Peru Second Phase of Health Reform Program Implementation Completion and Results Report

6. Lessons Learned

91. 
    Some of the lessons learned and reflections that emerge from the ex-post evaluation of the project, considering the strengths and weaknesses of design and implementation, include:
    

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  The importance of culturally-sensitive interventions to ensure effective access of indigenous populations to health services (e.g. vertical delivery and casas de espera); this requires action on the demand as well as on the supply side, since both families and healthcare professionals need to understand their respective roles and perceptions;
  
• 
  The pivotal role of the health system in promoting civil registration and vital statistics (CRVS) through awareness campaigns and through its network of clinics and hospitals, so that, from birth, individuals can be identified ― with benefits that go beyond the sector; this requires a strong coordination between the Ministry of Health and the authorities in charge of coordinating and administering CRVS programs. The health sector is well positioned to pioneer innovative ways of engaging with marginalized communities to this purpose, given the privileged entry point that health services offer;
  
• 
  The crucial role of M&E systems to monitor project performance and to ensure correction measures can be taken in a timely fashion and at the appropriate level; particularly, being able to recognize and address the weaknesses of M&E design early on and having a strong and meaningful RF from the start, which can be revised as needed to reflect the project’s success and implementation pace. The RF should reflect appropriate baseline and targets, identify indicators for outcomes and outputs directly attributable to the project and those to which the project only contributes, and present a clear results chain of PDO, outputs and project activities;
  
• 
  The importance of ensuring continuity of projects when financing a programmatic series; institutional environment and contextual factors can change substantially in the time frame of APL or DPL (Development Policy Lending) operations and keeping the momentum when transitioning from one phase of investments to the next is crucial for the relevance of the series of operations;
  
• 
  The difficult balance between the importance of maintaining ongoing dialogue and long-term engagement with a country, on the one hand, and the efficiency in the use of scares resources when pursuing relatively small investments in projects that require substantial levels of supervisions and high volumes of transactions, on the other. In this project, supervision efforts to oversee all program’s transactions were disproportionate compared to the size of the loan, which accounted for less than 10% of the program resources. As many countries transition from low-middle income to higher income levels, this questions becomes more and more relevant for Bank operations.
  

7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners

(a) Borrower/implementing agencies

Comments were received by the PIU on June 17 and 21, 2016 and were further discussed between the PIU team and the ICR Task Team Leader on June 21, 2016. Where appropriate, comments were incorporated in the main text of the ICR. All comments provided by the PIU are reported, as received, in Annex 7 after the executive summary of the Borrower’s ICR.
(b) Cofinanciers

No comments were received from the IADB.

Annex 1. Project Costs and Financing

(a) Project Cost by Component (in USD Million equivalent)

Components

Appraisal Estimate (USD millions)

Actual/Latest Estimate (USD millions)

Percentage of Appraisal

Strengthening of demand	6.00	6.43	107%
Improvement of service delivery network	142.30	138.54	97%
Government and Financing	5.20	3.25	62%
M&E and Administration	8.90	16.86	189%
Total Baseline Cost	162.40	165.08	102%
Total Financing Required	162.40	165.08	102%

(b) Financing

Source of Funds	Type of Cofinancing	Appraisal Estimate (USD millions)	Actual/Latest Estimate (USD millions)	Percentage of Appraisal
Borrower		132.40	138.23	104%
Inter-American Development Bank		15.00	15.00	100%
International Bank for Reconstruction and Development		15.00	11.98	80%