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Document of The World Bank

Report No: ICR0000142

IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-33130 JPN-26243)

ON A

CREDIT

IN THE AMOUNT OF US$4.0 MILLION

TO THE

SOLOMON ISLANDS

FOR A

HEALTH SECTOR DEVELOPMENT PROJECT

June 19, 2007

Human Development Sector Unit East Asia and Pacific Region

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CURRENCY EQUIVALENTS (Exchange Rate Effective June 11, 2007)

Currency Unit = SBD SBD1.00 = US$0.14 US$ 1.00 = SBD 7.19

FISCAL YEAR

January 1 – December 31

ABBREVIATIONS AND ACRONYMS

ADB Asian Development Bank AusAID Australian Agency for International Development

CAS Country Assistance Strategy DHLY Discounted Healthy Life Years

DO Development Objective ECA Europe and Central Asia FMS Financial Management System GDP Gross Domestic Product

HMIS Health Management Information System ICR Implementation Completion Report IDA International Development Association IEC Information, Education and Communication LIL Learning and Innovation Loan

MHMS Ministry of Health and Medical Services MTDS Medium Term Development Strategy

MUP Makira Ulawa Province NCB National Competitive Bidding NGO Non-Government Organization

NMCP National Malaria Control Program NRH National Referral Hospital

PCC Project Coordination Committee PCIU Project Coordination and Implementation Unit PMR Project Management Report PPC Project Preparation Committee

RAMSI Regional Assistance Mission to Solomon Islands SOE Statement of Expenditures TOR Terms of Reference

VBDCP Vector Borne Disease Control Program WHO World Health Organization

Vice President: James W. Adams (EAPVP)

Country Director: Nigel Roberts (EACNF) Sector Manager: Fadia M. Saadah (EASHD)

Project Team Leader: Lingzhi Xu (EASHD) ICR Team Leader: Lingzhi Xu (EASHD)

SOLOMON ISLANDS Health Sector Development Project

CONTENTS

Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph

1. Project Context, Development Objectives and Design........................................... 1 2. Key Factors Affecting Implementation and Outcomes .......................................... 3 3. Assessment of Outcomes ........................................................................................ 7 4. Assessment of Risk to Development Outcome..................................................... 12 5. Assessment of Bank and Borrower Performance ................................................. 12 6. Lessons Learned.................................................................................................... 15 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners....... 15 Annex 1. Project Costs and Financing.......................................................................... 17 Annex 2. Outputs by Component ................................................................................. 18 Annex 3. Economic and Financial Analysis................................................................. 22 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 23 Annex 5. Beneficiary Survey Results ........................................................................... 24 Annex 6. Stakeholder Workshop Report and Results................................................... 25 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR..................... 26 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders....................... 48 Annex 9. List of Supporting Documents ...................................................................... 49

MAP IBRD 33482

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A. Basic Information Country: Solomon Islands Project Name:

Health Sector Development

Project ID: P058358 L/C/TF Number(s): IDA-33130,JPN-26243ICR Date: 06/19/2007 ICR Type: Core ICR Lending Instrument: SIL Borrower: SOLOMON ISLANDSOriginal Total Commitment:

XDR 3.0M Disbursed Amount: XDR 2.4M

Environmental Category: C Implementing Agencies: Project Coordination and Implementation Unit Cofinanciers and Other External Partners: B. Key Dates

Process Date Process Original Date Revised / Actual Date(s)

Concept Review: 02/01/1999 Effectiveness: 03/09/2000 03/09/2000 Appraisal: 10/05/1999 Restructuring(s): Approval: 01/06/2000 Mid-term Review: 06/15/2004 Closing: 06/30/2005 12/31/2006 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Moderate Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Satisfactory

C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings

Quality at Entry: Moderately Satisfactory Government: Moderately Satisfactory

Quality of Supervision: Moderately Satisfactory Implementing Agency/Agencies: Moderately Satisfactory

Overall Bank Performance: Moderately Satisfactory Overall Borrower

Performance: Moderately Satisfactory

C.3 Quality at Entry and Implementation Performance Indicators

Implementation Performance Indicators QAG Assessments

(if any) Rating

Potential Problem Project at any time (Yes/No):

No Quality at Entry (QEA):

None

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Problem Project at any time (Yes/No):

Yes Quality of Supervision (QSA):

None

DO rating before Closing/Inactive status:

Moderately Satisfactory

D. Sector and Theme Codes

Original Actual Sector Code (as % of total Bank financing) Central government administration 13 13 Health 87 87

Theme Code (Primary/Secondary) Health system performance Secondary Secondary Other communicable diseases Primary Primary Population and reproductive health Primary Primary Rural services and infrastructure Secondary Secondary E. Bank Staff

Positions At ICR At Approval Vice President: James W. Adams Jean-Michel Severino Country Director: Nigel Roberts Klaus Rohland Sector Manager: Fadia M. Saadah Alan Ruby Project Team Leader: Lingzhi Xu Janet I. Hohnen ICR Team Leader: Lingzhi Xu ICR Primary Author: Betty Hanan F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The Project Development Objective is to assist the Government of Solomon Islands to improve health outcomes of rural communities through strengthening existing reproductive health and malaria programs, testing new approaches to reducing these problems, and through improved planning, managing and monitoring of priority health programs. Revised Project Development Objectives (as approved by original approving authority)

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(a) PDO Indicator(s)

Indicator Baseline Value

Original Target Values (from

approval documents)

Formally Revised Target Values

Actual Value Achieved at

Completion or Target Years

Indicator 1 : Assisted births/expected births

Value quantitative or Qualitative)

Makira 46% Guadacanal 43% National 41%



Date achieved 01/31/1999 01/31/2000 12/31/2006

Comments (incl. % achievement)

Although indicators related to reproductive health by the end of the project have reached the target set at mid-term, the information needs to be read with caution as despite a great deal of improvement, there are still problems with data accuracy.

Indicator 2 : First Antenatal visits/expected births


Maikira 62% Guadacanal 79% National 69%



Date achieved 01/31/1999 01/31/2000 12/31/2006



Indicator 3 : Outpatients with clinically defined malaria/1000 pop.


Makira 294, Guadacanal 292, National 268

Makira 213 Guadacanal 294 National 223

Makira 213 Guadacanal 290 National 293

Date achieved 01/31/1999 01/31/2000 12/31/2006



(b) Intermediate Outcome Indicator(s)

Indicator Baseline Value

Original Target Values (from

approval documents)

Formally Revised

Target Values

Actual Value Achieved at

Completion or Target Years

Indicator 1 : Slide diagnosed malaria/1000 pop. Value (quantitative or Qualitative)

Makira 64, Guadacanal 222, National 143

Makira <127 Guadacanal <300 National <8

Miakira 63 Guadacanal 126 National 162*

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Date achieved 01/31/1999 01/31/2000 12/31/2006 Comments (incl. % achievement)

*This is 2005 data as 2006 data was not available at the time of the preparation of the ICR.

G. Ratings of Project Performance in ISRs

No. Date ISR Archived DO IP

Actual Disbursements (USD millions)

1 06/15/2000 Satisfactory Satisfactory 0.21 2 06/19/2000 Satisfactory Satisfactory 0.21 3 12/27/2000 Satisfactory Satisfactory 0.30 4 06/04/2001 Satisfactory Satisfactory 0.41 5 12/12/2001 Satisfactory Satisfactory 0.63 6 06/25/2002 Satisfactory Satisfactory 0.72 7 01/03/2003 Unsatisfactory Unsatisfactory 0.85 8 06/17/2003 Unsatisfactory Unsatisfactory 0.93 9 12/23/2003 Unsatisfactory Unsatisfactory 1.03

10 06/25/2004 Satisfactory Satisfactory 1.48 11 12/21/2004 Satisfactory Satisfactory 2.31 12 05/04/2005 Moderately Satisfactory Moderately Satisfactory 2.66 13 06/17/2005 Moderately Satisfactory Moderately Satisfactory 2.81 14 05/20/2006 Moderately Satisfactory Moderately Satisfactory 3.43 15 12/17/2006 Moderately Satisfactory Moderately Satisfactory 3.50

H. Restructuring (if any) Not Applicable

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I. Disbursement Profile

1. Project Context, Development Objectives and Design

1.1 Context at Appraisal At the time of appraisal, the Solomon Islands (SI) ranked below most of other Pacific Island countries in overall health status. Infectious diseases, especially malaria, and maternal and infant conditions were the dominant causes of mortality and morbidity. Women were a high-risk group with the maternal mortality ratio in 1999 at 549 per 100,000 live births. This problem was compounded by rapid population growth (estimated in 1999 to be 3% per annum). The increasing population, declining skill levels of provincial staff, understaffing of health personnel in provinces, reduced supervision from Honiara, unreliable operating budgets and outdated equipment had led to reduced coverage and quality of services in the provinces. As a result, people increasingly traveled to Honiara for care. It was an expensive and inefficient solution, leaving most people inadequately serviced. In addition to the supply problems of service provision, there was low demand for services due to low levels of education, especially among women, and a lack of appreciation of the need to seek prevention or curative care. The health situation in SI was further aggravated by a fiscal crisis. While the government’s stated commitment to funding of health programs was strong, funds actually provided to the sector in 1998 were 40% lower than budgeted. During the later stages of project processing, SI experienced civil unrest. Fighting broke out when the Isatabu Freedom Movement began to force Malaitans out, accusing them of taking land and jobs. Around 20,000 people abandoned their homes, with many leaving the Guadacanal province. A rival militia group, the Malaitan Eagle Force, staged a coup in 200 and forced the then Prime Minister to resign. Given the situation, it was agreed with the Government that the Bank would provide funding for the public provision of essential rural health services at a time of budgetary constraint.

1.2 Original Project Development Objectives (PDO) and Key Indicators The PDO was to assist the Government to improve health outcomes of rural communities through strengthening existing reproductive health and malaria programs, testing new approaches to reducing these problems, improving planning, managing and monitoring of these and other priority health programs. Progress in achieving the PDO was to be assessed using the following key performance indicators.

• supervised delivery rate • proportion of pregnant mothers having at least one antenatal visit • proportion of women of reproductive age accepting an effective method of family

planning • incidence of clinically defined malaria • hospital/clinic admissions for malaria (outpatients) • incidence of slide diagnosed malaria deaths from malaria (all types) • incidence of slide diagnosed Plasmodium falciparum • use of adequately impregnated bed nets • proportion of houses sprayed in the last year

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• daily case load per health worker • availability of good quality provincial health program reports to stakeholders

1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification While the original PDO was maintained throughout project implementation, given problems with collection of data and analysis, the mid-term review (June 2004) agreed on a simplified set of indicators to be monitored. This set of indicators was systematically monitored and reported on by supervision missions in the ISRs. In addition, it was agreed that the percentage of births attended by health personnel and the percentage of first time antenatal visits should be calculated using as the denominator “expected births”, rather than actual births as an accurate number of actual births was not available. The number of births was estimated on the basis of the demographic characteristics of the population in SI and fertility rates of similar populations with reliable statistics elsewhere.

1.4 Main Beneficiaries, The primary beneficiaries were to be families in rural areas facing a high burden of disease in malaria and reproductive health, and inadequate prevention and control services. The secondary beneficiaries were to be rural health staff, whose skills and functional capability would be upgraded through the project’s training programs. Other beneficiaries were to be provincial and Ministry of Health managers, who were to benefit from the capacity building initiatives, which were to improve planning, resource use, and monitoring in the sector.

1.5 Original Components The project was to be implemented in up to four provinces, which were to join in stages during the first two project years. The project’s components were: (i) reproductive health, (ii) malaria prevention and control, (iii) capacity building in the Ministry of Health and Medical Services (MHMS)1 and provincial health services, and (iv) Project Coordination and support activities for the project. Component A - Improved Reproductive Health. MHMS was to improve provincial services for reproductive health, with special attention to the training of medical and nursing staff in-country and overseas, and improved clinical supervision, and upgrading of rural health facilities. A new post-basic course for nurse-midwives was to be piloted, with oversight by a representative committee on midwifery services. International assessment and monitoring guidelines for reproductive health service quality and use were to be adapted. An inter-sectoral task force with provincial representation was to provide feedback to the Ministry on reproductive health matters. The project was to fund the work of the task force, staff training, clinical supervision and technical support, upgrading of health centers, staff housing, training facilities, and necessary equipment and supplies.

