Document of The World Bank FOR OFFICIAL USE ONLY Report No: 23855 IMPLEMENTATION COMPLETION REPORT (IDA-26300) ON A CREDIT IN THE AMOUNT OF SDR 62.7 MILLION (US$88.6 MILLION EQUIVALENT) TO THE GOVERNMENT OF INDIA FOR A FAMILY WELFARE (ASSAM, RAJASTHAN AND KARNATAKA) PROJECT June 21, 2002 HUMAN DEVELOPMENT SECTOR UNIT SOUTH ASIA REGION This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective) Currency Unit = Rupee Rupee 1.00 = US$ 0.0204 US$ 1.00 = Rupee 48.95 FISCAL YEAR April - March 31 ABBREVIATIONS AND ACRONYMS ANM Auxiliary Nurse-Midwife CBR Crude Birth Rate CDR Crude Death Rate CHC Community Health Centre CPR Contraceptive Prevalence Rate CVs Community Volunteers EFC Expenditure and Finance Committee (GOD FAQ Frenquently Asked Questions FRU First Referral Unit FW Family Welfare GOI Govemment of India HFWTC Health and Family Welfare Training Centre HMIS Health Management Information System ICB Intemational Competitive Bidding IDA Intemational Development Association IEC Information, Education, Communication IMR Infant Mortality Rate IPP India Population Project (I through IX) LCB Local Competitive Bidding LHV Lady Health Visitor MCH Matemal and Child Health (care, services, program) MIS Management Information System MTR Mid-term Review MTFP Mid-term Fiscal Plan NGO Non-Govenmmental Organization PDS Public Distribution System PHC Primary Health Centre PHN Public Health Nurse PMIS Project Management Information System PRIM Panchayat Raj Institution Members RCH Reproductive and Child Health Project SCHAC Sub-Centre Health Advisory Committee SMO Senior Medical Officer TBA Traditional Birth Attendant TFR Total Fertility Rate Vice President: Meiko Nishimizu Country Director: Edwin R. Lim Sector Director: Charles C. Griffin Task Teamn Leader Sadia Afroze Chowdhury FOR OFFICIAL USE ONLY INDIA POPULATION IX CONTENTS Page No. 1. Project Data 1 2. Principal Performance Ratings 1 3. Assessment of Development Objective and Design, and of Quality at Entry 1 4. Achievement of Objective and Outputs 4 5. Major Factors Affecting Implementation and Outcome 9 6. Sustainability 10 7. Bank and Borrower Performance 11 8. Lessons Learned 14 9. Partner Comments 16 10. Additional Information 18 Annex 1. Key Performance Indicators/Log Frame Matrix 19 Annex 2. Project Costs and Financing 24 Annex 3. Economic Costs and Benefits 28 Annex 4. Bank Inputs 29 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 32 Annex 6. Ratings of Bank and Borrower Performance 33 Annex 7. List of Supporting Documents 34 Annex 8. Government's Contribution to ICR 35 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization. Project ID: P010457 Project Name: Family Welfare Project Team Leader: Sadia Afroze Chowdhury TL Unit. SASHD ICR Type: Core ICR Report Date: June 21, 2002 1. Project Data Name: Family Welfare Project L/C/TF Number: IDA-26300 Country/Department: INDIA Region: South Asia Regional Office Sector/subsector: HC - Primary Health, Including Reproductive Health, Child Health KEY DATES Original Revised/Actual PCD: 08/31/1992 Effective: 09/22/1994 09/20/1994 Appraisal: 12/15/1993 MTR: 12/18/1998 12/18/1998 Approval: 06/16/1994 Closing: 12/31/2001 12/31/2001 Borrower/lmplementing Agency: GOI/TBD Other Partners: STAFF Current At Appraisal Vice President Mieko Nishimizu Joseph D. Wood Country Manager: Edwin Lim Heinz Vergin Sector Manager: Anabela Abreu Richard Lee Skolnik Team Leader at ICR: Sadia Afroze Chowdhury Althea Hill ICR Primary Author: Laura Kiang; Tazim Mawji 2. Principal Performance Ratings (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=Highly Unlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M-Modest, N=Negligible) Outcome: S Sustainability: L Institutional Development Impact: SU Bank Performance: U Borrower Performance: S QAG (if available) ICR Quality at Entry: S Project at Risk at Any Time: Yes 3. Assessment of Development Objective and Design, and of Quality at Entry 3.1 Original Objective: The project had two original objectives as stated in the SAR: (1) To strengthen and improve the functioning of the Family Welfare programs in Assam, Rajasthan and Karnataka; and (2) To lower the current levels of fertility, and maternal and childhood mortality in the three states. The project's goal was to provide further support to the Govemment of India (GOI), national Family Welfare Program in three focus states (Assamn, Karnataka, and Rajasthan). The objectives of the project were realistic and consistent with the needs in the Farnily Welfare sector, as detailed in the Country Assistance Strategy (CAS), and the national and state Action Plans for revamping the Family Welfare Program. The implementation arrangements were consistent with the capacities of each state, however, during the project preparation process, it was noted that the risks of implementation varied across the states. Many of the approaches and strategies to be implemented by the project such as those related to the outreach and community linkage schemes, and logistics component were new, innovative and untested in the Family Welfare Program. In addition, in Assam, there was a lingering security concern, the control of which was beyond the scope of the project. However, the objectives were clear to the GOI and the implementing states and commitments regarding implementation of the action plan were obtained from them during appraisal and negotiations. Both childhood mortality and fertility rates in India had fallen significantly during the 1980s. The contraceptive prevalence rate had risen to more than 40% and immunization coverage had reached 85%. Despite these achievements, the national Family Welfare Program continued to suffer from long-standing implementation problems such as inadequate financing, weak and over centralized management, inadequate supervision, low quality training, and inadequate attention to activities for demand generation, outreach and community linkages. If not addressed, these threatened further progress in reducing fertility, and matemal and childhood mortality. To address these issues, the GOI launched efforts to restructure the Family Welfare Program through its "Action Plan for Revamping the Family Welfare Program in India". This plan included a central strategy for improving the performance and impact of the entire program, as well as state plans reflecting the central strategy. Major assistance for putting the strategy into operation was support by IDA including the 4th, 5th, 6th and 7th Population Projects, the Family Welfare (Urban Slums) Project, and the national Child Survival and Safe Motherhood (CSSM) Project. This project provided support to the Action Plan in Assam, Karnataka and Rajasthan and increased outreach and coverage to the underserved and rural communities in the entire state of Assam, and the 10 and 13 most underserved districts in Rajasthan and Kamataka respectively. It also helped to develop the state's physical infrastructure and facilities to provide improved quality of health and family welfare services to mostly poor beneficiaries. 3.2 Revised Objective: No changes were made to the original objectives. 3.3 Original Components: The following lists the components as originally stated in the SAR: 1) Strengthening Facilities for Delivery of Family Welfare Services (US$55.2 million) through (a) extension and upgrading of Family Welfare infrastructure in underserved areas including rehabilitation of existing facilities, establishment of ancillary mobile clinics, transport for outreach and supervision; and (b) strengthening of outreach and commnunity linkages and participation systems using community volunteers. -2 - 2) Improvement of Quality of Family Welfare Services (US$23.8 million) through (a) strengthening and rationalization of training institutions and programs; (b) improvements in logistics systems for medical supplies and transport; (c) the provision adequate drugs and medical supplies; and (d) involvement of Non-governmental Organizations (NGOs) and private medical practitioners (PMPs). 3) Strengthening of Demand Generation Activities (US$ 11.1 million) through (a) strengthening and rationalization of Information, Education and Communication (IEC) institutions and programs; (b) lEC training for service providers and community volunteers; (c) EEC materials production; and (d) selected IEC activities. 4) Strengthening Family Welfare Program Management (US$9.6 million) through (a) development of states Management Information System (MIS) and planning capabilities; (b) development and monitoring of service delivery strategies for populations with special needs; (c) an office building for the Assam Department of Family Welfare; and (d) upgrading of staffing and equipment in the Ministry of Health and Famnily Welfare (MOHFW)'s Area Projects Division. 