 to be managed autonomously by the Director of the Hospital Velez Santana. The creation of a network of health service providers, offering different levels of care in a densely populated and marginal area, is one of the Project's greatest achievements. The Project also supported the preparation of a pilot experience in health Region IV for decentralization and distribution of functions within the sector. The Project supported the preparation of a decree, approved in April 2001, empowering SESPAS to pilot a decentralization in the provision and management of health services in the region. An agreement for service delivery was signed between SESPAS, the regional authorities of the provinces of Barahona, Pedernales, Bahoruco, and Independencia, and the area hospitals. In April 2002, SESPAS, together with the Superintendence of Health and Labor Risks (SISALRIL) and CERSS, began to establish a network of health service providers. Together, they led a participatory process to prepare a strategic plan to create this network. The preparation process included the: (i) identification of actions to be carried out before the approval of the agreement; (ii) definition of the health network; (iii) design of a strategic plan to implement the network within a framework of separation of functions; and (iv) preparation of family folders for the MIS, registering around 360,000 inhabitants in Region IV to identify potential beneficiaries to the SENASA. Additionally, this preparation process resulted in the training of around 120 managers (representing 10 percent of all professionals conforming the network). Specifically, the Project supported: training on clinical practices, information systems and management, equipment and lab improvements, and technical assistance for the preparation of the Quality Improvement Plans by each participating hospital. Simultaneously, the piloting of the national health insurance system (SENASA) - 10 - was launched in this health region. Tangible results of this process were the: (i) definition of the potential flow of patients that would be included in the network; (ii) the creation of sub-regional referral centers as Strategic Health Service Units, based on the qualifications and medical specialties of the different hospitals, ambulatory centers, and other providers in Region IV, and on the demand for those services; (iii) identification and implementation of actions by providers to reach an integration among the first, second, and third levels of health care provision; (iv) definition of referral protocols for rural clinics, ambulatories, and hospitals in the SENASA; (v) implementation of the MIS for clinical records in six hospitals in Region IV, plus Hospital Jaime Mota; (vi) definition of a basic menu of health services provided by the sub-regional referral centers to be negotiated with SENASA; and (vii) generation of regulations based on this experience, for the General Health Law, such as Decree (635-03) that separates functions within the health system; Decree (738-03) that defines SESPAS' contractual modalities for the provision of health services and Decree (1137-03) that creates the provision of health services. . The management agreement (Convenio de Gestion) between SESPAS and Region IV health service providers that participated in piloting the national family health insurance was signed in May 2003. Implementation of this pilot experience was delayed by the financial crisis that the Dominican Republic faced in 2003. One of the main achievements has been the creation of a regional structure of health providers at different levels, and the referral mechanisms that are key for the consolidation of the health services network. Component 2. Policy Development and Studies ICR Rating: Highly Satisfactory This component was extremely successful in supporting the Executive Commission for Health Sector Reform (CERSS) to achieve approval of a modern legal framework for the health sector. This framework included the General Health Law, the Social Security Law, Hospitals Decree, as well as a wide array of regulations and norms. While this component did not have monitorable numeric targets, its accomplishments far surpassed expectations. The Project provided financing for the technical team in the PCU in CERSS to carry out eight studies to deepen the health reform efforts and provide technical support for the completion of the "Plaza de la Salud " hospital project. The legal team within the PCU was in charge of implementing these activities. The CERSS, as both the agency leading the efforts to reform the health sector and coordinating project implementation, was instrumental in the approval of these Laws and in their dissemination throughout the health system. As a result of CERSS' strong role, the Health Secretariat (SESPAS) was less involved. In addition, there were overlaps in the roles and responsibilities of CERSS and SESPAS which led to some friction between the two agencies. The main achievements under this component were: (a) Approval of the General Health Law. The Project financed technical assistance to support the improvements of the draft law. In February 2001, a new General Health Law was approved by Parliament and the Project played a key role in this accomplishment. Without delay, CERSS' legal team carried out a detailed analysis of the law's draft text then under discussion in the Senate, and identified its weaknesses and omissions. Then, CERSS played a leading role in revising this draft legislation. In October 1998, CERSS organized a workshop where over 70 public, private, lucrative and nonprofit institutions participated in the review of the legislation, proposing improvements to the - 11 - draft law. In April 1999, CERSS presented the revised draft law to Congress, and between 1999-2001, it held about 15 meetings with the Parliamentary Health Commission. In all, about 95 percent of the changes proposed by CERSS were incorporated into the law. In addition to technical legal assistance to revise the draft law and promote stakeholder consultation, CERSS provided technical input to the Parliamentary Health Commission through the financing of several studies. These included a: (a) report to harmonize the Health Law and the hospital legislation; (b) study to assess the financial implications for the health sector, including the rights and incentives for medical personnel in the new Law; and (c) set of comparative analyses between the new Health Law and the Social Security Law, including the proposed text for the Health Law and the Environmental Law. CERSS was instrumental in reaching a key agreement with the medical association (ADM), who provided crucial support for the approval of the Health Law. (b) Preparation and Approval of the Health Law Regulation: CERSS supported the National Health Council (CNS) in producing the regulation that enabled the implementation of the new Health Law. By project closing, a total of 13 regulations complementing the General Health Law had been prepared and approved (see Annex 9), and around 20 additional draft regulations had been elaborated by CERSS and are pending approval by the CNS. CERSS closely coordinated its efforts with IADB, seeking synergies and using IADB funds to complement IBRD funds. (c) Approval of the Social Security Law: The project financed technical assistance to support the approval of the Social Security Law in 2001. Initially, CERSS concentrated its work on analyzing the draft text for the Social Security Law and ensuring that there were no inconsistencies between the proposed law and the General Health Law. CERSS' suggestions to harmonize the two legal texts were accepted by the Social Security Commission in Parliament. Additionally, CERSS carried out a study to analyze the financial implications of implementing the proposed Social Security System under the new law. Finally, CERSS successfully undertook the task of reaching agreements with key sector stakeholders -- the Dominican Medical Association (AMD) and the National Council of Private Companies (CONEP) -- to support the approval of the Law. The results of these agreements were conveyed to Parliament, and the Social Security Law was approved in May 2001. (d) Additional contributions: Two additional noteworthy activities carried out by CERSS were: (i) consultations with stakeholders and consensus building that culminated in the approval of the new hospital regulation (Reglamento General de Hospitales), which includes new modalities of hospital management, decentralization and modernization of hospitals, and beneficiaries' participation; and (ii) preparation and approval of a decree to decentralize the State Health Secretariat (SESPAS). This decree enabled the implementation of the pilot in health Region IV, described under Component 1. The Project financed a consultancy to explore the options to include the "Plaza de la Salud" hospital in the network of public health care providers and transform it into a referral center, providing access to the poor. Nevertheless, implementation of the main recommendations of the report are still pending due to the difficult decision-making context for this institution and the lack of political commitment to transform it. Component 3. Project Administration. ICR Rating: Satisfactory This component financed most of the PCU's administrative and operating costs. This component is rated satisfactory since the PCU was able to implement the Project and reach its development objectives, successfully