Review of Bank Assistance Effectiveness to the Health Sector
Africa faces major health challenges, which are adversely impacting economic development, human development, and poverty reduction efforts. In addition to a high disease burden resulting from persistence of such infectious diseases as HIV/AIDS, malaria and TB, ongoing demographic and epidemiological transitions have led to a substantial rise in prevalence of non-communicable diseases accidents and injuries. Poor health delivery systems in most of Africa, the migration of health professionals to urban areas and to other countries and continents, weak infrastructure with lack of clean water, poor roads and communications, and poorly maintained health facilities, have compounded the problems. Underlying all of this is a very poor funding base for health and historic biases towards urban curative care financing. However, during the past decade, funding for health in Africa from international agencies has dramatically increased and governments have become more aware of the importance of health in economic and social development. It is therefore an opportune time for the African Development Bank to increase its commitment to health and focus its activities on those areas that will have the greatest impact on health improvement as discussed below.
Objective and Methodology of the Review
This review aims to assess how effective are the Bank policies, strategies and interventions in the health sector in order to draw lessons for the future. The review was carried out through an extensive review of Bank documents dealing with policy, project and post-evaluations; relevant literature on the health sector in Africa; analysis of Bank project-related data; consultations with Bank health staff and managers in charge of policy formulation and project and programme implementation. The review also benefited from a field mission led to Brazzaville during 6-10 February 2006, for consultations with development partners and sharing the main findings.
Review of Policies and Strategies
To respond to Africa’s health problems, Bank interventions in the health sector were initiated in 1975. The first and second health sector policies were formulated in 1987 and 1996, and the health sector policy guidelines were prepared in 1998. While the policies and guidelines have generally reflected international thinking and consensus on health sector policies, strategies, and interventions, they have not set forth operationally practical priority areas in which to invest. The broad nature of the policies have thus led the Bank to accommodate diverse Regional Member Countries RMCs) requests, including some that may not have been most effective in addressing problems at hand and some in which the Bank’s strength was not evident. Though the health policy guidelines were prepared in 1998, the paper was not made available to the health experts and task managers who were to translate the policy into practice. This resulted in a weak projectpolicy linkage for some priority areas like human resource development and reproductive health.
Quality of Project Design
The review examined the project design quality with respect to the following criteria: quality of project justification, objectives and components, epidemiological analysis, economic and sector analysis, institutional and political analysis, performance indicators and evaluation, project management, demandingness, and complexity of projects. While the projects are generally relevant in their stated objectives, few have appropriate data to substantiate them, especially before the introduction of Logical Framework in 1993. Weak use of the sector analysis, coupled with the superficial treatment of epidemiological data, recurrent costs, and the lack of specific cost projections based on expected service levels, have hindered the Bank projects in meeting quality standards for epidemiological and economic analyses. Institutional and political analysis is also weak with inadequate discussion on the political economy of the health sector. Project management shows that in-country co-ordination with other external donors and funding agencies has increased. Demandingness of the project is high and it has increased due to the combined effect of shrinking capacity of the Ministries of Health and the increasing complexity of the projects. Finally, complexity of the Bank projects has increased with increasing requirements for donor co-ordination, number of different activities in any given project, and more emphasis on capacity building by moving away from the focus on health infrastructure.
Health Sector Portfolio and Resource Distribution
During the period under review (1987-2005), the bank financed 154 operations corresponding to 108 projects spread in 39 countries for a total commitment of UA 990.72 million. Commitments to health-targeted projects have constituted a low level of 3.4 per cent of the total Bank commitment to all sectors. This percentage for the last 10 years is 3.7 and for the last five years only 3.5. This implies that the Bank financing did not increase significantly towards the achievement of the health millennium development goals. During the last 10 years, the number and the size of the health projects have increased slightly but the size of health projects saw a slight decrease in its percentage of financing in the total Bank portfolio. The average size of health projects is UA 9.17 million with operations spread over many sub-sectors, compared to UA 17.3 million for the total Bank commitments for almost the same period. During the earliest years of health activities, the highest share of commitments went to development and rehabilitation of infrastructure, but in more recent years, share of health projects infrastructure’s has declined substantially, offset by increased commitment to institutional capacity development, health reform, and disease specific activities.
The Bank’s health sector portfolio has demonstrated a lacklustre overall implementation performance, with a stagnant score around 50 per cent of all projects doing satisfactorily for the period 1998-2005 where coherent data are available. Only financial performance registered improvement over this period while procurement performance, the quality of activities and works including project management, as well as compliance with conditions declined. Time and cost overruns have been significant. Borrower performance has been marred by long delays in effectiveness, deficiencies in management capacity, delays in providing counterpart funds, auditing, and reporting irregularities. At the Bank level, inadequate quality-at-entry and insufficient project supervisions are prominent among the major impediments in implementation performance.
Bank Assistance Effectiveness
The Bank has not invested adequately in documenting performance of its project interventions in order to know what works. For instance, only 14 of 59 health projects completed since 1987 have PCRs and only 2 have a Project Performance Evaluation Report. This makes independent evaluation difficult and restricts the Bank’s capacity to learn from its past operations and be more accountable to its Members. Only 5 of the 12 completed projects have PCRs showing a satisfactory overall outcome performance. In their stated objectives, all projects considered in this review have some relevance to the Bank health policy as well as to the policies and strategies of the RMCs but less than 10 per cent have justified this relevance appropriately. Among the outcome performance indicators, Relevance and Achievement of Objectives was satisfactory or better in 6 out of 12 cases. Institutional Development was considered satisfactory in 5 out of 12 cases, signalling glaring gaps in project management capacity and training of health human resources. Sustainability, satisfactory in only 4 out of 12 cases, was considerably undermined by inadequate resource provision for recurrent expenditures, non-availability of trained health personnel to operate modern medical equipment provided and, in some cases, poor equipment quality and structures. Overall, the analysis of available information shows that the Bank’s performance in health sector has not been satisfactory, and that there is a need for significantly improving the quality of its interventions to produce better results. This should be seen and understood against performance of most African countries - which is poor and needs to be improved - and performance of other RMC development partners.
