Document of The World Bank FOR OFFICIAL USE ONLY Report No.: 17756 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRAT'ED CHILD DEVELOPMENT SERVICES PROJECT (CREDIT 2173-IN) April 28, 1998 Health, Population and Nutrition Unit South Asia Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (as of January 23, 1998) Currency Unit = Indian Rupee (Rs.) Rupee 1 = US$0.025 US$1.00 = Rupee 39.50 GOVERNMENT FISCAL YEAR April 1 - March 31 ABBREVIATIONS AND ACRONYMS ACDPO Assistant Child Development Project Officer APERP Andhra Pradesh Economic Restructuring Project AWC Anganwadi Center AWW Anganwadi Worker ANM Auxiliary Nurse-Midwife CARE Cooperative for American Relief Everywhere CDPO Child Development Project Officer CSSM Child Survival and Safe Motherhood Project DPEP District Primary Education Project DTT District Training Teams DWCD Department of Women and Child Development DWCRA Developing Women and Children in Rural Areas GOI Govenmment of India ICDS Integrated Child Development Services IDA Intemational Development Association IMR Infant Mortality Rate LBW Low Birth Weight NNMB National Nutrition Monitoring Bureau PMU Project Management Unit SAR Staff Appraisal Report SRS Sample Registration System TINP Tamil Nadu Integrated Nutrition Project WILL Women's Integrated Learning for Life Vice President Mieko Nishimizu Director Edwin Lim Sector Manager Richard Skolnik Team Leader Anthony Measham FOR OFFICIAL USE ONLY IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT (CREDIT 2173-IN) CONTENTS Page No. Preface Evaluation Summary ii PART I: Project Implementation Assessment A. Project Objectives 1 B. Achievement of Project Objectives 3 C. Major Factors Affecting Project Implementation 9 D. Project Sustainability 10 E. Bank Performance 10 F. Borrower Performance 11 G. Assessment of Outcome 11 H. Future Operation II I. Lessons Learned 12 PART II: Statistical Tables Table 1: Summary of Assessments 15 Table 2: Related Bank Credits 17 Table 3: Project Timetable 20 Table 4: Credit Disbursements 21 Table 5: Key Indicators for Project Implementation 22 Table 6: Studies Included in the Project 24 Table 7A: Project Costs 27 Table 7B: Project Financing 28 Table 8: Status of Legal Covenants 29 Tablle 9: Compliance with Operational Manual Statements 33 Table 10: Bank Resources: Staff Inputs 34 Table 11: Bank Resources: Missions 35 APPENDICES Appendix A. The ICR Mission's Aide-Memoire Appendix B. Borrower's Contribution to the ICR This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT (CREDIT 2173-IN) PREFACE This is the Implementation Completion Report (ICR) for the Integrated Child Development Services Project in India (Credit No. 2173-IN). The total credit amount of US$106 million, which was approved on October 23, 1990 and made effective on January 28, 1991, included an IBRD share of US$10 million and an IDA share of US$96 million (SDR 73.6 million equivalent). This amount was subsequently revised to include only an IDA credit of US$74.35 million. The credit closed on the original closing date of December 31, 1997 and was fully disbursed. This ICR was prepared by Anthony Measham (Task Leader) and Stuart Gillespie (Consultant), with technical assistance from Kathleen Finn, P. Subramaniam, Alaka Singh, Meera Priyadarshi, R. Sethuraman and Krishna D. Rao. Nira Singh provided office technology assistance. The ICR was reviewed by Richard Skolnik (Sector Manager, SASHP) and Kazuko Uchimura (Project Advisor, SARRI). Preparation of this ICR began during the November 1997 supervision mission. It is based on material in the project files, field visits, and discussions with beneficiaries, project staff, Government officials and Bank staff. The Borrower contributed to the preparation of the ICR by preparing its own evaluation of the project with the assistance of the State Governments of Andhra Pradesh (GOAP) and Orissa (GOO). Comments on the draft report were received from the Borrower and taken into account in the final version. However, the Borrower in both states was more positive regarding the achievement of project objectives than Bank staff. In particular, Bank staff were not convinced that the project could have been responsible for most of the improvement in impact indicators, since many key process indicators performed relatively poorly. The cooperation and assistance of GOI and the State Governments of Andhra Pradesh and Orissa is gratefully acknowledged. IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT (CREDIT 2173-IN) EVALUATION SUMMARY Introduction 1. Following the Tamnil Nadu Integrated Nutrition Project (TIMP I) in the 1980s, the Integrated Child Devielopment Services (ICDS I) Project in Andhra Pradesh and Orissa was the second nutrition operation to be supported by the World Bank in India. Implementation of ICDS I coincided with TINE, HI. Other related Bank-assisted projects in India which soughit to improve family welfare and reduce maternal and child morbidity and mortality during the 1970s and 1980s include seven population projects, and the Child Survival and Safe Motherhood Project. Project Objectives 2. The broad ovrerall objective of the ICDS I project was to improve the nutrition and health status of children under six years of age, with special emphasis on 0-3 year-olds, and pregnant and lactating women, in the states of Andhra Pradesh and Orissa. Specifically, the project aimed to halve rates of severe malnutrition amnong 6-36 month-old children, increase by 25% the proportion in normal or mnild malnutrition grades, reduce the incidence of low birth weight by 30% in Andhra Pradesh and 20% in Orissa; and contribute towards a reduction in the infant mortality rate to 60 per 1 000 live births in Andhra Pradesh and to 1 00 per 1 000 live births in Orissa. 3. The project covered a total of 301 rural, predominantly tribal blocks in both states, covering an estimated 12.9 million population in 13 districts of Andhra Pradesh, and 9.5 miillion in 12 districts of Orissa. 4. Project strategy centered on the following approaches: (a) improving maternal nutrition through strengthenedi antenatal care and on-site food supplementation for high risk women by mid-pregnancy; (b) iimproving household health and nutrition behavior through communications and community mobilization; (c) increasing health service coverage to prevent or reduce the detrimental effect of infections and refer severely malnourished children to the appropriate levels of the health care system; and finally; (d) providing therapeutic food supplementation to malnourished under-three year-old children. 5. These four strategic approaches were to be supported by strengthened systems of management, training), communications, logistics, monitoring and evaluation. In addition, the following three innoviations were planned: (a) supervision was to be improved through better ii training, reorganized work routines, and the addition of a block-level supervisor; (b) supplementary feeding criteria were to be modified, if warranted, by the findings of operational research, in order to more effectively prevent malnutrition among the youngest children; and (c) women's programs were intended to enrich the ICDS through optimizing community support and participation. Implementation Experience and Results 6. The delay in reporting the terminal evaluation has prevented a conclusive judgement being made on the project's progress towards its objectives. The 1996 mid-term review, also delayed, points to significant differences between the two states in project outcomes. Andhra Pradesh appears to have made significant progress towards the main nutritional impact objectives, while the nutritional situation in Orissa may have actually worsened. On the other hand, Orissa has surpassed its infant mortality reduction objective, while the situation in Andhra Pradesh has remained largely unchanged. The limitations regarding the reliability and representativeness of low birth weight incidence data preclude an accurate assessment of progress towards this objective, but it is unlikely that the project contributed much to improvements in this area. One of the main problems experienced in this project was the poor planning and implementation of monitoring and evaluation. Overall, the process indicators suggest that the project is unlikely to have made much of a dent in any of the impact objectives, and the changes noted are mainly due to secular trends. 7. Service delivery on the whole was quite poor, particularly with regard to the main nutrition interventions of child weighing and supplementary feeding. This was associated with inadequate training in general and particularly the missed opportunities of employing supervisors as local trainers. There were also significant delays in the development of a communications strategy which constrained communications efforts and the quality of service delivery, although Andhra Pradesh made some late progress through an interim strategy. On the community mobilization front, there were significant examples of local-level success which suggest there is potential for an active sustained involvement of communities in the ICDS program. 8. A fundamental problem of program philosophy affected the implementation of this and the ICDS II project. ICDS is widely viewed, by political leaders, bureaucrats, functionaries and beneficiaries alike, as a government program providing pre-school education and child feeding. In contrast to TINP, no major effort has been taken to market the program as one aimed at preventing malnutrition through behavior change among mothers. This accounts in large measure for the preoccupation of GOI and the states with quantity over quality, and their related lack of interest in research and evaluation. As a result, and as shown in multiple evaluations, ICDS has relatively limited impact on its main objective of reducing malnutrition. Social indicators are better in ICDS blocks than non-ICDS blocks, and ICDS runs better in Bank-financed blocks than in other blocks. But despite strenuous efforts over many years, the Bank has not succeeded in its efforts to promote in ICDS, the kind of behavior-change program Tamil Nadu succeeded in harnessing through TINP. ii 9. Many operational research studies were initiated although their completion was usually delayed into the final years of the project, thus limiting their utility. The mid-term review was delayed until the middle of the penultimate year of the project. A significant advance was however made with the development of an information system in Andhra Pradesh, which has since served as a model for other states. Monitoring in Orissa on the other hand was relatively weak. The fact that quantity (of hardware) took precedence over quality (of software) in the project, was most clearly reflected in the prioritization of indicators for monitoring. In both states, the monitoring and indeed the achievement of fiscal and physical targets was better than with regard to other process and outcome indicators. 10. The prospect for sustaining the project in Orissa and Andhra Pradesh is quite good given the expressed commitment of the national and state governments and the overall commitment of the Government of I]ndia to universalize the ICDS within the next few years. Key Lessons Learned 11. Ensure Service Quality. One main lesson learned is that high quality and timely training of project functionaries is a sine qua non for high quality service delivery. It is also essential to prioritize inter-personal communications for home-based behavior change if a sustained impact is to be expected on moderate, as well as severe, child malnutrition. The role of additional supervisor, as initially envisaged, should have been focused on supporting the anganwadi worker in appropriate nutritional counseling during targeted home visits -- yet these posts were not filled in this project. The national training curriculum for AWWs and supervisors requires a greater focus on strengthening capabilities to prevent malnutrition among very young children, in their own homes. Timely job and refresher training backed up by one-to-one support of the anganwadi worker by the supervisor should be the bedrock of such capacity-building in projects of this type. 12. Avoid Overemphasizing Food. A second, related lesson concerns the need for an increased emphasis on the health and care-related factors determining nutrition outcomes in the youngest children. Food supplementation should not be considered as the raison d'etre of the project, but rather as one of several means to improve child growth and nutrition. Such a pervasive food distribution bias has reduced the attention and priority attached to inter-personal communications and counseling, which are vital to improve the care-related determinants of child nutrition. 13. Prioritize Operational Research. Third, operational research needs to focus on a reduced number of high quality, carefully conducted and punctually reported studies to be carried out within the first 2-3 years of the project, in order that findings can be used to improve the project. One important overriding question to be addressed is how, in a future beyond externally- supported programs, can all the food, health and care preconditions for child nutritional well- being be ensured and sustained in rural India. The quality and timeliness of mid-term reviews and endline surveys also needs to be improved. Better procurement planning, improved quality assessment of bidding agency proposals, timely monitoring of implementation and follow-up of specific recommendations are also required. Failure to comply with covenants in such areas should be considered as grounds for project suspension in future. iv 14. Improve Monitoring and Evaluation. Fourth, more importance needs to be attached to monitoring, with respect to quality in general, and the need to more visibly track progress towards the impact objectives in particular. Child nutritional status data need to be made more visible at all levels in the project management system, and to be used for improved action where outcomes are lagging. Evaluation planning and implementation needs to be significantly improved. 15. Strategic Issues. ICDS I brought into sharp focus three strategic program issues: * the bias towards expansion (quantity) over quality; * the under-funding of training; and * the one-worker versus two-worker model. The project demonstrated clearly that rapid expansion of ICDS into new blocks usually comes at the expense of service quality. It appears that the Bank contributed to this problem by financing a project that was beyond the absorptive capacity of the two states. The hardware components were completed but quality of training, communications, and services was not up to the mark. 16. Experience with ICDS I and preparation of the forthcoming WCD project and ICDS component of APER project have brought out the fact that the current finance norms for training are much too low to ensure quality training, which is fundamental to ICDS success. Both new projects include, as conditions of Negotiations, adoption of the greatly enhanced norms proposed by the Department of Women and Child Development but not yet approved by GOI. 17. International experience and that of Tamil Nadu suggests that it is not possible simultaneously to provide nutrition, health and pre-school education with one worker. Ongoing GOI/Bank collaborative sector work is examining the one-worker versus two-worker question. The outcome of ICDS I suggests that ICDS will only achieve its potential impact if two workers are employed. That would require either targeting the food supplementation, or increasing the GOI or state financing of ICDS, neither of which would be easy, but both of which would have the desired impact on child malnutrition in India. Project Outcome 18. Although definitive terminal evaluation findings were not yet available, the poor service delivery performance suggest project outcomes are unsatisfactory in both states. One significant achievement of the ICDS I project however was the fact, borne out by the mid-term review, that it was successfully targeted to the most disadvantaged population groups, thus improving their access to nutrition and health services. Notwithstanding the fact that the project failed to meet its development objectives, it still enabled ICDS to perform better than in non-Bank-financed states, and was responsible for service delivery improvements well worth sustaining. 