handling: (i) the emergency created by Hurricane George in 1998; (ii) shortages of counterpart funds; (iii) stagnation in decision-making resulting from two electoral periods; (iv) large - 12 - turnover of government staff as a result of administration changes; and (v) the financial crisis of 2002. It is noteworthy that the team implementing the first IBRD-financed health project in the Dominican Republic was pro-active while taking advantage of the flexible design of the project to better respond to the country's changing realities. The PCU also played a key role in the implementation of the MIS, providing all of the training and technical assistance to the participating health providers and regional participating institutions. As a result of this work, the PCU now has the capacity at the national level to configure and program applications, work with the system, and provide technical support to the hospitals throughout the country. The PCU worked efficiently and effectively to maximize the use of loan resources and all available national resources. Disbursements were ahead of schedule throughout most of implementation. The PCU was staffed with committed and well trained personnel, who performed high quality work in procurement, financial management, and management of implementation processes. The PCU provided technical assistance for the development and implementation of the project. Due to the high demand for technical assistance from the PCU's core team and for additional experts to support DPS at the provincial level, extensive technical assistance was required to implement components 1, 2 and 4. As a result, this component required almost twice the amount of resources for technical assistance compared to the original estimate. Finally, this component also financed the development of software that allowed the PCU to have an inventory of all the assets acquired under the Project, including a detailed description of their location, users, and depreciation. Together with this, the PCU carried out electronically the architectural designs for the hospitals and medical buildings supported by the project. Component 4. Emergency Subprojects ICR Rating: Satisfactory This component was added to the Project in response to the emergency created by Hurricane George in 1998. It aimed to provide support to mitigate the effects of the hurricane in the health sector, as well as to prepare better the country for future emergency situations. The scope of the Project was expanded to cover all provinces affected by the hurricane. The amount of loan resources allocated to this component (US$3 million or 10 percent of the loan) came from Component 1, in addition to the approximately US$852 thousand that had remained unutilized under the PPF refinancing category. Counterpart funds allocated to this component were to total US$0.44 million. Funds under this component were committed quickly and executed entirely. While the Project was not the only source of support for this crisis, the funds were used in a strategic manner aimed at avoiding the spread of infectious diseases and other epidemics, thus contributing to the achievement of the Project Development Objective. Overall, this component was critical in ensuring that Project gains would not be corroded by the emergencies resulted from Hurricane George. The component financed the following activities: l Rehabilitation and equipping the Center for Control of Tropical Diseases (CENCET) so it is better positioned to cope with a similar crisis in the future, and training of 54 entomology technicians. l Equipping the National Institute for Potable Water and Sewage (INAPA). l Distribution of chlorine to households and emergency shelters, bottled water and information leaflets on water treatment, and suitable containers for water to be transported to households and institutions without this service. l Purchase and distribution of medical inputs for the control of respiratory infections, diarrhea, and sickness, and incinerators to safely dispose of medical residues. - 13 - l Purchase of generators to guarantee uninterrupted patient care, refrigerators with generators, and thermo-backpacks. l Purchase and distribution of medicine for people with tuberculosis, and mosquito nets in endemic malaria zones. l Production and distribution of educational materials to affected households. l Construction of around 1,260 latrines with support from the communities. This component was carried out by the Project's PCU, which provided effective financial and organizational support. Even though it required coordination with over ten institutions, the implementation of this component was satisfactory. 4.3 Net Present Value/Economic rate of return: Not applicable. 4.4 Financial rate of return: Not applicable. 4.5 Institutional development impact: ICR Rating: Substantial The Project has contributed significantly to institutional development in the health sector. The main achievements were: l A new and modern legal framework for the health sector, providing the backbone for its reform; l A wide set of regulations and norms on key areas of the health sector reform, impacting: (i) licensing of new health centers, health providers, and clinical laboratories; (ii) contractual modalities for the provision of health services; (iii) separation of functions in the National Health system; (iv) provision of networks for delivery of health services; and (v) organization of human resources in the health sector; l A well-designed and implemented MIS, developed by modules which have been adopted in the DPS and DRS and in a representative number of hospitals, that has impacted positively and visibly the management and delivery of health services in the areas targeted by the project; l A National Health Council (Consejo National de Salud), created as an entity that includes all key players in the health sector, and reflects the decentralization process; l A critical mass of health professionals trained in management issues and management of information systems, who are currently participating in several reform initiatives; l Better informed stakeholders as a result of extensive education and continuous involvement of key stakeholders in decision making and strategic planning throughout the project. The use of a wide participatory methodology to reach consensus and define actions strengthened community leaders and organizations, enhanced transparency, and educated a critical mass of citizens who have the legal right to play a key role in the management of the health sector; l A change in expectations for service delivery in the sector (more accountability, higher standards, and greater client service orientation); l A decentralized structure of health providers and established referral mechanisms in health Region IV, which will be key for the consolidation of the health services network and the pilot of the National Health Insurance (SENASA); l A stronger SESPAS at regional and provincial levels; and l A competent national team in CERSS, who has earned widespread respect at the national and local levels, based on its commitment to the objectives of the national health reform and its efficient and participatory work. - 14 - 5. Major Factors Affecting Implementation and Outcome 5.1 Factors outside the control of government or implementing agency: Hurricane George. As mentioned in section 3.4, in September 1998 the Dominican Republic was hit by a hurricane that had devastating effects on the island. As a result, health priorities in the health sector changed. The Project adjusted to face this unexpected challenge and to implement the necessary actions to meet its development objectives in the new context. Around 10 percent of project resources had to be reassigned to help mitigate the effects of the hurricane on the health sector and the Project's coverage area had to be expanded to cover all affected areas. Planning and implementation of actions under this new component and disbursement of project funds set a dynamic rhythm of execution of project activities that impacted the rest of the life of the Project. Approximately half of the funds for the emergency plan were committed and/or disbursed during the first six months of project implementation. Outbreaks of polio and measles. Despite having been certified by the Pan-american Health Organization (PAHO) as free of such epidemics, in 2000 the country experienced outbreaks of polio and measles in the region bordering Haiti. Immediately, it was realized that combating these outbreaks was necessary to ensure the accomplishment of the Project's overall development objective. The Project financed the development and implementation of a national vaccination campaign over the 2000 - 2004 period, that covered 98 percent of the target population. About US$3 million of project funds, within Component 1, were directed for this purpose. Financial crisis of 2003. The Dominican Republic faced a severe financial crises during the second half of 2003. This was precipitated by the bankruptcy of key commercial banks and led to high inflation and devaluation of the Dominican Peso. As a direct consequence, counterpart funds became scarce, despite numerous meetings between the PCU, CERSS leadership, the Budget office, and the Bank. This scarcity of counterpart resources close to project completion prevented an even greater consolidation of project supported initiatives. 