1 MHMS is referred to in the rest of the document as Ministry of Health (MOH)

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Component B - Improved Malaria Prevention and Control. The component was to help reduce funding gaps in the National Malaria Control Program, while improving analysis and monitoring of factors affecting the program success, and testing ways to improve its effectiveness. The project was to support a new inter-sectoral task force and fund pilot studies to improve community response and health services. Studies were to be conducted by local professionals within an international training program. Training, supervision and supplies to improve prevention and case management in health centers were to be provided. The project was to fund incremental costs for program improvement; analysis of historical information on malaria control; design and implementation of operational studies and related staff training; and the evaluation/dissemination of the findings to policy makers and health managers. Component C - Capacity Building. The project was to increase the capacity of MOH and the participating provinces in health planning, with emphasis on improvements in: (i) the Health Management Information System (HMIS), (ii) monitoring, evaluation and research, and (iii) donor coordination. The project was also to provide support for central level strengthening and for piloting new arrangements to increase outreach and community participation. The project was to finance costs associated with in-country and overseas training, staff costs and consultants associated with the HMIS, and monitoring and evaluation. Component D - Project Coordination and Management. This component supported the operation of the Project Coordination Committee (PCC), and the Project Coordination and Implementation Unit (PCIU), within the Planning Unit of MHMS, which was to provide the project support functions, including financial and procurement management, and liaison with implementing units in MHMS and the provinces. The project was to fund the staff, operating costs and limited additional refurbishment and equipment.

1.6 Revised Components The scope of the components remained the same throughout the period of implementation, but the number of participating provinces was limited to two for reasons elaborated on below.

1.7 Other significant changes Two significant changes happened after approval. The first related to the support by the project of two provinces rather than “up to four”. The number of participating provinces was overtaken by events, i.e. lengthy periods of civil unrest, economic crisis and inability of the Government to pay external debt, which in turn caused the suspension of disbursements from the IDA credit for two years. The second related to the decision by the Ministry of Finance in mid-2005 not to finance under the project rural civil works planned for Makira and Guadacanal provinces because these works are planned to be financed under other projects.

2. Key Factors Affecting Implementation and Outcomes

2.1 Project Preparation, Design and Quality at Entry Project design was appropriate and grounded in technical, institutional and social analyses. The project addressed the key elements of the Government’s Medium Term Development Strategy

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through strengthening provincial services in the high priority areas of reproductive health and malaria control. The project activities allowed flexibility for MOH to adjust work plans on an annual basis if grants became available. During preparation, the national programs in reproductive health and malaria prevention and control were analyzed by technically qualified experts and were considered to be appropriate. The technical analysis recognized a high standard of technical leadership in these programs within the Ministry, supported by WHO. In line with relevant international experience, the project design included enhancements to the two programs. It included specific pilots and training to test and adapt to the local conditions. The key role of strong donor coordination was rightly identified in all key documents; the documents acknowledged that funds from the Credit would supplement and not replace grant funds. They acknowledged the need for flexibility in the allocation of resources to the provinces, recognizing that certain areas were suffering from civil unrest. Relevant Lessons from health projects in comparable countries and from the Education Project in SI were taken into account in the design of the project: (i) allowances were made for inexperience and limited institutional capacity and the relative size of the operation, (ii) donor coordination was assigned as a high priority, with provision to adjust financing arrangements as other funds became available, (iii) flexible arrangements were put in place for the timing and scope of activities, and (iv) monitoring, evaluation and dissemination of lessons learned were incorporated in the project design, and supported with technical assistance. Project was prepared following extensive consultations with a range of stakeholders. It was prepared under the overall leadership of a Project Preparation Committee (PPC) established in MOH. The PPC provided active counterparts for consultants engaged in analysis and project design. Extensive consultations with other development partners were carried out to ensure that activities to be supported by IDA would complement and not duplicate those of international partners. MHMS showed ownership and commitment to the design and scope of the project. The PAD identified well the specific risks associated with the operation, but the ratings of some of the risks did not reflect adequately the levels of the risk. For example, the risk for civil unrest in potential project areas was rated “Modest” when there was already ethnic unrest in the Guadacanal province; indeed the PAD noted that “the planned participation of the Guadacanal province in the project has been deferred due to civil unrest”. Equally, the risk rating for late or inadequate counterpart funding was rated as “Modest” when it should have been evident at appraisal that the fiscal crisis was highly likely to result in limited availability of counterpart funding. The overall risk rating in the PAD should have been assessed as “High”. The QAE is rated Moderately Satisfactory.

2.2 Implementation The project was implemented during a highly volatile and difficult period, including ethnic armed conflict and social unrest. Shortly after the Credit became effective (March 2000) and during the first 3.5 years of project implementation, the country endured widespread ethnic unrest. The unrest caused a macro-economic crisis, which in turn, made health service delivery very difficult. The severe economic crisis led to the Government defaulting on its debt service obligation to the Bank, which resulted on suspension of disbursements. For over two years, the

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project faced substantial challenges to sustain implementation during the suspension, reinstatement of disbursements for only two months, and then suspension again from September 2001 to October 2003. The suspension impacted on the work programs from late 2001 through 2003. Thus, implementation of the project during its early years was hampered by the ethnic disruptions, the decline in fiscal capacity of the Government and its inability to meet its debt service obligations. Through this period, the balance and pace of activities were readjusted, shifting the focus to preserving essential services in the provinces, improving the management and cost-effectiveness of service delivery, and increasing community participation. The project was implemented directly by the MHMS under the overall guidance of the PCC. The PCC met regularly to provide policy and operational guidance. The project had only one Director, the Undersecretary of Health, who was assisted by a small Project Coordination and Implementation Unit (PCIU) comprised of local contracted staff. No international consultants were hired to guide implementation. Short-term international assistance was engaged from time to time to assist with technical matters such as to review architectural designs and help prepare international competitive bidding documents, including technical specifications and bills of quantities. Despite the relatively high turnover of staff within the Ministry and in the provinces, most activities were implemented (Annex 2). Project implementation has required close attention to policy and institution building at the central level and in the two provinces supported by the project. It has benefited from effective interaction with other major health donors, particularly AusAID and the Global Fund. The implementation period can be divided into two phases: (i) immediately after credit effectiveness (March 2000) and up to the mid-term review (mid-June 2004), characterized by slow progress of activities due to ethnic conflict and macro-economic instability, and (ii) from the MTR when implementation accelerated considerably. In the four years from Credit effectiveness to the MTR, only about 23% of credit funds were disbursed. The expenditures were mainly for training (in and outside the country), PCIU salaries, and procurement of limited equipment and supplies for malaria control. No civil works had taken place prior to the MTR. This first phase was characterized by dedication from Bank staff to provide encouragement to the Ministry during the suspension and to seek alternative financing from other donors to ensure implementation of key activities. Some missions visited during the suspension, which is not typical in such situations. However, there were no missions from November 2001 until October 2003. A virtual supervision was arranged with GSI participation through a video conference organized from the Sydney WB office in May 2002. Through strong working relationships, agreement was reached for Australia to pre-finance priority activities under the project. In addition, as part of its development assistance, Australia paid the SI’s debts to the development banks (ADB and WB), opening the way to the lifting of suspension and re-engagement. Health indicators deteriorated during the conflict with high levels of IMR reported and after eight years of successful control of malaria, with progressive decline in reported cases and incidence rates, an increase in these indicators were reported in 2000-01. Government allocation for the National Malaria Control Program was discontinued in late 2000. Implementation of the malaria program under the project was beginning to have a positive impact until the World Bank suspended disbursements. Once suspension was lifted, the performance of the Program improved a great deal in the two project provinces.

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Immediately after the lifting of suspension, a high level joint World Bank-Asian Development Bank mission took place in October 2003 to conduct brief economic and sectors assessments (including of the health sector). The joint mission concluded that the security situation had improved significantly since the establishment in July 2003 of the Regional Assistance Mission to Solomon Islands (RAMSI). The improvement boosted public confidence and reinvigorated formal business activity, particularly in the capital. After four years of contraction, the economy expanded in the first nine months of 2003 particularly primary production, construction and services. The economic recovery was attributed to a resilient private sector and rapid, substantive improvement in the law and order situation consequent upon RAMSI’s arrival. RAMSI also provided a significant direct demand-side stimulus to the economy; inflation in 2003 was recorded at around 8%. The MTR aide memoire (June 2004) noted that the overall macroeconomic and security situations appeared to be on a path to sustained recovery and stability. These positive developments allowed the MTR to consider full implementation of the project, which at one point had been considered for cancellation. Agreement was reached with the government during the MTR on the need to extend the Credit closing date until December 31, 2006 (original closing date was June 30, 2005). The MTR Aide Memoire reported that the health status of the population had been negatively affected by the period of tension, the interruptions of services in Guadacanal and the sudden decline in government financing of the sector. Further, it reported that the incidence of malaria and death in Guadacanal and Makira had risen sharply since the late 1990s and increased again in 2003 and 2004. Maternal mortality and infant mortality rated had also increased since the pre-tension conditions. Residual house spraying, a key malaria control activity that had worked successfully, and bed net distribution had also declined sharply during the 2000-03 period. The ICR rates implementation as Moderately Satisfactory.

2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization The results framework included a large number of key performance indicators, for which baseline data was not available. As noted in Section 6.3, at the MTR the modality for monitoring outcome indicators was redefined and the percentage of births attended by health personnel and percentage of first time antenatal visits was to be calculated using as the denominator “expected births”, rather than actual births. The first mission after the MTR, in March 2005, indicated that the agreed indicators in the PAD and the DCA had not been systematically collected or monitored. Targets had not been set at project launch and had not figured in project management and supervision. Given the many difficulties with civil unrest and the disbursement suspension, this oversight was understandable. However, with the Health Information System (HIS) in operation, a table of simplified project indicators was prepared in March 2005, including outcome targets. These indicators were monitored and reported on for the remainder of the project. Although the quality of the data still needs improvement, the achievements so far of the HIS should not be underestimated. For the first time, MOH has had data to enable it to make policy decisions and allocate funds according to priorities. M&E is rated Moderately Unsatisfactory.

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2.4 Safeguard and Fiduciary Compliance

The project [was categorized as C with regard to the safeguard policies, and it encountered no significant safeguard issues during implementation. No adverse environmental impacts were associated with the construction and rehabilitation of the limited number of health facilities supported under the project.

Regarding the Bank’s fiduciary requirements, the QSA7 (for FY05/06) rated the supervision of procurement as Highly Satisfactory and noted that the project could serve as a “best practice” for procurement supervision. Also, recognizing the size and remote location of the SI and the US$4 million size of the project, the QSA7 stressed the exemplary performance of the project team in carrying out the procurement based on service to the Borrower, resourcefulness, and pragmatism. However, looking at the performance on procurement throughout the entire period of implementation, the ICR finds that considerable delays in project implementation were as a result of slowed procurement. Delays encountered in the procurement of civil works ultimately led to the decision by the Ministry of Finance to not approve the rural civil works in the provinces. While Financial Management complied with the Bank’s requirements and FM and audit reports were presented to the Bank in a timely manner during the early stages of project implementation, turnover of FM staff resulted in delays and accuracy of the FM information. Given the overall procurement and FM performance, the ICR rates the compliance with Safeguard and Fiduciary Compliance as Moderately Satisfactory.

2.5 Post-completion Operation/Next Phase The reforms introduced under the project have been integrated on the Government’s strategy for health and are likely to be carried forward under a Health SWAp, currently under preparation with support from the Bank and AusAID. 3. Assessment of Outcomes

3.1 Relevance of Objectives, Design and Implementation The project’s DOs continue to be highly relevant to the Bank's strategy in the Solomon Islands. In terms of design and implementation, however, the Government and its two main health development partners (AusAID and the World Bank) have agreed to work towards the adoption of a sector-wide approach for the delivery of health sector development assistance in the future.

