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Bolivia: Reducing Maternal and Infant Mortality: A multi-project evaluation of 16 years of World Bank support to the health sector (PPAR)

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Bolivia’s poor maternal and child health outcomes were of great concern in the 1990s. Infant and child mortality rates were 67 and 92 per 1,000 live births in 1998, and maternal mortality was 390 per 100,000 live births, risking Bolivia’s achievement of the Millennium Development Goals (MDGs). The capacities of the Bolivian health system were insufficient to respond to the need for health care Show MoreBolivia’s poor maternal and child health outcomes were of great concern in the 1990s. Infant and child mortality rates were 67 and 92 per 1,000 live births in 1998, and maternal mortality was 390 per 100,000 live births, risking Bolivia’s achievement of the Millennium Development Goals (MDGs). The capacities of the Bolivian health system were insufficient to respond to the need for health care access, availability, affordability, quality, and equity. Health facilities lacked essential drugs and equipment needed to provide good care. In addition to scarce and inefficiently distributed health workers, heath staff were often poorly trained, compromising the quality of treatment. The Expanded Immunization program had too little funding, poor communication strategies, and unreliable data, which led to declining immunization rates starting in 1996. Cultural and economic barriers limited demand for both preventive and curative care. The World Bank supported the government’s health sector reforms through a series of Adaptable Program Loans (APLs) over 16 years, including the 1999 Health Sector Reform Project, 2001 Second Phase of the Health Sector Reform Program, and 2008 Expanding Access to Reduce Health Inequities. The reforms supported by these projects are the subject of this Project Performance Assessment Report (PPAR). This report spans three projects. Ratings for the first project, Health Sector Reform (APL 1) is as follows: Outcome is satisfactory, risk to development outcome is moderate, Bank and Borrower performance is both moderately satisfactory. Ratings for the second project, Sector Phase of the Health Sector Reform Program (APL II) is as follows: Outcome is moderately satisfactory, risk to development outcome is moderate, Bank and Borrower performance is both moderately satisfactory. Ratings for the third project, Expanding Access to Reduce Health Inequities (APL III) is as follows: Outcome is moderately satisfactory, risk to development outcome is moderate, Bank and Borrower performance is both moderately satisfactory. Lessons from these projects include: (i) The definition of a common results framework is useful to align the efforts of different government levels. (ii) A robust results-based approach needs to define a clear mechanism of rewards/sanctions to function well. Otherwise it risks turning into a mere monitoring tool that could lead to perverse incentives. (iii) Project design coordinating efforts with parallel programs that have similar goals has a great potential for efficiency, but it raises methodological concerns about the attribution of outcomes. (iv) While continued focus on quality objectives is certainly commendable, it needs to be accompanied by more robust outcome measures to prove quality enhancements. (v) Programmatic approaches are suitable where sector knowledge is strong, program objectives are long-term and clear, and country ownership is established. (vi) Ambitious projects partially relying on a government promise to pass a reform law are likely to need a restructuring. Reallocation of project funds in response to ad hoc government requests may lessen the logic of the results chain and risk the M&E framework from providing sufficient evidence of project achievements.

Mexico: Support to the Social Protection System in Health Project (PPAR)

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This is the Project Performance Assessment Report for the Mexico Social Protection in Health Project (P116226). The project, approved by the World Bank’s Board of Executive Directors on March 25, 2010, provided an International Bank for Reconstruction and Development (IBRD) loan of $1,250 million (IBRD-78600), which represents the second largest World Bank operation by commitments of the entire Show MoreThis is the Project Performance Assessment Report for the Mexico Social Protection in Health Project (P116226). The project, approved by the World Bank’s Board of Executive Directors on March 25, 2010, provided an International Bank for Reconstruction and Development (IBRD) loan of $1,250 million (IBRD-78600), which represents the second largest World Bank operation by commitments of the entire World Bank human development cluster. The Government of Mexico provided counterpart financing of $26 billion equivalent. The loan became effective on December 29, 2010, and closed after three years on December 31, 2013. This report serves an accountability purpose by evaluating the extent to which the operation achieved its intended outcomes, but also a learning purpose. The Independent Evaluation Group (IEG) Review identified the project for evaluation to verify the project’s ratings following IEG’s revision of the outcome rating from satisfactory in the Implementation Completion and Results Report (ICR) to moderately satisfactory in the ICR Review. In addition, this report aims to identify lessons for similar health insurance schemes and relevant World Bank–supported operations. Ratings for the Support to the Social Protection System in Health Project is as follows: Outcome is moderately satisfactory, Risk to development outcome is moderate, World Bank performance is moderately satisfactory, and Borrower performance is satisfactory. Lessons from the project include: (i) In times of economic crisis, if the country has a well-designed health program in place, the World Bank’s financial support can be effective in helping the government to sustain and expand access to health services, protecting the poor from the adverse impact of the crisis. (ii) Investment Project Financing can be an efficient alternative to development policy financing if there is government ownership of the national program and a strong monitoring and evaluation (M&E) system to monitor results. (iii) It may not be possible to achieve universal health coverage in fragmented health systems without an individual mandate for health insurance coverage. (iv) In decentralized health systems, to achieve the desired changes at the local level the use of incentives (compatibility) should be preferred to the use of regulations and aligned with the institutional capabilities of the agents.