5.2 Factors generally subject to government control: Selection of the Executive Commission for Health Sector Reform (CERSS). During project preparation, the Government created the CERSS as an entity which would catalyze the efforts to promote health sector reforms. This institution was in charge of executing the Project and coordinating with the Technical Secretariat from the Presidency (in charge of the effort for the modernization of the State) and the Health Secretariat (SESPAS). Additionally, CERSS was responsible for coordinating external funding for the health sector. This decision was made because of the lack of managerial capacity within SESPAS. Though SESPAS had strong reservations regarding housing the management of project funds by CERSS, this decision benefitted project implementation, preventing additional problems that might have been created when moving forward with the SESPAS decentralization process. Nonetheless, it should be noted that the decision to give project implementation responsibility to CERSS prevented greater project ownership on SESPAS' part. Delays and shortages of counterpart resources. Throughout project implementation, there were delays in making counterpart funds available to finance project implementation. In all, by project completion, US$3.5 million had not been made available. Annually, except in 2000, the Government fell short of providing the amount of counterpart funding approved in the budget for the project in a timely manner. In - 15 - 2000 the Government only provided 92 percent of the committed counterpart funds. For the rest of the years, it provided between 45 and 70 percent of the counterpart funds committed. In 2004, there were no counterpart funds allocated to the project. Between 1998 and 2003 the main reason behind the shortage in counterpart financing was the inefficient management of approved budgetary resources by the Government. From 2003 onwards, the shortage in counterpart funds was due to the financial crisis affecting the country. In 2000, the Bank considered the possibility of suspending disbursements due to a cumulative deficit of over US$1.2 million in counterpart funds, but this problem was resolved through an agreement between the Bank and the Government that recognized SESPAS' investment expenditures as counterpart funds for the Project. Despite this shortcoming, the PCU was extremely proactive in strategically managing available project resources, focusing on carrying out activities that required the least amount of counterpart financing, and using SESPAS' investments as counterpart funds. As a result, despite counterpart shortages, disbursements were higher than foreseen at appraisal and by project completion most of the loan resources had been disbursed. Fortunately, because of the PCU's skilled resource management, counterpart funding did not compromise the achievement of project's objectives. Personnel turn around due to political changes. During project implementation, there were two national electoral campaigns (2000 and 2004) and two changes in administration. As a result, decision making and implementation processes slowed during the year preceding and after elections, resulting from changes in government officials with the new administrations. Changes reached both political and technical personnel at national and provincial levels. The head of CERSS was changed after the 2000 election and twice after that. Nonetheless, this change did not cause disruptions in project implementation. It is worth noting that the changes in administration did not weaken the Government commitment to initiatives supported by the Project, such as the legislative reforms. Continuity of the project team in the CERSS. Though changes took place at the leadership of CERSS, the technical coordinator and technical team in charge of project execution were maintained, ensuring continuity of project activities and implementation. 5.3 Factors generally subject to implementing agency control: PCU ability to adjust to changing circumstances. The PCU showed remarkable ability to adjust the Project to face upcoming challenges and to effectively use available project resources, reprogramming planned activities accordingly. This permitted successful progress in implementation and in the achievement of project objectives. Strong and productive dialogue between the national and the IBRD teams. The quality of the dialogue between the client and the Bank allowed the PCU to overcome the difficulties that appeared during project implementation, from early moments. Between both teams, it was possible to adapt quickly the Project and adequately respond to the changing realities. This was particularly true when seeking alternatives for the lack of counterpart funds, defining a less cumbersome arrangement to work with participating provinces in the implementation of component 1 (See section 3.5), and defining elements of the health reform to be supported by the Project, in a context were the concept of health reform had just been launched and was subject to different interpretations and widely discussed. 5.4 Costs and financing: Initially, the PAD foresaw a total project cost of US$42 million, with a contribution from the Bank of US$30 million and US$12 million by the Borrower. By project completion, the project had financed about US$38.5 million, about 92 percent of the total project cost, of which the Bank's contribution totalled - 16 - US$29.9 million (99.7 percent of the loan amount) and the Borrower's totalled US$8.5 million (71 percent of originally expected counterpart funds). The loan closed in June 2004, as originally scheduled. The total cost of Component 1 (Provincial Subprojects) was US$27.4 million (82 percent of the appraisal estimate) mostly because of the reallocation of US$3 million in funds to finance the Emergency Subprojects Component. Project Component 2 (Policy Development and Studies) cost US$2.5 million (93 percent of the appraisal estimate). Shortfalls for both of these were in part the result of less than expected counterpart financing. Project Component 3 (Project Administration), on the other hand, cost US$4.3 million (almost twice appraisal estimates). In trying to understand the reason for the higher than expected cost of the project administration component, the ICR team found that besides typical administrative expenditures, this component also financed consultants who provided technical assistance for the development and implementation of Components 1, 2, and 4, particularly the cost of legal assistance for the elaboration and revision of the new laws, of supporting for strengthening the technical and implementation capacity at the provincial level, and for training related to the MIS. In retrospect, these expenditures should probably have been allocated under the other three components, thus increasing their total costs, and reducing the final cost of component 3. In addition to the US$3 million allocated to emergency financing, in November of 1999 an additional US$852,747 of unused funds under the category for refinancing the Project Preparation Advance (category 7) was also reallocated to the financing of the Emergency Subprojects. Together with counterpart funds, the total cost of Component 4 was close to US$4.3 million. Because the Project did not set specific implementation targets at the onset, the implementation team was able to address shortages in counterpart financing by focusing on carrying out activities that required the least amount of counterpart financing --several disbursement categories were financed by the Bank at 90 to 100 percent-- without the risk of not meeting project targets. Additionally, in some occasions, the PCU changed implementation strategy, including having PCU staff carry out the work, to ensure that the work got completed with less resources. The Government also requested that the Bank consider several of SESPAS' investments as counterpart funds, to which the Bank agreed. The Project was externally audited five times and, on each occasion, the auditors found that loan resources had been used in compliance with the IBRD procedures and the loan agreement, and in a transparent manner. 6. Sustainability 6.1 Rationale for sustainability rating: ICR Rating: Likely. It is likely that the achievements supported by the Project will be sustained for the following reasons: Legislative framework. During project implementation, there was significant progress in consolidating the legislative framework regulating the health sector in the Dominican Republic. The following were significant achievements: l Approval of the General Health Law (Ley General de Salud N. 42-01); l Approval of the Social Security Reform Law (Ley de Reforma de la Seguridad Social - March 2001); l Approval of the norms (reglamentos) to develop and implement the aforementioned laws; l Approval of the General Regulation for Hospitals (Reglamento General de Hospitales - 1999); and - 17 - l Approval of protocols which provide a common understanding of the set of actions to be carried out and services to be provided by level of care. Human Resources. The professionals (doctors, nurses, management information system technicians, etc.) trained during the project will most likely remain within the national health system. Thus, even if the mobility of professionals remains high, the human capital and skills built will stay within the health sector. Furthermore, there has been a perceptible change in attitude in the health sector professionals, who have started to be aware of the importance of providing better quality of health services. Management Information System. The information systems designed under the Project continue to be successfully implemented in the hospitals, and have already had an impact in the delivery of service. Tangible improvements can be observed in the following areas: (i) patient information; (ii) management of diagnostics; (iii) prescription management; and (iv) hospitalization process. Despite evidence pointing to the sustainability of Project actions, the scarcity of Government resources due to the overall country situation towards the end of project implementation may have somehow undermined the consolidation of some of the processes initiated under the project (e.g., autonomous management experience of hospitals, improvement of infrastructure of some hospitals, and consolidation of the pilots undertaken in the IV Region). 