Evaluation Summary HLH Project Mid- term Evaluation 2021

Objective: Purpose of the Mid-term Evaluation was to conduct an evaluation of project performance to date, strengths, and weaknesses in implementation aimed at making recommendations on priority actions or change of direction needed to deliver on the project outcomes by end 2022. The Mid-term Evaluation measured project interventions against the efficiency, effectiveness, and relevance, sustainability, coherence, and impact standards of the project.

Method: Document reviews, Focus Group Discussions (FGD), structured questionnaire, Key Informant Interviews (KII) and field visits.

Key Findings: NCA performance as grant manager: NCA has been in the forefront in making sure the hospital management reforms, board reforms, feasibility studies, technical, equipment and infrastructure support results positively in enhancing HLH governance. On annual basis; NCA conducts annual clinical review assessments and financial reviews and audit visits just to make sure HLH is run according to professional standards, guidelines and contractual agreement. NCA has demonstrated efficiency and value addition to the project as grant manager in the following areas:

• Increased efficiency in funds transfer to HLH
• NCA has increased capacity to follow up issues at HLH and attend them quickly
• With adequate capacity building, NCA has enabled the owner and the board to be professional and proactive as well
• NCA has helped change the mindset of HLH staff, owners and the board to creativity and sustainability focus
• NCA conducted financial sustainability training for HLH senior and middle managers
• NCA also has been instrumental in mobilizing extra Norad funding on top of the grant funds: - 2018 -2019 bridge funding from old to new grant, which helped to secure important investments in strategic equipment - NOK 5 million in extra funding to respond to the impacts of COVID in 2020. Without this funding HLH deficits in 2020 would surely have increased.

Progress vs KPIs:

 Overall there was a remarkable progress in the key results areas of the HLH project: 16 indicators (42% of the total 38 indicators) have already surpassed 2020 targets and are closer to the End-of the Project (EOP) targets, 8 indicators (21% of them) were close to 2020 targets. 9 indicators (24%) were far from 2020 targets and 5 indicators (13%) were totally off the 2020 targets.

Generally; the project is on track towards attaining the required project impact but more reforms are still needed to attained the required sustainability aspects

Sustainability:

• Percentage (%) of Norad funding to the total HLH budget: 2019: Target (28%), Actual (31%), 2020: Target (26%), Actual (35%), EOP Target (23%). The numbers put a doubtful trend if the target of reducing the dependency to 23% by 2022 will be realized.
• Annual deficit decreased significantly to 126 million in 2020 million from TZS 1.4 billion in 2019. The EOP is having 0 deficit by 2022.
• Trend on GoT funding to HLH: The target of GoT funding was missed in both years (i.e.2019 and 2020), targets were 20% and 21% in year 2019 and 2020 respectively. Actuals were only 19% and 18% in year 2019 and 2020 respectively.
• Funding from Non-medical Services including Gifts: The income target of 9% (in 2019 and 2020) of total budget was missed in both years and ended at only 6% in 2019 and only 4% in 2020. The HLH explained the problem as attributed to the ongoing COVID 19 pandemic that has downsized the flow of students who normally come for short term courses, research and income generated
• The income from medical services increased from TZS 3.8 billion in 2019 to TZS 3.87 in 2020 billion, marking an increase from 28.2% of total HLH budget in 2019 to 31.2% in 2020. The trend is positive, but the target of reaching 36% of the total budget by 2020 was missed.

Relevance: The HLH project is rated as relevant based on consistency to the country’s and global development priorities, soundness of the analysis of the development problem, and appropriateness of the proposed solution to the development problem.

Effectiveness: The assessment team marked HLH project interventions as effective in achieving planned outcomes. The evaluation shows that there is positive collaboration between all stakeholders of HLH. HLH abides to all GoT rules and regulations, including submitting all necessary reports to the Government on time including adhering to regulatory and compliance standard as evidenced by regional, district and Mbulu District Council representatives. The board was restructured to suit the growing and professional needs of the modern health facility and future sustainability. The most significant area they have been working together is in advocacy and lobbying for more support from the Government, although the financial results/achievement are yet to be realized so far as GoT funds is declining.

Efficiency: The HLH medical and non-medical income increased between 2019 and 2020; this achievement is attributed to the project interventions between the project periods; hence, evaluated as successful. However, income from the projects did not meet expectation as performed below the target. The findings from the financial reports showed that HLH costs were not proportionate to incomes, this led to discrepancies. Inadequate documentation for the services provided to patients for record keeping and for billing purposes. Shortage of financial control on the use and handling of medicine, medical supplies, stationary items and food items.

Effects of factors outside of the control of the project on project implementation: The outbreak of COVID-19 pandemic significantly affected the implementation of project and its objectives, for instance in the Reproductive and Child Health (RCH) services, HLH served 27,678 pregnant women and 67,097 children in 2020 compared to 30,730 pregnant women and 100,160 children in 2019. Moreover, the decreased funding from the GoT has largely affected the implementation of the project activities since the expectation was for the Government to increase its funding to HLH. Finally, the affordability to services was somehow affected as the newly introduced improved iCHF is not acceptable at HLH; this led to the decline in iCHF patients and income from TZS 101 million in 2019 to zero (0) in 2020.

Specific Recommendations:

• NCA and HLH need to fast track the preparation of the planned sustainability strategy (refer HLH Strategic plan 2019 -2023) which will show both short term and long-term measures to reduce dependency rate on donors (e.g., Norad funds) and increased efficiency in corporate business and income generating projects.
• A sustainable capacity building plan should be prepared with a target of increasing income at HLH in the three pillar areas: Medical Services, Projects/Corporate Unit and the Research Unit.
• NCA needs to prepare a clear exit strategy for HLH support that shows gradual stages for Norwegian Government funds reduction at the same time building capacities in the required sustainability aspects.
• Potential future Norad support should concentrate on financial sustainability. Specific investments should be done in areas of human resources so that HLH has enough technical health experts who can offer specialized medical services that ensures stable income.
• Additionally, investment should be geared towards building or renovating for modern infrastructure (e.g., wards with private rooms, private family rooms, and fast-tracking services etc.) and medical equipment, which could generate sustainable sources of income for the hospital.
• HLH and its core stakeholders; NCA, Mbulu Diocese and CSSC should continue advocating for an increase in Government support to the facility, the signing of MoU between the Government and HLH and endorsement of PPP documents to allow smooth future engagement with the Government.
• HLH board should be proactive and professional enough to make use of HLH financial and service delivery data, triangulation of information and act as a mechanism to monitor financial, relational, security and strategic risks of the facility.
• NCA and HLH should revise the Project results framework to include Performance Indicator Reference Sheet (PIRS) indicating precise indicator definitions, unit of measure, and frequency of reporting, data sources and means of verifications. This will allow easy tracking of project results and assessment of the entire Monitoring and Evaluation System.
• HLH Board should hire a Business Continuation Advisor for effective supervision of business strategies, models and plans.
• NCA should consider involving a partner with more specific competence in medical and health management, which can adapt and contextualize the training and supervision to a hospital operating in a resource poor setting.
• HLH Research Unit should capitalize on research grants and opportunities coming in Tanzania and Africa for various themes. The unit is matured and scientific enough to hold scientific conferences, find other partners worldwide, and hold international symposiums and conventions.