China: Hubei Hydropower Development in Poor Areas Project (PPAR)

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This is the Project Performance Assessment Report (PPAR) by the Independent Evaluation Group (IEG) of the World Bank Group on the China: Hubei Hydropower Development in Poor Areas Project (IBRD-46660). The project had three project development objectives: (a) to facilitate economic growth in Hubei by expanding electric power generation capacity in an economically and environmentally sustainable Show MoreThis is the Project Performance Assessment Report (PPAR) by the Independent Evaluation Group (IEG) of the World Bank Group on the China: Hubei Hydropower Development in Poor Areas Project (IBRD-46660). The project had three project development objectives: (a) to facilitate economic growth in Hubei by expanding electric power generation capacity in an economically and environmentally sustainable manner; (b) to enhance the efficiency of the electricity sector in Hubei by commercializing county-level generation companies; and (c) to contribute to poverty alleviation efforts in poor communities in Hubei. Ratings for Hubei Hydropower Development in Poor Areas Project are as follows: Outcome is satisfactory, Risk to development outcome is moderate, Bank performance is moderately satisfactory, and Borrower performance is moderately satisfactory. The main lessons that emerge from the experience of this complex project are the following: (i) Integrating hydropower investments with institutional development and poverty alleviation can yield strong synergies. (ii) The rigorous quality and depth of appraisal for implementing agencies needs to be maintained throughout the project cycle, including project components added late.

Central African Republic: Emergency Food Crisis Response and Agriculture Re-Launch Project (PPAR)

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This is a Project Performance Assessment Report (PPAR) on the World Bank Emergency Food Crises and Agriculture Re-launch project designed to provide emergency assistance to vulnerable populations in the Central African Republic following a coup d’état in 2013. Because of the extent of the crisis, and the loss of government capacity in the wake of the crisis to implement emergency aid, the project Show MoreThis is a Project Performance Assessment Report (PPAR) on the World Bank Emergency Food Crises and Agriculture Re-launch project designed to provide emergency assistance to vulnerable populations in the Central African Republic following a coup d’état in 2013. Because of the extent of the crisis, and the loss of government capacity in the wake of the crisis to implement emergency aid, the project was executed by the World Food Program (WFP) and the Food and Agriculture Organization (FAO), contracted by the Ministry of Rural Development. Ratings for the Emergency Food Crisis Response and Agriculture Re-Launch Project are as follows: Outcome is unsatisfactory, Risk to development outcome is high, Bank performance is unsatisfactory, and Borrower performance is unsatisfactory. Lessons from the project include: (i) Standard Agreements between World Bank clients and UN executing agencies can facilitate success if they include a common vision about intended objectives, a clear and achievable results framework and related outcome indicators, and a clear articulation of how risks to the environment and social framework will be monitored, reported on, and managed. (ii) Efficient seed procurement for conflict-affected countries is complex owing to disruption of trading networks and normal supply and demand signals: the recruitment and funding of a technical team needs to be a prior condition of project effectiveness. (iii) Emergency food security operations do not necessarily require food agency coupling (such as WFP and FAO). (iv) Post-conflict emergency assistance in highly agrarian economies should try to maximize synergies across sectoral operations to optimize the delivery of food aid while laying a foundation for growth of the agricultural sector.

Lao People’s Democratic Republic: Trade Development Facility Project (PPAR)