1 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT (CREDIT 2173-IN) PART I: PROJECT IMPLEMENTATION ASSESSMENT 1. Prior to the Integrated Child Development Services (ICDS I) Project in Andhra Pradesh and Orissa, IDA had supported one nutrition operation in India -- the Taniil Nadu Integrated Nutrition Project (TINP I) -- between 1980-89. Implementation of ICDS I coincided with TINP II. Other related Bank-assisted projects in India, approved between 1972 and 1991, include seven population projects, and the Child Survival and Safe Motherhood Project -- projects which sought to improve family welfare and reduce maternal and child morbidity and mortality. 2. Both ICDS I and TINP II aimed at improving the nutrition and health status of young children and pregnant and lactating women through an integrated package of community-based activities, with a village-based nutrition worker as the focal point. The ICDS I project represents the first direct support by the World Bank to the ICDS program in India. Following its approval in 1990, a second loan was approved in 1993 for support to ICDS in the states of Bihar and Madhya Pradesh (ICDS II). A. PROJECT OBJECTIVES 3 . The overall objective of the ICDS I project was to improve the nutrition and health status of children under six years of age, with special emphasis on 0-3 year-olds, and pregnant and lactating women, in the states of Andhra Pradesh and Orissa. 4. Project Coverage. The project covered 110 predominantly tribal, drought-prone and disadvantaged rural blocks in Andhra Pradesh and 191 tribal and rural blocks in Orissa. In Andhra Pradesh, the project aimed at strengthening and enriching services in 44 existing ICDS blocks and extending the program to an additional 66 blocks covering an estimated 12.9 million population in 13 districts. Similarly, in Orissa, 69 existing blocks and 122 additional blocks were to be covered, the latter including 70 tribal blocks and 52 blocks with a high proportion of disadvantaged population groups. In total, an estimated population of 9.5 million in 12 districts in Orissa were to be covered. 5. Specific Objectives. The specific objectives of the project were to: * reduce by 50% severe malnutrition (Grade III and IV) among 6-36 month-old children; * increase by 25% the proportion of 6-36 month-old children in normal or mild (Grade I) malnutrition status; 2 * reduce the incidence of low birth weight (LBW) by 30% in Andhra Pradesh and 20% in Orissa; and * contribute towards a reduction in the infant mortality rate (IMR) to 60 per 1000 live births in Andhra Pradesh and to 100 per 1000 live births in Orissa. 6. In addition to these impact objectives, 23 process objectives were specified in the Staff Appraisal Report (SAR) with state-specific targets. Key available data which permit an assessment of progress towards these objectives are provided in Table 5. 7. Project Strategy. The overall project strategy consisted of three elements: an expansion of ICDS coverage; the application of lessons learned in the first Tanil Nadu Integrated Nutrition Project (TINP-I); and the testing of new approaches towards community mobilization. Specific approaches included: * improving maternal nutrition through strengthened antenatal care and on-site food supplementation for high risk women by the twentieth week of pregnancy; 3 improving household health and nutrition behavior through communication and community mobilization; 3 increasing health service coverage to prevent or reduce the detrimental effect of infections and refer severely malnourished children to the appropriate levels of the health care system; and * providing therapeutic food supplementation to malnourished under-three year-old children. 8. Strengthened systems of management, training, communications, logistics, monitoring and evaluation were intended to support this strategy. In addition, three innovations were planned. First, supervision was to be improved through better training, reorganized work routines, and the addition of a block-level supervisor. Second, supplementary feeding criteria were to be modified, if warranted, by the findings of operational research, in order to more effectively prevent malnutrition among the youngest children. Third, women's programs were intended to enrich the ICDS through optimizing community support and participation. These were to take place on an experimental basis in the early years of the project. If found to be successful following the mid- term review, the innovations were to be extended throughout the project. 9. At the outset, it was recognized that conditions differed between the two states. Both the rural health infrastructure and institutional capacity for training and communication activities are better developed in Andhra Pradesh than in Orissa. Social development indicators also reflect these differences. State-specific targets for impact and process objectives reflected what was considered achievable for each state. 10. Several operational research studies were proposed for the early years of the project to ensure a good fit between beneficiary perceptions and needs and the ICDS services to be provided. One main study was to consider alternative modes of therapeutic supplementary feeding, seeking the most cost-effective approach. Another was a functional analysis of work routines of the ICDS and health functionaries in order to prioritize and harmonize activities, thus 3 maximizing efficiency and impact. B. ACHIEVEMENT OF PROJECT OBJECTIVES 11. Conclusive evidence of progress towards both impact and process objectives will only emerge with the findings of the terminal evaluation which was not available at the time of finalizing this ICR. When the evaluation becomes available, achievements in project areas may be compared with the secular change in child nutritional status. As regards the past secular trend, according to data from the National Nutrition Monitoring Bureau, the mean annual reduction in severe malnutrition in Orissa during the 1980s was 2.8% in Orissa and 4.2% in Andhra Pradesh. The ICDS-I project aimed for an annual reduction of just over 7%, which was a challenging but potentially achievable goal. 12. The only available independent data source for judging progress against process and impact objectives is the mid-term review survey (MTS), which was delayed until 1996, the penultimate year of the project. According to the MTS, both of the main malnutrition reduction objectives have been, or are close to being, met in Andhra Pradesh while neither has been met in Orissa, where severe malnutrition has reportedly increased. However, major concerns regarding the validity of the MTS data especially, were raised during the mid-term review (MTR) and the Bank recommended that the data be reanalyzed. This reanalysis was not carried out. 13. Monitoring data cannot be used to assess impact as they refer only to those women and children actually reached by the project. MTS data suggest that (at least in the case of under-three year-olds being weighed) this proportion is less than two-thirds of those eligible at any one time. Given these limitations, routine monitoring data, as shown in the Table A below, do suggest an improving trend in child nutritional status in Andhra Pradesh during the project period and a relatively unchanged situation in Orissa (the latter between 1994 and 1996, when data were available). Table A: T'rends in Nutritional Status of Under-Three Year-Old Children using Data from Monitoring Sources, Baseline and Mid-Term Surveys (MTS) Grade l 1990 | 1991 1992 1993 1994 1995 1996 1996 1997 Baseline _ l MTS tar et* N & I 62.8 60.5 68.3 69.6 70.8 73.6 75 6 82 0 78.6 II 27.2 31.9 26.6 26.4 26.6 24.4 22.8 12.6 -- III & IV 10.0 7.6 5.1 4.0 2.6 2.0 1.6 5.4 5.0 N&I 68.4 NA NA NA 67.8 69.1 68.9 68.7 85.5 II 23.4 NA NA NA 26.7 25.9 26.6 19.5 -- III & IV 8.2 NA NA NA 5.5 5.0 4.5 11.8 4.1 N = normal, I = Grade I, etc. according to the Indian Academy of Paediatrics weight-for-age classification. * the 1997 target is derived by applying the impact objective targets to the actual baseline values. 14. With regard to the infant mortality rate (IMR), and according to Sample Registration 4 System (SRS) data, the target for Orissa has been easily met, unlike that for Andhra Pradesh. Orissa experienced a sharp drop in IMR from 123 per 1000 live births in 1990 to 95 per 1000 live births in 1996, with the improvement being particularly dramatic in rural areas. The IMR in Andhra Pradesh, on the other hand, changed little from 70 to 66 per 1000 live births. 15. Finally, data limitations preclude any definitive statement on the change in low birth weight incidence, but there is some evidence of improvement in line with targets. For both states, the baseline estimate of low birth weight incidence was 30%, while the mid-term surveys provide estimates of 23-24%. These data were, however, weighted towards institutional deliveries which might be expected to have higher birth weights. There remains a need to improve birth weight data collection throughout the ICDS program. 16. Conclusion. In sum, it is not possible to make a definitive judgement on project outcomes, due to the lack of terminal evaluation data. Indeed, the overall paucity of relevant, reliable and timely data is one of the main shortcomings of this project (see "Monitoring and Evaluation Objectives"). The evidence that currently exists from the delayed mid-term review points to significant differences between the two states in project outcomes. Andhra Pradesh appears to have made significant progress towards the main nutritional impact objectives, unlike Orissa. Orissa, on the other hand, has exceeded its infant mortality reduction objective, while the situation in Andhra Pradesh has changed little. Additional comparable data are not available to shed further light on these differences. In any event, as discussed below, performance on process indicators suggests that it is unlikely that the project could have made more than a small contribution to the achievement of the impact objectives. Service Delivery Objectives 17. According to the 1996 mid-term review data, service delivery in both states was generally quite poor with respect to most process objectives. Among children, only 1-2% of under-threes were regularly weighed (target: 80%) and around 40% received supplementary food (target: 90%) for an average of 16-19 days per month (target: 25 days). 21-26% of young children were completely immunized (target: 85-90%) and only 8% received vitamin A twice a year (target: 80%). 47-48% of children received semi-solid complementary foods from 6 months of age, compared to targets of 50% and 60% in the two states. 18. Although the target of registering 80% of pregnant women was nearly reached in both states, only 29-38% were registered in the first 20 weeks, as compared to a target of 50%. Virtually all pregnant women registered had, however, undergone an obstetrical and nutritional risk assessment and received tetanus toxoid immunization. The strategy of supplementary feeding to malnourished pregnant and lactating women did not work well, as food uptake was low (less than 30%, as compared to targets of 60-90%) and generally untargeted. Only 8-15% of pregnant women consumed iron and folic acid tablets for at least 12 weeks, as against a target of 60%. 19. The low coverage and poor targeting of the supplementary feeding component, both for children and women, and the sporadic nature of growth-monitoring, are related. The purpose of growth monitoring as one means of growth promotion has not been internalized (see 5 "Communications Objectives"). Food uptake was perceived as more important than targeting food to those who most need it, using growth criteria. Growth monitoring thus became yet another perfunctory task for the overworked AWW to undertake -- one of 23 process variables for which she had responsibility. 20. Referral System. The referral system did not perform well, with little use being made of the Nutrition Rehabilitation Centers, which have now been closed. An internal study showed that this was because mothers did not perceive malnutrition as warranting such center-based rehabilitation and because few women had the time to stay with their children at these centers. 21. Pre-school Education. Pre-school activities for 3-6 year-old children, which used joyful- learning methods, were moderately well attended (43-53% compared to targets of 60-80%). In Andhra Pradesh, there was strong convergence of services with the District Primary Education Project (DPEP), financed by IDA in both states. However, the pre-school component did not address the need for early childhood stimulation in under-three year-old children. 22. Training. There were serious problems with training, in an environment where project expansion took priority over quality improvement. While initial job training was conducted in a relatively timely manner, there were heavy backlogs in joint health-nutrition training and in refresher training at all levels for most of the duration of the project. A decentralized, field-based approach to reducing these backlogs through mobile District Training Teams did not work well. With regard to quality, training curricula were not adequately focused on developing skills for preventing malnutrition among under-three year-olds, the priority age group. Nor did they include orientation on tec:hniques such as participatory rural appraisal which would have proved valuable in community mobilization. The potential role of supervisors as in situ trainers of anganwadi workers was also not realized. 23. Under-funding of training, resulting from low national financial norms for ICDS training, was a major constraint. This problem is being addressed in the proposed Woman and Child Development Project, for which enhanced financial norms for training are a condition of negotiations. 24. Health-Nutrition Coordination. The crux of health-nutrition coordination --joint training of anganwadi workers (AWWs) and auxiliary nurse-midwives (ANMs) -- was not successfully achieved, nor was there much joint planning of home visits to at-risk households. There is a perception among health professionals that nutrition is not sufficiently technically-demanding to warrant serious attention. Orissa did however make a start on strengthening the health interface with the "Children Campaign" which linked immunization, nutrition and health education and referral. Andhra Pradesh initiated the "Child/Mother Health Day", which was celebrated every other month with various awareness-creation activities using folk media. Operational research in Orissa recommended "specific guidelines and stipulations with accountability fixed at all levels" if there is to be active coordination between health and ICDS. 25. Conclusion. Overall, service delivery was quite poor, for both women and children, in both states, and particularly so with regard to growth monitoring and supplementary feeding. The 6 main reason for this was inadequate training in general and particularly the missed opportunity of employing supervisors as local trainers. Communications Objectives 26. The communications component in Orissa was seriously constrained by the inability to fill the Communications Advisor post and the posts of additional supervisors for the duration of the project. Neither state developed a comprehensive communications strategy due to years of delay in completing the formative research, originally intended for the first year of the project. An interim communications strategy was implemented in Andhra Pradesh from late 1995 on, which comprised the preparation and distribution of posters, growth monitoring cards, advocacy films, and a newsletter. 27. There was a marked lack of emphasis on the inter-personal aspects of comnmunication, including maternal counseling on child care, feeding and health practices. The formative research should have provided the basis for a focused, topic-specific and area-specific strategy, targeted at the appropriate care-givers, and backed up by relevant district-level training. Home-based behavioral change is key not only to preventing severe malnutrition, but also to sustainably reducing rates of moderate malnutrition. Community Mobilization Objectives 28. Community mobilization centered around support to women's groups (mahila mandals) which were registered in villages throughout the project areas in both states. Once registered, the mahila mandals undertook thrift and credit activities and received skill training. Comparatively little effort was devoted to more directly nutrition-relevant activities, such as improving the caring capacity and practices within the community. Orientation of mahila mandal presidents and secretaries lagged somewhat in both states. Income-generation activities mainly comprised fabrication of leaf-plates, baskets and brooms for sale in local markets. In Andhra Pradesh, women took the initiative to contribute their labor towards the construction of anganwadi centres. In Orissa, women's groups in Phulbani district monitor all village-based development programs and propagate health messages. The resources and energy of the community-based panchayati raj institutions (democratically-elected, village-based development committees) were not actively utilized, despite their emerging potential for sustained community mobilization, monitoring and evaluation. 