3.2 Achievement of Project Development Objectives The project has partially achieved its DOs. Although the government has continued to make progress in improving the health outcomes of rural communities by strengthening reproductive health and malaria control programs, especially in the project provinces, considerable and sustained efforts are still required to expand the progress throughout the country. The Project assisted the efforts to reduce maternal mortality and incidences of malaria through improved care in pregnancy and childbirth, increased rates of contraceptive use, reduced hospital admissions and deaths from malaria through increased use of bed nets, and community awareness of malaria control. The lessons from the project in the areas of reproductive health, malaria and health

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management information have been incorporated into national health policy as articulated in the Solomon Islands National Health Strategic Plan 2006-2010. Provincial reproductive health have been strengthened, but not to the extent planned due to the cancellation of construction of the rural civil works. The two key indicators for reproductive health (as defined after the MTR) were achieved: (i) assisted births/expected births, and (ii) first antenatal visits/expected births. Data with respect to these indicators show that the project has been effective in improving reproductive health and enhancing capacity in the use of information for health planning and management in MOH and the participating provinces. While the project included only two provinces, the project supported improvements in reproductive health outcomes in general through its midwifery training program, which trained nurses from all over the country (62 graduated prior to project closing) and who have returned to the work force in their respective provinces. (For details of outputs under the project please refer to Annex 2). The key indicator for malaria control was achieved -- outpatients with clinically defined malaria/1000 population. Provincial malaria control services were strengthened through the implementation of a comprehensive malaria strategy initiated with support of the project and now being supported with support from the Global Fund. The strategy aims at reducing clinical malaria and preventing mortality, by providing early diagnosis and prompt treatment of all suspected or confirmed cases, and at reducing malaria morbidity through feasible and sustainable vector control interventions. The project supported extensive training for lab technicians to be able to detect malaria more accurately. Malaria staff, field workers and community leaders also participated in a great number of workshops organized under the project to enhance community participation and awareness of the disease burden. Bed nets were procured and insecticides to treat bed nets. Good progress was made in building capacity in the use of information for health planning and management in MOH and participating provinces. Through the project, MOH has been successful in building institutional capacity for planning, managing and monitoring priority health programs as demonstrated by the design of the HIS and the increased level of HIS reporting from the provinces thanks to extensive training under the project. The project’s objectives for institutional building, however, were necessarily narrow and did not target overall capacity building for the Ministry. For example, the project did not target policy analysis and formulation; these areas were being supported by AusAID. Even in the areas of capacity building under the project, the achievements are still fragile as the turnover of staff is high. However, it is necessary to take into account the highly volatile and difficult project context due to the armed ethnic civil conflict. Despite improvements in the past years, sector capacity is still weak, but capacity building is a process. There are several important outcomes derived from outputs under each of the components. In terms of strengthening reproductive health: First, MOH is committed to sustaining and expanding the midwifery program and is ensuring its sustainability by financing the recurrent costs of the Program with appropriate budget allocations in MOH’s 2006 and 2007 budgets. Second, the Midwifery Program has been accredited by the Solomon Islands College of Higher Education and formal diplomas are being conferred to all graduates. Third, trained midwifes are required to return to their original place of work throughout the country where they can apply

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their strengthened technical skills to improve the delivery of health services. Fourth, the project achieved the attainment of the reproductive health outcome indicators in participating provinces. Although still fragile, there are other important outcomes: (i) the strengthened outreach services to villages are now more focused and regular and are beginning to have a positive impact on the indicators, (ii) the pilots conducted prior to fully rolling out the Family Health Card nationwide shed light on the reasons for the low level of indicators and have enabled MOH to prioritize activities aimed at improving performance, and (iii) improved supervision and support of first-level health workers is playing an important role in helping improve the RH indicator outputs. It is important to stress, however, that the data should be taken cautiously because the reliability of data collected in provinces still requires considerable improvement. In terms of Malaria Control, the project has helped to strengthen a comprehensive control program in the two participating provinces, which has become applicable nation-wide with the support of the Global Fund and other development partners (see discussion above). In terms of capacity building, the high turnover of staff has constrained the impact of capacity building efforts as several of the staff trained under the project have left MOH’s services and many of them have left the country seeking better opportunities. In several cases, however, trained staff moved, but remained within the system so that the sector is still benefiting from their improved skills. Although the project has been successful in building institutional capacity for planning, management, coordination, procurement, and financial management, MOH capacity is still limited and will continue to require a lot of attention in the coming years to expand its base beyond a limited number of individuals. In addition, with the closing of the PCIU, there is the danger that the capacity for procurement, and to a certain extent, financial management, which was achieved under the project will be lost. Linkages between outputs and outcomes. A number of outputs were supported in each of the sub-components (Annex 2). With the exception of activities that were discontinued in agreement with the Bank, i.e. rural civil works in the two participating provinces, the project was successful in implementing most activities, albeit with delays mainly caused by the armed ethnic civil conflict and the macro-economic/fiscal constraints. There were strong linkages in the design between outputs and outcomes, for instance: (i) the project supported the design and the implementation of the successful in-country Midwifery Program, (ii) financed extensive overseas training for midwives and nurses, including several bachelor and master programs in obstetrics and gynecology (See Exhibit 1 of Annex 7), (iii) provided medical equipment and supplies, canoes, outboard motors, and radio communication equipment to enable provincial staff to carry out their outreach activities and satellite clinics more frequently and regularly. Achievement of Development Objectives is rated Moderately Unsatisfactory. 3.3 Efficiency No NPV, ERR, or FRR were calculated a priori for the project, and no analyses are available to assess them as economic or financial results. The PAD presented supporting evidence of comparative costs of the investment choices considered. The PAD cited a cost- effectiveness study of project expenditures in terms of discounted healthy life years (DHLY) for Component A (Improved Reproductive Health) and the cost per malaria case averted for Component B (Improved Malaria Prevention and Control). The analyses reviewed the rationale for investing in

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learning and development activities to improve reproductive health and reduce malaria both during the project period and beyond. It compared the cost-effectiveness of two approaches or categories: Category I: strengthening of existing health sector operations; and Category II: learning and innovation through analysis of past program performance and piloting of new or enhanced methods for reducing the priority health problems. Under the assumption of strengthening existing activities, the PAD indicated that the project would sustain the Government’s achievements for the five-year duration of the project, averting maternal and infant deaths at a cost of about US$394 per DHLY gained in comparison to the approximate costs of a year of healthy life to the country of US$930 (assuming that the value of a year of healthy life in SI is approximately equal to its per capita GDP). Averting malaria was estimated to cost about US$5.80 per case, a substantial bargain in comparison to the approximate cost to the country of US$465 per case of malaria (assuming each case of malaria costs approximately one half year of healthy life). In comparison, the benefits of the learning activities for each component while being less certain were estimated to be potentially much higher -- the cost per DHLY gained (by averting maternal and infant deaths) could be reduced by 44% and the cost of averting a malaria case could be reduced by 10% to 20%. The analysis also showed that if benefits accrued under the project were retained after project completion, they would improve the efficiency and effectiveness and lower the costs of existing reproductive and malaria services. Since activities are to be continued after the Credit closing, the benefits derived are expected to continue, thus improving the efficiency and cost-effectiveness of these services.

3.4 Justification of Overall Outcome Rating Rating: The rating of Moderately Satisfactory is justified on the following basis: • Throughout the implementation period, the objectives remained highly relevant to issues

facing the sector in SI, particularly to the reproductive health and malaria sub-sectors. • The results of the key performance (output) indicators show that the project contributed to

strengthening reproductive health and that interventions for malaria control helped to strengthen a comprehensive control program in the two participating provinces. However, the strengthening of the services could have been greater if the rural civil works were undertaken under the project. As planned, the project tested new approaches to reduce reproductive health and malaria problems, and helped to strengthen planning, managing and monitoring of priority health programs more broadly.

• Targets on reproductive health and malaria control are potentially problematic, therefore, it is difficult to totally attribute or assess the precise impact of the project on the overall improvement in these areas. However, the results of the three outcome indicators in project areas are better than those of the country as a whole or to other comparator (non-project) provinces at the time of project completion.

• The civil unrest and macro-economic difficulties, and the consequent suspension of the Credit, delayed project implementation, which explains why the project assisted fewer provinces than originally foreseen, and also delayed the start of important rural civil works planned for Makira and Guadacanal.

• The rating takes into account the highly volatile and difficult project context due to the armed ethnic civil conflict from 1999 to 2004, the two-year suspension of disbursements, the fact that this was the first Bank-supported health project in the SI, and the administrative challenges of keeping implementation moving under extremely difficult

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conditions. As noted by QAG, the Bank deserves credit for the hard work put in by the supervision Task Team and for sustaining the relatively high costs associated with supervising a small project in a small country.

3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development The operation had a positive effect on community involvement in reproductive health. Both participating provinces achieved the reproductive health targets prior to Credit closing. Steady gains in antenatal care and assisted births are evident, while contraceptive use approached the target. Improved supervision and support of first-level workers have been attained through use of supervision checklists, radio consultations, and supplemental resources for staff visits. The provinces achieved improved outreach by health workers through use of the family health card, following a review and assessment of the card pilot in the two provinces. Data gathered from the health card exercises shed light on the low level of some reproductive health indicators, the cultural and behavior factors at work, and how the indicators and behaviors could continue to be improved. The ICR team visited some formerly conflict-ridden areas (in Guadacanal) where the Project interventions have played an important role in catalyzing community cooperation for improved knowledge of reproductive health and use of family planning tools. Survey data, collected as part of a province-wide survey on the reasons for choice of home vs. clinic births combined with an awareness-raising tour by reproductive health nurses, indicated more positive attitudes toward assisted births and better family planning practices. (b) Institutional Change/Strengthening) Implementation has yielded lessons and information that have been incorporated into the National Health Strategic Plan for 2006-2010. Training activities supported through the project have been instrumental not only in strengthening the performance of reproductive health programs, but in raising the morale of health staff in areas heavily affected by the conflict. Training has been conducted in and outside the country for midwives and nurses, and in integrated management of childhood illnesses. The HMIS system has provided lessons regarding the use of data and other information for planning and policymaking. Provincial-level planning and supervision systems have been strengthened as a result of participating in data collection for the HMIS. The high turnover of staff has constrained the expected impact of capacity-building efforts under the project as several of the staff trained left the services of MOH or Provincial Health Directorates. However, in several cases, the staff moved within the system or have continued to work elsewhere in the country, which therefore continues to benefit from their improved skills. The project has been successful in building institutional capacity for planning, management, coordination, procurement, and financial management. These improvements are being scaled up to help improve GOS’s administrative system as a whole and the health sector in particular.

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Project experiences and materials have been shared with other development partners, including during a stakeholder workshop carried out as part of the ICR mission, but they should be disseminated more widely. (c) Other Unintended Outcomes and Impacts (positive or negative) The project has contributed to helping to standardize architectural designs for rural health facilities, which can be easily amended to suit other parts of the country, depending on terrain and climate.

3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops Together with MOH, the ICR team organized a Stakeholders’ Workshop in Honiara with the participation of the Ministry of Planning; Ministry of Health; Vector Borne Disease Control Program; School of Nursing; Midwifery School; Provincial Health Directors and staff; and International partners - UNDP, UNICEF, AusAID, JICA, World Bank, and the British High Commission. The objective of the workshop was for the central and provincial authorities to present the results of the project and lessons learned from its implementation. The Bank team encouraged an open discussion and recommended participants to measure as far as feasible the outcomes and impact of project interventions, rather than concentrating only on outputs. Presentations were made for each project component sub-component, focusing on results and remaining challenges. For more details on the workshop, please refer to Annex 6.

4. Assessment of Risk to Development Outcome Rating: Limited. At the present time, there appears to be limited risk to sustaining the DOs for the project, given that lessons from strategies and approaches developed and tested under the project have been drawn for the development of the National Health Strategic Plans for 2006-2010, which are to be supported by financing through, among others, the World Bank and AusAID. However, given the fragile institutional capacity, the risk should not be underestimated.

5. Assessment of Bank and Borrower Performance

5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Satisfactory. Project design was appropriate and grounded in sound technical, institutional and social analyses. The project design addressed the key elements of the Government’s MTDS in health. The design was modified during preparation to streamline the components, scope and strategy to facilitate provincial participation and to enable adjustments of funding in response to the plans of other donors. Thus the project activities, as approved, were expected to be influenced by the evolving activities of other donors, allowing flexibility to adjust work plans on an annual basis if and when donor grant funding became available. The national programs in reproductive health and malaria prevention and control supported by the project were analyzed by technically qualified experts and were considered to be appropriate. The Bank team promoted ownership and commitment from the outset and worked hand in hand with counterparts to ensure that foreign and local technical assistance worked closely with staff.