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This Project Performance Assessment Report (PPAR) assesses the Lao People’s Democratic Republic (Lao PDR) Trade Development Facility project that was financed from a multi-donor trust fund. The project’s objectives were as follows: (i) To support the Recipient’s aims in poverty reduction and economic development of Lao PDR, by facilitating trade and cross-border movement of goods, and by Show MoreThis Project Performance Assessment Report (PPAR) assesses the Lao People’s Democratic Republic (Lao PDR) Trade Development Facility project that was financed from a multi-donor trust fund. The project’s objectives were as follows: (i) To support the Recipient’s aims in poverty reduction and economic development of Lao PDR, by facilitating trade and cross-border movement of goods, and by increasing capacity of the Government to undertake specific tasks related to regional and global economic integration; and (ii) To assist the Recipient in implementing the Action Matrix for Trade-Related Assistance approved by the Recipient and donors in September 2006, and achieve the goals set up in the Recipient’s medium-term strategy for increasing growth and export competitiveness, as reflected in the Recipient’s Poverty Reduction Strategy and the National Socio-Economic Development Plan. Ratings for the Trade Development Facility Project is as follows: Outcome is satisfactory, Risk to development outcome is moderate, World Bank performance is satisfactory, and Borrower performance is satisfactory. Lessons from the project include: (i) Early engagement with the government: Appropriate analytic work can lay the basis for sound project design and enhance the commitment of the government. (ii) Attribution issues: The final outcomes in a results framework should be specific and attributable to the project. (iii) Simple project design: In the context of low institutional capacity, simple project design with fewer components may enhance the focus of a project and the likelihood of full implementation. (iv) Capacity building: In a limited capacity environment, a “learning-by-doing” approach can be effective in building government capacity. (v) Political commitment: Accession to a major regional or global agreement such as WTO can serve as a strong incentive for reforms and ensure political commitment.

Mongolia: Renewable Energy for Rural Access Project (REAP) (PPAR)

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The purpose of this Project Performance Assessment Report (PPAR) is to evaluate the development outcomes of the Renewable Energy and Rural Electricity Access Project (REAP) in Mongolia. The project’s development objectives (PDOs) were to expand access to electricity and improve reliability of electricity services in selected off-grid soum centers and among the herder population, and to remove Show MoreThe purpose of this Project Performance Assessment Report (PPAR) is to evaluate the development outcomes of the Renewable Energy and Rural Electricity Access Project (REAP) in Mongolia. The project’s development objectives (PDOs) were to expand access to electricity and improve reliability of electricity services in selected off-grid soum centers and among the herder population, and to remove barriers to the scale-up of renewable energy use. Ratings for the Renewable Energy for Rural Access Project are as follows: Outcome is moderately satisfactory, Risk to development outcome is significant, Bank performance is moderately satisfactory, and Borrower performance is moderately satisfactory. Lessons from the project include: (i) An appropriate balance between affordability and cost recovery is essential for scaling up the adoption of portable renewable energy systems by those who cannot afford the full investment costs. (ii) Proper market assessments are an essential requirement for projects that rely on the private sector for distribution of equipment, after-sales service, or the operation of local off-grid utilities. (iii) To be sustainable and to realize the potential for expansion in demand, renewable energy technologies (RETs) require established and regulated equipment quality standards to guide purchases, and proper handling and disposal of used SHS batteries. (iv) Regular dialogue and consultation at the appropriate client government level regarding government policy intentions and their consequences are critical to inform project design and implementation.

Georgia: First, Second and Third Development Policy Operations

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This Project Performance Assessment Review (PPAR) evaluates a programmatic series of three development policy operations (DPOs) for Georgia, including three credits and one loan, in the amount of $85 million for DPO-I, $50 million for DPO-II, and $40 million for DPO-III, implemented between July 2009 (World Bank Board of Executive Directors approval of DPO-I) and March 2012 (closing of DPO-III). Show MoreThis Project Performance Assessment Review (PPAR) evaluates a programmatic series of three development policy operations (DPOs) for Georgia, including three credits and one loan, in the amount of $85 million for DPO-I, $50 million for DPO-II, and $40 million for DPO-III, implemented between July 2009 (World Bank Board of Executive Directors approval of DPO-I) and March 2012 (closing of DPO-III). All operations were fully disbursed. The Government of Georgia requested these operations in a context of economic downturn resulting from the August 2008 conflict with the Russian Federation and the global financial crisis. Ratings for the First, Second and Third Development Policy Operations are as follows: Outcome is satisfactory, Risk to development outcome is moderate, Bank performance is satisfactory, and Borrow performance is satisfactory. Among the key lessons are the following: (i) DPO programs during times of crisis may involve a trade-off between providing predictable budget support and the quality of the reform agenda. (ii) Although scaling up Georgia’s TSA program was fully justified, cash transfer programs are mainly geared toward the chronically poor, whereas many persons affected by crises fall into temporary poverty. (iii) In a fiscally constrained environment, a move to universal health coverage may not necessarily bring an improvement in the financial protection of the poor. (iv) The World Bank can play a significant role in helping focus government’s efforts in policy areas where other development partners mainly support reforms, such as in the trade-related reforms required to negotiate Georgia’s Deep and Comprehensive Free Trade Agreement with the EU.