29. The Adolescent Girl's (AG) scheme involved the AWW in training selected local adolescent girls in nutrition, health and child care. The girls would assist the AWW for two days per week and act as a link between the AWW, mahila mandals and the community in general. However, the AG scheme did not perform well because of design shortcomings, such as the difficulty in forming adolescent girls' groups on a village cluster basis instead of one per village. Also, providing appropriate skill training for these groups was found to be difficult for the time- constrained AWW who herself may have been awaiting refresher training. Both states felt the need for better strategies to more directly address the needs of adolescent girls, such as the provision of iron and folate supplementation and deworming drugs, as well as training selected adolescents as social mobilizers. These strategies are included in the forthcoming, five-state 7 Woman and Child Development (WCD) project to be financed by the Bank. 30. Women's :ntegrated Learning for Life (WILL), in which the AWW trained local women in literacy, health, nuitrition and development, worked reasonably well. Despite adding to her workload, it raised her status in the village, particularly among mothers. However, a significant proportion of women found it difficult to regularly attend WILL evening classes due to time and work constraints. 31. A 1997 qualitative field study in Orissa found that involvement of people in ICDS remains largely passive, with workers acting as "doers" rather than change agents, and communities acting as recipients rather than participants. Nevertheless, there were significant local-level examples of successful community mobilization e.g., kitchen garden promotion and community maintenance of handpumps, which does indicate potential for active community involvement. Monitoring and Evaluation Objectives 32. In Andhra Pradesh, a systematic review of the monitoring system was undertaken. In collaboration with the National Institute of Nutrition, an innovative pilot nutrition surveillance scheme was testecl during the second half of the project and subsequently used in the revision of the monitoring proformae for the WCD project. Andhra Pradesh produced useful and regular updates on progress towards the key impact and process objectives. In contrast, in Orissa, monitoring was relatively weak, with little use being made of monitoring data to modify project implementation at any level. Prior to April 1994, child nutrition monitoring data were not computerized in Orissa. In both states, the management information system was virtually non- existent. 33. The regularly tabulated key project indicators which were reviewed by each supervision mission, contained only a few process objectives. Nutrition outcome indicators were not routinely reported using these formats, which tended to be predominantly quantitative data on hardware aspects. The Department of Women and Child Development (DWCD) of the Government of India closely monitored both physical and fiscal targets. 34. Monitoring was adversely affected in both states by delays in the supply of weighing scales and growth charts. The scales in use from 1993 on were baby-cum-child weighing scales. While these may have been more convenient than hanging scales, they are less reliable, being only able to measure to within the nearest 200g (as compared to lOOg for the hanging scales). An internal study also found them to be less durable than hanging scales. 35. The mid-term evaluation was not completed until the penultimate project year, which significantly constrained the ability of project management to make timely mid-course corrections and to assess overall progress towards project objectives. Moreover, there was a marked dissonance between monitoring and evaluation data, with suggests the need for periodic quality control checks on monitoring data. In addition, the terminal evaluation was delayed and the results are not available for this report. This follows the general pattern of delay in procurement and low quality of evaluation studies in Bank-financed nutrition projects in India. As discussed 8 below, this calls for a much more stringent approach in ongoing and future projects. Operational Research Objectives 36. At appraisal, assurances were given that various operational research studies and mid-term and final evaluation surveys would be carried out. These were not fulfilled on time, and several studies remain uncompleted. The most important uncompleted study, which was intended to examine alternative modes of therapeutic supplementation, was reportedly delayed by the non- supply of the food supplements by the state's production unit. While up to a dozen studies were initiated in each state at some time, the quality of the work has generally been poor. Where research has been completed, some attempt has been made to utilize the findings in improving implementation (as shown in Table 6), although in many cases, particularly in Orissa, no details are available of actions taken. The GOI and authorities in the two states have pledged that findings from delayed studies will be used in the general ICDS program in Orissa and in Andhra Pradesh. 37. Conclusion. In hindsight, it would have been preferable to focus on improving the quality and timeliness of a reduced number of key operational research studies. Better procurement planning, improved quality assessment of bidding agency proposals, timely monitoring of implementation and follow-up of specific recommendations are critical. Supervision missions need to pay more attention to this early on in the project. The importance of information for accountability -- whether gained through operational research, monitoring or evaluation -- needs to be signaled by assigning specific responsibility for quality control to an individual in the Government of India project management unit. Failure to fulfill covenanted agreements should result in the Bank seeking appropriate remedies instead of repeatedly recommending action, if action is not taken in a reasonable time-frame.. Physical Targets 38. After initial slow progress with installation of handpumps and civil works in Orissa, the pace picked up in the latter years of the project. The originally-approved civil construction program, consisting of 2292 anganwadi centers (AWCs), 90 block-level office-cum-stores and 2292 handpumps, was eventually completed. During June 1996, the Government of India sanctioned the construction of an additional 1600 AWCs, 19 office-cum-stores and 3000 extra handpumps, financed by exchange rate savings. This construction was 90% complete when the project closed. Even though the software components of the project were not going very well, Bank staff felt that the additional physical infrastructure would strengthen ICDS in the state. 39. There was generally good progress with the construction of anganwadi centers (AWCs) and hand-pump installation in Andhra Pradesh. The originally-approved civil construction program, providing for construction of 1650 AWCs, 55 CDPO office-cum-stores and 880 handpumps was 99% completed. To utilize exchange rate savings, the Government of India sanctioned the additional construction of 2500 AWCs, 19 CDPO office-cum-stores and the installation of a further 750 handpumps in 1996-97. The Bank was pleased to agree to this proposal, since by this stage the project was making more satisfactory progress in Andhra 9 Pradesh. This additional construction was almost completed by the credit closing date. 40. Procurenient of weighing scales was delayed in mid-project with adverse repercussions on growth monitoring and promotion. On the whole, the monitoring of fiscal and physical targets in both states was better than of other process and outcome indicators. C. MAJOR FACTORS AFFECTING PROJECT IMPLEMENTATION 41. The location of the project was appropriate in that it was targeted to the most socio- economically and geographically marginalized rural communities, as borne out by mid-term review data on beneficiary characteristics. 61% and 38% of beneficiaries in Orissa and Andhra Pradesh, respectively, were of a scheduled caste or scheduled tribe. Only one-third of female beneficiaries in both states was literate. This successful targeting to the most disadvantaged population groups represents a significant improvement in their access to nutrition and health services. 42. Implemerntation was oriented disproportionately towards hardware and input targets. Disbursement was slow initially. Correspondingly, insufficient attention was paid to software (e.g., communications support, training) outputs and outcome targets. Service delivery inevitably was negatively affected. A perception of food as a quantitative input predominated over one of nutrition as a qualitative outcome of food, health and care-related factors. 43. The high turnover of staff and the persistence of unfilled vacancies in the Orissa Project Management Unit (PMU) constrained progress in general, and prevented the implementation of an interim communications strategy. Continuity, commitment and overall management of the project were adversely affected. In both states, the high percentage of vacancies at supervisor and Assistant Child Development Project Officer (ACDPO) level, and the lack of recruitment of additional supervisors, limited the degree of localized follow-up and support. 44. A fundamental problem of program philosophy affected the implementation of this and the ICDS II project. ICDS is widely viewed, by political leaders, bureaucrats, functionaries and beneficiaries alike, as a government program providing pre-school education and child feeding. In contrast to TINP, no major effort has been taken to market the program as one aimed at preventing malnujtrition through behavior change among mothers. This accounts in large measure for the preoccupation of GOI and the states with quantity over quality, and their related lack of interest in research and evaluation. As a result, and as shown in multiple evaluations, ICDS has relatively limited impact on its main objective of reducing malnutrition. Social indicators are better in ICDS blocks than non-ICDS blocks, and ICDS runs better in Bank-financed blocks than in other blocks. But despite strenuous efforts over many years, the Bank has 10 not succeeded in its efforts to promote in ICDS, the kind of behavior-change program Tamil Nadu succeeded in harnessing through TINP. D. PROJECT SUSTAINABELITY 45. The prospects for sustaining the project in Orissa and Andhra Pradesh are quite good given the expressed commitment of the national and state governments and the overall commitment of the Government of India to universalize the ICDS within the next few years. In Andhra Pradesh, universalization will take place within the ICDS component of the proposed IDA-assisted Andhra Pradesh Economic Restructuring Project (APERP), which goes to the Board in June 1998. Andhra Pradesh in the past two years has become one of the better- performing states on ICDS. 46. The sustainability of the District Training Teams (DTTs) constituted for this project is questionable. The final supervision mission recommended the recruitment of four technical posts within the Government of India-sanctioned district ICDS cell so that permanent DTTs could be constituted. Sustainability of the income-generating activities of the women's groups is dependent on the state government facilitating and supporting appropriate linkages with similar schemes. 47. The SAR estimated that when the project was fully operational, recurrent costs for Andhra Pradesh and Orissa (excluding food costs) would be around Rs.361.3 million. The Government of India's budgetary allocation for the ICDS program for 1997/98 is Rs. 6.75 billion, making total recurrent costs for these two states around 5% of the total. This should not be a problem for GOI, which is committed to universalizing ICDS in the 30% of blocks not now covered by the program. The food costs for ICDS are borne by the respective state governments and both Andhra Pradesh and Orissa are committed to sustaining this part of the program. Attention however should be paid to the fact that as supplementary feeding coverage rises from its current levels, food costs will rise correspondingly. E. BANK PERFORMANCE 48. The Bank's performance was mixed. With the benefit of hindsight, the project appears over-ambitious in terms of size and scope. In particular, performance might have been better if the project had covered fewer new blocks, supported fewer innovative programs which added to the workload of the AWW, and included less operational research. Where supervision missions can most be faulted is in their reluctance to seek remedies. Supervision reports provide abundant evidence that implementation problems were fully recognized and that appropriate actions were recommended and agreed. However, when action failed to materialize, the Bank failed to seek appropriate remedies. Suspension was many times considered but never actually recommended by the task team or by management. Nor was the project restructured, mainly because the mid- term review occurred just one year before the closing date. It is clear that suspension should have taken place, e.g., over the failure to appoint staff in Orissa, the failure to undertake the therapeutic supplementation study, formative research and mid-term evaluation in a timely way, and over the persistent procurement delays. The end result was a fully-disbursed project, but one with a strong bias for hardware over software, quantity over quality, despite the fact that the Bank started out 11 trying to reverse this bias. Overall, the Bank performance is judged to be unsatisfactory. F. BORROWER PERFORMANCE 49. The Borrower's performance was satisfactory with respect to project preparation. However, project management was weak throughout the project period in Orissa and improved only in the last two years of the project in Andhra Pradesh. The main reasons were failure to recruit and retain competent staff in the Project Management Unit (PMU). The project started slowly in both states, and implementation only reached an adequate pace in the final two years. Government of India delays in clearing procurement, especially of studies and in obtaining Ministry of Finance sanction for additional construction, contributed to the slow pace of implementation. The Borrower failed to comply fully with covenants on operational research and evaluation, resulting in significant information gaps. These gaps, which persisted throughout the project, prevented design and implementation shortcomings from being highlighted, and timely, remedial action from being taken. There is therefore no alternative but to rate the Borrower's overall performance as unsatisfactory. G. ASSESSMENT OF OUTCOME 50. The project has successfully established a village-based worker in many remote and disadvantaged tribal and rural communities, with the primary responsibility for improving child nutrition and health. However, she is likely to be over-worked and under-supported with regard to both training and supervision. Service delivery has consequently been relatively poor on the whole. Nevertheless, the project was rated as performing satisfactorily during most of the project period. This appears defensible until the results of the delayed mid-term review were known, which was just one year from the closing date. At that point, performance was improving in Andhra Pradesh, but not in Orissa, except in the area of civil works construction. The delayed mnid-term review has pointed to gains in nutrition in Andhra Pradesh and in infant mortality rate in Orissa, but these are unlikely to owe much to the impact of the project. The weak performance in areas such as growth monitoring, Iron and Vitamin A supplementation, argue against attributing much of the improvement in social indicators to the impact of the project. Overall, the project outcome is rated as unsatisfactory both in terms of achievement of development objectives and of implementation effectiveness. H. FUTURE OPERATION 51. ICDS is to be universalized, and Andhra Pradesh and Orissa have sanctioned the program in all development blocks. All project blocks in Orissa have been taken over under the general ICDS program, and its PMUs has merged with the directorate of ICDS. A new ICDS project for Andhra Pradesh was appraised by the Bank in January 1998 and is scheduled for the Board in June 1998. This is a component of a larger project, i.e., the Andhra Pradesh Economic Restructuring Project (APER). I. LESSONS LEARNED 12 52. Ensure Service Quality. One main lesson learned is that high quality and timely training of project functionaries is a sine qua non for high quality service delivery. It is also essential to prioritize communications for home-based behavior change if a sustained impact is to be expected on moderate, as well as severe, child malnutrition. Space needs to be made for this to happen. The role of additional supervisor could have created this space, yet these posts were not filled in this project. Supervisors should have a greater responsibility for communications support and monitoring, regularly accompanying AWWs on home visits to at-risk households. Training should also reflect this prioritization. The national training curriculum for AWWs and supervisors requires a greater focus on strengthening capabilities to prevent malnutrition among very young children, in their own homes. Timely job and refresher training backed up by one-to-one support of the anganwadi worker by the supervisor should be the bedrock of such capacity-building in projects of this type. Given the forthcoming expansion into new blocks in A.P, it will be particularly important to institutionalize such a focus on quality from the start. 