5) Innovative Schemes and Preparation of Future Investments (US$4.2 million) through (a) small pilot innovative schemes to improve service delivery; and (b) preparation of proposals for Family Welfare investment in the heavily tribal and underdeveloped states of Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland and Tripura in the Northeast. 3.4 Revised Components: The project components were revised several times over the life of the project. There was a change in the scope of civil works being supported by the project. Another was the diversion of funds for the Gujarat Emergency Earthquake Assistance Project. And a third revision was the agreement at Mid Term to closely integrate the implementation of the training, EEC and community mobilization activities planned under this project with that supported through the IDA assisted Reproductive and Child Health project. The mid-term review (MTR) identified a price escalation in civil works which was much higher than that was anticipated at project appraisal. This was also aggravated by a slippage of the planned works from the earlier to later years. The MTR recommended an additional provision for civil works to provide for escalation and cost over-runs to complete the number of works, and the other software activities in accordance with the project objectives. To accommodate this, and also avoid a disproportionate increase in the category, the total number of works in the three states were reduced and the amount of the IDA credit between expenditure categories in the Schedule I form of the Development Credit Agreement (DCA) were adjusted. The steady devaluation of the Rupee against the US Dollar during the project period (the Rupee devalued from Rs. 33.9 per USD at appraisal to Rs. 48.95 per USD at project completion), led to project savings. After the earthquake in Gujarat in 2001, US$10.0 million (SDR 7.8 million equivalent) of the project savings was reallocated for the IDA supported Gujarat Emergency Earthquake Assistance Project. Recognizing that the activities of this project and the IDA supported RCH projects were quite similar and focussed towards the same audience - the woman and child at the household level - and also the fact that management capacity at the states was limited, it was agreed, that the training, IEC, and community mobilization activities would be integrated and closely coordinated so as to orient the community to the paradigm shift from a vertical family planning concept to the integrated reproductive health and rights based approach, to avoid duplication of efforts, and, to produce a demonstrable impact on health and -3 - fertility. The training targets were subsequently revised with the load for awareness generation training being incorporated in the RCH project, and the content of the skill development training under this project being revised to reflect the same training undertaken by the RCH project. 3.5 Qualitv at Entry: The project was designed before routine quality assessments at entry were initiated and so there was no formal QAG rating. However, as the program fitted well with both the Bank and the borrower strategies, and the GOI and the participating states had given their commitments during appraisal and negotiations that the project's components were appropriate to their institutional capacities, the project's quality at entry is rated as satisfactory for the purposes of this report. 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: Overall, the outcome of both objectives was satisfactory. The first objective, which was to strengthen and improve the functioning of the Family Welfare program in the three states, was satisfactory. The project provided for an expansion in the Family Welfare service delivery system in the participating states through the construction, equipping and upgrading of 2,655 sub-centers, 125 PHCs, 433 staff quarters, 316 FRUs (with the addition of an operating theatre), 29 drug warehouses, and 46 state and district level training institutions. Most of the planned civil works were completed as planned, except in Rajasthan where 6% of the facilities remain incomplete. 96,739 medical and paramedical professionals were provided with in-service training to upgrade their skills. In terms of IEC, the project provided support to the ongoing activities being implemented by the Family Welfare IEC Bureau in each state. Although planned, due to the limited capacity in the states, efforts to develop and implement innovative initiatives for demand generation, especially through the private sector, were constrained. The IDA supported national Reproductive and Child Health Project also started during the life of the project (1997). This provided support in all states for the development of management and specialized technical skills, access to services for the under-served population, and demand-generation through innovative initiatives. Therefore, it was decided at the MTR that the efforts of the two projects would be coordinated in the three participating states, and the targets and resources (in training, IEC and social mobilization), would be combined. This prevented duplication of efforts and provided a strengthened focus on training and IEC, especially during the last three years of the project, as well as led to a revision of outcome indicators for training and EEC in the three states. The second objective was to lower the levels of fertility, and maternal and childhood mortality. During the seven and a half year life of the project, all three states showed moderate to significant improvements in these indicators (see Annex 1). Direct attribution of the project to these outcomes is difficult as there were other simultaneous development efforts in the health and family welfare sector, as well as in education, water and sanitation, and rural development. However, it is reasonable to infer that the improvements in the Family Welfare sector in the three states, sponsored by the project, contributed to the improvement in outcomes for fertility, contraceptive prevalence, and infant and child mortality. 4.2 Outputs by components: The project aimed to improve the performance of the currently weak family welfare programn in the three focus states through the strengthening of program infrastructure and support systems necessary to maximize the program coverage, accessibility and quality as well as the many innovative initiatives to - 4 - improve upon current service approaches in conformity with the action plan strategy. This project was envisaged as a bridging operation between the series of projects designed to build family welfare infrastructure and support systems in needy states and a future program of policy based lending. 4.2.1 Strengthening Facilities for Delivery of Family Welfare Services In light of the outlined risks of irnplementation, including the low capacity of the states, the progress in this civil works sub-component was commendable and is satisfactory. Assam completed all the targeted construction, renovation and upgradation of facilities. This included 1,316 service facilities, 54 training facilities, 163 living quarters for the staff, and 6 Central and Regional Drug Warehouses. Rajasthan completed all of the planned works including 929 service facilities, 32 district and state level training facilities, I computer site, 27 Major and Minor Drug Warehouses, and I Drug Testing laboratory. In Karnataka, 1,120 of the planned 1,127 service facilities and training centers were completed, and 1,760 service facilities were renovated and upgraded in place of the planned 1,652. In addition, 2,500 Family Welfare facilities constructed through the First and Third IDA supported Population Projects, were upgraded in Karnataka with state funds, in compliance with the project covenant. All the works, as per the revised plans of the project, have been completed and have been handed over to the district health authorities for use. All the new facilities and a large number of existing ones were fully equipped and furnished, and provided with essential supplies ranging from daily consumables to essential instruments. In Rajasthan, however, procurement remained incomplete mainly due to delays in decision making of the State Empowered Commnittee. As a result, the necessary furniture and equipment and equipment for the State Institute for Health and Family Welfare in Jaipur and the Health and Family Welfare Training Center in Jodhpur could not be procured. 