ICRR 11424 Report Number : ICRR11424 ICR Review Operations Evaluation Department 1. Project Data: Date Posted : 05/28/2003 PROJ ID : P009963 Appraisal Actual Project Name : Population Viii Project Costs 91.08 88.46 US$M ) (US$M) Country : India Loan /Credit (US$M) Loan/ US$M ) 79.00 73.28 Sector (s): Board: HE - Health (84%), Cofinancing 0 0 Sub-national government US$M ) (US$M) administration (8%), Vocational training (4%), Other social services (4%) L/C Number : C2394 Board Approval 91 FY ) (FY) Partners involved : no Closing Date 06/30/2001 06/30/2002 Prepared by : Reviewed by : Group Manager : Group : Ronald G. Ridker Ridley Nelson Alain A. Barbu OEDST 2. Project Objectives and Components a. Objectives Original objectives were to (a) reduce fertility by improving access to and demand for family planning services and (b) improve maternal and child health by helping to decrease maternal and infant mortality rates among slum populations in four metropolitan areas of Bangalore, Delhi, Hyderabad, and Kolkata . b. Components (1)Improve access to family welfare (FW) and maternal and child health (MCH) services through creation and upgrading of facilities and deployment of a fleet of trained female volunteers ($40.4m), (2) improve quality of FW services through training, involvement of community organizations and private medical practitioners, and provision of essential supplies ($10.01m), (3) increase demand for FW services through creating client -friendly ambience and expanded information-education-communication (IEC) activities ($9.18m), (4) improve management of the FW program through technical assistance, training, equipment, vehicles and salaries of additional managers on a declining scale ($3.14m), (5) support innovative schemes, focused mainly on women's empowerment and income generation ($7.76m), and (6) prepare future projects ($8m). At MTR, a seventh component was added, to strengthen FW logistics in Tamil Nadu and Uttar Pradesh . c. Comments on Project Cost, Financing and Dates Project savings at midterm review (MTR) were estimated to be $38m, largely due to depreciation of the rupee against the SDR and nonutilization of project preparation funds . Most of these savings were used to expand the scope of the project to additional urban areas . The original effectiveness date was delayed by 2 years because of changes in government after negotiation . Clearance for expanding the project scope after MTR was delayed by 18 months because of national elections . The closing date was extended by one year to compensate . 3. Achievement of Relevant Objectives: The total fertility rate fell during the course of the project, significantly in Bangalore, Delhi and Hyderabad and marginally in Kolkata where it was already below replacement . The infant mortality rate fell significantly at all four sites. No data are available for the urban areas added after the MTR . The extent that these declines can be attributed to the project cannot be determined . But process indicators (contraceptive prevalence rate for modern methods, antenatal coverage, institutional deliveries and percent of fully immunized children ) increased at all major sites. Reproductive and Child Health (RCH) RCH ) outreach services were ex tended to twice the number originally estimated. This was accomplished by renovating and building new facilities close to the slums and by mobilizing double the number of female volunteer outreach workers estimated in the SAR . Quality of FW and MCH services were improved through training and provision of quality -enhancing equipment and supplies. For the first time in the public sector, 30 urban health centers in the project area received ISO 9002 accreditation. Demand for services was encouraged by improving quality and convenience and by carefully targeted IEC activities and interpersonal communications . Planned activities were accomplished at lower cost than originally estimated . Management and administration of municipal health departments were strengthened through training and problem-solving interventions. Innovative schemes focused on empowering women through vocational training and education. This was accomplished as planned at the four major sites but not elsewhere due to limited time remaining in the project for the expanded sites . Efforts to prepare future projects were dropped after MTR when the project was extended to several new states. Logistic systems in two states were strengthened nearly as planned at MTR when this component was added. 4. Significant Outcomes/Impacts: The most significant outcome/impact was the improvement in TFR and IMR and the provision of quality services to slum populations. It is also significant that a large number of girls in the four major cities were given vocational training and that this resulted in jobs . 5. Significant Shortcomings (including non-compliance with safeguard policies): Delayed GOI clearance and staff appointments affected takeoff and implementation especially in areas added after MTR. Coordination and referral arrangements with secondary and tertiary agencies were weak . 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Satisfactory Satisfactory Institutional Dev .: Modest Modest Sustainability : Likely Likely Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Satisfactory NOTE: NOTE ICR rating values flagged with ' * ' don't comply with OP/BP 13.55, but are listed for completeness. 7. Lessons of Broad Applicability: Effectiveness and sustainability of health projects targeted at urban poor will be enhanced by (among other things): Anticipating political and other events that could delay initiation and implementation, for example, by obtaining approvals and clearances before these events occur . Decentralization and involvement of local politicians . Involvement of female community volunteers and local leaders in planning and implementation . Involvement of private practitioners through use of incentives . Provision of client-friendly services at convenient locations and times . Use of user charges that take into accountability to pay . Collaboration and coordination with referral health services and other slum development programs . Careful attention to a focused set of interventions and messages based on sound communications research and identification of needs in order to generate demand . 8. Assessment Recommended? Yes No 9. Comments on Quality of ICR: ICR quality is good and includes sufficient evidence to judge what is going on . The only exception is that the ICR does not explain why the shortage of time to implement the project in new areas was not anticipated and dealt with before expansion of the project .