6.2 Transition arrangement to regular operations: Once the Project was completed, the CERSS continued working on fostering the health sector reform, including implementing activities financed by the IADB. A new APL operation (Health Reform Support Project) was approved by the Bank's Board in 2003 and is waiting for parliamentary approval. The new loan supports deepening the health sector reform and will provide sector wide support for the reform efforts, including critical financing to support these efforts. In particular, the new loan will support decentralization of health services, strengthening the local levels, and the implementation of the social security system and the national health insurance, efforts that were initiated under the Project. The new project will also support strengthening SESPAS at the national level to reinforce its regulatory and policy making functions. Hospitals have remained in charge of managing and upgrading the MIS and of keeping the IT technicians among their personnel, financed with their own resources. After project completion, this commitment appeared to have been maintained in the majority of the participating hospitals. Trained personnel at medical and administrative levels have remained within the health sector, though not necessarily in the same positions where they were originally trained, ensuring an upgrade in overall skills in the sector. Because of the decentralized nature of project actions, they have been absorbed mostly by local offices. The arrangements to work with the Provincial authorities have been instituted and, after project completion, the consensus building and participatory processes to define priorities and action plans have remained in place. - 18 - 7. Bank and Borrower Performance Bank 7.1 Lending: Satisfactory. Overall, the Bank's performance during preparation was satisfactory. It engaged in a fruitful dialogue with the Borrower and together prepared the first Bank-financed operation to support the health sector in the Dominican Republic. Project design was grounded in economic and sector work, appropriately responded to the country's priorities and policies, and had enough flexibility to respond to the country's changing needs during its implementation. There was a strong Bank effort to coordinate its interventions in the health sector with ongoing efforts from other international financial institutions, particularly the Inter-American Development Bank, and donors. 7.2 Supervision: Satisfactory. Bank supervision is rated as satisfactory. The Bank performed very well after project approval and before project launching (the project was officially launched in November 1998, but the Bank started to work with the Borrower in September 1998, right after the Hurricane). The Bank team reacted in a timely fashion to support the Government in facing the devastation brought by Hurricane George, bringing to the Dominican Republic the experience gained with the "El Nino phenomenon" in Ecuador. In responding to the emergency, the Bank team provided technical support to refine the Government's emergency plan and played an important role in promoting consensus among donors in its support of the plan. Furthermore, the Bank team adjusted procurement and disbursement procedures to adequate them to the emergency situation, and positively responded to the Government's request to create a new component to finance emergency efforts reallocating funds across disbursement categories to support the new component. During supervision, the Bank showed the needed flexibility to adjust the project to the changing reality of the country and, together with the Borrower, set the path to progress in achieving the development objectives. In particular, the Bank team showed flexibility to address the shortage of counterpart financing problems in the country, working with legal, disbursement, and financial management to recognize SESPAS' investments as counterpart funds so that implementation would not be delayed. The Bank team carried out numerous missions, supervising project implementation while providing technical assistance and advice to the Borrower. The Bank also provided training for the procurement and financial management team within the PCU, thus promoting fiduciary compliance during project implementation. There was a frequent work exchange between the Bank team and the PCU, and Bank staff were constantly engaged in a dialogue with the relevant actors and stakeholders in the health sector, supporting the Government's efforts to increase participation in the health sector and building consensus while decentralizing the health sector. One of the strengths of the Bank's supervision team was the depth with which the supervision missions were carried out, giving the team a deep and detailed knowledge of the different realities of the Regions and numerous provinces that benefited from the project. This allowed the Bank team to provide advice that was highly valued and used by the Borrower to pilot the various experiences supported by the project. There were two areas where supervision could have been better. First, the Bank team underestimated the conflict between SESPAS and CERSS caused by the unbiguity of their roles in carrying out the health reform. By working more closely with CERSS, the Bank missed the opportunity to build capacity within SESPAS to play a greater role in the reform process. - 19 - A second area of weakness was that the Bank did not always respect its own deadlines to provide no-objections or to replenish the special account. 7.3 Overall Bank performance: Satisfactory. Overall Bank performance is rated satisfactory for: l Designing a project that appropriately addressed the country's priorities while maintaining flexibility to respond to changing needs of the Borrower; l Coordinating project design with other international organizations and donors, so as to complement and leverage efforts; l Quickly and adequately responding to the Borrower's emergency needs and reality; l Effectively providing technical assistance based on both technical knowledge as well as a deep understanding of the country and its reality; l Good team work and good communications with the implementation agency and the Borrower in general; and l Supporting Government's efforts to increase participation and decentralization. Borrower 7.4 Preparation: Satisfactory. The Government collaborated closely with the Bank in the preparation and design of its project. During preparation, the Government showed its ownership of the Project as well as commitment to its proposed development objectives with the preparation of a policy letter (August 1997) containing a description of the proposed health sector reform and modernization program, to be supported by the IBRD and IADB. The policy letter provided the framework for the Project's activities included in its design. Additionally, the Government enacted a Presidential Decree establishing the Executive Commission for Health Sector Reform (CERSS) to set in place adequate institutional capacity to carry out reforms in the health sector and implement the project. Finally, the Government made an effort to include different stakeholders in the preparation process, in particular the institutional representatives. 7.5 Government implementation performance: Satisfactory. Government's implementation performance is rated satisfactory, despite the problems in assigning timely counterpart funding to the project. Throughout project implementation, the Government unwavered its political support to the reforms and decentralization efforts in the health sector, including ensuring the approval of key legislation (see Section 4) that set the modernization process of the health sector irreversible. Furthermore, legislation was prepared under one administration and approved and signed by a different President, which is a significant achievement given the Borrower's political reality. 