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However, the risk assessment did not recognize the extend of the risks given that ethnic unrest had already started at the time of appraisal. (b) Quality of Supervision Rating: Moderately Satisfactory. The Bank team maintained its focus on development impact. Because of delays in implementation caused mainly by ethnic unrest, during the MTR the team agreed on a simplified set of output indicators (see relevant sections). Supervision of fiduciary tasks was carried out in a timely manner. Supervision missions could have been more regular during the last years of project implementation. Ratings of DOs and IP were generally fair, but inadequate explanations were given in ISRs to justify these ratings. There are two clear phases of project implementation/supervision. The first phase was between Credit effectiveness and the MTR (March 2000-June 2004). The second was post-MTR until December 2006 when the Credit closed. During the first period, the Bank team was proactive and resourceful, continually engaging the government and keeping the PCIU staff motivated by ensuring continuity of implementation guidance during the difficult and long periods of suspension. The Bank worked closely with the PCIU to readjust annual work programs on the basis of limitations and alternative sources of funding. The Bank was successful in catalyzing other development partners’ financing to pre-finance priority activities that could be later reimbursed under the Credit after the suspension was lifted. Despite the suspension financing continued for a limited number of activities during the suspension period, such as in-country and overseas training and the salaries of the PCIU staff. Without these efforts, the project could easily have collapsed as practically no counterpart funds were available for project implementation during the severe fiscal crisis. Because of the ban imposed by the UN on travel to SI, the Bank team was not able to visit the country for a period of 2 years. In May 2002 a “virtual supervision” was organized with the Government team visiting the Bank’s office in Sydney to conduct the supervision through video with HQ. The project had only 3 TLs during its turbulent implementation period. Staff continuity was a good feature of the Bank’s supervision support. However, only nine (9) supervision missions took place during the 7-year implementation period; 15 PSRs were filed in SAP; several of them reflected desk reviews of progress reports and telephone discussions with the PCIU. As noted earlier, the project was implemented during a highly volatile and difficult period, characterized by ethnic armed conflict. No missions were possible from November 2001 until October 2003. The project team ensured continuity by engaging a senior Bank consultant based in New Zealand to maintain regular contact through telephone with counterparts and helped to identify issues and provide advice on project implementation. However, more such “virtual supervisions” could have been organized. The quality of the supervision (as per Aide Memoires/ISRs) was mixed. During the early stages of implementation, efforts were devoted to improving the understanding of the project by counterparts and to clarify procedures and practices. The MTR Aide Memoire was comprehensive; it argued well for the importance of intensifying the Bank’s efforts to bring the project back on track. During the later period of implementation, however, the documentation could have been more robust. For example, only 4 ISRs were completed, basically one a year, although there were more than 4 site visits. Although a region practice, in the view of the QAG

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(QSA7) panel and this ICR, one ISR a year was not adequate in view of the complex issues facing the project. In addition, while ISRs included comments from SM, ISR did not include CM’s comments. The ISRs show that prior to the MTR, the project received "unsatisfactory" ratings for the DOs and IP; these ratings were upgraded to Satisfactory at the MTR. The MTR’s Aide Memoire recorded the agreement with the government to rebalance the focus of activities away from training (continued during Credit suspension) towards delivery of health services. After the MTR, there was stronger emphasis by the Ministry and the Bank on development impact and on following up on agreed actions. However, the Bank made only 3 site visits after the MTR. More generally, the basis for the DO and IP ratings in the ISRs could have been better explained. The first section on Key Issues and Actions for management attention in several ISRs provided a general overview of project implementation rather than focusing on issues that required management attention. These comments notwithstanding, discussions with the client revealed that especially important for MOH was the Bank team's focus on identifying problems and taking a collaborative approach to finding common solutions, seeking a partnership, and building trust among all participants. MOH appreciated the Bank’s willingness to engage the services of the Sr. consultant to provide guidance during the period that no Bank missions could take place. (c) Justification of Rating for Overall Bank Performance Rating: Moderately Satisfactory. Please see (b) above

5.2 Borrower Performance (a) Government Performance Rating: Moderately Satisfactory. (please see justification below) (b) Implementing Agency or Agencies Performance Rating: Moderately Satisfactory PCIU The project faced big challenges during the 7 years of implementation. One of

the challenges included maintaining cohesive and effective management and supervision of project activities by the PCIU. The project made an excellent start in establishing the PCIU and its financial and procurement management systems, supported by continued high-level of interest by senior MOH officials. However, with rising ethnic tensions and civil unrest, the PCIU lost several of its staff, including the project coordinator. After reinstatement of disbursements, there was more stability in PCIU staff. During the last year of project implementation, however, both the Procurement Officer and the Accountant left the project and the Project Coordinator with the Administrative Assistant had to assume additional responsibilities, which led to delays in the preparation of progress reports, including FMRs. A new accountant was recruited six months prior to Credit closing, however, given his lack of familiarity with the FM system and Bank’s FM/disbursement procedures, FM reporting was also delayed. All in all, however, the PCIU should be commended for maintaining a high standard of project management and ensuring that the project did not collapse during the difficult periods of suspension and civil unrest.

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(c) Justification of Rating for Overall Borrower Performance Rating: Moderately Satisfactory. It reflects the overall Borrower performance. 6. Lessons Learned

• Close coordination with development partners to ensure coherence and complementarity of activities was critical. Establishing strong working relationship with development partners, especially AusAID, was key to ensuring pre-financing and therefore continuity of priority activities during suspension of disbursements.

• Financing some training activities and arranging alternative financing during the suspension period was essential to keeping the project going.

• Stakeholders’ involvement throughout project life is crucial. Local empowerment for planning and implementing locally developed work plans results in greater ownership, commitment and transparency.

• Ownership and dedication by the Project Coordination Committee, which met on a regular basis, demonstrated commitment to the objectives of the project and was essential to ensuring that the project did not collapse during the lengthy period of instability in the country.

• Learning by doing, experimenting, carrying out small pilots (for example in the use of the family health card) and being willing to make mid-course corrections was critical.

• For planned civil works and major procurement, it is important to start the process early, especially in small countries where competition and capacity is limited.

• A focus on identifying problems and seeking solutions as a coherent, collaborative Bank-client team is important for achieving results.

• Providing continuous guidance in the context of a LICUS/fragile state context is essential. Bank supervision has to be more intensive than normal. Adequate supervision resources need to be allocated and staff should remain engaged on implementation progress on a regular basis to ensure that implementation is proceeding effectively.

• Engaging an external consultant to provide day-to-day implementation guidance during periods when no Bank mission could take place was a proactive way of ensuring adequate implementation guidance.

• The implementation of the HIS has highlighted clear issues that need to be addressed going forward, including: (a) how the roles, responsibilities, and accountabilities of provincial staff should be defined and clarified to ensure the systematic collection of data and improvement in its quality, and (b) what roles and responsibilities central staff should have to oversee the process and carry out the data analyses.

• Ensuring better networking in the provision of health care services among all stakeholders, including the Government, communities, churches, NGOs, and international development agencies, and encouraging community participation in health promotion and delivery are essential to project success.

7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies See Annex 7

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(b) Cofinanciers NA (c) Other partners and stakeholders

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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

IMPROVED REPRODUCTIVE HEALTH 1.88 1.89 99

IMPROVED MALARIA CONTROL AND PREVENTION 1.21 0.71 57

CAPACITY BUILDING 0.34 0.30 88 PROJECT COORDINATION AND MANAGEMENT 0.44 0.41 91

3.31 86 Total Baseline Cost 3.87 3.31 86

Physical Contingencies 0.190

0.15

0.00

Price Contingencies 0.34

0.30

0.00

Total Project Costs 4.40 3.76 85 Project Preparation Fund 0.00 0.00 .00 Front-end fee IBRD 0.00 0.00 .00

Total Financing Required 4.40 3.76 85

(b) Financing

Source of Funds Type of Cofinancing

Appraisal Estimate

(USD millions)

Actual/Latest Estimate

(USD millions)

% of Appraisal

International Development Association (IDA) 4.00 3.76 94

Category of Expenditure

Allocated

Disbursed

Percentage of Allocated

1. Works 2. Goods 3. Consulting Services 4. Training/Studies/Workshops 5. Incremental Operating Costs 6. Unallocated TOTAL

906,114 1,057,133 739,993 1,193,050 407,751 226,528

4,530,570*

434,210 1,119,583 608,799 1,146,001 288,168

160,882** 3,757,642***

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106 82 96 71

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* Amount is higher than approved because of currency fluctuations between SDR and US$ ** Represents funds remaining in the special account which need to be reimbursed to the Bank *** Disbursed amount as of April 2, 2007

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Annex 2. Outputs by Component

Component Planned outputs at Appraisal Actual outputs at ICR Comments Reproductive Health (i) upgrade service coverage and quality

(a) adapt and use international guidelines and standards (b) supervision checklists, radio consultation, and resources for staff visits (c) family health card (FHC) (d) upgrade selected facilities

(a) Partogram health guidelines updated/adapted for local use. Obstetrics survey form updated. (b) supervisory checklist introduced; new radio network was installed. (c) FHC piloted and introduced in Makira and Guadacanal provinces. (d) Midwifery program building, office, dormitory, and two staff houses constructed. Other rural civil works cancelled by MOF. Canoes, outboard motors, medical equipment and supplies for all clinics in Guadacanal and Makira procured.

(d) provincial rural civil works were not implemented under the project, these civil works have been selected as priority works to be financed under the proposed AusAID/WB SWAp under preparation. Moderately Satisfactory

(ii) increase professional skills

(a) establish Midwifery Training Program (b) overseas training fellowships for doctors/nurses (c) upgrade distance learning program for nurses

(a) program established and running successfully; sixty two trainees have graduated from the program. (b) Eighteen medical/nursing staff benefited from training overseas (see Exhibit 1 of Annex 7).

(a) sustainability ensured through funding from MOH. Operating costs included in MOH’s 2006 and 2007 budget. The program is in great demand in all provinces. Moderately Satisfactory

Malaria Prevention and Control (i) enhanced support to malaria activities

(a) case detection and treatment (b) bed nets and focal spraying

(a) extensive training was provided to lab technicians in both provinces to be able to more accurately detect malaria. Many workshops were also carried out for malaria staff and field workers and community leaders to enhance community participation and awareness of the disease burden. (b) bed nets were procured and insecticides to treat bed nets were

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carried out from 2003-05 (delay due to suspension of disbursements prior to 2003).


(ii) strengthened monitoring and evaluation

(a) analysis of historical data (b) creation of a supplementary data management team (c) collection of population-based information

(a) computers and related equipment were procured to support the existing SI Malaria Information System (SIMIS). Upgrade of the software for SIMIS was undertaken with support of the Global Fund. (b) data collectors were engaged in Makira to assist malaria staff to improve data collection. (c) community mapping was undertaken in both provinces; this proved most useful.


(iii) Pilot specific enhancements to the national program

(a) post graduate studies of up to 5 researchers

(a) two senior research officers were funded under the project for post-graduate degrees. Two other officers funded by other donors for post-graduate degrees.


(iv) dissemination of results

(a) workshop to discuss lessons learned at MTR (b) national malaria conference at the end of the project

(a) and (b) several workshops have taken place to discuss progress with malaria control. Dissemination of results was undertaken through the National Malaria Conference in 2004 where a research paper commissioned under the project was discussed. Findings of the research have been used to train nurses in both provinces. Although other conferences are planned with funding from other donors, no malaria conference at the end of the project was convened.

(a) and (b) malaria control is being supported by the Global Fund which has continued and expanded on activities previously supported by the project. Moderately Unsatisfactory

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Capacity Building (i) Health Planning

(a) Development of Health Information System Development (b) Data analysis for planning and monitoring (c) Project Monitoring and Reporting

(a) HIS was designed and is operating. This activity has been carried out in close collaboration with AusAID. (b) four data entry clerks and one medical statistician have been funded under the project (b) and (c) project monitoring and reporting is taking place regularly. The project funded extensive training of provincial HIS officers in the upgraded version of the HIS software and provision of computers to provinces. As a result, there has been an increased level of HIS reporting from the provinces.

(a) and (b) AusAID is continuing support for the HIS. After the Australian-funded Health Institutional Strengthening Project is closed, further support is expected with funding from the SWAp. Moderately Satisfactory

(ii) Health Promotion (a) capacity building on the basis of a needs assessment (b) development of communication strategies (c) up to 3 pilot initiatives to strengthen coordination with NGOs.

(a) five staff from the Health Promotion Division of MOH received training, including one staff who attended and received a certificate for health promotion from the Fiji School of Medicine. (b) and (c) these activities were to be supported with assistance from the Asian Development Bank, but the assistance did not materialize. Support for the activities continued through funding selective activities such as “World AIDS Day” with the participation of village health workers and local communities.

(a) capacity building is a process that must continue with or without support from external funding. Moderately Unsatisfactory

Project Coordination and Management

(a) operations of the PCIU (b) regular meetings of the Project Coordination Committee (PCC)

(a) (b) (c) and (d) the PCIU worked well under most difficult conditions. Functions of FM and

(a) through (d) the project was successful in building considerable capacity for planning, management, coordination, procurement, and

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(i) Project Coordination and Implementation Unit

(c) semi-annual progress reports (d) external audits

procurement were performed well. Project reporting was carried out in a timely manner. Delays with procurement of civil works were due to departure of the Procurement Officer. PCC met on a regular basis and played a key role on guiding policy and implementation. External audits were conducted annually and reports were unqualified.

financial management. These capabilities can be put to good use in future projects and ultimately for improvement of the government’s systems more broadly. PCCs-type committees are established in many projects/countries, but often they do not function as well as the PCC has functioned under this project. Moderately Satisfactory

(ii) Baseline, mid-term, and final evaluation

(a) obstetric services survey (b) analysis of data on morbidity and mortality caused by malaria (c) survey on health service infrastructure

(a) survey designed and conducted in Makira and Isabel provinces. (b) data on malaria control, morbidity, and mortality have been collected and analyzed on a monthly basis to establish disease trends and identify strengths and weaknesses of the program. (c) survey was conducted in 2005 in close collaboration with AusAID. In 2006 a review report on rural clinics was prepared and issued.