88% of the facilities are being fully utilized, and the remainder are being utilized partially. Based on an independent survey, the quality of works in Assam has been rated as good, and in Karnataka and Rajasthan, as satisfactory. As a whole, the progress in this sub-component for awareness generation was marginally satisfactory. The MTR in late 1998, showed that the states had made very little progress with this sub-component. In all three states, the bulk of the effort and project investments concentrated on the hardware components. This emphasis prevented due attention on the software components, and so the breadth of community based mobilization envisaged by this project was not fully achieved. Assam and Rajasthan had implemented mobile clinic and health camp approaches in limited areas, through the use of boats and vans, but had not monitored the activity or assessed its output. Karnataka had not implemented this sub component. Therefore, it was agreed that all three states would invest special attention to enhance this strategy during the remaining project time. This would be done by improving outreach and community linkage activities in the designated intensive action districts, establish monitoring systems and reporting regularly on progress. The achievement discussed below is for the period between the latter part of 1998 and the end of the project in December 2001. Moped and bicycle loan schemes to increase mobility of the outreach workers had a poor response in all states. It was stopped in Karnataka due to failure to establish procedures to receive loan re-payments. Rajasthan replaced the scheme with an increased travel allowance for ANMs, but utilization of this allowance was only 35%. 5,026 mobile health camps were conducted in Rajasthan, through the public system as well as through NGOs, providing services to over 600,000 people. In Karnataka, mobile health camps were conducted by 14 NGOs who had been contracted to provide services for the population in the remote tribal areas and poor performing districts. This is described in detail in section 4.2.5. In Assam, 4 mobile teams were created to conduct outreach health activities in two districts where two boats clinics were used to transport service providers, drugs and equipment for the camps. - 5- Several pre-existing community based volunteer schemes were supported and taken to scale, especially in Rajasthan. These community based schemes involved community members and eligible couples volunteering as depot holders for contraceptives and basic drugs, and to provide contraceptive information to the conmmunity. This activity was financed in 25 districts, where 7,754 couples were trained against a target of 11,065 and 7,396 of them functioned in the field. Due to the prevailing law and order situation in Assam, the activities under this sub-component were delayed until 1998, and the achievements were limited. Of the planned training for 75,000 Women Health Promoters to disseminate health education information to the community, 44,967 (60%) were ultimately appointed and trained. The End line Surveys revealed that the actual number of those who worked as volunteers was much lower. During the course of the project, Karnataka decided that it would not pursue the planned activity of utilizing the Village Health Guides as the link volunteers in the commrunity. This was due to the fact that the state had made this activity redundant based on its assessment of the scheme. Instead, the state decided to train the available Anganwadi Workers (AWW), and support them to function as link workers, supplementing the work of the Auxiliary Nurse Midwives (ANMs). 25,000 Anganwadi Workers were trained and appointed as link workers for Family Welfare activities in the project districts. 4.2.2 Improvement of Quality of Family Welfare Services The objective for the training activity was to create 48 training facilities, and train service providers, community based providers and members. The achievement was satisfactory; the project was successful in developing a network of training infrastructure, with a total of 46 newly built or renovated institutions. This component resulted in the construction of a new State Institute of Health and Family Welfare (SIHFW) and an Apex training institution in Rajasthan, and the extension and renovation of the SIBFWs in the other two states. It also led to the construction and upgrading of a network of Health and Family Welfare Training Centers, District Training Centers (DTCs) and Auxiliary Nurse Midwife Training Centers (ANMTCs) in each state to facilitate in-service training to the para-medical staff for ensuring the up-to-date knowledge and skills required for better and effective service dispensation. This ensured decentralization of training to the districts. As mentioned earlier in section 3.4, during the MTR, it had been decided that the training under this project would be integrated with that of the on-going RCH project. The awareness generation training would be shifted to the RCH project and the clinical skills development training would be revised in line with the guidelines of the RCH project. The original training target for the project was to complete training of 1,142,649 medical and paramedical staff, and community members. The total training load of this project was revised to 229,000, and a total of 183,000 medical and paramedical staff from the sub-centres and PHCs as well as community members in the three states were trained through this project. Therefore, about 80% of the revised training targets were achieved. The project's performance in training is rated as satisfactory. The End Line surveys in the three states show that the training material utilized by the states was focussed on the needs of the trainees, and the courses were structured appropriately in terms of the aim of the training sub- component and category of health personnel. Through the project, the training curriculum has been upgraded for various categories, with increased emphasis on participatory learning methods. Linkages have been made with clinical training sites to establish clinical skills training. More than 80% of the health personnel working in PHCs and Sub-Centers have received training during the project period, which seems to have improved their general ability to provide services. Another achievement of this component was the large number of community members who were trained and oriented for family welfare and public health. This assisted in implementing the innovative schemes with community participation. - 6 - The appointment of critical academic teaching staff in the training institutions in all three states remained unsatisfactory during the project. Procurement of equipment was also problematic and slow, as capacity for managing procurement was weak both in Rajasthan and Kamataka. The SIHFW in Rajasthan has been completed after a long delay due to indecision of the Department of Medical, Health and Family Welfare, on the need for this facility. This indecision also hampered the pace of procurement. As a result, the SIHFW and some of the district training facilities had not been fully furnished by the close of the project, and were not utilized to full capacity. During project preparation there was a felt need to examine the whole issue of drug availability, logistics, quality and supply, as well as the development of infrastructure. The construction and rehabilitation, as well as the equipping of the drug warehouses were successfully completed in Rajasthan and Assam. However, the warehouses were not utilized to their full capacity due to staff shortages and incomplete implementation of the logistics management system. The logistics support, including software, computer hardware and training, is being provided by the MOHFW with assistance from the IDA supported India Family Welfare (Urban Slums) Project. It is anticipated that when the system is in place, an enhanced level of functioning of the drug warehouses will be achieved. The issue of drug availability and supply is being addressed by the Reproductive and Child Health (RCH) project. An essential drugs list has also been established by each state. 