7.6 Implementing Agency: Highly satisfactory. The implementing agency's performance during implementation is rated as highly satisfactory. The PCU was staffed with a group of dedicated and capable professionals that, for its majority, remained in CERSS until project closing. The PCU was excellent in its management of the procurement and financial aspects of the project, setting a best practice example within the country for other IBRD-financed projects. Its professionals were highly sought by other national and international institutions who work in the health sector in the country. Additionally, the PCU team did a superior task when implementing project activities, engaging in dialogue with stakeholders at provincial and regional level, creating capacity at the local level, empowering key stakeholders to actively participate in the implementation of the project and trying to seek complementarity among the activities financed by different financiers. - 20 - Finally, the PCU was very proactive in effectively and strategically managing available resources, particularly given the constant shortage of counterpart financing. When faced with counterpart shortages, it continued implementation by developing activities that required less counterpart financing and it worked with the Bank to acknowledge SESPAS' investments in the project areas, carried out in line with Bank requirements. It also succeeded in obtaining additional counterpart resources (about $1.45 million), approved for the Project that had not been made available. 7.7 Overall Borrower performance: Satisfactory. Overall Borrower's performance is rated satisfactory for: l Overall commitment to the health sector reform, including passing key legislation to ensure sustainability of the reforms; l Working with international organizations and donors during preparation and implementation, favoring complementarity of support by external financiers; l Ensuring continuity of the PCU technical staff throughout the life of the project, despite significant staff changes at other levels; l Successfully managing fiduciary aspects of the project; l Involving beneficiaries and stakeholders at local and regional level; l Introducing positive changes in management and attitude towards the delivery of services; and l Achieving the majority of project objectives and targets, despite the shortage of resources and financial difficulties the country was facing. 8. Lessons Learned Agreeing on a flexible design supports efforts by the Borrower and the Bank to take risks, be innovative, and react proactively to events that can affect achievement of development objectives during implementation. In a context of modernization and reform of a sector, keeping flexibility in design is key to allow the Borrower and the Bank to explore new venues and to adapt to the changes in a highly volatile sector context, while the definition of reforms is taking place. The flexibility in project design allowed for timely adjustments in the agreed implementation strategy, as the country's needs and priorities evolved. This was the case of the changes introduced in the project to provide support to mitigate the efforts of Hurricane George in 1998. The methodology of Annual Operational Plans and yearly evaluations allowed the provincial teams to take risks and explore while learning by doing, with Bank support during this process. Relevance of donor coordination and Borrower's capacity to carry out this role. Whereas proper donor coordination ensures that efforts are not duplicated while investments are leveraged, it requires strong capacity from the Borrower's side. In the case of this project, part of its success can be attributed to the good coordination between the Bank, IADB, PAHO and others, though much of the coordination resulted from efforts by the organization representatives themselves. Thus, lending operations should take this need into consideration and, whenever feasible, ensure that the project fosters such capacity. Creating an independent core technical group can provide continuity to project efforts, particularly in a context of great political volatility, but can also undermine the institutional capacity of the line Secretariat. The project could have mitigated the conflict between SESPAS and CERSS by striking a better balance between supporting CERSS and fostering the technical capacity of SESPAS. - 21 - The legal, policy, and institutional instruments require adhesion of key stakeholders to ensure sustainability of reform efforts. The establishment of the legal framework as well as the definition of institutional and leadership roles should be the backbone of changes in the health sector. Nonetheless, it is the support of key Government and private sector stakeholders that will ensure long-term sustainability of the changes. The project supported efforts to facilitate the preparation, consultation, and consensus building processes to establish an appropriate legal framework to adequately back the reform. Additionally, it simultaneously financed tangible improvements in the physical capacity of the health system, that was key to enlist support for reforms. The definition and implementation of a MIS should be done jointly with the future users of that system. In order to guarantee that among the possible technological options the most adequate one is chosen, it is crucial to involve the users in the selection of technology. In the case of the Project, because user-beneficiaries in the hospital units (i.e. emergency units) were consulted, the proposed final application adequately responded to their needs, and this participation helped overcome the initial inadequacies detected in the original technological proposals. Decentralizing implementation responsibility to local levels is important to build ownership and local capacity. The implementation unit chose to decentralize and delegate responsibilities in the preparation and execution of activities during the life of the Project. This was extremely positive, as it fostered local level commitment and interest in the Project. Training at the provincial level allowed the provincial authorities (DPS) to design and implement their own annual programs, building a core capacity in the country that benefited other project and programs. Additionally, transferring responsibilities to the provincial level - as key actor and beneficiary of a project - fosters commitment and a culture of accountability. In the case of the Project, this mechanism was positive, forcing them to undertake strategic planning and to reflect on the priorities and implementation strategies to achieve goals at their level. Appropriate and timely information sharing with legislative body promotes support for reform efforts. CERSS held about 15 meetings with the Parliamentary Health Commission to discuss revisions to the new health law, including providing technical legal assistance in specific aspects of the law. Additionally, at the request of the Commission, it financed several key studies providing important technical input to them. This close collaboration effort led to the incorporation and ratification of about 95 percent of the changes to the law proposed by CERSS. 9. Partner Comments (a) Borrower/implementing agency: Partner comments are included in Annex 8 of this document. (b) Cofinanciers: (c) Other partners (NGOs/private sector): 10. Additional Information Not Applicable. - 22 - Endnotes 1/ When the project was designed the participating provinces were to those low-income provinces located initially in the Health Regions 0, III, IV, and VII, where 48 percent of the Dominican Republic's population lived. Health Region Provincial Area Health Region 0 National District Metropolitan Area. Heath Region III Duarte, María Trinidad Sánchez, Salcedo, Samaná and Sánchez Ramírez Health Region IV Barahona, Independencia, Bahoruco and Pedernales Health Region VII Valverde, Montecristi, Santiago Rodríguez and Dajabón Health Region VIII Sánchez Ramírez 2/ PDC, created by Presidential Decrees (Decrees N 613-96 and N.312-97), comprised provincial, municipal authorities and community representatives. They were responsible for promoting social participation in planning, administering and implementing development programs at the provincial and municipal level. 3/ The Inter-American Development Bank (IADB) provided, under a Health Reform Project, US$65 million in financing to support the health reform process in the Dominican Republic. 4/ Given the lack of baseline statistics to evaluate project impact, data from the 1996 and 2002 Demographic and Health Survey (Encuesta Nacional Demografica y de Salud -ENDESA (1996 data were used as baseline) and the Health Secretariat ( Secretaría de Estado de Salud Pública y Asistencia Social - SESPAS) was used. While these statistics provide a good overview of project impact, it should be noted that their quality needs improvement. - 23 - Annex 1. Key Performance Indicators/Log Frame Matrix Outcome / Impact Indicators: 1 Indicator/Matrix Projected in last PSR Actual/Latest Estimate 1. Reduce infant mortality, under 5 mortality health survey under assessment Between 1996-2002: and maternal mortality rates by 30% in project areas. - Infant mortality reduced by 35% - Children under 5 mortality reduced by 34% - Maternal Mortality reduced by 22% (estimated) 2. Increase to 60% the proportion of mothers 80% 93% that receive four prenatal visits during most recent births. 3. Reduce incidence of immune preventable n.a - Measles reduced from close to 300 cases diseases in children 12 to 23 months old./1 in 1999 to 0 cases in 2002 - Polio reduced from 10 cases reported in 2000 to 0 cases reported in 2002. 