53. Avoid Undue Emphasis on Food. Linked to quality concerns, there is a need for increased emphasis on the health and care-related factors determining nutrition outcomes in the youngest children. Food supplementation should not be considered as the raison d'etre of the project, but rather as one of several means to improve child growth and nutrition. The preoccupation with food distribution, which percolates down from state-level management to the anganwadi worker herself, has reduced the attention and priority attached to inter-personal communications and counseling, which are vital to improve the care-related determinants of child nutrition. 54. Growth promotion, not food distribution, should be viewed as the crux of the program, with growth monitoring as one highly important means to this end. De-linked from communications and targeting, growth monitoring is useless. It needs to be re-activated as an essential tool for AWWs to prioritize their counseling support to those mothers and children who most require it. Without an explicit strategy for communications, linked to community mobilization, and backed up by high quality training and supervision, there is little chance of any project making a sustainable dent on moderate malnutrition. This is the biggest future challenge for the ICDS. 55. Future operational research should prioritize this area, and be directed towards eliciting the most effective communications approaches. Indeed, the ultimate question is how, in a future beyond externally-supported programs, can all the food, health and care preconditions for child nutritional well-being be ensured and sustained. 56. Prioritized Operational Research. There is a real need to prioritize operational research and to ensure that studies are carried out within the first 2-3 years of the project, in order that findings can be used to improve the project. A few key operational research studies (no more than five) should start in the first year of the project with results being made available ahead of the mid-term review, which itself should be finalized by the end of the third year of a five-year project. In addition to the above mentioned need to prioritize studies of how to improve home- based caring and feeding practices, there also remains an ongoing need to learn how best to mobilize communities for self-sustaining nutrition improvement. Formative research leading to a communications strategy needs to be started in the first year of the project, with a strategy being 13 fully implemented by year two. The terminal evaluation survey, analysis and reporting all need to be completed by the end of the last year of the project so their findings can be drawn upon for the ICR. This will require more stringent criteria for recruiting competent research agencies, more diligent and expeditious procurement of operational research by GOI and the state governments, and tighter monitoring and supervision of quality and timeliness of studies in the early years. Failure to comply with covenanted requirements to conduct priority studies, including evaluations, in an agreed time period should lead to the Bank seeking appropriate remedies. 57. Improve Monitoring and Evaluation. Monitoring needs more emphasis, with respect to quality in general, and the need to more visibly track progress towards the impact objectives, in particular. Child nutritional status data need to be made more visible at more levels in the project management system, and to be used for improved action. This applies at all levels, throughout the project management system - from an individual child's growth chart right up to the monthly Monitoring Progress Reports and the "key project indicators" monitored by project management and reviewed by each supervision mission. Evaluation, particularly the mid-term review, needs to be more rigorously planned, implemented and communicated. This requirement should be covenanted and its adherence stringently monitored. Consideration should be given in future to creating a specific post or convening an expert panel to provide regular technical and operational advice, quality control and supervision throughout the evaluative process. 58. Strategic Issues. ICDS I brought into sharp focus three strategic program issues: * the bias towards expansion (quantity) over quality; * the under-funding of training; and * the one-worker versus two-worker model. The project demonstrated clearly that rapid expansion of ICDS into new blocks usually comes at the expense of service quality. It appears that the Bank contributed to this problem by financing a project that was beyond the absorptive capacity of the two states. The hardware components were completed but quality of training, communications, and services was not up to the mark. 59. Experience with ICDS I and preparation of the forthcoming WCD project and ICDS component of APER project have brought out the fact that the current finance norms for training are much too low to ensure quality training, which is fundamental to ICDS success. Both new projects include, as conditions of Negotiations, adoption of the greatly enhanced norms proposed by the Department of Women and Child Development but not yet approved by GOI. 60. International experience and that of Tarnil Nadu suggests that it is not possible simultaneously to provide nutrition, health and pre-school education with one worker. Ongoing GOI/Bank collaborative sector work is examining the one-worker versus two-worker question. The outcome of ICDS I suggests that ICDS will only achieve its potential impact if two workers are employed. That would require either targeting the food supplementation, or increasing the GOI or state financing of ICDS, neither of which would be easy, but both of which would have the desired impact on child malnutrition in India. 14 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) PART II: Statistical Tables Table 1: Summary of Assessments A. Achievement of Obiectives Substantial Partial Negligible Not applicable (0i) (0) (E3) (0i) Macro Policies al E 0l Sector Policies l I3 0 0 Financial Objectives El E] 0 m Institutional Development [- ] 0Q Physical Objectives [3 Q a Q Poverty Reduction D E Gender Issues 0 IX 0 0 Other Social Objectives [0 5 5 Environmental Objectives E E E l Public Sector Management [El El E Private Sector Development 0x E El Other (specify) l El E X B. Project Sustainability Likely Unlikely Uncertain (0) (0) (0) Fxl 1El El 15 Table 1: Summary of Assessments (continued) Highly C. Bank Performance satisfactory Satisfactorv Deficient (IXI (0) (0) Identification o 5 Preparation Assistance ml ] Appraisal I] :E Supervision E l I IIighlv D. Borrower Performance satisfactory Satisfactor Deficient (0) (0) (0) Preparation 0 5 Implementation 5 E Covenant Compliance 5 5El Operation (if applicable) S ] S Highly Highlv E. Assessment of Outcome satisfactorv Satisfactor Unsatisfactory unsatisfactory (I) (0) (M) (0) Andhra Pradesh 5 5 [E] 5 Orissa E] 5E] 16 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Table 2: Related Bank Credits Credit title Purpose Year of Status approval 1. First Population To support the family welfare program in 1972 Credit closed June Project CR 312-IN five districts of Mysore (now Karnataka) 30, 1980 and six districts of Uttar Pradesh. Project Completion Report (PCR) 6/81; PAR 1/82 2. Second Population To support the family welfare program in 1980 Credit closed March Project six districts of Uttar Pradesh and three 31, 1988 districts of Andhra Pradesh PCR 1/90; PPAR 8/90 3. Tamil Nadu To improve the nutrition and health status 1980 Credit closed March Integrated Nutrition of preschool children and pregnant and 31, 1989 Project I (TINP I) CR nursing women 1003-IN PCR 1/91; Impact Evaluation Report 12/94 4. Third Population To support the family welfare program in 1984 Credit closed March Project CR 1426-IN six districts of Karnataka and four districts 31, 1992 of Kerala PCR 8/93 5. Fourth Population To support the family welfare program in 1985 Credit closed March Project CR 1623-IN four districts of West Bengal 31, 1994 PCR 12/94 6. Fifth (Bombay and To reduce infant, child and maternal 1988 Credit closed March Madras) Population morbidity and mortality and to moderate 31, 1996 Project CR 1931-IN fertility in the cities of Bombay, Madras and Implementation other urban areas of Tanil Nadu, and to Completion Report assist the Municipal Authorities in 10t96 designing and implementing improved health and family welfare programs. 17 Table 2: Related Bank Credits (continued) 7. Sixth (First National To support the family welfare program in 1989 Credit closed May Family Welfare Training the states of Uttar Pradesh, Andhra Pradesh, 31, 1997 and Systems and Madhya Pradesh ICR ??? Development) Population Project CR 2057-IN 8. Second Tamil Nadu To improve the nutritional status of children 1990 Credit scheduled to Nutrition Project (TNIP aged 6 to 36 months and contribute to a close December 31, II) CR 2158-IN reduction in infant mortality rate and 1997 incidence of low birth weight. 9. Seventh (Training) To support lower-income women in the 1990 Credit is scheduled Population Project CR rural areas of Bihar, Gujarat, Haryana, to close June 30, 2133-IN Jannu, Kashmir and Punjab, through the 1998 training of new and existing health workers and non-Health Department personnel 10. Eighth (Family To help the Government of India increase 1991 Credit scheduled to Welfare Urban Slums) the supply of family welfare services in the close June 30, 2001 Population Project CR slum populations of Andhra Pradesh, 2394-1N Karnataka, West Bengal and Delhi 11. Child Survival and To increase child survival and promote safe 1991 Credit closed on Safe Motherhood Project motherhood, including establishing first September 30, 1996 CR 2300-IN referral units for secondary-level care of ICR 3/97 mothers and their newborns 12. Second Integrated To improve the nutrition and health status 1993 Credit scheduled to Child Development of pre-school children and their mothers by close September 30, Services Project II (ICDS strengthening and increasing the outreach of 2000 II) CR 2470-IN the ICDS program in Bihar and Madya Pradesh. 13. Ninth (Family To support the family welfare program in 1994 Credit scheduled to Welfare Assam, the states of Assam, Rajasthan and close December 31, Rajasthan and Karnataka 2001 Karnataka) Population Project CR 2630-IN 14. Andhra Pradesh First To (i) improve efficiency in the allocation 1994 Credit scheduled to Referral Health System and use of health resources through policy close March 31, Project CR 2663-IN and institutional development: and (ii) 2002 improve system performance of health care through improvements in quality, effectiveness and coverage of health services at the first referral or secondary level to better serve the neediest sections of society. 18 Table 2: Related Bank Credits (continued) 15. Second State Health To (i) improve efficiency in the allocation 1997 Credit scheduled to Systems Development and use of health resources through policy close March 31, Project CR 2833-IN and institutional development; and (ii) 2002 improve performance of the health care system through improvements in the quality, effectiveness and coverage of health services at the first referral level and selective coverage at the primary level to better serve the neediest sections of society. 16. TB Control Project To reduce mortality, morbidity and 1997 Credit scheduled to CR 2936-IN disability due to TB and to reduce the close December 31, incidence of infectious TB by focusing on 2002 the cure of infectious patients 17. Malaria Control To reduce death, morbidity and social and 1997 Credit scheduled to Project CR 2964-IN economic losses from malaria through and close March 31, improved malaria control program 2003 including: (i) using a better mix of effective malaria control interventions responsible to local needs; and (ii) strengthening the Directorate of the National Malaria Program (NMP) and modifying its orientation 18. Reproductive Health To improve quality, coverage and 1997 Credit scheduled to Project CR N0180-lN effectiveness of existing Family Welfare close March 31, (FW) services and expand their scope to 2003 include more elements of a defined package of reproductive and child health (RCH) services 19. Rural Women's To strengthen processes that promote the 1997 Credit scheduled to Development Project economic development of women and create close June 30, 2002 CR 2942-IN an environment for social change, including improving access to better health care 19 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Table 3: Project Timetable Steps in Project Cycle Date Actual! Latest Estimate Identification (Executive Project Summary) April 26, 1988 Appraisal January 12, 1990 Negotiations May 8, 1990 Board Presentation September 4, 1990 Signing October 23, 1990 Effectiveness January 28, 1991 Midterm review (if applicable) January 8, 1997 Credit Closing December 31, 1997 20 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Table 4: Credit Disbursements: Cumulative Estimated and Actual (USS millions) FY91 FY92 FY93 FY94 FY95 FY96 FY97 FY98 Appraisal Estimate 5.00 10.50 24.70 44.00 64.60 83.20 100.20 106.00 Revised 51.00 67.00 73.00 74.35 Actual 5.64 15.77 18.97 27.56 38.98 47.43 58.74 80.57 Actual as % of Estimate 113 150 77 63 60 57 59 76 Date of Final Disbursement: April 24, 1998 *Credit in the amount of USS23.5 million equivalent was canceled on May 1, 1993. 21 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Table 5: Key Indicators for Project Implementation I. Key Implementation Indicators in SAR/ Presidents Report Estimated (%) Actual (%) (SAR target) (1996 MTS) Andhra Pradesh Impact Indicators lI. Reduce severe malnutrition (Grade In & IV) among children 6-36 months by 50% 46% II. Increase proportion of children 6-36 months in normal and Grade I status by 25% 31% m. Reduction in IMR 70/1000 66/1000 IV. Reduction in incidence of low birth weight by 30% 23% Process Indicators 1. Early registration of pregnant women. 50 38 2. Total registration of pregnant women. 80 -79 3. Obsterical and nutritional risk assessment of those registered 100 79 4. Tetanus toxoid immunization of pregnant women. 90 86 5. Consumption of iron and folic acid tablets for at least 12 weeks by pregnant 60 8 women 6. Administration of post-partum vitamin A to attended deliveries 80 NA 7. Food supplementation for at least 20 weeks to registered pregnant women with 80 28* inadequate nutrition status. 