4.2.3 Strengthening Demand Generation Activities From the outset, it was acknowledged that there were implementation risks, given the weak capacity of the states to plan and provide guidance for district specific IEC activities. At the MTR, the IEC survey revealed that IEC efforts had been ad-hoc, and the first year action plans developed for each state based on the beneficiary needs assessments and a corresponding communications needs assessment during project preparation did not appear to have been utilized to support the development of the targeted IEC efforts envisaged in the project. There had been no inputs from either Assam or Karnataka, and the capacity of the Rajasthan IEC bureau was weak. After the MTR, the focus on this component increased and targeted state focused IEC activities were started. Therefore, on the whole, this component is rated as unsatisfactory. In light of the experience gained from this project, it is important to note that equal emphasis must be given to the supervision of both hardware and software project activities. Given the project management structure in the three states, it was difficult to strengthen state IEC institutions. In Assam, the IEC activities took place through the [EC cell in the autonomous project implementation agency, which had very tenuous links with the State Family Welfare IEC Bureau. As a result, it was not possible to impact the capacity of the State Bureau or to mainstream IEC activities. Even in Rajasthan and Karnataka, where the project worked with the State IEC Directorate, it was difficult to change the traditional approach of providing information into the more modem approach of communicating to achieve behavior change. Even though it is difficult to gauge the precise impact of the investments done under this component, it is possible to enumerate several achievements in the specific state focused IEC activities. A variety of IEC materials were developed and a range of IEC activities, such as awareness generation through high profile public events and competitions, and use of the print and electronic media, took place. The awareness generation training of service providers and community volunteers was carried out and, as indicated earlier, this was later subsumed under the RCH project from 1999. Karnataka was successful in contracting out IEC activities in two underserved districts to NGOs, and in several other districts to a private sector communication firm in Bangalore. These organizations used video vans and street plays to increase awareness of health issues. In both cases, IEC activities were conceptualized and delivered in a very effective manner. This will continue to be supported through the Bank funded RCH project. The - 7 - newsletter of the Kamataka Family Welfare Department has been restarted with support from this project, and the Family Welfare Department printing press strengthened. District level NGO engagement in the project for awareness generation was significant, and is detailed in sections 4.2.1 and 4.2.5. In Rajasthan, the IEC activities continued to be conducted solely through the IEC Bureau of the Family Welfare Directorate, with less community participation and NGO involvement than initially envisioned. The IEC activities have been of a more traditional nature and included radio and television spots and the distribution of print material such as posters and leaflets. In Assam, due to the law and order situation, the original emphasis on commnunity-level activities with community involvement did not transpire as planned. In the later part of the project, the awareness generation activities took place in seven districts with the assistance of 10 NGOs. 4.2.4 Strengthening Family Welfare Program Management This component has been marginally satisfactory. Achievements include the construction and equipping of a new office building for the Family Welfare Department in Assam, as well as varying levels of fulfilLnent of the state based plans for upgrading computer facilities, installation and maintenance of systems and training of staff in line with the state based plans. Assamn has also set up a computer unit within the Project Office for activity planning and reporting of project progress. Karnataka upgraded the computer center of the Family Welfare Department with an additional supply of computers coupled with a new Community Needs Assessment (CNA) software platform. They also employed a senior management consultant for support and trouble shooting and implemented a Management Information Systems (MIS) for work planning for the comrnunity needs assessment (CNA) under the RCH program. In Rajasthan, district based computer systems were installed and 41% of the planned staff are in position. The remaining staff will be supported by the RCH project and other on-going assistance to the national RCH program. Though planned, the integration of the information systems and the collection and use of data for program planning purposes has not been done through the project. It has been planned that the states will complete implementation of the HMIS through the IDA supported RCH project. With respect to the project plan to strengthen the Area Projects Division of the MOHFW, the project upgraded the division's computer departrnent. This upgrading will likely benefit project reporting and financial management of all projects managed by the Area Projects. The strengthening of the Area Project Division's capacity through the addition of 5 posts was not fully realized. Given that the resulting strengthening of the Division, especially in the area of project monitoring, would have positively affected this as, it would be important to examine and address the systemic issues that inhibited this achievement. 4.2.5 Innovative Schemes and Preparation of Future Investments During project preparation this component was left quite loosely defined so that states would have the flexibility to develop activities feasible within their respective contexts and capacity. Innovations have also been extended to the other components described under 4.2.1 and 4.2.3. Given the limited institutional capacity of the states to implement such schemes, this component has been satisfactory. Karnataka was able to implement several innovative schemes through partnership with the private sector- contracting of NGOs in order to provide access to services in the remote and tribal areas of the state. It also contracted a private communication firm to implement the IEC strategy in the poor perforrning districts. Two NGOs were contracted to provide family welfare services through 2 PHCs and 10 sub-centres in tribal areas thereby increasing access to family welfare services in remote and underserved areas to a population of approximately 50,000. 37 tribal girls were also trained as ANMs and certified to work in the tribal areas. The contracting of PHCs to NGOs in the tribal areas of Karnataka has been very successfil. This has been extended by the Government of Karnataka for an additional 10 years and expanded to other poor performing districts. -8 - Rajasthan used community members as depot holders for contraceptives as well as to provide information on basic health care. 426,401 eligible couples received services from them in 25 districts. In addition, 14 NGOs were funded to provide information to community members on contraception, spacing and pregnancy related care. 376 mobile health camps were conducted in the desert districts for delivery of family welfare services. Assain contracted 10 NGOs already working in 7 hilly and tribal districts to create greater awareness of contraception, ante natal care, institutional deliveries, and full immunization coverage. The other component which involved the extension of support of Family Welfare services to the North Eastern states was not done through this project. It is now being supported through the Bank assisted RCH project. The expenditure in this component was only 30% of the amount originally budgeted, indicating that the role of NGOs in this project has not been fully utilized. The role of NGOs in project implementation could have been enhanced with more focus on this from the implementing agencies. 4.2.6 Emergency Earthquake Assistance for Reconstruction in Gujarat This component has been satisfactory. Following the earthquake in Gujarat in 2001, funds were made available to the Gujarat Emergency Programn by internal reallocation of the proceeds of the Loans/Credits under twelve projects, one of which was this project. For this purpose, a new project objective and a new part Z for Gujarat earthquake reconstruction and rehabilitation was added to the project description schedule of the legal agreements for this project. To reflect these reallocation, new categories 97-100 for part Z were inserted in the disbursement schedules of the legal agreements for the existing projects in which the reallocation were made. SDR 7.802 million (US$10.0 million equivalent) was reallocated from this project to the Gujaat Emergency component. SDR 7.51 million (US$9.53 million equivaient) have been disbursed only under Category 97 (Civil Works) for the Housing Component No disbursement have been made against any other category. The funds were spent on reconstruction of fully collapsed houses and repair of partially damaged houses in earthquake affected area. 4.3 Net Present Value/Economic rate of return: Not applicable 4.4 Financial rate of return. Not applicable 4.5 Institutional development impact: The project's contribution to the development of institutional infrastructure through expansion of physical infrastructure in all three states, human resources capacity development, increased access to care especially in low performing and difficult to access districts; are detailed in earlier sections. 