4. Reduce incidence of acute diarrhea, n.a Between 1996-2002: respiratory infections and malnutrition in children under 5./1 - Acute diarrhea in project regions reduced by 31.4% (at national level reduced by 4.9%) - Respiratory infection reduced by 17% in project regions (at national level reduced by 19.6%) /1 These indicators were not originally included in the PAD's logframe but, due to their significance, the ICR team decided to include them in the table. Output Indicators: 1 Indicator/Matrix Projected in last PSR Actual/Latest Estimate FINANCING/IMPLEMENTATION OF PROVINCIAL SUBPROJECTS Number of agreements signed between the n.a. 14 Framework agreements signed between PCU and the Provincial Development participating provinces and the CERSS. Councils granting financial and managerial Annual Operational Plans signed yearly with flexibility to the participating provinces. each Provincial Development Council. Number of completed provincial subprojects n.a. n.a in project regions. ENHANCED ORGANIZATION AND MANAGEMENT CAPACITY FOR PROVINCIAL HEALTH SYSTEMS New methods for allocating funds to n.a. Management agreement between SESPAS providers selected, developed, tested, and and Hospital Jaime Mota signed, agreeing on adopted at provincial health systems. innovative mechanisms to allocate resources. Hospital Herrera created as an autonomous hospital. Cost accounting and financial management n.a MIS modules for management of resources systems selected, tested, and adopted at and budgeting developed and implemented in provincial health systems. the participating provinces. Prototype medical records model designed, n.a. MIS modules designed and implemented in tested, and adopted at provincial health the participating provinces on the following systems. aspects: clinical registration, financial management, demography and population, medical inputs and medication distribution, - 24 - and human resources. Quality Assurance systems selected, n.a. Sensitization activities with health developed, tested, and adopted at provincial professional carried out. health systems. Inventory to identify and address main problems in delivery of obstetric services in four hospitals carried out. Norms and protocols for health service provision defined and implemented. Norms and regulations defined on key health areas: opening of health and ambulatory centers, transport services, blood banks, transfusion services, radiology and clinical laboratories. Pre-service training of medical personnel in the universities of the country in the areas of Pediatrics and Obstetrics reviewed, modernized, and unified. Administrative and financial personnel trained n.a. Around 20,000 professionals trained in management and health specific issues. Over 5,000 personnel at provincial level trained in basic computer skills and MIS. Staff trained in 14 hospitals on strategic planning and financial management. 100 professional trained on health economics and reform. 74 managers trained on management of health services and systems. Number of service delivery n.a. Management agreement between SESPAS agreements/contracts signed between and Hospital Jaime Mota signed, agreeing on Provincial Development Councils and innovative mechanisms to allocate resources SESPAS health facilities, NGOs and private based on results. providers IMPROVED ACCESS TO, AND QUALITY OF, ESSENTIAL HEALTH INTERVENTIONS PACKAGE TARGETED TO THE POOR IN PARTICIPATING PROVINCES Increase to 90% the proportion of 95% 95% professionally attended deliveries Increase to 95% the proportion of children 95% 95% with complete immunization schedule Clinical standards for interventions in the Different protocols and standards developed Over 27 National Norms for Health Care essential package of health services defined, and implemented in health facilities. developed, approved, and under tested, and adopted at provincial health implementation. systems 90% of health facilities in project areas in 80% 90% compliance with standards for essential health interventions - 25 - Increased client satisfaction with access to, under assessment n.a. and quality of provincial health systems Greater community participation n.a. Community inputs sought during the support for approval of legal framework. Community stakeholders involved in consensus building. Communities involved in the management of hospitals: participation of communities in Boards of Directors. 1End of project - 26 - Annex 2. Project Costs and Financing Project Cost by Component (in US$ million equivalent) Appraisal Actual/Latest Percentage of Estimate Estimate Appraisal Component US$ million US$ million 1. Provincial Subprojects 33.50 27.40 81.8 2. Policy Development and Studies 2.70 2.50 92.6 3. Project Administration 2.20 4.30 195.5 4. Emergency Subprojects 0.00 4.28 Total Baseline Cost 38.40 38.48 Physical Contingencies 1.20 Price Contingencies 2.40 Total Project Costs 42.00 38.48 Total Financing Required 42.00 38.48 Project Costs by Procurement Arrangements (Appraisal Estimate) (US$ million equivalent) 1 Procurement Method Expenditure Category ICB NCB 2 N.B.F. Total Cost Other 1. Works 0.00 5.00 3.30 0.00 8.30 (0.00) (2.00) (1.40) (0.00) (3.40) 2. Goods 4.10 5.30 4.00 0.00 13.40 (3.40) (4.30) (3.40) (0.00) (11.10) 3. Services 14.70 0.00 14.70 () () (13.70) (0.00) (13.70) 4. Operational Costs 0.00 0.00 0.00 3.80 3.80 (0.00) (0.00) (0.00) (0.00) (0.00) 5. PPF 0.00 0.00 1.80 0.00 1.80 (0.00) (0.00) (1.80) (0.00) (1.80) 6. Emergency Subprojects 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) Total 4.10 10.30 23.80 3.80 42.00 (3.40) (6.30) (20.30) (0.00) (30.00) - 27 - Project Costs by Procurement Arrangements (Actual/Latest Estimate) (US$ million equivalent) 1 Procurement Method Expenditure Category ICB NCB 2 N.B.F. Total Cost Other 1. Works 2.20 2.40 0.00 4.60 () (0.90) (0.60) (0.00) (1.50) 2. Goods 3.60 5.50 2.50 0.00 11.60 (3.60) (4.40) (1.60) (0.00) (9.60) 3. Services 1.80 0.20 10.68 0.00 12.68 (1.80) (0.20) (9.30) (0.00) (11.30) 4. Operational Costs 0.00 0.00 4.30 0.00 4.30 (0.00) (0.00) (2.90) (0.00) (2.90) 5. PPF 0.00 0.00 0.90 0.00 0.90 (0.00) (0.00) (0.90) (0.00) (0.90) 6. Emergency Subprojects 0.00 3.00 1.40 0.00 4.40 (0.00) (3.00) (0.80) (0.00) (3.80) Total 5.40 10.90 22.18 0.00 38.48 (5.40) (8.50) (16.10) (0.00) (30.00) 1/Figures in parenthesis are the amounts to be financed by the Bank Loan. All costs include contingencies. 2/Includes civil works and goods to be procured through national shopping, consulting services, services of contracted staff of the project management office, training, technical assistance services, and incremental operating costs related to (i) managing the project, and (ii) re-lending project funds to local government units. Project Financing by Component (in US$ million equivalent) Percentage of Appraisal Component Appraisal Estimate Actual/Latest Estimate Bank Govt. CoF. Bank Govt. CoF. Bank Govt. CoF. Provincial Subprojects 21.30 6.10 Policy Development and 1.80 0.70 Studies Project Administration 3.00 1.30 Emergency Subprojects 3.84 0.44 Total 30.00 12.00 29.94 8.54 99.8 71.2 The PAD did not contain costing data disaggregated by component and by source of financing. Available data was insufficient to reconstruct this table. - 28 - Annex 3. Economic Costs and Benefits Not applicable. - 29 - 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 July/ 1995 2 Task Manager (1); Health Specialist (1). February/1996 4 Task Manager (1), Health Specialist (2); Health Consultants (1). August/1996 3 Task Manager (1), Health Consultants (2). Appraisal/Negotiation May/1997 4 Task Manager (1); Health Consultants (2); MIS and Institutional Development Consultant (1); Operations Specialist (1). October/1997 4 Task Manager (1); Health Consultants (2), Lawyer (1) Supervision October/1998 4 Task Manager (1); S S Procurement Specialist (1); Crisis Management Consultant (1); Water and Sanitation Consultant (1) 01/29/1999 4 Sr. Health Specialist (1); S S Procurement Specialist (1); Health Systems Specialist (1); Project Officer (1). 06/02/1999 6 Task Manager (1); S S Administrative Assistant (1); Arquitect Consultant (1); Medical Care Specialist (1); Procurement Consultant (1); Health Consultant (1). 01/10/2000 9 Task Manager (1); S S Administrative Assistant (1); Health Systems Specialist (1); Consultants (2); Procurement Analyst (1); Public Sector Management Specialist (1); WB Resident Representative (1); Operation Officer (1). 04/03/2001 12 Task Manager (1); S S Administrative Assistant (1); Health Systems Specialist (1); Institutional Specialist (1); Sector Leader (1); Sector Manager (1); - 30 - Procurement Specialist (1); Procurement Assistant (1); Financial Management Specialist (1); Disbursement Analyst (1); Social Development Specialist (1); Senior Economist (1). 02/04/2002 1 Task Manager (1). S S 06/20/2002 5 Task Manager (1); Health S S Specialist (1); Health Systems Specialist (1); Institutional Specialist (1); Administrative Assistant (1). 11/4/2002 1 Financial Management Specialist S S (1). 