(a) conducted with delays. The survey was not conducted in Guadacanal because of the ethnic tensions there. (b) carried out on a regular basis. (c) priority infrastructure has been selected for financing as a result of the survey. Moderately Satisfactory

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Annex 3. Economic and Financial Analysis (including assumptions in the analysis)

No NVP, ERR, or FRR were calculated a priori for the project, and no analyses are available to assess them as economic or financial results. However, the PAD presented supporting evidence of comparative costs of the investment choices considered. Annex 4 of the PAD cited a cost-effectiveness study of project expenditures in terms of discounted healthy life years (DHLY) for Component A (Improved Reproductive Health) and the cost per malaria case averted for Component B (Improved Malaria Prevention and Control). The analyses reviewed the rationale for investing in learning and development activities to improve reproductive health and reduce malaria both during the project period and beyond. It compared the cost-effectiveness of two approaches or categories: Category I: strengthening of existing health sector operations; and Category II: learning and innovation through analysis of past program performance and piloting of new or enhanced methods for reducing the priority health problems. Under the assumption of strengthening existing activities, the PAD indicated that the project would sustain the Government’s achievements for the five-year duration of the project, averting maternal and infant deaths at a cost of about US$394 per DHLY gained in comparison to the approximate costs of a year of healthy life to the country of US$930 (assuming that the value of a year of healthy life in SI is approximately equal to its per capita GDP). Averting malaria was estimated to cost about US$5.80 per case, a substantial bargain in comparison to the approximate cost to the country of US$465 per case of malaria (assuming each case of malaria costs approximately one half year of healthy life). In comparison, the benefits of the learning activities for each component while being less certain were estimated to be potentially much higher—the cost per DHLY gained (by averting maternal and infant deaths) could be reduced by 44% and the cost of averting a malaria case could be reduced by 10% to 20%. The analysis also showed that if benefits accrued under the project were retained after project completion, they would improve the efficiency and effectiveness and lower the costs of existing reproductive and malaria services. Since activities are to be continued after the Credit closing, the benefits derived from the project are expected to continue, thus improving the efficiency and cost-effectiveness of these services.

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Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team Members

Names Title Unit Responsibility/Specialty

Natasha Beschorner ICT Policy Spec CITPO ICT Policy Specialist

Thomas Roderick Burkot Consultant EASHD

Christopher Chamberlin Consultant EASHD

Janet Hohnen TL EASHD TTL, Public Health

Richard Cibulskis Consultant EASHD Health Information

Lingzhi Xu TL/Procurement

Specialist EASHD Procurement

Rekha Menon TL/Economist EASHD Health Economist

John Malmborg Consultant EASHD Facilities, Civil Works

Junxue Chu Finance Officer LOAG3 Disbursements

Robert Cohen Consultant EACNQ Financial Management

Janet Nassim Operations Of. HDNHE Operations Specialist

Silvio Luculescu Health Specialist EASHD Public Health Specialist

Betty Hanan Consultant EASHD Implementation Specialist

Dorothy Judkins Program Assistant EASHD Administrative Support (b) Staff Time and Cost

Staff Time and Cost (Bank Budget Only) Stage of Project Cycle

No. of staff weeks USD Thousands (including travel and consultant costs)

Lending FY99 71.02 FY00 32 116.42 FY01 0.00 FY02 0.00 FY03 0.00 FY04 0.00 FY05 0.00 FY06 0.00 FY07 0.00

Total: 32 187.44

Supervision/ICR FY99 0.00 FY00 4 12.02 FY01 9 42.83 FY02 6 72.51 FY03 5 13.48 FY04 15 117.68 FY05 5 51.74 FY06 6 54.65 FY07 7 60.28

Total: 57 425.19

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Annex 5. Beneficiary Survey Results (if any) N/A

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Annex 6. Stakeholder Workshop Report and Results Together with MOH, the ICR team organized a Stakeholders’ Workshop in Honiara with the participation of: Ministry of Planning; Ministry of Health; Vector Bone Disease Control Program; School of Nursing; Midwifery School; Provincial Health Directors and staff; and international partners - UNDP, UNICEF, AusAID, JICA, the World Bank, and the British High Commission. The objective of the workshop was for the central and provincial authorities to present the results of the project and lessons learned from project implementation. The Bank team encouraged an open discussion and recommended participants to measure as far as feasible outcomes and impact of the project interventions, rather than concentrating only on outputs. Presentations were made for each project component and sub-component, focusing on achievements and the remaining challenges. The Permanent Secretary and Project Director presented an overview of the project, government evaluation of the implementation, and the National Health Strategic Plan for the next five years. Each presentation was followed by sessions on questions and answers, where participants openly discussed issues. Participants acknowledged the successes, the less positive experiences, and the challenges ahead. They recognized the strong need to draw lessons from this project to inform the development of future reforms in the sector, especially experiences with the implementation of activities at the provincial level that could be scaled up to other provinces and in some cases nation-wide. Issues of ownership and sustainability of activities were openly discussed. One activity under the project that has been very successful and appreciated by national and provincial authorities has been the design and implementation of the Midwifery Program, which has accepted students from all over the country. This program is being continued beyond the Credit closing date with financing from the Ministry of Health. Allocations have been provided under the Ministry’s 2006 and 2007 budgets. At the time of writing this report, the 2007 Program has been initiated with the participation of 20 trainees. The Bank team was encouraged by the expressions of commitment by the government to continue with implementation of several activities once the Bank financial assistance under the project ends. An anonymous survey was conducted during the workshop to evaluate the quality of preparation and implementation in terms of both the Borrower’s and the Bank’s performance. The results of this survey were incorporated into the rating on the Government’s contribution to the ICR (Annex 7).

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Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR I. Background

The Health Sector Development Project (HSDP) has come this far successfully notwithstanding operational and implementation challenges during its life span. The original goals and objectives of the Project were “to assist the Government (MHMS) to improve the health of Solomon Islands people through better maternal care and family planning, more effective prevention and control of malaria and improving the capacity of MHMS to plan and manage provincial health programs and mobilize community awareness and participation.” Whilst the original goals remain valid throughout the Project’s timeframe, the situation on the ground undermined the Project’s focus in ensuring health sector development that was conducive to enable better health outcomes through strengthening of the key components of malaria prevention and control and ensuring better reproductive health services to the mothers and children of the country.

The Solomon Islands has come out of a very futile situation as caused by the conflict and its aftermath impact to the primary health care services delivery of the country. It is evident that the most active period of the Project has been the period 2004 to 2005. Whilst the Project begun as a developmental and enhancement of the existing health care services of the country, the change of focus was imminent as post-conflict rebuilding of the health services. It, in some ways, re-emphasises the need for continuation and sustaining the Project’s activities in the provinces (especially in Makira and Guadalcanal). HSDP’s role in the health development (legitimately) turned out to be one of post-conflict restructuring, which was enabled with some flexibility by the World Bank management team with strong focus on the original goals.

The Government increased efforts in re-construction and re-establishment of health care services in 2003-2004 and sustained it in 2005. Other donor partners, AusAID in particular, had rescued the appalling financial situation of the SIG’s health sector. The project components were specific and very sensitive towards the local context. The surrounding milieu caused by unexpected event did not curtail the project’s focus, and the local drive to ensure that malaria control and reproductive health programs are implemented both at the national and provincial levels.

The HSDP has it own challenges faced during the years of implementation. One of these challenges included maintaining a cohesive and effective management and supervision of project activities by the Project Implementation and Coordinating Unit (PCIU) at the Ministry of Health. The PCIU should be commended for maintaining a high standard of project management. The HSDP ended successfully on a high note, but with mixed results. The level of outputs of the project is significant and needs close monitoring towards the desired outputs and impact at a longer term in ten years time.

Malaria remains a serious health problem worldwide and Solomon Islands is one of 107 countries where malaria transmission occurs. According to the National Health Report 20052,

2 Ministry of Health (2006): National Health Report 2005: MOH/HQ

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clinical malaria remained very high. In 2005 clinical malaria and fever were responsible for 28% of acute care attendances. The rate of malaria in pregnancy has remained essentially unchanged according to one set of data (Health Information System) and has been found to be higher by another (Solomon Islands Reproductive Health Surveillance System) approximately 8%. Nonetheless, the level of Malaria infection remains very high.

Malaria vector control measures have picked up, but need further improvements in terms of reaching more to the vulnerable people. The Ministry’s Household Income Expenditure Survey (HIES) Report 20063 revealed a variation in the level of use of bed nets by households. From the study, the number of people who had a mosquito net in the household ranged from a high of 98.2% in Western Province to a low of 29.2% in Renbel Province.4 Meeting the challenge of decreasing malaria incidence needs increased community participation and understanding of malaria control and prevention activities. Improved health outcomes also need to include timely treatment and early diagnosis. II. Introduction

The aim of the HSDP was to contribute to the Government’s goals of improving the health status of its people and of keeping population growth in line with the national development aspirations. The objective of the Project is to assist the Ministry of Health to improve reproductive health and to reduce illness and deaths from malaria through strengthening essential aspects of the current health programs and a program of specific learning activities to improve program coverage, effectiveness, acceptability and utilization. III. Project Financing The credit agreement between the Government of Solomon Islands and the International Development Association (IDA) was signed on January 27, 2000. The date of effectiveness was March 9, 2000 and the original credit closing date was December 31, 2004. The credit had one extension from June 30, 2005 to December 31, 2006. The IDA Credit was for US$4.0 million equivalent, but because the Credit was expressed in SDRs, the dollar amount at the end of the project was US$4.51 million. Project Project objectives The project’s development objective was to assist the government to improve health outcomes of rural communities through strengthening existing reproductive health and malaria

3 Ministry of Health (2006) Solomon Islands Household Income Survey Report: Health Module 2005-2006 4 In Renbell, malaria is non-endemic which would account for the low coverage

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programs, testing new approaches to reducing these problems, and through improved planning, management and monitoring of priority health programs. Progress in achieving the Project’s objective was to be assessed using the following key performance indicators: Increased proportion of mothers receiving skilled care in pregnancy and childbirth Increased acceptance of effective contraception Reduction of hospital admissions and deaths from malaria Increased use of bed nets for prevention of malaria Improved health service utilisation in the provinces Availability of good quality health program reports to stakeholders Successful completion of the Project’s defined learning program, incorporation of results into national policy and dissemination to non-project areas. Project Components The Project had three substantive Components covering: (A) Improved Reproductive Health; (B) Improved Malaria Prevention and Control; and (C) Capacity Building in the Ministry of Health and provincial health services. A fourth Component (D) comprised the Project’s coordination and support activities. Achievement by Objectives The implementation of the Project assisted the Government’s initiative to reduce maternal mortality through increased skill care in pregnancy and childbirth, increase contraceptive prevalence rates, reduce hospital admissions and deaths from malaria through increased use of bed nets and community awareness on malaria control and the incorporation of the Project’s results in the areas of reproductive health, malaria and health management information into national policy. Outputs by Components Component 1 - Improved Reproductive Health – Usd2.16m MOH was to improve provincial health services for reproductive health, with special attention to the training of medical and nursing staff in-country and overseas, improved clinical supervision and upgrading of rural health facilities. A new post-basic course for nurse-midwives was to be piloted, with oversight by a representative committee on midwifery services. International assessment and monitoring guidelines for reproductive health service quality and use were to be adapted. An inter-sectoral taskforce with provincial representation was to provide feedback to MOH on reproductive health matters.