5. Major Factors Affecting Implementation and Outcome 5. r Factors outside the control of government or implementing agency: The law and order situation in Assam, which was identified as a potential project risk delayed the implementation of the community based activities. Overall however, Assam managed its risks so well it was able to surpass the other states in terms of implementation results. 5.2 Factors generally subject to government control: There were two main factors that affected implementation at the GOI level; the limited capacity of the Area Projects division of the Ministry of Health and Family Welfare to provide adequate supervision and the disconnect between the commitment to the project by the GOI and the respective states. The Area Projects division was effective in its ability to provide oversight on financial matters; it was not however, able to provide the project states with critical on-site monitoring and the technical supervision necessary to identify -9- and address implementation issues, due to lack of adequate manpower. The provision made under this component to hire five consultants to strengthen the division, was not utilized. In addition, although there was a firn conunitment from the GOI to IDA for the project, the same level of commnitment was not evident at the state level, especially in Rajasthan and Karnataka. This point is addressed further below. 5.3 Factors generally subject to implementing agency control: This project was part of a large centrally sponsored national Family Welfare Program. As such, states received 90 percent of the funds as grants-in-aid from GOI and contributed 10 percent themselves. The project interventions were designed by MOHFW after detailed consultation with states and the World Bank, and implemented by the states. This approach was beneficial from an equity viewpoint since it provided relatively protected funds for critical interventions for the poor, which would otherwise probably not be received by the states. The states were to ensure that these funds were protected and utilized at the appropriate time, solely for the purposes of the project. Karnataka and Assam ensured this, however, Rajasthan failed to adhere to this thus the funds flow problem persisted until the last 2 years of the project. Due to a critical ways and means situation in the state, project monies were not always immediately available for activities supported by the project. This also contributed to a delay in implementation of activities. In Rajasthan and Karnataka, the lack of commitment resulted in weak management and slow implementation of project activities. This was evidenced by a high turnover in project directors and key project management unit staff (there were eleven project directors in Rajasthan and nine in Karnataka over the life of the project) and, inadequate delegation of financial and administrative powers to the project directors. Rajasthan was especially plagued by delays in decision making by the State Empowered Committee, particularly in relation to procurement and civil works. This was complicated by a decision to repeat the facility survey for assessing the need for civil works, goods and equipment. This resulted in the state having to forgo the procurement of a significant number of items of furniture and equipment, and unnecessary delay in completion of the construction of the State Institute of Health and Family Welfare (SIHFW). In Assam, this project represented the only donor inputs in the health sector, and as such the state had a commitment to make it work. In order to ensure that the project was implemented without obstruction and delays, the Government of Assam created a separate autonomous society as the project implementing agency, guided by the state level Empowered Committee. The autonomy given to the society and the stability of the project leadership (one project director for the full project period) was instrumental in ensuring that all project activities were implemented in time. 5.4 Costs andfinancing: The total cost of the seven-year project at appraisal was estimated at US$103.8 million (Rs. 4,409.8 million equivalent). Of that, US$88.6 million (SDR 62.7 million equivalent) was to be financed by an IDA Credit and US$15.2 million by the GOI. At the project closing, the GOI estimated that the total project expenditure was Rs.3,841.76 million. This was 87% of the original project cost estimates in rupee terms. The total project expenditure was financed by a Government contribution of US$18.91 million (exceeding the above committed amount), and an IDA credit of US$81.6 million including the Gujarat Emergency Earthquake Assistance. Due to steady devaluation of the Rupee against the US Dollars and the US Dollar appreciation against SDR (the SDR 62.7 million is currently equal to US$ 83.0 million equivalent), there remains a undisbursed amount of US$1.4 million (SDR 1. I million equivalent), of the IDA Credit at the end of project period. Details are given in Annex 2. - 10 - 6. Sustainability 6.1 Rationale for sustainability rating: The sustainability of the project interventions in all states is likely. The issue of sustainability in the context of the evolving demands of the family welfare program in India, needs to be approached with realism and as a process which goes much beyond the limited horizon of this project. This also needs special attention in the context of the relative isolation of project efforts from mainstream activities in family welfare during implementation. Nevertheless, significant strides have been made toward setting up a large network of infrastructure and staff development for enhanced training and service delivery. The challenge for sustainability will however be in ensuring that the service facilities created under the project are fully utilized and maintained; quality and coverage of the training is ensured; and the trained manpower continue to be appropriately utilized in the Family Welfare Program in the three states by making adequate provisions for salaries in the budget and supervision to ensure and enhance quality of their performance. All the states have assured considerable additional support to bring the investments made under the project to full fruition. The states have already initiated steps in this direction by making adequate provision in the state budget, and by coordinating with the other program been funded by the state/GOI, such as the RCH project. The project has also been successful in making the states seek out alternatives to ensure access to services in remote and tribal areas, through partnership with the private sector. The achievements through these strategies have differed in the three states, with Kamataka now going on to develop policies with their experience, while Rajasthan and Assam have recognized these as options which need to be tested and replicated for greater access. In addition sustainability of the efforts will also be affected by the on-going Reproductive and Child Health Project, covering all the states, as this will continue and expand the activities of this project. 6.2 Transition arrangement to regular operations: All three states have developed a plan for the sustainability of the software activities initiated under the project Starting with a strategy for the hand-over of the project activities to the State Family Welfare Directorate, this plan includes continuation of all training, IEC and innovations in service delivery in the states under the RCH program. The states have also initiated steps to make adequate provisions in the state budget for family welfare for the continuation of staff positions and activities created under the project. The prospects for mainstreaming the project initiatives seem to be the best in Kamataka where several steps have already been taken by the state Government. For example, Karnataka has discussed and initiated steps to make sustainable 19 DTCs and the SIHFW by creating a regular higher position of Director, SIHFW and making a provision of separate budget head of training for SIHFW and DTCs before January 2002. Salaries and allowances of staff working in DTCs and SIHFW up to March 2002 was provided by the Steering Committee resolutions. Budget estimates for payment of salary and allowances, office expenses and POL, amounting to about Rs. 17 million annually, has been provided under State Family Welfare plan head as per commitment by the state. Maintenance of facilities created under the project is also adequately provided for by increasing the non-wage non-plan budget for 2002-2003 through the Mid-Term fiscal plan. The Government of Rajasthan and Assam are also in the process of making requisite financial provisions in the state budget to sustain the efforts made in the project. However, the prospects for accommodating the salary for the new positions of faculty/staff in the training institutions and the drug warehouses, and the maintenance of these facilities in Assam and Rajasthan, are less certain as these states have financial - 1 1 - constraints. Even though a decision has been taken to hand over all assets of the project to the State Family Welfare Directorate, and continue all current activities of the project through the same, further support and attention from the GOI will be necessary to ensure that these project initiatives are mainstreamed in the two states. 