03/22/2004 3 Task Manager (1); Health S S Specialist (1); Health Systems Specialist (1). ICR October/2004 1 Operations Consultant (1) S S (b) Staff: Stage of Project Cycle Actual/Latest Estimate No. Staff weeks US$ ('000) Identification/Preparation n/a 64.2 Appraisal/Negotiation n/a 149.8 Supervision 55.0 314.9 ICR 3.13 22.0 Total 530.2 - 31 - Annex 5. Ratings for Achievement of Objectives/Outputs of Components (H=High, SU=Substantial, M=Modest, N=Negligible, NA=Not Applicable) Rating Macro policies H SU M N NA Sector Policies H SU M N NA Physical H SU M N NA Financial H SU M N NA Institutional Development H SU M N NA Environmental H SU M N NA Social Poverty Reduction H SU M N NA Gender H SU M N NA Other (Please specify) H SU M N NA Private sector development H SU M N NA Public sector management H SU M N NA Other (Please specify) H SU M N NA The Project's impact on poverty reduction is considered substantial due to the fact that the bulk of its activities targeted the poorest provinces in the Dominican Republic. The Project was successful in improving the capacity of health providers to better deliver health services and to increase the quality of those services in particular for the most vulnerable population. The Project also focused on improving the health status of women. Due to the significant outputs benefiting maternal health, the rating on gender impact is also substantial. - 32 - Annex 6. Ratings of Bank and Borrower Performance (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HU=Highly Unsatisfactory) 6.1 Bank performance Rating Lending HS S U HU Supervision HS S U HU Overall HS S U HU 6.2 Borrower performance Rating Preparation HS S U HU Government implementation performance HS S U HU Implementation agency performance HS S U HU Overall HS S U HU - 33 - Annex 7. List of Supporting Documents World Bank Project Documents: l World Bank, Project Appraisal Document for the Dominican Republic Provincial Health Services Project. Report No. 17199 DO. December 15, 1997. l World Bank, Loan Agreement for the Dominican Republic Provincial Health Services Project. Loan No. 4272-DO. March 9, 1998. l World Bank, Loan Amendment for Dominican Republic Provincial Health Sercives Project. Loan 4272-DO. October 13, 1998. l World Bank, "Aide Memoires" 1995 - 2004. l World Bank, "Project Status Reports" March 12, 1998 - May 26, 2004. Borrower Documents: l Comisión Ejecutiva para la Reforma del Sector Salud - Secretaria de Estado de Salud Publica y Asistencia Social, " Proyecto De Desarrollo de Sistemas Provinciales de Salud - Informe Final de Evaluación 1998 - 2004," April 2004. l Secretaria de Salud Publica y Asistencia Social - Dirección de Normas y Protocolos Clinicos - Comisión Ejecutiva de Reforma del Sector Salud, "Normas Nacionales en Salud Reproductiva 1er nivel de Atención," July 2004. l Secretaria de Salud Publica y Asistencia Social - Dirección de Normas y Protocolos Clinicos - Comisión Ejecutiva de Reforma del Sector Salud, "Protocolos de Atención en Hospitales 2do. y 3er Nivel - Obstetricia - Ginecologia," July 2004. l Secretaria de Salud Publica y Asistencia Social - Comisión Ejecutiva de Reforma del Sector Salud, "Reglamentos de la Ley General de Salud (42 - 01) Volumen I," April 2004. l "Encuesta Nacional Demografica y de Salud 1996 y 2002" -ENDESA (Demographic and Health Survey) - 34 - Additional Annex 8. Borrower's Contribution 1. The Provincial Health Services Project proposed "to contribute to the improvement in health of the most socially and biologically vulnerable population (particularly pregnant and nursing women, as well as children under 5 years of age), in health Regions 0, III, IV and VII," comprised of 14 provinces where 48 percent of the total population of the country reside, taking actions aimed at: · improving the quality and coverage of health services, and · conducting studies of institutional and policy reforms, including those that serve as a foundation for the decentralized management of the provision of services. 2. The total cost of the project, reaching approximately US$42 million, was to be financed with contributions from the Government of the Dominican Republic of approximately US$12 million and with a World Bank loan (4272-DO), signed on March 8, 1998, and declared effective in November of the same year for the amount of US$30 million. 3. Its execution was led by the Executive Commission for Health Sector Reform during the 1998-2004 period, a presidential commission created by decree on July 10, 1997, with the objective of articulating the reform efforts of the health sector. 4. This was the first project to carry out institutional transformations that would allow the health system to provide solutions for problems related to financing, coverage, inequality, poor quality of services offered, high levels of user dissatisfaction and little or no community participation in the management of services. Previously, the sector was known for public and private providers operating without rules and accountability for health results. There was also no governing institution able to formulate those rules and much less to enforce them. 5. The complexity of the Project forced the use of different implementation strategies in the different geographic intervention areas that finally led, by different paths, to the same objectives. 6. In spite of three hurricanes that occurred during its implementation, including Hurricane George in 1998, the appearance of cases of polio and measles between 1999 and 2001, and the great financial crisis that occurred in 2003, the Project managed to exceed the goals it committed to in the design phase. The project was designed to allow for a variety of options according to the possibilities and opportunities of each region, province, or health center. 7. The policies and studies component of the Project, initially consisting of six studies, focused its efforts on the creation of a modern legal framework that would replace the Health Code of 1956, would incorporate the principles to guide the sector reform, and would allow institutional changes required to overcome the main problems of the Dominican health system. In this context, the studies cease to have a purpose in and of themselves and are used as an input for the creation of this new legal framework of the Dominican health system. 8. The Project not only supported the revision, update, approval, and enactment of the General Health Law (Law 42-01), but it also encouraged and obtained, in coordination with the IDB's Modernization and Reconstruction of the Health Sector Project ­ as considered in the design ­ regulation of the law by more than 70 percent and supported the formation of the National Health Council as mandated by the Law, as a co-managing body of Public Health. Accordingly, unlike most Dominican laws, Law 42-01 is one of the - 35 - first to manage to formulate the tools for its application within the framework of a project. 9. Among the 12 most important regulations that constitute the mechanisms to revolutionize the Dominican health system, it is important to mention: 1) Regulation governing and separating functions, allowing the separation of the basic functions of the health system (Governing, Provision, Financing and Insurance) then concentrated in the State Health Secretariat; 2) Regulation of human resources, containing the guidelines for the modernization of human resources management; 3) Regulation of the provision network, transforming the delivery of isolated health services, along with its problems of quality, coverage and inefficiency; and 4) Regulation of contracting regimes that will allow generalization of the pilot developed by the project with the objective of demonstrating that "if financial resources are tied to clearly agreed results," services improve. 10. Advances in terms of regulation were also obtained with the elaboration of a guide for the accreditation of clinical laboratories consented to in several Latin American countries in a strategic alliance with PAHO/WHO and the Latin American Confederation of Clinical Biochemistry. 11. Definition of norms and instruments that will allow SESPAS to exert one of its most important roles in the area of governance: the regulation of health centers and services that operate in the country. This was achieved by handing over to SESPAS the proposals of the norms that define the minimum requirements for the opening of health centers with in-patient and out-patient services, health transportation services, imageology, radiology, clinical laboratory, blood banks and blood transfusion services. The last two were completely agreed upon by all sectors involved (public, private, and non-governmental organizations). 12. Another important achievement was the revision of the law that created the Dominican Social Security System (Law 87-01) -previously non-existent in the country- which was passed around for more than ten years without reaching approval, thus facilitating the consensus process with the unions of health professionals, businesses and the working-class, conducting studies to avoid contradictions with Law 42-01 and others that were required in order to reach its approval. 13. Component one, that initially considered the formulation and execution of the sub-projects, changed its strategy to a more flexible modality based on the annual formulation of Operational Plans at the local level, which addressed the particular realities of each region and province. 14. The initiation of a new assistance model (defined under the leadership of PAHO) that assigns geo-population responsibilities to a health team regarding first steps that all models coming out of the health center must take, which is the understanding of the epidemiological reality of the community under the responsibility of the health team. 15. In support of service quality improvement, National Assistance Guidelines were formulated and/or revised, published and distributed in more than 27 areas, particularly the maternal-infant ones, with a high protocol content that will allow the management team of the health centers -once incentive systems are established- to count on a tool to monitor the quality of service delivery and to control costs of inputs used. 16. The training programs of the Pediatrics and Obstetrics-Gynecology areas were evaluated, leading to the unification of all universities' training programs, incorporating the new management elements mandated by Law 42-01 and most importantly, agreeing on standards that, if implemented, will allow a competitive advantage in the face of globalization. - 36 - 17. Renovating and equipping hospitals and primary care centers in order to update their capacity and resolve the problem of handling hospital waste with the provision of incinerators (in the country's 11 biggest hospitals). It was possible to respond to more than 85 percent of needs identified in the Annual Operational Plans in Regions IV and 0 (Santo Domingo), and to 60 percent of the cases in Region III. On the other hand, valuing the importance of clinical laboratories as support to diagnostics, all laboratory services in Project regions were equipped at 100 percent of provincial hospitals (14) and 100 percent of municipal hospitals (23). 