Removing Constraints to Effectiveness
The Bank often spends insufficient time to assess risks, RMCs’ capacity to implement projects, and the demand for the programmed services. This is in part due to the incentive structure at the Bank, which rewards the staff, including senior managers, for the number of projects sent to and approved by the Board, without sufficient regard for project quality. The health document review and interviews with the Bank’s staff indicate that the lack of emphasis on performance-based project design and responsibility for achieving results, both at the staff and project levels, makes it difficult for the Bank to hold staff accountable for implementing demonstrably effective projects and programmes. Further, while the Bank health experts appear to be competent and experienced, they operate under intense pressure leaving little time and incentive to direct expertise towards policy and strategy development or to provide technical support for project design and implementation. This problem is compounded by the limited sharing of knowledge that seems to occur at the bank among health staff due to the ‘silo-like’ structure that separates the staff.
Pre-requisites for Effectiveness
The Bank’s unique position as a major African institution with 40 years of experience in African development financing and significant possibilities for raising funding resources confer it access to key decision-makers including in the health sector. Further, the Bank has laid many of the building blocks and undertaken significant reforms necessary to provide leadership in selected health areas. In this context, removing constraints to effectiveness can help the Bank strategies and projects to produce better health impacts in Africa. The major pre-requisites include: (a) strategic selection of interventions which have the greatest impact on health; (b) establishment and maintenance of technical leadership and increasing project design and supervision skills in areas selected; (c) effective and efficient use of staff to implement strategy on the basis of appropriate incentives and rewards, and re-profiling of staff where necessary; (d) enhancement of the knowledge base through Economic and Sector Analysis and its effective use to inform project identification, design, and implementation, along with associated policy dialogue; and (e) increase in resource commitment to the sector.
Strategic Areas for Development in the Sector
The strategic areas where the Bank investments could be concentrated for better results include: supporting health human resources development, reproductive health, developing sustainable and integrated health systems, policy dialogue for financing and economic reforms, advocacy for African institutions with other donors, promoting African technical assistance institutions, and developing appropriate health infrastructures.
(a) Inadequate attention given to preparation and appraisal leads to unreasonable estimates of time and cost required for project implementation and inadequate attention to risk factors, eventually jeopardising implementation and outcome performance; (b) The participation of different stakeholders in the design of health project enables enhanced utilisation and sustainability of the facilities; (c) Lack of adequate monitoring and evaluation system prevents the Bank and RMCs from learning from health investments and from being fully accountable towards stakeholders and African populations; (d) Lack of adequate incentives makes it difficult to attract and retain qualified personnel in rural areas and to find a solution to human resources deficit and regional imbalances; and (e) Lack of emphasis on performance-based project design and responsibility for achieving results makes it difficult for the Bank to hold the staff accountable for implementing demonstrably effective projects and programmes; (f) When governments are part of the private sector project implementation arrangements, there is a need to adopt more stringent forms of legal obligations; (g) Governments’ commitment and quality of institutions are crucial for making successful equitable investments from national revenue and international assistance.
Health Sector Specific Recommendations
(a) The Bank should revise its current health sector policy and guidelines to make them more operationally focused by identifying areas where the Bank can have the greatest impact on health; (b) The Bank is recommended to improve the quality of its health sector projects at the design and appraisal stages through adequate assessment of the capacity within the Bank and in RMCs to design, monitor and implement projects; (c) The Bank should actively participate in or initiate Sector-Wide Approaches in the health sector; (d) The Bank should take a lead in selected policy dialogue with RMCs; (e) Staff should be rewarded for contributing to effectively promoting national policies that have a positive impact on the health outcomes and the Bank should enhance its co-operation with other Development Partners based on the strengths of each participating organisation; (f)The Bank should augment its assistance to selected areas of strategic importance with high priority given to development of health human resources, integrated aiming at exploring possibilities to effectively support the private sector financing; (h) The health sector policy guidelines should contain detailed guidance for performing technical aspects in project design and management.
(a) The Bank should rigorously execute portfolio improvement measures, especially those bearing on quality-at-entry, quality-atimplementation, and quality-at-exit in close collaboration with the RMCs to encourage them to play a more active role in the project cycle. The Bank must draw upon well informed economic and sector analysis in developing appropriate country strategies and relevant lending programmes; (b) The Bank should effectively use existing tools to facilitate assessment of project/programme outcomes and impacts, and the staff incentive structure must incorporate monitoring and supervision activities as a factor in staff performance evaluation; (c) The Bank should provide administrative support to technical staff and consider increasing current staffing profiles and levels of both professional and administrative personnel; and (d) The Bank should ensure that managers have appropriate skills, capacity, and incentives to manage for sustainable results on the ground.
The Way Forward
The initial step to implement the above recommendations should be to prioritise and cost the recommended actions. Contributing to this, a process is underway in the Operations Policy and Compliance Department (former Operations Policy and Review Department) for the revision of the 1996 Health Sector Policy. The Operations Evaluation Department should prepare a follow-up report within two-three years to assess how the recommendations have been addressed. It should also carry out specific evaluations of assistance to the health sub-sector themes for a better understanding of interventions that really succeed and what are the factors of success.