7. Bank and Borrower Performance Bank 7. I Lending: The overall Bank performance in project identification, preparation and appraisal is satisfactory. During the preparation phase the Bank provided extensive preparation assistance which resulted in the project fulfilling several criteria for readiness at entry. Although these criteria are now standard practice they were less common at the time. The Bank also ensured that the project was targeted to the poorest and most underserved areas for extension and upgrading of the Family Welfare Program infrastructure, and that the project supported the GOI's Action Plan for revamping the Family Welfare Program. The project fulfilled the criteria with Operational Directive 4.20 at entry. The project covered states whose populations are 4-16 percent tribal (plus 2 percent nomadic in Rajasthan). Based on a beneficiary needs assessments, the project focused on: special tribal/nomad service strategies, service delivery to the underserved and poor women and children through mobile services, improving transport for providers, experiments with smaller coverage norms, and relaxation of staffing norms. There was a clear awareness of the project risks by the preparation team. These risks were identified as (a) the possibility of poor implementation in all three states; (b) the potential that project-created infrastructure and programs will not be maintained; (c) that many of the proposed approaches and programs were new and untested, particularly the outreach and community linkage schemes; and (d) the unpredictable security situation in Assam may make various schemes difficult to implement. 7.2 Stupervision: Overall, the Bank's performance in supervision is rated as unsatisfactory. Frequent changes in task management (seven task managers over the life of the project) and inadequately equipped task teams that were unable to provide appropriate support and advice to the client negatively affected project implementation and supervision. In 1997, a Quality of Supervision assessment of this project deemed the overall quality of supervision as marginal. The report found that project supervision did not adequately address the developmental impact of the project. It identified issues such as lack of attention in providing the client appropriate advice and solutions on project related matters and inadequate level of appropriateness and speed of follow-up limited the impact and effectiveness of the Bank's actions. Following the QAG review and the Mid-Term Review, Bank supervision improved substantially with the formation of a more cluster based approach in project supervision and the addition of adequate technical expertise in the team. The Bank team recognized the need to be more supportive of the client's need and also hold the client more accountable for factors affecting implementation. Supervision was done in a systematic and holistic manner simultaneously with other Bank supported projects in the three states, i.e. the Population and State Health Systems Development projects, to better coordinate project inputs and provide the state health/family welfare authorities an opportunity to look at the outcomes in a holistic manner. This integration of efforts also allowed the team to be pro-active and have an opportunity for a stronger and effective dialogue with the states, challenging them to move away from infrastructure orientation in order to achieve the development objectives. An example of this was the downgrading of the project from satisfactory to unsatisfactory in 1999. This down grading of project status had the salutary effect of making the state implementing agencies become more committed and focussed in completing - 12 - project implementation. The project status was later upgraded to satisfactory in 2000 when key benchmarks affecting project implementation were met. The work of the team was appreciated by the MOHFW, who also used it as an opportunity to hold the states accountable for their performance. 7.3 Overall Bank performance: Overall, the Bank's performance is rated as unsatisfactory. Borrower 7.4 Preparation: The Borrower's performance was satisfactory with respect to project preparation. The performance of the three states was satisfactory during preparation although the tasks appeared to have overwhelmed them at times notably in Kamataka and Rajasthan. Experience of implementation has shown that the initial plans and cost estimates underestimated the difficulties of construction in the project areas. Project scope in terms of overall size and number of components was ambitious. As a result, the start-up phase took longer than expected due to problems in setting up the management structure including the high-level state Empowered Committee. Additionally, it took considerable time for project staff to familiarize themselves with Bank procedures such as the procurement guidelines and the financial reporting requirements and the auditing authority. 7.5 Government inmplementation performance: The overall performance of the borrower was satisfactory, however with varying levels of perfornance between the states, and between the center and the respective states. The level of willingness to implement this project varied between the MOHFW, which had a high level of commitment, and the states (specifically Karnataka and Rajasthan), which showed lower levels of commitment. The level of dedication by the MOHFW resulted in good supervision of the financial matters. The provision of oversight and on-site monitoring of the states, however, remained inadequate. Had the MOHFW been more pro-active in this area, a lot of the implementation problems at the state level could have been avoided or addressed earlier. There was a provision made within the project to strengthen the Area Projects Division for improved on site supervision. The MOHFW did not utilize this provision. At the state level, the lack of political commitment led to the persistence of many issues including the high staff turnover, weak procurement capacity, fund flow problems, inadequate delegation of financial and administrative powers to project directors. In addition in Rajasthan, delays of the State Empowered Committee to make key decisions affected project implementation specially in regards to procurement and civil works. The audits reports were generally received after the due date (December 31) and had major disallowances in case of Rajasthan basically on account of advances having been claimed from IDA. Although this systemic weakness prevailed throughout, Rajasthan, at the end of the credit period, Rajasthan was able to get the disallowed amounts recertified from the auditor to a major extent and reclaim them back from IDA. Similarly Kamataka was also able to get the audit disallowances recertified and claim them back from IDA. Due to non-receipt of audit report, SOEs were discontinued for Rajasthan and Assamn for the years 1997 and 1999. The covenants have all been met, with some delays especially in Karnataka, where the covenant relating to maintenance of civil works built under the Population One and Three projects were not complied with until after the MTR. 7.6 Implementing Agency: It was satisfactory in Assam and Karnataka, and marginally satisfactory in Rajasthan. Given the special nature of the project management structure in Assam, namely that the project management was undertaken - 13 - by an autonomous body that operated independently from the Family Welfare Directorate and also enjoyed significant financial independence, many of the implementation issues were circumvented. However, long term sustainability remains pertinent in Assam (articulated in section 5 and 6 of this report). In Rajasthan and Karnataka, where the project management unit was an integral part of the Family Welfare Directorate, the lack of ownership and limited project management capacity led to slow project implementation in the early years. Karnataka over came this problem by upgrading the position of Project Director after the MTR to that of full time IAS officer with the rank and status of Special Secretary, Department of Health and Family Welfare. Thus, the project implementation unit was mainstreamed and this significantly enhanced the financial and management authority of the Project Director. This also assisted in focusing the attention of the state machinery in completing project activities. The main issues in Rajasthan, included poor delegation of authority to the project implementation staff, failure to appoint critical and appropriate staff to the project management, inappropriate fund flow mechanism and weak procurement capacity compounded by the perennial delays in the decision-making processes of the State Empowered Committee. This situation in Rajasthan improved to some extent during the latter part of the project life. 7.7 Overall Borrower performance: The overall performance of the borrower was satisfactory. 