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1.1 Upgrade Service Coverage and Quality The following innovations were to be supported to improve service delivery in participating provinces: (a) adapt and use international guidelines and standards for assessment and monitoring of availability and use of obstetric and family planning services; (b) improve supervision and support of first level workers, through use of supervision checklists, radio consultation and supplemental resources for staff visits and (c) improve outreach by health workers through use of a family health card which has been successfully tested in one province. An inter-sectoral task force was to be set up to improve communication with non-health sector stakeholders and provincial community leaders. The attempt to adopt and adapt international health guidelines and standards such as the obstetrics survey form, partogram and supervisory checklists for use in clinics and hospitals in the country got off to a slow start because in the project’s initial year, the country experienced the peak of social unrest mainly affecting Guadalcanal and Honiara. Many, if not all, of the Ministry’s Reproductive Health Division staff involved repatriated themselves back to their home villages thus suspending the process indefinitely. a) Obstetrics Survey Form The design of the obstetrics survey form began in late 2001 and was finally first tried in February 2003 at Isabel Province with later trials being conducted in most of the clinics at Makira Ulawa Province (MUP), including Kirakira Hospital from June 2 to 13 2003. The obstetrics survey form was tried in MUP together with the Family Health Card (FHC). b) Family Health Card (FHC) The piloting of the FHC for the Project was done at Tawaraha AHC on MUP from 26 to 30 May 2003. Training workshops were held to familiarise nurses in the Provinces with this tool. The main purpose of the FHC was to assist nurses to identify family health problems at home and provide appropriate advice or counselling in the privacy of the family home. The late procurement of registration books for the FHCs was a major drawback to the pilot program in the MUP as it meant the nurses could not complete registration of FHCs after completing them. The FHC was later piloted in Guadalcanal Province (GP) in 2005 with follow up visits on the nurses concerned in 2006. The printing and distribution of the FHC was delayed due to two reasons. First the suspension of disbursements meant that the printing of the FHC and its accompanying registration books had to be put on hold. Second, when the suspension was lifted and the printing of the registration books were to be reactivated, the printer lost the original template and when given a copy they were not able to print the book. The registration book then had to be sent overseas for printing.

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c) Partogram The partogram was also another standard health guideline that was updated and adapted for local use under the Project. Nurses throughout the country have been trained in the use of this obstetrics tool. The partogram was tried at the NRH, Gizo, Kirakira and Kilu’ufi Hospitals. More partograms were printed for trials, but printing problems at the local press further delayed the initial distribution effort. d) Supervisory Checklists, Staff Visits, Radio Consultations There was a delay in the introduction of the updated supervisory checklist as the RHD felt certain aspects of the newly introduced nursing tool, the Integrated Management of Childhood Illnesses (IMCI), needed to be incorporated into the supervisory checklist. The RHD wanted to see final changes to the nursing treatment and management of child survival programs in the IMCI before amending the supervisory checklist accordingly. This did not happen until late 2004. A new radio network was installed at the MoH HQ under the AusAID funded HISP with a contribution of eight (8) radios for MUP clinics under the Project. Most clinics in GP and MUP are now equipped with two-way radios. e) Infrastructure (Civil Works) Only the midwifery program’s civil works was undertaken and completed by end of 2006. This began in June 2004 and was completed in October 2005. Two staff houses, a classroom/office block and a dormitory were buildings constructed by a local building contractor. By the end of 2005 four (4) primary health care facilities together with four (4) malaria storage sheds and two (2) malaria staff houses were earmarked for construction in the year 2006 as part of the rural health facilities civil works. This did not eventuate, however, due to delays in the bidding process and the need to re-tender due to first round bids not meeting World Bank procurement requirements. The bids received after the re-tender period was in excess of initial Project budget estimates prepared by the Project Officer which led to a further reduction in the scope of works. The untimely departure of the Project Officer further exacerbated the difficulties already experienced by this procurement process and as time was pressing it was decided to drop the whole rural health facilities civil works altogether in the hope that the identified facilities will be included as priorities under the new AusAID/World Bank funded Sector Wide Approach Program (SWAp). f) Procurement During the course of the Project, canoes and outboard motor engines (OBMs) were procured for the RHD of MUP and GP, the NMCP in both MUP and GP and the Health Promotion Division of MUP. This enabled the staff concerned to be able to carry out their outreach programs, satellite clinics, school visits and work related programs more frequently and

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regularly weather permitting. Medical equipment were also procured in late 2005 for distribution to all clinics on GP and MUP and Kirakira Hospital in MUP. There was also procurement for the midwifery program in terms of textbooks, stationery, teaching aides, furniture and refurbishments for the program’s new buildings and computers for students use. In 2006 new air-conditioning units were installed in the program’s classroom/office block. g) Midwifery Advisory Committee A Midwifery Advisory Committee (MAC) was also set up to assist the RHD and the Ministry in the delivery of the Advanced Diploma in Nursing (Midwifery) training program. It played a key role in the support of the curriculum developed and also lent support to the final designs for the obstetric survey form, partogram and supervisory checklist. h) Reproductive Health Taskforce The Reproductive Health Taskforce was made up of all stakeholders in this Component to improve communication and dissemination of information with non-health sector stakeholders and community leaders. Unfortunately this Taskforce did not function as intended as it has only met once in the five (5) years of the Project. 1.2 Increase Professional Skills Training and Distribution Based on a new human resource plan for reproductive health, the Project was to support an intensive effort to improve midwifery, obstetric and family planning skills. The Project was to help the School of Nursing in the Solomon Islands College of Higher Education (SICHE) to establish a midwifery training program, based in the National Referral Hospital and associated provincial hospitals. Overseas training fellowships were to be provided for medical and nursing staff. The distance learning program for nurses was to be improved. The Project was also to support some costs for overseas health staff to fill provincial posts while national officers were being trained. a) Advanced Diploma in Nursing (Midwifery) Training Program The midwifery training program (Advanced Diploma in Nursing (Midwifery)) was piloted in 2001 with seven (7) students and by 2006 had trained a total of 62 midwives. This is just under the target figure of 83 as stipulated in the PAD. The distribution of student midwives by province, from 2000 to 2006 is as follows:

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Malaita Province 14 Western Province 11 Makira Ulawa Province 6 Choiseul Province 4 Guadalcanal Province 5 Isabel Province 4 Central Islands Province 3 Temotu Province 1 Renbel Province 1 National Referral Hospital 8 Honiara City Council 4 Nursing Council 1 As can be seen in the above listing, the two project provinces came well behind Malaita and Western Provinces and the National Referral Hospital (NRH) in terms of numbers participating in the training program. MUP sent six (6) whilst GP only sent five (5). This was due to the fact that some of the applicants for the course from the two provinces did not meet the academic requirements to take up the study. As such applicant nurses from other provinces and nursing institutes were given the opportunity to undertake the midwifery program. All awardees returned to their original postings with the exception of one (1) who left the country to join her husband working overseas and another who is currently not practicing due to illness. The program has had its fair share of problems with regards to teaching staff. This has not been helped by the high turnover of teaching staff in the program since its inception in 2000. In the period from 2001 to 2006, a total of nine (9) qualified midwives were selected and engaged for the four (4) teaching positions offered in the program. During this time six (6) of the lecturers/tutors resigned at different times for various reasons. Currently there are only two (2) full-time lecturers/tutors with a third one currently on study leave. The fourth position remains vacant since July 2006. b) Overseas Training Over the six (6) years of the Project’s life, a number of doctors, nurses and health workers received skills development training funded by the Project. A comprehensive listing is given as Exhibit 1. All awardees returned home to resume duties at either their original posting or were transferred to other health facilities. The doctor who undertook a Master in Obstetrics and Gynaecology, however, left to work in an overseas hospital after only one year in the position of Consultant Obstetrician at the NRH. The leader of the midwifery lecturers/tutors team who returned after completing her Master in Midwifery course also resigned to join her husband overseas in 2006 after less than a year back at work. Such departures have stretched the already limited resources at their work places leaving vacancies that are filled due to circumstantial need and not necessarily merit. The NRH was without a Consultant Obstetrician for a while and the midwifery training program suffered yet another blow to its ongoing staffing problems.

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1.3 Sustainability All the activities funded under the sub-component 1.1 “Upgrade Service Coverage and Quality” have been implemented and continue to be funded for implementation under the RHD’s budget either under its appropriate budget head within the Ministry of Health’s or through other donors funding. The operational costs initially provided by the Project for MUP and GP for outreach visits, satellite clinics, fuel and transport repairs and maintenance are now part of the RHD’s annual recurrent costs. The cost of administering the midwifery training program has also been included in the RHD’s budget for 2007. As all staff trained under the sub-component 1.2 “Increase Professional Skills Training and Distribution” came from existing positions within the Ministry’s staff establishment, there was no problem with the continuation of their employment at the end of their studies. The midwifery lecturers/tutors positions have also been transferred to line positions within the Ministry staff establishment and should be remunerated by the GoSI from 2007. Every year the human resource plans of each department or division is revised to capture the staff turnover. 1.4 Lessons Learned

• Efficient coordination of all donor funded health activities within a department/division is critical if goals are to be achieved.

• Stakeholders involvement throughout Project life is crucial. • Supporting committees need to be more active. • Credit terms can be subject to adverse conditions not necessarily of the Borrower’s

doing. • Local printers may not have the capacity to typeset complex forms. • Not everyone who has trained and qualified overseas will be happy with their job. • Criteria for selecting applicants for training awards set the tone for who receives

training, therefore, defining selection of applicants in terms of provincial representation is a misnomer.

Expect trained and qualified workers to move on to where working conditions and remuneration are better.

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EXHIBIT 1. Overseas training awards funded by the Project. 2000 to 2006.

STUDENT NAME COURSE/PROGRAM INSTITUTION COUNTRY Year 2000

Mrs. Rebecca Betty Manehanitai Advanced Diploma in Nursing (Midwifery) College of Allied Health Sciences PNG Ms. Niumally Tutuo Advanced Diploma in Nursing (Midwifery) College of Allied Health Sciences PNG

Year 2001 Dr. Kevin Bisili (2001 – 2003) Master Obstetrics & Gynaecology Fiji School of Medicine Fiji Dr. John Kure (did not complete) Master Obstetrics & Gynaecology Fiji School of Medicine Fiji Mrs. Alberta Veo Comprehensive Basic FP Attachment Jose Fabella Memorial Hospital Philippines Mrs. Christina Qotso Comprehensive Basic FP Attachment Jose Fabella Memorial Hospital Philippines Ms. Michelle Lumukana Comprehensive Basic FP Attachment Jose Fabella Memorial Hospital Philippines Mrs. Smyrna Karibongi Comprehensive Basic FP Attachment Jose Fabella Memorial Hospital Philippines Mrs. Catherine Piuna Comprehensive Basic FP Attachment Jose Fabella Memorial Hospital Philippines

Year 2002 Dr. Kevin Bisili (2001 – 2003) Master Obstetrics & Gynaecology Fiji School of Medicine Fiji Mrs. Jessie Larui Bachelor of Clinical Nursing (Midwifery) University of PNG PNG Mrs. Judy Face Bachelor of Clinical Nursing (Midwifery) University of PNG PNG Mrs. Glance Faka Bachelor of Clinical Nursing (Midwifery) University of PNG PNG Mrs. Edna Titiulu (did not complete) Bachelor of Clinical Nursing (Midwifery) University of PNG PNG

Year 2003 Dr. Kevin Bisili (2001 – 2003) Master Obstetrics & Gynaecology Fiji School of Medicine Fiji Mr. Makiva Tuni (2003 – 2004) Master in Public Health Queensland University of Technolog Australia

Year 2004 Mrs. Betty Bero Bachelor of Clinical Nursing (Midwifery) University of PNG PNG Mrs. Cherrie Galo Bachelor of Clinical Nursing (Midwifery) University of PNG PNG Mrs. Hellen Marau Bachelor of Clinical Nursing (Paediatrics) University of PNG PNG

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1.5 Main Factors Affecting Implementation The RHD has a lot of its programs funded by donors other than the World Bank; therefore, competing priorities often lead to oversight of activities to be implemented under the Component each year by its responsible officers. It was thought the engagement of a Project Coordinator for the RHD would resolve this situation, but this has not been so due to the fact that the position has become an accounting post that monitors and disburses donor funding for the Division rather than coordinating projects and programs on their behalf. The MAC and the RH Taskforce have not met regularly as planned and as such have not actively contributed inputs that would have assisted the Division to effectively participate in the Project. The frequent disbursement suspensions imposed by the World Bank too contributed heavily to the disruption of activities for implementation during the years 2000 to 2003. There are two factors affecting the smooth implementation of the midwifery training program. One reflects the high turnover of teaching staff at frequent and short intervals. This disrupted, to some extent, the comprehensive delivery of the training program. New lecturers were coming in with no experience in the administration of the program and were, more often than not, left on their own to carry on where the last lecturer/tutor left off, without support from previous staff. This high turnover of teaching staff meant critical milestones like the review of the curriculum and evaluation of the program could not take place. The other factor is that it has not been realistic to allow a higher participation of nurses from the two pilot provinces, MUP and GP, due to the set selection criteria for admission to the training program. As such training of more midwives for both these two provinces have been somewhat hampered due to the academic selection criteria. Another factor that stretched the human resource plan was the issue of doctors, nurses and health workers that returned after their training for a short stint at their post only to move on to bigger and better jobs overseas, leaving gaps in their work positions. 2. Improved Malaria Prevention And Control – USD1.35m This Component was to help fill funding gaps in the National Malaria Control Program (NMCP) while analysing past experience and testing ways to improve the cost effectiveness of the Program. There were four sub-components: (i) enhanced support to a basic package of malaria control activities; (ii) strengthened monitoring and evaluation of malaria control in coordination with the MOH monitoring and evaluation efforts; (iii) pilots of specific enhancements of the malaria program in five groups of villages; and (iv) dissemination of results for policy and Program improvements.