8. Food supplementation for at least 16 weeks of registered lactating women with 90 27* malnutrition in pregnancy. 9. Immunization (UIP-6) of children. 90 26 10. Vitamin A megadose (100,000 - 200,000 i.u.) semi-annually to children 6-36 80 8 months. 11. Regular growth monitoring (>9 times a year) of children 0-3 years. 80 1 12. Supplementation of monitored children 0-3 years with grade II-IV malnutrition. 90 41 * 13. Completed referral of severely malnourished children (grade Im and IV) or non- 80 NA responding children 0-3 years to VHNIMPWF and PHC. 14. Quarterly growth monitoring, weighing and charting of children 3-5 years (>3 80 17 times of year). 15. Referral of severely malnourished children 3-5 years of age to MPWF/PHC. 90 NA 16. Administration of vitamin A megadose semi-annually to children 3-5 years of 80 NA age. 17. Pre-school attendance (>80 % of working days) 80 53 18. Routine deparasitization of monitored children in heavily infected communities 90 NA as determined by parasite surveys 19. Household use of oral rehydration in the last incidence of diarrhea in the target 60 33 group. 20. Treatment of pneumonia by MPWF/AWW with co-trimaxazole in cases of acute 30 5 respiratory infection (ARI) 21. Additional feeds of local weaning food initiated by 6 months in infants. 60 47 22. Provision of 4 additional weaning feeds/day by 9 months in infants. 60 NA 23. Active women's working groups (> 9 meetings a year) 80 NA 22 * Data not disaggregated by nutritional status Table 5: Key Indicators for Project Implementation (contnued) I. Key Implementation Indicators in SARJ Presidents Report Estimated (%) Actual (%) (SAR target) (1996 MTS) Orissa Impact Indicators 1. Reduce severe malnutrition (Grade 11m & IV) among children 6-36 months by 50% 44% :I. Increase in proportion of children 6-36 months in normal and Grade I status by 25% 0.4% m. Reduction in IMR 100/1000 95/1000 IV. Reduction in incidence of low birth weight by 20% 23% Process Indicators 1. Early registration of pregnant women. 50 29 2. Total registration of pregnant women. 80 71 3. Obsterical and nutritional risk assessment of those registered 100 61 4. Tetanus toxoid immunization of pregnant women. 80 71 5. Consumption of iron and folic acid tablets for at least 12 weeks by pregnant women 60 15 6. Administration of post-partum vitamin A to attended deliveries 80 NA 7. Food supplementation for at least 20 weeks to registered pregnent women with 60 26* inadequate nutrition status. 8. Food supplementation for at least 16 weeks of registered lactating women with 90 23* malnutrition in pregnancy. 9. Immunization (UIP-6) of children. 85 21 10. Vitamin A megadose (100,000 - 200,000 i.u.) semi-annually to children 80 8 6-36 months. 11. Regular growth monitoring (>9 times a year) of children 0-3 years. 80 2 12. Supplementation of monitored children 0-3 years with grade II-IV malnutrition. 90 42* 13. Completed referral of severely malnourished children (grade m and IV) or non- 80 NA responding children 0-3 years to VHN/MPWF and PHC. 14. Quarterly growth monitoring, weighing and charting of children 3-5 years (>3 times 60 25 of year). 15. Referral of severely malnourished children 3-5 years of age to MPWF/PHC. 90 NA 16. Administration of vitamin A megadose semi-annually to children 3-5 years of age. 70 7 17. Pre-school attendance (>80 % of working days) 60 43 18. Routine deparasitization of monitored children in heavily infected communities as 80 NA deternined by parasite surveys 19. Household use of oral rehydration in the last incidence of diarrhea in the target 50 32 group. 20. Treatment of pneumonia by MPWF/AWW with co-trimaxazole in cases of acute 20 10 respiratory infection (ARI) 21. Additional feeds of local weaning food initiated by 6 months in infants. 50 48 22. Provision of 4 additional weaning feeds/day by 9 months in infants. 50 NA 23. Active women's working groups (> 9 meetings a year) 70 NA * Data not disaggregated by nutritional status 23 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Table 6: Studies Included in Project Purpose as Defined Study at Appraisal/Redefined Status Impact of Study Andhra Pradesh 1. Baseline Survey To assess the level of nutritional Completed Based on the report, WB status in A.P. ICDS project has been launched. 2. Operations research on To determine, test and disseminate Completed The strategies evolved have Work routine, Supervision, knowledge on optimum methods and been field tested & Referral Services, Joint alternative systems in work routines, implemented: Coordination, Mgmt. supervision, joint coordination, 1. Registers modified Information System referral services and MIS. 2. Communication material distributed to private practitioners. 3. Revised instructions have been issued for utilization of referral fund. 3. Study on Communicaltion To identify gaps in knowledge, Completed Communication material Strategy attitudes and practices in have been developed to communications. focus on ante-natal and post-natal care and on growth monitoring and promotion. 4. Mid-term Evaluation To assess the performance of the Completed Recommendations of the program on key impact and process study are being objectives. implemented: 1. Adolescent Girls Scheme I extended in 110 projects. 2. Nutrition Resource Centers closed. 3. Adolescent Girls Scheme I closed. 5. Study on Therapeutic Food To identify alternative approaches to Not therapeutic supplementary feeding complete for growth faltering, moderately and severely malnourished children under 3 years of age. 6. Mini evaluation on IGA To assess the effectiveness of Completed Modifications in Income implementation of IGA. Generation Activities scheme like change of joint account from Supervisor to AWW; training component for skill upgradation supply of tool kit; training on maintenance of account have been incorporated. 24 Table 6: Studies Included in Project (continued) Purpose as Defined Study at Appraisal/Redefined Status Impact of Study 7. Nutritional Surveillance Being conducted by NIN to Not System streamline monitoring system in complete ICDS. 8 Internal Evaluation on Conducted by PMU to find out Completed Study findings Adolescent Girls Scheme I the effectiveness and impact of implemented to improve the scheme for further the scheme, e.g., (a) Girls improvement. are interested to assist AWW in preschool and conduct WILL classes, (b) the two years scheme has been reduced to six months to cover more number of girls. 9. Internal Evaluation on Conducted by PMU to find out Completed Finding of the study used to Adolescent Girls Scheme II. the effectiveness and impact of improve the program: the scheme for further 1. Two years scheme improvement. reduced to six months to cover greater number of girls. 2. Skill training on new activities have been taken up. 3. Preference is given to girls trained under AG II to get loans under various other schemes like IGA, DWCRA after completion of 18 years age. 10. An evaluation study of Conducted by PMU to find out Completed Study findings 'WILL' program the effectiveness and impact of implemented to improve the scheme for further scheme, example: a) Girls improvement. are interested to assist AWW in pre-school, Conduct WILL classes. b) The two year scheme has been reduced to six months to cover more no. of girls. 11. A study on the pre-school Conducted by State Resource Report To assess the quality, education in ICDS. Center ECE, Andhra Mahila was utilization of services, Sabha, AP. submitted perception and attitudes of during community. 1996. Recommendations would be implemented in the future. 25 Table 6: Studies Included in Project (continued) Purpose as Defined Study at Appraisal/Redefined Status Impact of Study Orissa 1. KAP study To assess the existing condition of Completed Action being taken to children and mothers. improve targeting 2. Alternative Therapeutic Impact of different supplemental Completed Most effective Supplementation strategies strategies supplemental strategy used. 3. Communication Examine existing behavior and Completed Used to improve the Strategy understanding of program benefits. effectiveness of program 4. Functional Task Improve worker effectiveness. Completed Improve project Analysis (work routines) effectiveness. 5. Mid-term Evaluation Review project mid-way from Completed Identified areas that project commencement. needed strengthening. 6. End line survey To collect end line survey data after Not completion of project. completed 7. Base line survey To collect base line survey data Completed Provided yardstick to before conunencement of project. measure project impact. 8. Evaluation of Women's To evaluate Mahila Mandals Income Completed Used to increase the program Generation Activities, WILL involvement of Mahila Program and Adolescent Girls Mandal members in the Scheme various activities. 9. Therapeutic food To know the impact on the Completed Used to improve targeting supplementation nutritional status of children & of the project. mothers. 10. Nutrition Determine the extent to which the Completed Used to improve operation Rehabilitation Centers scheme has fulfilled its objectives and effectiveness of the (NRC's) and suggest changes in its operation. NRC's. 11. Baby-cum-Child To assess the advantages and Completed Used to improve weighing Weighing scales disadvantages of Baby-cum-Child accuracy.. Weighing Scale against supply of Salter weighing scale. 12. CHEER program To know the extent of increased Completed Used to increase listening skill, vocabulary, on the effectiveness of the social and cultural enrichment of the program. children. 26 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Table 7A: Project Costs Appraisal Estimate (US$M) Actual/Latest Estimate(US$M) Local Foreign Total Local Foreign Total Item Costs Costs Costs Costs Service Delivery 1. Nutrition 97.3 5.5 102.8 2. Health 10.1 2.1 12.2 3. Training 14.9 0.7 15.6 Communications 9.4 0.5 9.9 AWAITING DATA FROM GOI. DATA Community 10.8 0.2 11.0 IS NOT MAINTAINED BY GOI IN $ Mobilization Project Management 1. Project 4.6 0.2 4.8 Organization 2. Monitoring and 1.2 0.0 1.2 Evaluation Total Project Costs 148.3 9.2 157.5 * including taxes and duties of US$4.0 mnillion 27 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Table 7B: Project Financing Appraisal Estimate (US$M). Actual/Latest Estimate(US$M) Local Foreign Total Local Foreign Total Source Costs Costs Costs Costs IDA 96.8 9.2 106.0 GOI 40.4 0.0 40.4 NOT YET AVAILABLE FROM GOI Andhra Pradesh 5.5 0.0 5.5 Orissa 5.6 0.0 5.6 Total 148.3 9.2 157.5 28 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Table 8: Status of Legal Covenants Agreement Section Covenant Present Original Revised Description of Comments type status fulfillment fulfillment covenant date date Article Im 3.01(a) 03, 04, C The Borrower to cause the 05 project States to perform their obligations under the Project Agreement and provide resources as necessary. Article m 3.01 (b) 03 C The Borrower to make the Credit proceeds available to each Project State. Article III 3.02 05 C Procurement to be governed All procurements will by the provisions of be completed as Schedule I to the Project scheduled before Agreement. project closing. Article Ill 3.03 10 C The Borrower to cause each Project State to carry out obligations relating to insurance, use of goods and services, plans and schedules, records and reports, maintenance, and land acquisition. Article M 3.04 (a) 09 C 12/31/1993 The Borrower to participate Mid-term review done in carrying out the mid-term as ofOl/08/1997. review, and Article Ill 3.04 (b) 09 C 09/30/1997 The Borrower to participate in the final evaluation of the Project. Article IV 4.01 (a) 01 C The Borrower to maintain adequate financial records and accounts. Article IV 4.01 (b) 01 C The Borrower to: (i) have the financial records and accounts audited. Article IV 4.01 (b) 01 C (iii) furnish to IDA other related information, as 29 Agreement Section Covenant Present Original Revised Description of Comments type status fulfillment fulfillment covenant date date requested. 30 Table 8: Status of Legal Covenants (continued) Article IV 4.01 (c) 01 C For all SOE expenditures, Submitted as required. the Borrower to: (i) maintain adequate records and accounts; (ii) retain all records evidencing such expenditures at least one year after IDA has received the audit report; (iii) enable IDA representatives to examine such records; and (iv) ensure that such records are audited and that the audit report contains a separate opinion on the SOEs. Article II 2.01 (a) 05 C Project States to carry out the Project with due diligence and efficiency and in conformity with appropriate practices, and Article nI 2.01 03, 04 C provide promptly the resources required for the Project. Article II 2.01 (b) 05 C Project States to carry out the Project in accordance with the agreed Implementation Program in Schedule 2 to the Project Agreement. Article II 2.02 10 C Project States to procure goods, works, and services in accordance with Schedule I to the Project Agreement. Article II 2.03 10 C Project States to carry out obligations relating to insurance, use of goods and services, plans and schedules, records and reports, maintenance, and land acquisition. Article II 2.04 (a) 09 C Project States to exchange views with IDA with regard to Project progress. Article II 2.04 (b) 09 C Project States to promptly inform IDA of any condition interfering with Project progress. Article III 3.01 (a) 01 C Project States to maintain adequate records and accounts; 31 Table 8: Status of Legal Covenants (continued) Article m 3.01 (b) 01 C Project States to (i) have the records and accounts audited. Article m 3.01 01 C 12/31/1993 (ii) furnish to IDA: (A) certified copies of their records and accounts, and (B) the audit report; and (iii) furnish to IDA other related information, as requested. Schedule 2 Para 1 12 C Each Project State to apply and maintain beneficiary selection criteria and procedures, acceptable to IDA, for nutrition supplementation. Schedule 2 Para 2 10 C Each Project State to (a) Final report for (i) carry out studies on made available to the nutrition and health under Bank for comments. satisfactory terms of reference, including: (I) organization, management and routines of ICDS and health staff at the block, sector, and village level; and Schedule 2 Para 2 10 (ii) alternate ways of providing therapeutic supplementation to growth faltering and moderately and severely malnourished children under three years of age; Schedule 2 Para 2 I1D CP 09/30/1991 (b) complete the study The base line for the under 2(a) (I) above, and study has been completed but the Government of Orissa suggested that the study be dropped as it will not be completed before project closing. Schedule 2 Para 2 05 C 04/01/1992 discuss the results of the study under 2 (a) (i) above with IDA; and Schedule 2 Para 2 09,10 C 09/30/1994 (c) complete and discuss with IDA the study under 2 (a) (ii) above. Schedule 2 Para 3 05 C 01/01/1991 Each Project State to (a) set up a Project Management Unit in accordance with a key staffmg plan staifactory to IDA; and 32 Table 8: Status of Legal Covenants (continued) Schedule 2 Para 3 05 C (b) thereafter maintain the unit. Schedule 2 Pam 4 09 C Each Project State to furnish to IDA, for review and discussion: (aO quarterly and annual progress reports within three months of the relevant implementation period; and Schedule 2 Para 4 10 C 01/31/1994 (b) aprospective annual work plan on the activities to be carried out under the project, in formats satisfactory to IDA. Schedule 2 Para 5 09 C 12/31/1993 The project States shall, in Completed. conjunction with IDA, and in accordance with satisfactory terms of reference and methodology, undertake and complete: (a) a mid-term review and evaluation of the Project; and Scbedule 2 Pama 5 09 CP 09/30/1997 (b) a final evaluation of the Field surveys for the Project. endline study is ongoing. Schedule 2 Para 6 12 CP Each Project State shall Sanctioned posts yet to place one Additional be completely filled Supervisor (A.S.) in each up. block in the Project area. Covenant types: 1. Accountslaudits S. = Indigenous people 2. = Finmcial perfomance/revenue generafion fromn 9. = Monitoring, review, and reporting bmenficiaries 10. = Project implementation not covered by categories 1-9 3. = Flow and utilization of projet fimds 11. Sectoral or cross-sectoral budgetary or other resource 4. = Co wnterpa fiunding allocation S. = Managemt aspec of the project or executing 12. = Sectoral or