8. Lessons Learned Some of the key lessons learnt from project implementation include: Management Political commitment at both the state and GOI level is critical for state ownership, successful implementation and project sustainability. It is imperative that states play an active role in the design and monitoring of projects and there is clarity in the roles and responsibilities, between the GOI and the states, in order to foster ownership and accountability of outcomes. In addition extemal inputs may not be sustainable unless the states themselves realize the critical needs for such institutions. Thus a shared vision binding functionaries together for unified and dedicated implementation can also lead to a sense of ownership Continuity of the core project team, as well as the Project Director and critical staff in all key positions such as those working on IEC and training, is pivotal for the successful implementation of time bound projects. Adherence to this has been key in ensuring the timely completion of all project activities in Assam, and conversely, has led to hampered progress in Karnataka and Rajasthan. An examnple of this lack of continuity includes the fact that there were eleven project directors in Rajasthan and nine in Karnataka over the seven and a half year life of the project. There needs to be an agreement to this effect with the Borrower and the implementing agency in order to limit disruptions and delays in project implementation. Management structures and implementation arrangements for the project need to be relevant to the state context and environment With a unstable law and order situation and security in Assam, the implementation of the project activities without an autonomous project implementation agency, would have been difficult. This was not necessary in Karnataka and Rajasthan, where an Empowered Committee headed by the Minister, Health and Family Welfare or Secretary, Medical, Health and Family Welfare, provided guidance on project implementation. Ensuring adequate funds flow is critical for smooth implementation of the project. Therefore routing of - 14 - funds through a mechanism separate from the state treasury, was vital in Rajasthan to ensure that project funds were readily made available for project activities. This however, did not become an issue in Karnataka where project fimds were also channeled through the treasury. Presence of program staff from the Family Welfare Departments in the project Empowered Committees did not bring about closer alignment of the project with the Family Welfare Directorate. A conscious effort to forge coUlaboration and build linkages and relationships with the parent body/department, as has been done in Karnataka, is critical. This requires an understanding of the role of the project in the overal context of health and development and ensuring having a shared vision and common understanding of the project goal and objective among all stake holders. While decentralization is desirable for timely and effective implementation, there are certain activities, such as civil works and procurement, requiring a high level of accountability and follow-up, and effective monitoring systems, are better done through a centralized unit and system. Training The large work force in the health sector justifies the need to have in-house training capacity and facilities. The training institutions should explore options to contract external experts to broaden the skill base of the trainers. They should also explore opportunities to market their services outside the Family Welfare sector: This will help to improve training quality and generate revenue. AU the training in the health sector should be part of a human resource development strategy. This strategy should incorporate all training; training that occurs within projects such as this, as well as the standard training offered by the Family Welfare Directorate. Additionally, an ongoing evaluation of training outcomes including the appropriate placement of personnel and their performance, follow up training and supervision of on-the-job training, should be conducted in order to gauge the effectiveness of the training component. Public Private Roles and Partnership Strategic choices regarding the roles of the public and private sectors, need to be made based on the core strengths of the sectors, institutional needs and the current capacity of the sector. The participating states have learnt that the training of large numbers of para-medical staff requires in-house capacity and resources, while the implementation and management of a behavior change strategy may best be done by a private sector firm. Similarly, the utilization of the PVO/NGO sector may not be the answer for all proposed interventions because they may not have the expertise to deliver the types of services required by the target population or the capacity to monitor and ensure results. This sort of analysis needs to inform the choices ultimately made. There have been in the project several opportunities for public private partnerships; (i) in planning and implementing behavior change communication strategies. This has been demonstrated in Karnataka, where a private sector communication firm has successfully implemented the behavior change strategy; and (ii) increasing access to health service to the marginalized and tribal population, through innovations. These have been explained earlier in Section 6. Community Involvement Involvement of the community in project implementation has been limited, even though it could have had a - 15 - greater impact for the project. One experience has been that involving the local conmnunity in sighting of health facilities is crucial in ensuring access. This approach has helped Assam ensure that the facilities are central and accessible for the community. To achieve this both the Bank and the Borrower needed to reach a common understanding on community participation, ways to achieve this, as well as developing the capacity for guiding this. Project Design It is imperative that the role of supervision by both the Bank and the GOI be heightened in order to yield better project outcomes. From the side of the GOI, regular monitoring and oversight of the project components, especially some of the software components, is crucial in order to provide support during implementation. From the Bank, a greater level of engagement with the client and pro-activity, along the lines of what occurred in the later stages of project implementation is necessary to ensure that impediments are removed in time and all planned activities are completed. The capacity for effective management of the procurement and financial aspects is critical in ensuring that all project activities are completed in time. In this project too the lack of these aspects in the participating states resulted in implementation delays. Project preparation needs to give adequate attention to ensuring that the project implementing units are fully conversant with and are fully equipped with necessary expertise in procurement and financial management. In particular, the finance and procurement functions for this project should have been paid adequate attention and professionals with skills in budgeting, accounting, financial management and reporting as well procurement management should have been deployed in the states from the early stages. In Assam and Karnataka, the irnplementation of civil works component progressed relatively smoothly, while in Rajasthan however, there were several issues. The construction of the sub-centres had been contracted to the Panchayati Raj Institutions (PRIs). This led to delays throughout the construction process of civil works. The contract was given to a body that was not held accountable for its performance, and the PRIs are part of a department different from the Family Welfare. Therefore there was no urgency to ensure timely completion. The PRIs were also responsible for site selection. In some cases selection of sites took a very long time and led to delays in the commencement of civil works, while in others the site selection was poor resulting in the construction of sub-centres away from the village. Coordination between project financed activities and non project Family Welfare activities was difficult to establish. In each state, project implementation was the responsibility of a unit that was separate from the state's Family Welfare Directorate. Although the project was expected to strengthen the Family Welfare program activities, there was poor coordination and as a result there were many difficulties in mainstreaming and coordinating activities. This again brings out the need to have a shared vision between all stake holders to ensure that the project can achieve the stated outcomes. 