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Improved Malaria Prevention and Control sub-components 2.1: Enhanced support to malaria control activities The Project provided support for key activities of the successful malaria control program in participating provinces, including case detection and treatment, provision of bed nets and focal spraying to reduce mosquito populations. An intersectoral task force was set up to improve communication with non-health sector stakeholders and provincial community leaders. a) Case detection and treatment The training of community microscopists for each Province was a strategy used by the Vector Borne Diseases Control Program (VBDCP) to improve case detection and treatment of the malaria disease. In the past, patients turning up at clinics with fever were treated on the presumption that they had malaria. Community microscopists, however, would be able to assess the fever accurately so that nurses can treat patients who have malaria accordingly and correctly. In the early years of the Project many of the microscopists trained were from MUP. In later years, however, participants came mainly from GP. The training of community based microscopists has not only increased data collection for malaria, but has also meant a more accurate analysis of data collected can be done. The tables below give some indication of the key malaria performance indicators for this Component over the period 1999 to 20065. The decline may be insignificant, but at best it can be said that the increased participation of community based microscopists mean there are more data collected now than in the past. Other workshops for malaria staff and malaria field workers and the community leaders (chiefs, men, women, youth) they worked with were also held in the years 2001 to 2004 in the Program’s efforts to improve and enhance community participation and awareness of the disease burden. The workshops were funded by the Project and were on topics geared towards community awareness and education on malaria prevention and control.

5 Submitted by Chief Medical Statistician, Ministry of Health, 22 November 2006.

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Malaria Indicators 1999 2003 2004 2005 2006 Malaria Control Program 1. OPD with clinically defined malaria/1000 National 288.6 367.9 347.1 343.1 283.4 GP 298.1 347.3 373.0 370.2 251.6 MUP 300.7 472.2 508.4 486.6 443.2 2. Slide diagnosed malaria/1000 population National 156.1 204.3 196.1 162.1 na GP 224.6 299.5 382.7 238.0 126.4 MUP 68.4 137.4 174.1 173.3 63.4* Notes: National data 2006 not available Figures for 2006 - 2nd Quarter 3. Deaths from malaria per 1,000 population National 0.22 0.35 0.69 0.28 0.09 GP 0.20 0.26 0.26 0.26 0.18 MUP 0.42 1.64 0.58 0.53 0.19 Note: hospital data is lacking

b) Bed nets and focal spraying Procurement of bed nets and insecticides for use in the re-treatment of bed nets were done in the years 2003 to 2005 given the suspension of disbursements from 2001 to early 2003. In both Provinces, this activity has been implemented but more effectively on GP due to more stable management in this particular province. Staff management problems in MUP hindered effective progress of bed net distribution and focal spraying in that Province. In addition to the procurement and distribution of bed nets, the construction of storage sheds and malaria staff houses for MUP was to be undertaken, but had to be shelved due to limited time and budget. c) Inter-sectoral Taskforce Two inter-sectoral taskforce meetings were held in Kirakira, MUP over the life of the Project. These meetings, however, involved stakeholders who were based in that Province. Only one taskforce meeting was held for stakeholders on Guadalcanal in early December 2005 due initially to the volatile situation in that province from 2000 to 2003.

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DATA/INDICATORS – GUADALCANAL PROVINCE 2004 2005 Population 64,969 65,951 Annual Incidence rate per 1,000 population 406 314 Number slide examination 53,756 50,817 Number of malaria cases 26,382 20,718 Percentage of P. falciparum (%) 80.2 79.9 Slide positivity rate (%) 49.1 40.8 Malaria mortality rate per 100,000 population 4.6 27.3 Infant malaria rate (%) 41.4 35.4 Number of nets treated per year 5,467 14,000 Treated mosquito net coverage by target population (%) 39 42 Number of persons protected by house spraying 9,404 19,380 Proportion of population covered by ITN and house spraying (%) 30 60 DATA/INDICATORS – MAKIRA ULAWA PROVINCE 2004 2005 Population 35,488 36,459 Annual Incidence rate per 1,000 population 169 181 Number of PCD slides examined 22,478 26,613 Number of PCD slides positives 5,983 6,586 Percentage of P. falciparum -PFR (%) 47.6 30.6 Slide Positivity rate -SPR (%) 26.6 24.7 Malaria mortality rate per 100,000 population 5.6 0 Infant malaria rate -IPR (%) 16.5 20.2 Number of nets treated per year 3,685 8,978 Number of persons protected by house spraying 3,423 10,295 Proportion of population covered by ITN or house spraying or both (% 25.2 65.2 2:2 Strengthened Monitoring and Evaluation The Project was to strengthen the ability of the NMCP to use information to manage its program, in coordination with other MOH monitoring and evaluation initiatives and to learn more about individual, household and community aspects of malaria control. The sub-component included: (a) analysis of historical data, (b) creation of a supplementary data management team, and (c) collection of population-based information about behaviour and attitudes relevant to malaria control. a) Analysis of historical data An existing Solomon Islands Malaria Information System (SIMIS) also received assistance under the Project with the provision of two computer sets and accessories solely for the use of SIMIS for GP and MUP. The upgrade and further development of the software for SIMIS was undertaken by the Global Fund.

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b) Creation of a supplementary data management team Data collectors were engaged in MUP to assist the malaria staff at Kirakira to improve on their data collection. This activity was funded between 2000 and 2004 and led to an improvement in data collection in that Province. c) Collection of population based information Between 2000 and 2001 community mapping was undertaken in both MUP and GP, but not so extensively in the latter province due to the unstable situation on Guadalcanal at that time. Collection of population based information for GP was finalised in 2002 to 2003. This proved crucial for the VBDCP as its aim is to improve community participation in the malaria prevention and control program and to have communities have a sense of ownership of the programs and activities being implemented. 2.3 Pilots of Specific Enhancement of NMCP To improve knowledge of malaria control, the Project was to test up to five enhancements to the current control program. The studies were to be conducted in a program of international post graduate study for up to five eligible local professional staff, with oversight of the MOH Research and Ethics Committee. a) Overseas Postgraduate Research and Training A Senior Research Officer, Solomon Islands Medical Training & Research Institute, (SIMTRI) was sent on a one year Master in Public Health program at the Queensland University of Technology (QUT), Australia in 2003. His research was on malaria in pregnancy. The research was done in the Marovo Lagoon area of Western Province. The research paper also led to malaria staff holding workshops with nurses in both MUP and GP on malaria in pregnant women. This has been an innovation not undertaken previously and has also given both groups of health workers the opportunity to update each other on treatment protocol for malaria. A second officer opted to undertake a Post Grad. Diploma in Public Health at the Fiji School of Medicine (FSM) in 2004, but the program went beyond the intended one year period of study. Project management decided that with competing priorities, the funding for this officer’s training would have to cease in 2005. The officer has continued her training with funding assistance from the World Health Organisation (WHO). Two other research topics that were also supposed to be funded under the Project were taken up by other funding agencies.

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2.4 Dissemination of Results for Policy and Program Improvements The Project was to finance dissemination of information of study findings at two stages: (a) a workshop roughly at the halfway point in the Project, to discuss lessons learned to date, and decide on province wide expansion of the best performing enhancements; and (b) at the end of the Project, when results will be disseminated to national stakeholders through a national malaria conference and related activities and publications, and to international audiences through articles and conference presentations. This particular sub-component has not been fully implemented. However, in the Annual National Malaria Conference in 2004 the research paper on malaria in pregnancy undertaken as one of the research postgraduate studies sponsored by the Project was presented. The findings of this research were later used to train nurses in both Provinces on how to handle severe malaria cases especially in pregnant women. 2.5 Sustainability Post graduate training opportunities in the field of research and training have been available outside of the Project. Other staff from the SIMTRI have had the chance to undertake postgraduate training through other donors such as scholarships from Taiwan. As mentioned above, one of the SIMTRI staff undertaking studies at the FSM in Suva, Fiji has had her sponsorship continued by WHO. These activities have been incorporated into the VBDCP operational plan for 2007 with budget allocations in the Ministry of Health’s annual budget. Other aspects of the Component have been taken on board by Rotary Against Malaria (RAM) especially on GP. The Global Fund is to assist those other provinces like MUP and GP whose financial support from aid donors or funding agencies, for example, the SIHSDP ceases. 2.6 Lessons Learned

• Inter-sectoral Taskforce Committees must be strengthened and maintained. • Staff management issues must be resolved. • Data collection and analysis must be rigorously tested given increased staffing and field

worker trainings. • Not everyone undertaking research studies may return to the work place. • Individuals undertaking postgraduate studies need to properly identify course structure

and research fields before taking up studies. 2.7 Main Factors Affecting Implementation On GP, the main factor affecting implementation of malaria prevention and control activities has been years of social unrest that meant malaria field staff could not access most if not all parts of rural Guadalcanal. In MUP, serious staff management issues created ineffectual

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leadership of the malaria prevention and control program there leading to impediment of progress in the implementation of activities and flaws in reporting data. Another factor affecting implementation was the fact that it took time to convince individuals to undertake postgraduate studies at institutions they perhaps were not to willing to attend. Ironing out differences and difficulties in intended research fields with the proposed educational institutions added to the delay in securing places for individuals in postgraduate studies thus all identified training did not happen in the early years of the Project. 3. Capacity Building – USD0.37 M To support the current public sector reform and reinforce the impact and sustainability of the priority programs, the Project was to help increase the capacity of the MOH and participating provinces in: (a) health planning and management, with emphasis on (i) the health management information system, (ii) monitoring, evaluation and research, and (iii) donor coordination; and (b) health promotion and education, with emphasis on improved effectiveness of health promotion in the priority program areas, and testing ways to improve outreach and community participation.

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3.1 Health Planning This Component was to improve MOH capacity in relation to the health sector as a whole and also in relation to the Project itself. It was to assist MOH to use its data to inform key stakeholders and to promote accountability in service delivery. The Project was to support activities to: (a) improve the development and use of the health management information system (HMIS), (b) monitor and evaluate both routine and special programs and initiatives, and (c) coordinate support from donors and other development partners. a) Improve the Development and Use of the HMIS Progress was made towards engaging a local HIS consultant to develop software to upgrade the then current HIS. The Project stopped short of funding the IT consultant as AusAID decided to take on the activity together with that of improving the National Referral Hospital (NRH) information system. Staffing for the HIS Unit was improved with the employment of four data entry clerks and one Medical Statistician Specialist under the Project. b) Monitor and evaluate both routine and special programs and initiatives The Project funded the training of provincial HIS officers in the upgraded version of the newly developed HIS software and provided computers to all provinces concerned for this purpose. There has been an increased level of HIS reporting from all provinces since the training happened which is encouraging. c) Coordinate support from donors and other development partners The position of Donor Coordination Officer in the Ministry’s Planning Unit was never filled as requested in the PAD. Despite this, efforts were made at the Ministry’s Executive level, through the Project Director, to coordinate support from donors and other development partners especially with the development and upgrade of the HMIS and the HIS which the Health Institutional Strengthening Project (HISP), funded by AusAID eventually funded. 3.1.1 Sustainability Three data entry clerk positions and one medical statistician specialist position initially funded by the Project have been transferred by mid 2005 to line positions within the Ministry’s established employment structure. Only one other data entry clerk position continued to be funded under the Project from 2005 to 2006. 3.1.2 Lessons Learned

• Finding an IT Specialist to develop and upgrade existing HIS software has been an almost impossible task

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3.1.3 Main Factors Affecting Implementation One of the main factors affecting implementation of this sub-component was that of the extreme difficulty in identifying an IT Specialist who could expertly handle the upgrade of the existing HIS software. A local IT Specialist was engaged (funded by HISP), but the software developed had initial teething problems and still has. Despite these difficulties, the HIS Unit continues to produce monthly and annual reports. Another factor affecting implementation was the incapability of the Ministry’s Planning Unit to effectively monitor and evaluate the Project’s progress due to staffing problems in the Unit. Over the duration of the Project, there were only two staff in the Unit; the Director and a Human Resources Officer. Additional human resources were only engaged by the Ministry in 2006. 3.2 Health Promotion The health promotion function in the reorganised Ministry of Health was to be assisted through: (i) essential capacity building based on a comprehensive performance review and needs assessment in the first six months of the Project. It was expected to include improved planning procedures, technical assistance, training and some equipment; (ii) development and implementation of communication strategies to support Components A and B, and (iii) implementation of up to three (3) pilot initiatives to strengthen coordination with local NGOs and increase community participation in improving the utilisation of health programs. As indicated in Exhibit 1, five (5) staff from the Health Promotion Division of the Ministry of Health benefited in training financially supported by the Project. 3.2.1 Sustainability Like the rest of the Components, this sub-component has transferred most of the operational costs supported by the Project to its budget under the Ministry. It is not clear whether the performance review will still be carried out or not. 3.2.2 Lessons Learned

• The process of engaging international technical advisors can be riddled with unexpected problems.