cross-sectoral policy/ regulatory/institutional agency action 6. = Enviometa covenan 13. = Other 7. = bnvolunSty resettlement 8. Present Sttus: C = covenat complied with CD = complied with after delay CP = complied with partially NC = not complied with 33 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRAT'ED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Table 9: Compliance with Operational Manual Statements (OMS) The ICR did not identify any deviation of substance from the relevant OMS. 34 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Table 10: Bank Resources: Staff Inputs (in Staff Weeks) Stage of FY Project Cycle Total 90 91 92 93 94 95 96 97 98* Lending Development Preappraisal 33.4 33.4 Appraisal 17.1 17.1 Negotiations 4.5 10.7 15.2 Supervision 10.0 29.0 51.7 41.7 14.5 45.8 30.5 18.2 241.4 Procurement 0.8 0.4 1.1 _ 2.3 Completion 11.5 11.5 TOTAL 55.0 20.7 29.0 51.7 41.7 15.3 46.2 31.6 29.7 320.9 * as of April 21, 1998 35 IMPLEMENTATION COMPLETION REPORT INDIA INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Table 11: Bank Resources: Missions Performance Rating | Number Total Specialized Implemen- Development Stage of Month/ of Days in Staff Skdlls tation Objectives Types of Il~~~~~~~~~~~~~~~~1 Project Cycle Year Persons Field Represented- Status Problems/ Through Appraisal _ Appraisal through Board Approval Board Approval through _ _ Effectiveness Supervision I July 1991 4 12 H, N, TM 2 1 R, M Supervision 2 June 1992 5 19 C, M, N, TM 3 2 Procurement Review 3 October 1992 1 4 P not applicable not applicable Supervision 4 February 1993 3 21 C,N,W 3 2 Supervision 5 July 1993 4 9 C, N, PH, TM 2 2 Supervision 6 November 3 11 C, PH, TM 2 2 1993 Supervision 7 April/May 7 4 C, F, H, M., N, not applicable not applicable M, R 1994 TM Supervision 8 May 1994 4 26 C, N, TM, W S U Supervision 9 April 1995 7 14 C, F, H, M, N, S U M, R, S TA, TM Supervision 10 Jul/Aug 1995 3 18 0, P, TM not applicable not applicable M, S Supervision 11 January 1996 4 8 F, M, PH, TM S S Supervision 12 June 1996 5 30 ME, TM, 0, M S 2 S, M Mid-term review 13 Jan/Feb 1997 4 9 F, M, N, TM 2 S R, C Supervision 14 May 1997 4 8 M, N, TM S S AF, R Completion 15 November 5 6 F, N, H, M _ - _ 1997 /1 C=Communications, F=Finance, H=Health, M=vManagement, ME=Monitoring & Evaluation N= Nutrition, O=Operations, PH= Public Health, TM=Task Manager, W=Women in Development /2 1=No Significant Prolems, 2=Moderate Problems (i.e., there are significant, but not critical problems from appraisal expectations), HS=Highly Satisfactory, S=Satisfactory. /3 AF=Availability of funds, M=Project Management, S=Studies Progress, R=staff recruitment, C=civil works Appendix A Page 1 of 6 INDIA INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT (ICDS I) CREDIT NO. 2173-IN WO]RLD BANK IMPLEMENTATION COMPLETION MISSION NOVEMBER 1997 AIDE-MEMOIRE 1. A World Bank implementation completion mission visited Bhubaneswar from November 17 .19, 1997 and Hyderabad from November 20-22, 1997. The field team consisted of Mr. R. Sethuraman (Finance Specialist), Ms. Meera Priyadarshi (Nutrition Specialist), Dr. Stuart Gillespie (Consultant) and Mr. P. Subramaniyam (Consultant and Team Leader). Mr.A.K.Nanda from the DWCD of the Government of India accompanied the mission to Orissa and Mr.B.K.Sharrna from the DWCD of the Government of India accompanied the mission to Andhra Pradesh. This aide-memoire summarizes the main findings of the mission. 2. The mission is thankful to the States of Orissa and Andhra Pradesh for their full co-operation, work facilitation and kind courtesies. Mission had detailed discussions with the Directors of WCD Departments and the Project Coordinators and their staff members in Bhubaneswar and Hyderabad. Wrap-up meetings were chaired by the Secretaries, WCD Departments in Bhubaneswar and Hyderabad. Mission Objectives and Overall Progress 3. The objectives of the mission were to undertake a final review of progress before the close of project on December 31, 1997 and to: (a) provide advice and support to the Borrower in the preparation of its contribution to the Implementation Completion Report (ICR); and (b) record the views of the Borrower and the Bank on project implementation 4. Overa]ll progress in the implementation of the project since the last review mission was judged as fair in Orissa and very good in Andhra Pradesh although a definitive judgement on the overall impact of the project will have to await the findings of the Endline Evaluation which will be available in early 1998. Very good progress was in evidence in Andhra Pradesh in the completion of the civil works While in Andhra Pradesh the Project will be almost fully implemented, Orissa will have to double up its efforts to achieve a similar status before project closing date. This is so because Orissa could not make progress on civil works during the rainy season of the current year and is planning a special drive to complete the pending works before close of project. Appendix A Page 2 of 6 5. The performance against key indicators appears to be rather flat in Orissa and quite good in Andhra Pradesh with a clear decline in the level of malnutrition. The prospect for project sustainability in Orissa is quite good on the field level infrastructure and provision of food supplement. However, it is dependent upon pro-active efforts to internalize the capacities built under the project in areas like communication planning, training and monitoring (see Annex 1 for details). The endline evaluations of the project currently under way in both the states will throw more light on the impact of the project. 6. While Andhra Pradesh will be almost fully spending the sanctioned amount under the project (amount spent as on October 31, 1997 is Rs. 147.94 crores), Orissa will have to double up its efforts in the remaining period of the project in order to achieve the same (amount spent as on date is Rs. 147 crores against an EFC approved outlay of Rs. 184.27 crores. Out of this the State has already released Rs. 173.55 crores which is reported to be available in the field for the various items of works.) Details of the financial status for Andhra Pradesh may be seen in Annex 2. Project Issues 7. Completion of Thera eutic Study in Orissa. The baseline part of this study has been completed, though delayed considerably. The completion of the supplementation part of the study will take another twelve months. The agency is yet to start this part of the work. The reason for the delay is stated to be the non-supply of the needed food supplement by the state's production unit. The state, therefore, proposes to drop the remaining part of the study as the project is drawing to a close. 8. The mission agreed with this proposal as there is no time left for completing the study. However, if the state chooses to go ahead with the study with its own resources, the mission will have no objection to it. 9. Construction of Additional Rooms in CDPO Office-cum-godowns in Orissa. Availability of space for such construction appears to be a problem in certain places and therefore the project management proposes to construct the additional rooms in places away from the main office-cum-godowns. Mission discouraged this move and recommended relocating the same near the main offices as far as possible, and it was agreed to by the state. Implementation Completion Review 10. Mission received, reviewed and commented on the draft contributions to the ICR from the Orissa and Andhra Pradesh project authorities. The mission's main comment was that the drafts were in the nature of descriptive reviews of progress in terms of physical and financial targets and generally lacked a critical analysis of the specific areas of successes and failures along with reasons for the same. The lessons learned portion and how these will be used for future project options was also missing. Appendix A Page 3 of 6 11. The reports were more in the nature of the usual status reports. Mission has shared some samples of earlier contributions with the project authorities in both the states and requested them to prepare their drafts accordingly and restrict the write-up to about ten pages in each case. 12. Mission held extensive discussions with the project staff and other experts in both the states regaLrding the outcome of the project and the factors considered responsible for success or failure. The present assessments will be fine tuned after the availability of the endline evaluation findings expected by end December, 1997. Dr. Stuart Gillespie will be responsible for drafting the Bank's contribution to the ICR, with the assistance of the other members of the mission and make it available to the New Delhi Office of the Bank in January, 1998 for review and comments. A first draft of the Bank's contribution will be made available in February, 1998 to the Government of India and the State Governments of Orissa and Andhra Pradesh for their review and comments, and after finalization will be submitted to Bank headquarters by March, 1998 . Key Factors affecting Project Implementation and Impact 13. The specific nutrition and health impact objectives for project areas in Andhra Pradesh and Orissa differ in accordance with the staff appraisal report (SAR). They are: Andhra Pradesh Orissa Reduction in severe malnutrition (grade III and IV) among children 6-36 months by percent 50 50 Increase in proportion of children 6-36 months of age in norrmal and grade I status by percent 25 25 Contribute towards reduction in IMR from project start level to 60 100 Contribute to reduction in incidence of low birth weight by percent 30 20 14. Project Lmpact. Regarding project impact, conclusive evidence of progress towards reducing severe and moderate malnutrition among under-three year olds will only emerge with the findings of the endline survey which will be available in April 1998. The mid-term review had earlier been considered flawed with respect to child anthropometry. Monitoring data however suggest an improving trend in Andhra Pradesh between 1991 and 1996 and a relatively unchanged situation in Orissa between 1994 and 1996 for which period data are available. With regard to the infant mortality rate, Orissa has experienced a sharp drop in the seven years of the project, particularly in rural areas, while the IMR in Andhra Pradesh has changed little. It is not possible to delineate the contribution of this project to these IMR trends. Appendix A Page 4 of 6 15. Finally, data limitations preclude any definitive statement on the change in low birth weight incidence, but there is some evidence that points to improvements in line with the targets. 16. Service Deliverv. In terms of service delivery, using 1996 mid-term survey data, progress in both states has been limited with respect to most of the process objectives. Only 1-2% of 0-3 year old children are regularly weighed, around 40% receive supplementary food for an average of 16 days per month. 20-25% of young children were completely immunized and 8% received semi-annual mega-doses of Vitamin A. Less than 50% children received semi-solid complementary foods from 6 months of age. With regard to service delivery to pregnant and lactating women, 70-80% pregnant women were registered, although only 29-38% were registered in the first 20 weeks. Most registered pregnant women had however undergone an obstetrical and nutritional risk assessment and the great majority had received tetanus toxoid immunization. Sustained consumption of iron and folic acid tablets however was low, at 8-15% pregnant women. A conclusive picture of progress will be gleaned from the forthcoming endline survey. 17. IEC and Training. The differential in nutritional status between the two states particularly the limited impact on moderate malnutrition is likely to be due to the apparent non-performance of the EEC component in Orissa and the late start on EEC interim strategy in Andhra Pradesh. Had the formative research studies been completed in both the states in time and the EEC strategy developed and implemented in time in both the states it could have resulted in better movements from moderate to grade I and normal levels. Similarly for the training input. Had the training focused better on the needs of 0-3 years age group children and more particularly focused on the role of supervisors as in situ trainers of Anganwadi workers to enable them to better respond to the specific needs of the individual workers, the quality of service delivery would have improved resulting in the achievement of better nutritional status of children covered under the project. 18. Women's Empowerment. Mahila mandals have been formed in all 17,793 centrs in Orissa. All these groups have been supported with funds either from the project or under the IMY program for group formation, skill training or upgradation. More than 500 women's groups have matured into thrift and credit societies and regular income generation activities have been taken up by these groups. The project in Andhra Pradesh has successfully trained (through their pranganams) and provided tool kits to women and involved them in the construction of Anganwadi centres. 19. Monitoring and Evaluation. In Andhra Pradesh, a systematic review of the monitoring system had been undertaken. An innovative pilot nutrition surveillance scheme has been tested with the National Institute of Nutrition (NIN), and subsequently used in the revision of the monitoring proformae for the forthcoming Woman and Child Development Project. Andhra Pradesh has provided useful regular updates on progress towards the key impact and process objectives. In contrast, in Orissa, monitoring has been relatively weak and little use is made of monitoring data to improve project implementation at any level. MIS is virtually non-existent. Appendix A Page 5 of 6 20. Operational Research. Several operational research projects were planned for ICDS-I. Most of these have been seriously delayed - so much so that their findings can only be used for future projects. Some studies e.g. the therapeutic food supplementation trials have still not been completed. Where research has been completed, some attempt has been made to use the findings to improve the project though this is not clear in all cases. The quality of the Operational Research studies, however, has been generally poor. It is essential that whatever findings are still found useful from the many delayed studies are used in the general ICDS in Orissa and in the ICDS component of the proposed APER project. The lack of an explicit communication strategy (due to delayed formative research and qualitative field trials) has probably seriously limited the potential of the project to improving caring behaviours and practices. Without a thrust on inter-personal communications, it will be difficult to make a sustained dent on moderate malnutrition in particular. 21. Better Targeting on the Most Vulnerable. In both the states, the geographic and socio-econornic targeting on the most vulnerable communities especially the tribals has been a very significant achievement of the project. The opening of regular anganwadi centres and mini anganwadi centres in the inaccessible tribal areas has resulted in reaching the benefits of service delivery to the indigenous populations which otherwise would not have received the same. 22. Ca acit& BuildiLng. The project authorities in both the states are agreed on the fact that the project has resulted in substantial capacity building in terms of planning for certain crucial components like training, IEC, and MIS. Both the states have plans to build on these gains. While Orissa proposes to do this as part of their general ICDS program, Andhra Pradesh will do this under the proposed APER project's ICDS component as well as in their general ICDS program. 23. Infravtructural Base. The commitment of both the states to improving the nutritional and health status of women and children has in fact resulted in the perceptible infrastructural and capacity base for the delivery of such services. The enthusiasm to sustain these gains is encouraging. If the lessons learnt are used in improving program performance in future, that would result in substantial nutritional gains for the women and children of the two states. 24. Comments on the performance of the Bank will be included in the draft ICR. The project authorities generally felt that the Bank's review missions were useful in gearing up the implementation machinery for faster and better performance. However, procedures of recruitment and procurement seemed to bog down the pace of implementation to a great deal. These issues need to be addressed in future projects. 