18. Provision of adequate work space and means of transportation to the Provincial Health Departments of the 14 provinces within the Project's area, thus supporting the development of decentralized governing entities. 19. The Management of Information Systems (MIS) as a strategic instrument to strengthen management capacity, efficiency, and operation of health suppliers and Provincial Health Departments (DPS) came from the development of an agreed and dynamic conceptual framework that had reached an 11th version at the Project's closing date. 20. The implementation strategy that was followed took off from the contracting of services for the parameterization and implementation of modules of Clinical Registries (SIG-REG); Financial Management (SIG-FIN); Human Resources (SIG-RRHH) and Medical and Medicinal Provisions (SIG-SUM); Budget (PROLOC) and Demography and Population Registry (SIG-DEM). As a starting point, pilot experiences were evaluated before continuing with the expansion, until reaching -in the case of the Clinical Registry System supporting the Clinical Management- 24 hospitals (21 of SESPAS, two of IDSS and one autonomous), an image diagnosis center of national reference, with 20 to 400 beds, representing almost 28 percent of the total capacity of the country's public health network and serving 30 percent of the country's population. 21. The Project satisfactorily consolidated a LAN-Network infrastructure, a system of auxiliary energy (UPS), personnel capable of handling the system in all intervened establishments, guaranteeing gradual and sustainable growth with recurrent costs within the budgetary capacity of the establishments. It was also able to incorporate the technology into the work culture of personnel who hide ­through pen and paper- great and diverse things that not only have repercussions on the management of the health centers but on the quality of service they provide. 22. The project effectively faced the three hurricanes that occurred during its execution without deviating from its objectives. Efficient procurement and distribution of inputs contributed to -at least- maintaining the epidemiologic profile that tends to be altered by natural phenomena such as a hurricane, undergoing a great coordination effort, mobilizing society and, above all, preparing the Center for Tropical Disease Control to provide quick answers in emergencies that might occur in the future. Other achievements include training of 54 entomologists throughout the country, renovating and equipping the Entomology Laboratory, improving the work spaces of this center and providing it with fumigation equipment and transportation means, among others. 23. Support for the 5-year Vaccination Plan formulated, among other objectives, to avoid future disease outbreak emergencies preventable through vaccines, which managed to impact the rate of infant mortality. 24. In light of the economic crisis, management developed innovative processes for obtaining counterpart funds. Details can be reviewed in the final report. - 37 - 25. The first and only process of resource allocation tied to results was put in place through the signing of a Management Agreement. Quarterly evaluations demonstrate that it is possible to reach better health results with slightly more resources as well as clear and agreed goals. 26. The only autonomous public hospital in the country was designed and developed with the Project's support. The results and instruments are available in the Dr Marcelino Vélez Santana Hospital or the Herrera Hospital. 27. The only coordinated proposal for a provision network whose methodology served as reference for the formulation of the Provision Network regulation was developed. It will serve to face one of the greatest challenges of the Dominican Health System: the coordination of decentralized and autonomous networks that comprise one of the components included in the first stage of the Health Sector Reform Support Program, which awaits ratification in Congress. 28. The goals of reducing infant and maternal mortality rates by 30 percent were exceeded in both cases, with the exception that ENDESA of 2002 did not obtain sufficient cases to make estimates of maternal deaths at the regional level, as in 1996, and therefore the change could be measured at the national level but not in the project regions. 29. The previous achievements and others (that could not be included due to space limitations or because they were not measurable) were possible due to a set of factors summarized as follows: · Execution of the actions with transparency, since out of five external audits carried out , none received conditions. · Formation of mixed procurement committees at the local and national levels for the opening, evaluation and procurement of the goods, civil works and services, which also implied the transfer of knowledge. · High levels of efficiency in the procurement of inputs for the execution of the activities or achievements of the products, whose details are in the final evaluation report. · The participation of UNDP in the project's administration also contributed to the construction of institutional credibility. · Formation of a competent national team located outside of the institutions subject to reform, the Executive Commission for Health Sector Reform, that through its work gained respect and remained on the project even throughout changes in the government. · The continuance of the same World Bank specialist during the execution of the entire project, and the work culture of the specialist and the team, which facilitated the necessary adjustments under each given context in a highly efficient manner. The latter made it possible to give quick answers to the needs of the country without deviating from the objectives of the Project. · The establishment of an excellent work relationship between the National Team and the World Bank, who became partners committed to the changes and processes. · Formation of a critical group of professionals, that are currently an integral part of the different sector reform processes in various health sector institutions in the country, both public and private. · Training of more than 20 thousand professionals in different areas under the innovative modality of transferring the training centers to the local level, thus reducing costs and desertion. - 38 - Additional Annex 9. Legislation Supporting the Implementation of the General Health Law APPROVED AS OF 6/21/04 LEGISLATION STATUS 1. Guidelines for the preparation of proposals -APPROVED by the National Health Council (CNS) on November 6, for implementation of the General Health 2001. Does not require enactment by the Executive. Law. 2. Internal rules of operation for the National Health -APPROVED by CNS. Council. -ENACTED by Decree 1130-01 on November 20, 2001. 3. Ensure health facilities and services are fully -APPROVED by CNS. operational. -ENACTED by Decree 1138-03 on December 23, 2003. -PUBLISHED officially in Hoy newspaper on January 28, 2004. 4. Guidelines for routine contracting of SESPAS for -APPROVED by CNS on July 2, 2003. provision of public health services. -ENACTED by Executive Decree 738-03 on August 7, 2003. -PUBLISHED officially in Hoy newspaper on August 9, 2003. 5. Rectorship and separation of functions of the -APPROVED on December 17, 2002. National Health System. -ENACTED by Decree 635-03 on June 20, 2003. -PUBLISHED officially in Hoy newspaper on August 8, 2003. 6. Guidelines for provision of public health service -APPROVED by CNS on June 3, 2003. networks. -ENACTED by Decree 1137-03 on December 23, 2003. -PUBLISHED officially in Hoy newspaper on January 28, 2004. 7. Ensure blood banks and transfusion services are -APPROVED by CNS on May 7, 2002. fully operational. -ENACTED by Decree 349-04 on May 23, 2004. -Pending official publication. 8. Guidelines for reagent registry for clinical -APPROVED by CNS on May 7, 2002. diagnostic. -ENACTED by Decree 351-04 on May 23, 2004. -Pending official publication. 9. Guidelines for making clinical laboratories fully -APPROVED by CNS on July 23, 2002. operational. -ENACTED by Decree 350-04 on May 23, 2004. -Pending official publication. 10. Water for consumption. -APPROVED by CNS on August 19, 2003. -SENT to the Executive for enactment by decree and official publication. 11. National Health System's human resources. -APPROVED by CNS on May 4, 2004. -ENACTED by the Executive by Decree 732-04 on August 3, 2004. 12. Health promotion. -APPROVED by CNS on April 20, 2004. -SENT to the Executive for enactment by decree and official publication. 13. SESPAS' guidelines for emergencies and -APPROVED by CNS on July 20, 2004. disasters. -In process of legal revision. - 39 - - 40 -