3.2.3 Main Factors Affecting Implementation The major factor affecting implementation of this sub-component was the failure to instigate the structural and performance review of the Health Promotion Division. If this important activity was carried out there would have been a more clearer vision for the Division hence more appropriate and relevant training of staff undertaken. Initially the Asian Development Bank was interested in assisting this sub-component, but when all plans fell

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through, the sub-component became an ad hoc piece to Component C. As such, support for this sub-component was in the form of funding once a year activities like “World AIDS Day” only with ad hoc support for the training of village health workers. 4. Project Coordination And Management – USD0.52m A Project Coordination and Implementation Unit (PCIU) was established in the Planning Unit of the Ministry of Health to provide Project support functions and liaise with implementing units within the Ministry and provinces. The Unit was responsible for financial management, non-technical procurement functions and support to implementing units for activities funded by the Project. The Unit served as the Secretariat for the Project Coordination Committee (PCC) and the Project Director and handled communications with the World Bank. 4.1 Financial Management The Project’s financial management system was designed around the four main components of the Project with their set activities. The expenditure was divided into five (5) categories namely civil works, goods and equipment, consultants’ services, training and incremental operating costs. Large value procurements in civil works, goods and equipment, training and consultants’ services were also included in these categories. The financial management system further comprised five main components: 1) the commitment system; 2) the payment system; 3) the accounting system; 4) the drawdown system and 5) the reporting system. Official stationery used in the system were existing forms from both the Solomon Islands Government and the IDA. The system established manual registers and files and only managed to translate the commitments ledger in 2003 to electronic form. Monthly, quarterly and annual financial reporting was regularly undertaken by the Project Accounting Officer with assistance from the Project Officer and the Project Coordinator. 4.2 Procurement Functions The procurement functions of the Project were guided by World Bank standard guidelines on procurement of goods and selection of consultants. These were read in conjunction with the SIG’s financial instructions. Due to the fact that in the early years of the Project the Central Tender Board was practically non-existent, the PCIU relied heavily on the World Bank standard guidelines for its procurement functions. 4.3 Support to Implementing Units The main support given to implementing units was the coordination of annual work plans and requests for payments towards each of the four (4) Components set activities according to the work plans each year. The PCIU also provided much guidance in terms of decision making for each of these Components and their sub-components especially when bottle neck situations arose. Often the PCIU found it had to play a leading role when it came to decisions affecting more than implementing units.

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4.4 Project Coordination Committee (PCC) Meetings The PCIU also provided secretariat support to the Project Coordination Committee (PCC) which met regularly up to 2005. In 2006 only two PCC meetings were held before the final close in December. These meetings guided the Project through difficult times and were a measure of keeping the Project on track. 4.5 Specific Component Feedback 4.5.1 Component A The obstetrics services survey was supposed to be carried out in the first year of the Project, but this unfortunately did not happen due to various reasons, the main one being the social unrest prevailing in the country during the inception year. An obstetrics services survey was, however, carried out in late December 2005 at Aola on Guadalcanal Province by the Reproductive Health Division of that province. The aim of this survey was to assess why more than 50% of pregnant women chose to deliver their babies at home rather than in the clinics under supervised assistance. The survey was done through individual interviews using a questionnaire. Trained survey assistants carried out the survey. Of the total 80 individuals interviewed 40 were men whilst the other 40 were women. The survey was carried out over a period of 14 days from 12 to 20 December 2005. 4.5.2 Component B Data on malaria control, morbidity and mortality has been collected and analysed on a monthly basis to establish disease trends and the effectiveness of the malaria control operations of the VBDCP. Since the year 2000, there have been monthly, quarterly, some times six-monthly reports and annual reports produced by the VBDCP not only on the disease trends, but also on the weaknesses and strengths of the malaria control operations in both Guadalcanal and Makira Ulawa Provinces. As such, today the VBDCP has been able to regularly report on the reduction of malaria morbidity and mortality in each of these provinces each year. The reductions may be slight, but this indication alone allows the Program to evaluate and appropriately strengthen its control program in both provinces each year. 4.5.3 Component C A survey of health services infrastructure was conducted in 2005 by the Ministry of Health’s AusAID-funded Health Institutional Strengthening Project’s (HISP) Infrastructure Advisor. In May 2006 a review report6 on rural health clinics (RHCs) was prepared for the Ministry outlining the general state of the 115 RHCs throughout the country. It was found that the size of the RHCs were adequate except that they lacked space for public health care activities

6 Primary Health Care Infrastructure Review – Part 2: Rural Health Clinics, Prepared by JTA International for Australian Agency for International Development (AusAID), May 2006

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such as ante-natal classes for example. Delivery rooms were often too small and poorly planned whilst overcrowding in the outpatient departments were a concern. There was also lack of storage space in the RHCs. The report went on to state that the building condition of more than half the RHCs reviewed was poor or dilapidated due to lack of regular maintenance, white ant infestation and old age. Water supply, sanitation, infection control and waste disposal services were also insufficient. The provision of lighting to these clinics was also poor. Each clinic assessed by the review was measured against the utilisation benchmarks7 and on this basis was rated as having met or exceeded the benchmark for their current designation (AHC, RHC, or NAP). If this was unclear, it was stated. PHC clinic utilisation of 232 clinics was compared with the utilisation benchmarks. Of these, 95 (41%) were assessed as meeting one or more benchmarks, 33 (14%) exceeded the benchmarks for current designation, 55 (24%) met no benchmarks and for 49 (21%) the situation was unclear. A small number of clinics were very poorly utilised and should be considered for closure as they do not appear to be sufficiently isolated to maintain a full time clinical service. Identification (tables) and discussion of clinics failing to meet or exceeding benchmarks are included in the main document. Two (2) clinics reached the upgrade criteria for mini hospital (both in Malaita), four (4) RHCs met the upgrade criteria to AHC (all in Malaita). An additional four (4) were approaching the AHC upgrade criteria (2 Malaita clinics, 1 Central and 1 in Western. 52% of clinics exceeding benchmarks are in Malaita province. 78% of clinics identified for upgrade from RHC to AHC or AHC to mini hospital are also in Malaita. 4.6 Sustainability As the Project has come to an end, there is no longer the need to keep the PCIU functioning. However, it is timely to consider that due to the fact that there are many projects running concurrently within the Ministry, such a Unit should be maintained within the Planning Division especially for monitoring and evaluation purposes; an aspect that is lacking within the Ministry’s Planning Division thus making it difficult for the Ministry to evaluate its projects on a regular and timely basis. 4.7 Lessons Learned

• Not all staff engaged will have the necessary skills/knowledge to work as a team. • Multi-skilling is important and crucial given the short-term nature of projects.

7 Primary Source for the Clinic Utilization from: HISP/MOH 2006: in the Solomon Islands National Health Review – February 2006

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• It is better to delegate existing staff rather than employ new staff if only months remain before closing project.

• Skills development workshops to enhance and strengthen staff decision making important. • Communications between Ministry and project management need to be improved. • Regular stakeholders meetings must be encouraged. • Monitoring and evaluation critical to effective delivery of projects.

4.8 Main Factors Affecting Implementation The main factor affecting implementation of the Project was the on-and-off-again suspension of disbursement funding from 2001 to 2003. This set the Project back a couple of years and disrupted the general flow of activities for implementation. It also caused Project management to place greater emphasis on training putting the implementation of much needed rural health facilities on the back burner. This is one of the several reasons for why the rural health facilities never got off the ground at all. High staff turnover especially in the last year of the Project also contributed to a less efficient closing of the Project’s accounts and disrupted the process of rural health facilities civil works. 4.9 Bank and Borrower’s Performance a) Bank Performance During Project Preparation - Satisfactory During Project Implementation (supervision) – Satisfactory b) Borrower Performance During Project Preparation – Satisfactory During Project Implementation – Satisfactory

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Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders Comments from AusAID Overall the project contributed to improvements in reproductive health outcomes in Solomon Islands through its support to the midwifery training program and resources for increased reproductive health outreach service to rural communities. Provincial Health Advisers supported the project rollout where possible in the provinces. The eventual cancellation of the rural civil works component of the project, in particular the rehabilitation of clinics in Makira and Guadalcanal was a great disappointment to the MoH who had raised the expectations of these developments in local communities, and have no resources to cover this deficit.

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Annex 9. List of Supporting Documents

Bank Reports Aide Memoires, management letters during project preparation and appraisal

Project Concept Note (January 21, 1999) Minutes of PCN (February 9, 1999)

Project Information Document (January 21, 1999) Appraisal Completion Note (October 14, 1999) Invitation to Negotiations (October 16, 1999) Minutes of Negotiations (October 20, 1999) BTO of Appraisal/Negotiations mission (October 31, 1999) Status of Negotiations (October 25, 1999) Project Appraisal Document (December 9, 1999) Development Credit Agreement (January 27, 2000) Aide Memoires, management letters, PSRs/ISRs (sequence 1 – 15 from June 2000 to December 2006) Joint ADB/World Bank Assessment Report (October 2003) Mid-Term Review Aide Memoire (June 15, 2004) Letters to government (2000 – 2006) ICR for Education Project Government Reports Project Implementation Plan (September 17, 1999) Government letter confirming fulfillment of Board conditions (November 30, 1999) Semi-annual Government Progress Reports (2000-2006) National Health Strategic Plan (2006-2010) Health Status Reports Results of various surveys Borrower’s Completion Report (February 18, 2007) Borrower’s contribution to the ICR for the Education Project UN Reports Human Development Report 2002 Common Country Assessment – April 2002

W E S T E R N

M A K I R A

T E M O T U

M A L A I TA

CHOISEUL

ISABEL

GUADALCANAL

CENTRAL

RENNELL ANDBELLONA

Kundu

Sasamungga

Seghe

Kia

TatambaHapaiDaringali

Tarapaina

Heuru

Apaora

Mwaniwowo

Paruru

Tinggoa

Tutumu

Noka

Vana

Su'uMaravova

Dadale

Avu Avu

Luti

Sosolo

Tulagi

Buala

Kirakira

Lata

Auki

Tigoa

Taro Island

Gizo

HONIARA

PAPUANEW GUINEA

VANUATU

SOUTH PACIFICOCEAN

Coral Sea

Solomon

Sea

N e wG e o r g i a

S o u n d

Choiseul

Santa Isabel

Malaita

Ontong Java Atoll

IndespensableReefs

Roncador Reef

San Cristobal

Rennell

Nendo

Santa Cruz IslandsUtupua

Reef Is.

Duff Is.

Tinakula

Fatutaka

Tikopia

AnutaVanikolo

Bellona

Guadalcanal

Shortland Is.

Vella Lavella

Kolombangara

New Georgia

New GeorgiaGroup

Ranongga

Rendova

Tetepare

San Jorge

Russell Is.Florida Is.

Vangunu

Nggatokae

Vaghena

Ulawa

Dai

Maramasike

Mono

Mt. Makarakomburu(2,447 m)

156°E 158°E

156°E 158°E

160°E 162°E 164°E 166°E 168°E 170°E

164°E 166°E 168°E 170°E

6°S

8°S

10°S

12°S

14°S14°S

10°S

8°S

6°S

SOLOMONISLANDS

This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other informationshown on this map do not imply, on the part of The World BankGroup, any judgment on the legal status of any territory, or anyendorsement or acceptance of such boundaries.

0 50 100

0 50 100 150 Miles

150 Kilometers

IBRD 33482

MA

RCH

2005

SOLOMONISLANDS

SELECTED CITIES AND TOWNS

PROVINCE CAPITALS

NATIONAL CAPITAL

MAIN ROADS

PROVINCE BOUNDARIES

INTERNATIONAL BOUNDARIES