25. The experience gained in this project has informed the preparation processes of the proposed WCD and APER projects. Appendix A Page 6 of 6 26. Conclusions * The implementation of the project was judged by the mission as fair in Orissa and very good in Andhra Pradesh, though a definitive judgement on the overall impact of the project will have to await the findings of the endline evaluation. * The progress of completion of civil works was found very good in Andhra Pradesh, but not so in Orissa where the completion will depend upon the project's making extraordinary efforts to complete them before closing date. * Practically no communication strategy has been implemented in Orissa which is evident from the absence of any improvement to moderate malnutrition while the component has made some start in Andhra Pradesh though belated and interim. The lesson learned is that procedural delays noticed in development of communication strategy should have been avoided through a better understanding and appreciation of the procurement plans. * Almost all the operational research studies have been delayed. Some of them were not completed (e.g. therapeutic studies). The quality of these studies have generally been poor. Better procurement planning and better assessmemnt processes of the agencies entrusted with research assignments are called for. - The project has been successful in the creation of a wide infrastructure of service delivery centres and trained personnel although the quality of training has not been upto the mark. - The project has been quite successful in both the states in the establishment of service delivery centres in remote and inaccessible tribal areas thereby taking the benefits of the project to the indigenous people who otherwise would not have been so covered. Next Steps 27. The project authorities in both the states are requested to pursue the expeditious completion of the endline evaluations for the project and to revise their contributions to the ICR. The mission, on its part, will prepare and present its ICR contribution for review and comment by GOI, the project authorities, the State Governments, and Bank management as per the time table indicated earlier in this aide-memoire. 28. The mission would like to commend the project authorities in Orissa and Andhra Pradesh for all the efforts in the implementation of this project. New Delhi November 26, 1997 Appendix B Page I of 18 IMPLEMENTATION COMPLETION REPORT INDIA INTEG]RATED CHILD DEVELOPMENT SERVICES (ICDS 1) PROJECT (Cr. 2173-IN) Government of Andhra Pradesh Borrower's Evaluation Introduction 1. Andhra Pradesh (AP) has a population of 66.35 million (1991 census) with a large majority of 73.2% living in rural areas in 29,400 villages and the balance are Schedule Caste (14.9%) and Scheduled Tribes 5.9%. According to the 1991 census overall literacy in the state is 37.4% as compared with average of 52.1% in the country. Female literacy as in many other states in the country is 33.7% and male literacy is 56.2%. The sex ratio of females per 1000 males is 973. 2. The ICDS program was sanctioned by the Department of Women and Child Development in the year 1975 in Andhra Pradesh. By 1990, ICDS projects were covered in 126 blocks in all 23 districts. The World Bank ICDS project was sanctioned during the year 1990-91 for a period of six years covering 110 blocks in 13 districts in a phased manner. The blocks covered yearwise under the World Bank ICDS project are given below: Year Old New Total 1990-91 20 20 40 1991-92 24 23 47 1992-93 - 23 23 Total 44 66 100 3. A total of Rs. 159.4 crores has been sanctioned for implementation of various schemes under World Bank ICDS project. Given below are the yearwise details of amount sanctioned and expenditure incurred during project period, i.e., 1990-91 up to December 31, 1997: ADnendix B Page 2 of 18 Amount Released Budget Sanctioned Year as per EFC by GOI by GOAP Expenditure 1990-91 9.72 5.00 - 2.20 1991-92 26.40 28.00 25.57 21.49 1992-93 32.85 14.00 24.73 16.26 1993-94 22.66 15.00 21.04 17.62 1994-95 20.55 16.10 27.57 19.49 1995-96 18.61 23.00 27.62 18.33 1996-97 28.61 31.07 26.83 30.96 1997-98 - 17.58 33.94 32.94* Total 159.40 149.79 187.00 159.40 (including state share of Rs.9.61 crores) * Estimated expenditure by December 31, 1997 4. The World Bank Assisted ICDS project is being implemented to improve Nutrition and Health status of children under 6 years of age with special emphasis on children 0-3 years, and pregnant and nursing women with broad ICDS objectives for overall child development. Specific Nutrition and Health impact objectives of project areas in AP are given below: i) Reduction in severe malnutrition by 50%; ii) Increase in proportion of Normal and Grade I by 25%; iii) Reduction in incidence of low birth weight by 30%; and iv) Reduction in IMR from present level to 60. Reasons for Success of the Project 5. The Nodal Department at the state level is the Department of Women Development and Child Welfare in A.P. A separate cell was also established at Secretariat for speedy process of proposals relating to ICDS implementation. Project Management Unit was established during 1991. 6. The State of Andhra Pradesh has initiated a number of policies and programmes which have resulted in significant improvement in the situation of women and children to follow World Summit for Children held in September 1990 and the National Plan of Action by Department of Women & Child Development, GOI in August 1992. The State Programme of Action was released in May 1994 which identified major goals and specific goals to achieve by 2000 AD covering child health, maternal health, nutrition, education, girl child and adolescent girls. Andhra Pradesh State Action Plan for Women was also released in 1994 to integrate women at all levels into the mainstream of development and Appendix B Page 3 of 18 economic activity by 2000 AD. These activities taken up by State Government have contributed aL lot for the success of ICDS project implementation. 7. To monitor the progress of World Bank ICDS project an Empowered Committee has been constituted with all the Secretaries related to ICDS implementation as members under the chairmanship of Chief Secretary. The meetings were conducted from time to time during t:he project period to accelerate the progress of implementation of World Bank ICDS project, and to coordinate the activities of other departments towards ICDS objectives and also to monitor the activities. A State Level Coordination Committee with all the departments related to implementation activities on Women and Children was also formulated. 8. Regular monitoring of programme implementation was possible due to regular monthly review meetings conducted by the Director and Project Director with District level officers. It enabled us to give regular instructions to the field functionaries and to get feedback. Regional Review meetings conducted by Secretary and Director quarterly also gave the opportunity to give clear instructions to field functionaries and facilitated two- way exchange of information which led to quick decisions and solutions to the problems. Regular monthly meetings at district level, project level and at sector level also enabled the entire administrative set-up to monitor the programme effectively. 9. Various studies conducted during the project period like the Baseline study at the time of initiation helped the project to identify the priority issues Operations Research studies on work routines, supervision, referral services, joint coordination and management information were also conducted. Knowledge attitudes and practices (KAP) study was conducted for finalization of Communications strategy. To streamline the monitoring system in ICDS, Nutrition Surveillance system was undertaken by NIN in AP Orientation training on reporting systems were conducted to all field functionaries from Programme Officers level to AWW level for a period of one year. The final report will be presented during December 1997. 10. The quality of services at field level is taken care of by periodical job course, refresher course and orientation training programmes which provided them with strengthened capabilities like improved communication skills to perform their job well. For conduct of training two middle level training centres and 48 AWTCs were set up. The CDPOs were trained at NIPCCD. The need to strengthen the service delivery in ICDS with focus on reaching the most needy i.e. 0-36 months, pregnant and lactating women was identified through training need assessment study conducted by PMU. Based on the needs identified DTTs have been formed in all 13 West Bengal districts. 11. The Early Childhood Education programme being conducted at Anganwadi Centres aims to provide a learning environment for the promotion of social, emotional, cognitive physical and aesthetic development of the child through joyful play way method contributing to universalization of primary school education especially of girl children. Pre-school play material has been supplied to all AWCs. Supply of print material audio- ADDendix B Page 4 of 18 video cassettes under CHEER programme improved the attendance in pre-school classes. Standard Curriculum for ECE activities was also developed in collaboration with AMS. 12. Supply of Medicines to AWCs, Sub-centres, PHCs contributed for better utility of ICDS services in the community. Better coordination with Health functionaries helped in utilisation of medicines which also contributed for better coverage of immunisation both for children and pregnant women. 13. Communication cell was set up in Project Management Unit which played a crucial role in stimulating the demands for project services, increasing community participation and then by slowly owning the programme by the community. The communication strategies adopted were organising community education/awareness activities like well baby shows, exhibitions, folk performances, printing of material like posters, flip books, calendars, new letter development and multiplication of audio and video programmes to deliver ICDS messages, etc. 14. Around 10,500 Self help women groups have been formed in all 110 projects. Around 4020 groups have been benefited by the activity. Women groups in AP have taken active role to popularise the services of ICDS. Provision for skill training and supply of tool kit enabled sustainability of the programme. 15. Training to women groups in masonry/construction is a landmark in providing economic empowerment to women in AP. Some of the AWC buildings planned during later part of implementation of the project were constructed by women. 16. Adolescent Girls-I Scheme aimed to improve the health and nutritional status and overall development of future mothers. It provided in-house training to three girls per AWC through delivery of ICDS services and provision of non-formal education. Around 87,000 girls per year were benefited over six years in the project. 17. Adolescent Girls-II Scheme, a vocational-cum-production scheme, was implemented in 14 selected blocks up to 1995-96 and was extended to all 110 projects as it was identified as a felt need. Altogether 35,000 girls were trained under this scheme over a period of six years. 18. Good infrastructure to the project has been provided by sanctioning construction of a total number of 4150 AWCs covering 20% of the functioning AWCs. A total number of 73 office-cum-godown and 1630 handpumps are also sanctioned in the project buildings have been constructed with the help of construction agencies like AP State Housing Corporation Ltd., AP Industrial Infrastructural Corporation and Tribal Welfare Department. Appendix B Page 5 of 18 Degree of Achievement of Project Objectives Impact Objectives 19. Reduction in severe malnutrition by 50%. The percentage of severe malnutrition Grade III and IV was 8% durilng 1990-91 as per NIN study. Severe malnutrition percentage of children 0-3 years over project period is given below: 1991 1992 1993 1994 1995 1996 1997 7.57 5.06 3.98 2.59 1.95 1.61 1.10' The percentage of severe malnutrition was 7.57 in the year 1991 has come down to 1.10 by 1997. The percentage of reduction is 86 over a period of 7 years which means the degree of achievement of the objective is much better than the goal set. 20. Increase in proportion of Normal and Grade I by 25%. The percentage of Normal and Grade I was 57% during 1990-91 as per NIN study. The percentage of Normal & Grade-I children below three years during project period is given below: 1991 1992 1993 1994 1995 1996 1997 60.49 68.33 69.56 70.76 73.62 75.57 74.451 The percentage of Normal and Grade I had gone up to 74.45 during 1997 from 60.49 during 1991. The percentage of increase accounts to 23%. 21. Reduction of Infant Mortality Rate (IMR) from present level to 60. A positive trend has been obtained in the basic indicator of child health, i.e. IMR, over the project period. According,to NFHS (1992) IMR is 71 per 1000 live births. The Mid Term Evaluation (1996) findings say that the IMR is 62.4 per 1000 live births. Information available from Nutritional Surveillance System conducted by NIN in AP ICDS projects says that the average IMR is about 40 per 1000 live births. 1992 1996 1996 1997 NFHS MTE MPR NSS 712 623 55 40' 23. Reduction in incidence of low birth weight by 30%. National survey indicates that the mean birth weights in India range from 2.49 to 2.97 kgs, with about 30% new boms being less than 2.5 Kg. (1991). Mid term evaluation says out of 17% institutional deliveries accounts to 24% (1996) whereas NSS conduct by NIN in project areas says that it is around 7.29% which indicates reduction of 3/4th approximately as against 1/3rd (30% reduction) objective set for. However this information pertains to pregnant mothers registered in AWCs. Appendix B Page 6 of 18 Process Objectives Objective (%) Achievement (°) SAR (1990) (1997) * Early registration of pregnant women 50 383 * Total registration of pregnant women 80 80 * Obstetrical and Nutritional risk assessment of those registered 100 * Tetanus Toxoid immunisation of pregnant women 90 90/86' * Consumption of Iron and Folic Acid tabs. for at least 12 weeks by pregnant women 60 467/643 * Administration of post-partum to attend the deliveries 80 * Food Supplementation for at least 20 weeks to registered pregnant women with inadequate nutritional status 80 90 * Immunization (UIP-6) 90 90/66.54 * Vit. 'A' megadose (1,00,000-2,00,000) 80 524 * Regular Growth Monitoring more than 9 times in a year of children 0-3 years 80 57 3 Supplementation of monitored children 0-3 years with Gr. II-IV malnutrition 90 100 3 Completed referral severely malnourished children Gr. III and IV or non-responding children -3 yrs. to VHN/MPWF and PHC 80 * Administration of Vit. 