China: Thermal Power Efficiency Project (PPAR)

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The China Thermal Power Efficiency project sought to reduce coal consumption and greenhouse gas emissions per unit of electricity in three provinces in China – Shanxi, Shandong and Guangdong. The project was conceived as a response to the predominance of coal in China’s energy mix and the need to find ways of improving existing infrastructure over and above weaning the country away from this Show MoreThe China Thermal Power Efficiency project sought to reduce coal consumption and greenhouse gas emissions per unit of electricity in three provinces in China – Shanxi, Shandong and Guangdong. The project was conceived as a response to the predominance of coal in China’s energy mix and the need to find ways of improving existing infrastructure over and above weaning the country away from this reliance as an energy source. China’s rising energy demand had relied heavily on domestic coal production and the rapid expansion of local thermal power generation plants that utilized this coal. Increasingly, these plants were having adverse environmental impacts, particularly in regions experiencing significant increases in energy demand from manufacturing sector. Ratings for the project are as follows: Outcome is satisfactory, Risk to development outcome is moderate, Bank performance is satisfactory, Borrower performance is satisfactory, and Monitoring and Evaluation is satisfactory. Lessons from the project include: (i) Piloting and demonstrating potential technological improvements to lower costs and improve environmental performance works well in environments where operators are risk averse and constrained by government policy. (ii) The World Bank’s international experience and expertise has the capacity to make an important contribution to pollution reduction in the thermal power sector. (iii) External help and international expertise provided by World Bank projects at the provincial level in middle income countries helps support and reinforce successful central government policy. (iii) Analytical work needs to respond to the immediate needs of the sector rather than being determined by supply-side factors. (iv) A ‘hands-off’ approach by the World Bank in high capacity environments can lead to missed opportunities in maximizing a project’s potential. (v) Barriers to the closure of small inefficient power units are often political. Fostering the key relationships with partners is essential in knowing what and how reforms can be implemented in challenging environments.

Cambodia: Trade Facilitation and Competitiveness (PPAR)

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The FY05 Trade Facilitation and Competitiveness Project (P089196) was a US$10 million IDA grant to Cambodia. The objective of the project was to support the government’s strategy to promote economic growth by helping (i) reduce transaction costs related to trade and investment; (ii) introduce transparency in investment processes; and (iii) facilitate access of enterprises to export markets. The Show MoreThe FY05 Trade Facilitation and Competitiveness Project (P089196) was a US$10 million IDA grant to Cambodia. The objective of the project was to support the government’s strategy to promote economic growth by helping (i) reduce transaction costs related to trade and investment; (ii) introduce transparency in investment processes; and (iii) facilitate access of enterprises to export markets. The purpose of this PPAR is to assess the outcome of the Cambodia Trade Facilitation and Competitiveness project and to provide an input to IEG’s forthcoming macro evaluation on Facilitating Trade. Ratings for the project are: outcome is moderately satisfactory, risk to development outcome is negligible to low, Bank performance is moderately satisfactory, and Borrower performance is moderately satisfactory. Lessons of the project include: (i) Early involvement with government. (ii) Expert assistance. (iii) Implementation readiness. (iv) Trade-off between good governance and timely project implementation.

Cameroon, Chad, Central African Republic, Sao Tome, Principe: Internet and Mobile Connectivity (Central African Backbone Program APL 1A and APL 2) (PPAR)

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This Project Performance Assessment Report (PPAR) assesses the development effectiveness of the Central Africa Backbone Project Adaptable Program Loan (APL) 1A implemented in three countries: Cameroon, Central African Republic and Chad; and the Central Africa Backbone Project APL 2 implemented in Sao Tome and Principe. The objectives of the projects were to help to increase the geographical reach Show MoreThis Project Performance Assessment Report (PPAR) assesses the development effectiveness of the Central Africa Backbone Project Adaptable Program Loan (APL) 1A implemented in three countries: Cameroon, Central African Republic and Chad; and the Central Africa Backbone Project APL 2 implemented in Sao Tome and Principe. The objectives of the projects were to help to increase the geographical reach and usage of regional broadband network services and reduce their prices to end-users. Ratings for these projects are as follows: Outcome is unsatisfactory, Risk to development outcome is substantial, Bank and Borrow performance are both moderately unsatisfactory. For APL 2, the ratings are: Outcome was satisfactory, Risk to development outcome is substantial, Bank performance is satisfactory, and Borrow performance is moderately satisfactory. Lessons from the projects include: (i) A thorough political economy assessment and high-level national and regional commitment are key ingredients for complex regional ICT projects. (ii) The experience from the Central Africa Backbone APL 1 and 2 project shows that public private partnership arrangements are difficult to implement in multiple countries, particularly when countries have asymmetrical needs and incentives with respect to increasing competition for the provision of international and national capacity. (iii) Technical assistance for the preparation of legislation and sector strategies is only the first step to creating an enabling environment for the ICT sector. (iv) Assessing and funding the capacity needs of Regional Economic Communities is important for project coordination and implementation, so that they can carry out their functions effectively. (v) In weak capacity environments, it is beneficial that the projects build the needed institutional capacity for the Borrower to further / implement the crucial reforms and to ensure sustainability of the investments in the country.