'A' megadose semi- annually to children 3-5 years of age 80 52 * Preschool attendance (more than 80% of working days) 80 95 * Routine deparatisation of monitored children in heavily infected communities as determined by parasite surveys 90 * Household use of oral dehydration in the last incidence of diarrhoea in the target group 60 35 * Treatment of pneumonia by MPWF/AWW with co-trimaxazole in case of Acute Respiratory Infection (ARI) 30 35 * Additional feeds of local weaning foods initiated by 6 months in infants 60 473 Apoendix B Page 7 of 18 Plan for Project's Future Operations * Adolescent Girl Scheme and Income Generating Activities (IGA) for women was an appropriate policy initiative and needs to be sustained in future. * The positive experiences of ICDS I will be the basis to reach new heights under APER ICDS II. Source: I Nutritional Surveillance System by NIN in AP 1996-97 2 National Family Health Survey 1992 3 Mid-Term Evaluation conducted in ICDS projects 1996 4 Multi-Indicator Coverage Evaluation Survey 1995-96 by UNICEF Appendix B Page 8 of 18 INDIA IMPLEMENTATION COMPLETION REPORT INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS I) PROJECT (Cr. 2173-IN) Government of Orissa Borrower's Evaluation Introduction 1. In Orissa, 229 ICDS projects in 223 blocks and 6 urban areas have became operational. Out of these projects, 191 are World Bank-assisted ICDS projects. These 191 projects were covered in a phased manner in 1990-91 (107), 1991-92 (42), and 1992- 93 (42). The project coverage in different areas is as follows: Rural - 74 Tribal - 117 Total - 191 Special Features of World Bank Project 2. The special features of the project are: i) Enrichment of the existing ICDS schemes; ii) Supply of additional medicines, referral funds, and delivery kits; iii) Supply of communication materials to AWCs/Projects/Districts and State Headquarters; iv) Installation of hand pumps for supply of safe drinking water and construction of CDPO offices and AWCs; v) Training of ICDS personnel at all levels including joint training of ICDS and Health functionaries; vi) Supply of Early Childhood Education materials and supporting innovative training; and vii) Providing a revolving fund for mopeds to support mobility of Supervisors. Innovative Schemes of the World Bank Project 3. The innovative schemes under the project are: i) Community Mobilization; ii) Women's Integrated Learning for Life (WILL); iii) Scheme for Adolescent Girls (AG); iv) Income Generation Scheme (IGS); v) Nutrition Rehabilitation Centre (NRC); and Appendix B Page 9 of 18 vi) Therapeutic Food Supplementation The World Bank Project envisaged to achieve the following impact objective over six years of the project period from 1990-91 to 1996-97: Impact Objectives Target Achievement i) Reduction in severe malnutrition of 50% 30% (as compared Grade III and IV among children under with National Family 3 years of age Health Survey (NFHS)., 1993) ii) Increase in proportion of children below 25% 4.5 % (taking 3 years of age in Normal and Grade I National Institute of status Nutrition as the base) iii) Reduction of IMR from base level to 100/1000 95/1000 iv) Reduction in incidence of low birth 20% 23% weight babies 4. The achievements are based on the mid-term evaluation (MTE) study conducted during 1996. In the area of malnutrition, the project has two goals: malnutrition of Grade III and IV was to be reduced by 50% and proportion of children in normal and Grade I status had to be increased by 25%. By comparing the MTE estimates with the NIN base- line, there has not been much progress. Apart from the base line of NIN, the NFHS 1993 is another source with which the nutrition status of children as per the MTE was compared for this purpose. The MTE measure was converted to NFHS standards. This comparison revealed that the proportion of severely under-nourished children has come down by around 30% from 29.8% among Scheduled Tribes to 21.5% in the MTE. In case of Orissa, the comparison of Scheduled Tribes estimates of NFHS with MTE is valid because of the high proportion of Scheduled Castes and Scheduled Tribes in the project area. 5. In the area of low birth weight babies the achievement is absolutely on target. The achievement on reduction of Infant Mortality Rate (IMR) was absolutely in consonance with the set project goal. Looking at the SRS figure on IMR, in the year 1975 the IMR was 149 and in the year 1990, it came down to a level of 122 which means a reduction of 27 over a period of 14 years. But in the year 1996 this has come down to 95. Thus from 1990 to 1996 there was a reduction of 27 in the IMR. Incidentally, this period of 1990- 1996 coincides with World Bank project period. Since ICDS is an integrated approach for improvement of health and nutrition through a package of services, it may reasonably be concluded that the ICDS scheme is a major contributing factor for the sharp decline in the IMR. Appendix B Page 10 of 18 Process Objectives 6. The project had set some process objectives in the implementation of the ICDS program. The achievement in the field of process objectives is given below: Process Objectives Target Achievement (according to MTE findings) i) Total registration of pregnant women 80% 71% ii) Early registration of pregnant women 50% 29% iii) Obstetrical and nutritional risk assessment of these registered 100% 61% iv) T.T. immunisation of pregnant women 80% 71% v) Consumption of iron and folic acid tablets 60% 15% for a tleast 12 weeks for pregnant women vi) Food supplementation for at least 16 weeks 90% 22.6% of registered lactating women with malnutrition in pregnancy vii) Delivery attended by Doctors/Nurse/ 26% Mid wife/Trained Dai viii)Mothers given PNC check up 32% ix) Mothers with complication referred 4% Child Care i) Immunisation of children 85% 21% Process (complete objective immunisation) MTE findings Colostrum Feeding 50% As per the NIN study data 1990. The incidence of colostrum feeding was 26%. Thus the communications and nutrition and health education has had a definite impact Additional feeds of local weaning 50% 48% food initiated by 6 months The goal has been nearly met Appendix B Page 11 of 18 Growth Monitoring i) Regular growth monitoring of 0-3 years 80% 2.2 % children (9 times a year) ii) Weighed at birth - 8% iii) Weighed within one month of birth 52% iv) Children estimated to be in Grade III and - 12% IV (Severe malnutrition) v) Vitamin - A mega-dose semi-annually 80% 21% children 6 to 35 months vi) Children 36-71 months 70% 8% The Proportion of Children receiving Iron and Folic Acid Tablet i) Children 0-35 months 8% ii) Children (36-71 months) 11% Supplementary Feeding Children 6-35 months i) Children receiving supplementary food 42% Children 36-71 months i) Receives supplement - 33 % ii) Average days of feeding 25 17 Treatment Given for Fever/Cough i) Children 0-35 months 71 % ii) Children 36-71 months - 74 % The Proportion of Children given ORT i) 0-35 months 50% 32% ii) 36-71 months 50% 45 % 7. Thus the MTE finding reveals that the ICDS project had a positive impact in the area of reduction of IMR, reduction of low birth weight babies, reduction of severe malnutrition early/total registration of pregnancy, TT immunization of mother, colostrum feeding, knowledge of ORT, local weaning food, etc. Nevertheless, in state like Orissa there is miles to go in the area of health, nutrition care of children and mothers. Appendix B Page 12 of 18 Infrastructure Development 8. With the World Bank funds 140 CDPO office buildings, 90 additional godown buildings, 3892 Anganwadi Centres (AWCs) buildings have been constructed in the project area. Besides, 5292 hand pumps have been installed in the premises of AWC building. Apart from this, the State Government have taken up large number of buildings out of state resources, Employment Assurance Schemes (EAS) and Jawahar Rojgar Yojna (JRY) funds. Other Innovative Schemes 9. Under the referral scheme 243410 children and 103362 pregnant and nursing mothers have been benefitted during the project period. 10. In the adoloscent girls training progamm 271635 girls have been trained in literacy, health, hygiene child care etc. In order to prepare them as resource persons for the community and to face the challenge of motherhood in future, women's integrated learning for life which has been implemented in 14 projects and has benefitted 34357 number of adult women by providing them training in literacy and numeracy skill, training on health, hygiene, sanitation and safe motherhood. 11. Through the income generating schemes, funds to the tune of Rs.778.74 lakhs has been released. 17259 number of Mahila Mandals have been benefitted. The intemal evaluation of the scheme reveals that the average earning of the women groups from the Income Generating Scheme is about Rs. 150/- to Rs.200/- per month. Innovation under Monitoring and Information Systems (MIS) 12. The Project management unit has a computer system. All the ICDS reports and returns have been computerised at the state level and the data are being analyzed for better monitoring. For strengthening the MIS following steps have been taken: i) Reports are flowing from the project level to the PMU. These are channeled through the District Program Officers in order to strengthen the district level monitoring system; ii) The Statistical Assistants of the projects and the District ICDS Cells were given training on statistical techniques of systematic collection, compilation, representation, analysis and interpretation of data with reference to the ICDS Scheme. The software on Child Development Project Officers (CDPOs) Monthly Progress Report (MPR) was installed at the district level and the Program Officers were asked to computerize the ICDS MPR at district level with the help of District Unit of National Informatic Centre (NIC). In order to streamline the monitoring in the financial matter a software was developed by the statistics and monitoring cell of the Project Management Unit (PMU) with the help of officers of NIC. The ApDendix B Page 13 of 18 software has provision of generating project level, district level and state level report; iii) The Statistical Asstistants of the district ICDS Cells were trained on data entry and report generation in these two softwares (software for CDPOs MPR and software for financial MPR); iv) Impact indicators and process indicators relating to the objectives were analysed and feedback given to the districts and projects with the help of softwares on CDPOs MPR; and v) Nutrition trend analysis of children in 0-3 years of age group was done and the feedback given to the field level. Training 13. As a part, of the human resources development program, different job courses, refresher course,s orientation, joint training of medical and ICDS staff were conducted during the project period. The achievements are given in the attached Statement. Communicationi 14. The commnunication cell is the mouth-piece of the project in order to create the awareness of the facilities, services and their benefits etc. The communication cell has taken the following steps: i) The campaign captioned "Campaign CHILDREN" has been launched covering all the project areas to create awareness on delivery of services under ICDS schemes; ii) The CHEER programme captioned "KALIKA" was broadcast through All India Radio. 4058 AWCs were provided with two-in-one sets to receive the program; iii) Anganwadi news-letter was published and circulated in all the AWCs as a media of communication; and iv) The communication cell prepared camera ready (proto type) communication materials like posters, banners, leaflets, booklets, brochures and wall paintings which were designed and developed. The popular news letter "Anganwadi" was distributed to the AWCs. The training manual for District Training Teams (DTTs) training booklet and folders for campaign children were designed, printed and distributecd by the communication cell. State level workshop and district level workshop on traditional media were also organized. Field visits were undertaken to monitor the ongoing communication activities like exhibitions, baby shows, Nutrition and Health Education (NHED) sessions, etc. Besides, retransating of original Hindi/English version of State Action Plan for Children 2000 and State Appendix B Page 14 of 18 Policy for Disabled Children, was done. Manual for preparation and use of community growth chart, adolescent girls instructor kits, growth monitoring manual were also prepared. Studies 15. With World bank assistance, a good number of studies by external agencies and the staff of the PMU have been conducted. Based on the studies some interventions have been taken up and these studies will work as a guide in future as ICDS is going to be universalized in the state. Constraints 16. Procedural delay in purchase of medicine, equipment and instruments and huge vacancy of Supervisors with a case being subjudice in Hon'ble High Court for a long period are some of the major constraints of the project implementation. A large number of buildings (1600) AWC buildings, 50 CDPO office buildings, 90 addlitional godown buildings were sanctioned at a later stage (March 1997 to August 1997) and as a result difficulty was faced in their completion. Sustainability of the Project 17. The project period was over on December 31, 1997. Under the project a big infrastructure has been created. In the budget there is provision for maintenance of normal activities under ICDS out of central assistance. But for innovative schemes like IGA, WILL, Referrals, adolescent girls' training there is no such provision. As regards the staff of PMU, the Government of India have been moved for continuance of the post of Project Coordinator (PC), Supervisor-cum-DEOs, Chowkidars and Peons under Central ICDS Plan. A reply is yet to be received from GOI. It is felt necessary to establish the PMU consisting of PC, Research Advisor, Communications Adviser, Assistant Directors, and Research Officer, Statistical Investigators, Senior Assistants, Accountants, Stenographers, Drivers and Chowkidars. Conclusion 18. The Mid-Term Evaluation reveals that the Word Bank project has been able to achieve the impact objectives such as reduction of IMR, reduction of severely malnourished children in 0-3 years age group, reduction of low birth weight babies. Besides, many of the process indicators have been achieved and awareness in the area of health, nutrition, care of children and mothers have been generated in the rural and tribal areas. The sharp decline in the IMR during the project period also indicated positive impact of the ICDS program in the State. The schemes like training of adolescent girls, referrals, WILL, IGA have contributed for the development of women and children in the far flung rural and tribal areas of the state. Appendix B Page 15 of 18 19. In the area of health and nutrition of children and mothers, a lot more has to be done in the state to sustain the impact of the World Bank project. Nevertheless, the typical features of the state, characterized by high concentration of Scheduled Castes and Scheduled Tribes, low level of female literacy, high level of IMR and high level of severe and moderate malnutrition justified for special thrust in the ICDS program, to maintain the tempo of achievement of the World Bank project. In view of these the sanction of a second World Bank project for the state of Orissa merits consideration. Appendix B Page 16 of 18 Statement KEY INDICATORS FOR PROJECT IMPLEMENTATION Key Implementation Indicators Estimated Actual in SAR/President's Report A Expansion of New Areas 1 Establish new blocks/ICDS Project 122 122 2 Establish Dist. ICDS Cell 17 17 3 Setting of Anganwadis 17793 17793 4 Appointment of new Supervisor 444 299 (84 new blocks) B. Improved Coverage 1. TT Immunisation 88 71 (as per MTE) 2. Immunization 85 21 3. Regular growth monitoring 80 2 -do- 68 (as per MPR) 4. Referrals 80 103362 Mothers 243410 Children 5. Regular pre-school attendance 60 80 (as per MPR) C. Other Civil Works 1. Block office/warehouse 140 140 2. AW Construction 3892 3892 3. Additional Godown in 90 CDPO offices 90 90 4. Handpumps 1146 LWS 1146 ]5292 4146 RD 4146 ] D. Maternal and Nutritional Rehabilitation 25 25 Centers E. Pre-school Education Kits - 14155 Sets F. Therapeutic Supplementation 26726 C 26726 C 560 M 560 M Community Mobilization 1. Establish Mahila Mandals 17793 17793 2. Income generating grants released to 6800 17259 women's groups 3. WILL classes operating in Aws 720 1212 4. Adolescent girls training - 271635 3 days 248417 5 one day Appendix B Page 17 of 18 Training 1. Establishment of anganwadi training centers 26 22 2. Organization and training of District Training Teams (DTTs) 16 11 Pre-Service Training for New Staff 1. Anganwadi workers 17793 17676 2. Anganwadi helper 17766 17201 3. Supervisor 1046 901 4. Addl. Supervisor (Community Mobilization) 33 29 5. Child Development Project Officer 191 191 Refresher Training 1. Child Development Project Officers 191 113 (8 days every 3rd year) 2. Supervisors (8 days every second year) 901 835 3. AWWs (12 days every second year) 17667 13146 4. AWWs (8 days every second year) 17201 8546 Joint Training 1. CDPOs and MOs 191/939 197/893 2. Supervisor and Lady Health Visitor 1046/415 801/271 3. AWWs and ANMs 18351/3655 13494/4583 4. Helpers and TBAs 18351/18351 12836/10988 5. Nutrition management training of 975 745 Medical Officer 6. Trainers training 374 281 7. Training of DSWOs/TOs/ADSWOs/ 118 61 SSWOs 8. Helpers training (84 new projects) 7800 7403 9. Pre-job training of AWWs 4000 3165 (69 old projects) Orientation Training 1. CDPOs 96 29 2. Supervisors 1046 961 3. AWWs 17793 17558 4. AW Helpers 8000 2537 5. Mahila Mandal (President & Secretary) 15560 10137 6. Reorientation training of Helpers 9000 8688 Communication 1. Radio/TV 14/4580 14/4580 2. Audio Cassettes 22900 22900 3. Toys 17793 Sets 17793 sets 4. DTT 1 Set 1 set 5. Computer 1 Set 1 set ADendix B Page 18 of 18 Procurement 1. Weighing scale 21877 Sets 21877 sets 2. Vehicles 187 126 3. AW articles 191 proj. 191 proj. 4. Typewriter/Duplicator 153 153 5. Folk instrument 191 proj. 191 prj.