9. Partner Comments (a) Borrower/implementing agency: The Borrower's Contribution to the ICR is listed in the Annex 8. Below is a letter from the Project Director, commenting on the draft ICR dated April 30, 2002. D.O.No.L.19013/17/2001-APS (Vol.I) June 14, 2002. - 16 - Dear Dr. Kindly refer to your letter dated May 1, 2002 forwarding therewith the Implementation Completion Report (ICR) of the World Bank assisted Ninth India Population Project for comments of this Ministry. While ICR is quite comprehensive, the following observations/points may be noted:- i. Para 3.1 states that the 3 States Assam, Karnataka and Rajasthan were not previously covered under other India Population Projects does not seem to be correct as Karnataka was covered under IPP-I and IPP-III also. ii. The World Bank has rated both the achievement of objectives and outputs as satisfactory and to support this the latest data has been referred to. (para 4.1) We suggest that the latest data as revealed by the State-wise end-line survey reports may be utilized so as to make it more accurate iii. Para 4.2.1 regarding extension and upgradation of Family Welfare infrastructure of the State refers that about 2% buildings are under construction in Rajasthan. We suggest that the final data as revealed by the States ICR reports may be taken into account for working out percentages of the buildings completed and handed over. iv. Para 5.4 dealing with cost and financing, refers the cost at appraisal at Rs.440.98 crores and the likely expenditure at Rs.390.84 crores. In this connection, it is pointed out that the original cost of the project was Rs.335 crores, which was, enhanced to Rs.414.06 crores in May, 2000 and Rs.422.59 crores in January, 2001 and the expenditure reported upto April, 2002 is Rs.377.45 crores. Therefore, figures in para 5.4 may be replaced with these figures and percentage may be calculated accordingly. v. The World Bank report contains the Project Implementation Assessment, which is the draft Implementation Completion Report furmished by GOI in December (pages 17-27 of the report). There has been a lot of changes during the last 4 months and with the results of end-line survey already published and submission of the ICR by the State Government, we suggest that the final ICR report of the GOI should form a part of the ICR report of the World Bank. The final ICR report is under preparation. vi. In para 7.0 relating to assessment of outcome and in annexure 1 concerning key performance indicator, we suggest that the Word Bank may use the latest estimates of various indicators as revealed by end-line survey reports instead of taking the latest/1999 esfimates. Similarly, annexure-2 concerning project cost and financing may be prepared by taking the latest final expenditure figures so that the percentage of appraisal column in page 34 of the report may be more realistic. vii. The ICR has correctly identified non-fulfillment of the software components. It will also be useful to compare the achievements in the hardware sector with the less focused software sector as the project design does talk about the objective to strengthen and improve the functioning of the Family Welfare Programs of Assam, Rajasthan and Karnataka and to lower the levels of fertility and maternal and childhood mortality in the three states. viii. It is a fact that considerable hardware inputs have been put in place in the area of Training starting with ambitiously built and well equipped SIIHFWs. The moot question is the State's ownership of the same. The case of Rajasthan and Assam are cited as evidence where for most of the time regular faculty was not in place. Another issue is convergence with the overall RCH training. One lesson leamt is that external inputs may not be sustainable unless the states themselves realise the critical need for such institutions. - 17 - ix. There is a reference to interruptions in the training program of awareness generation program. The critical issue is one of designing training inputs for effecting behavioral change. From the ELS findings, it is clear that involvement of community, barring site selections has been limited. Another question is whether these interventions led to actual behavioral change. The contentions of the concluding sentence of this section namely that equal emphasis be given to supervision of both software and hardware activities of this project is relevant. x. One crucial issue is the preparedness of the project in the context of the implementing state. In the Rajasthan case, it has been admitted that as the knowledge of the state level functionaries on Bank procedures is often insufficient, the project must provide some preparatory time before launching the project and provide mechanisms that ensure that the project be implemented fully rather than partially. There is also a reference that the project design right formn the outset should incorporate mechanisms to develop common understanding of the project objectives, approaches, systems and procedures. This should also take care of induction of leadership changes with the concept and components of the project. xi. One lesson leamt that has come up from the ELS Rajasthan is that all future Area Projects should include an in built component of sustainability both in terms of infrastructure as well as staff salaries under the project. As a first step towards sustainability, the program needs to be accepted by the states and the sustainability dialogue should start halfway through the project. xii. The ICR has recomrnended the progress of civil works as commendable; this could be better substantiated with data on utilization of the assets created. xiii. The ICR may consider incorporating the need to have a Shared Vision which binds functionaries together for unified and dedicated implementation and also leads to a sense of ownership of effects created by the project. xiv. A finding of the ICR has been that modest interest has been shown by the community workers when deployed in an unpaid voluntary position. This finding may be substantiated by other country/project experiences or otherwise so as to enable pragmatic lesson learning from the project. With regards, Yours sincerely, (A.K. MEHRA) (1) Cofinanciers: (c) Other partners (NGOs/private sector): 10. Additional Information - 18 - Annex 1. Key Performance Indicators/Log Frame Matrix Outcome / Impact Indicators: Indicator/Matrix Projected In last PSR Actual/Latest Estimate Reduce Crude Birth Rate (CBR )(per 1000) Assam: 21 Assam: 1994: 27.5 1999: 21.8 (NFHS) 1999: 25.8 (RCH-all districts) 2001: 27.19 (Endline Survey) Kamataka: 20 Kanataka: 1994: 20.4 1999:20.4 (NFHS) 1999: 22.6 (RCH-all districts) 2001: 20.6 (Endline Survey) Rajasthan: 21 Rajasfthn: 1994: 33.7 1999: 29.9 (NFHS) 1999: 26.6 (RCH-all districts) 2001: 32.25 (Endline Survey) Raise Contraeptive Prevalence Rates Assam: 60 Assam: (CPR) % (Total) 1994: 29.3 1999: 43.3 (NFHS) 1999: 27.7 (RCH-all districts) 2001: 44.3 (Endline Survey) Kamataka: 60 Kamataka: 1994: 47 1999: 58.3 (NFHS) 1999: 65.6 (RCH-all districts) Rajasthan: 60 2001: 60.8 (Endline Survey) Rajasthan: 1994: 30.7 1999: 40.3 (NFHS) 1999: 43.5 (RCH-ali districts) 2001: 41.1 (Endline Survey) Reduce Total FerUlity Rate (TFR) Data not available Assam: 1994: 3.5 1999: 2.3 (NFHS) 1999: 3.34 (RCH-aII districts) 2001: 3.05 (Endline Survey) Kanataka: 1994: 3.1 1999: 2.13 (NFHS) 1999: 2.44 (RCH-all districts) 2001: 2.2 (Endllne Survey) Rajasthan: 1994: 4.6 1999: 3.78 (NFHS) 1999: 3.47 (RCH-all districts) 2001: 4.7 (EndUrne Survey) Reduce Infant Mortality Rate (IMR) (per Assam: 50 Assam: 1000) live births 1994: 77 1999: 69.5 (NFHS) 2001: 61.61 (EndUine Survey) Karnataka: 71 Kamataka: 1994: 71 1999: 55.2 (NFHS) 2001: 40.2 (Endline Survey) - 19- Rajasthan: 60 Rajasthan: 1994: 81 1999: 80.4 (NFHS) 2001: 39.0 (Endline Survey) 1/ Reduce Child Mortality Rate (CMR) (Per Assam: >10 Assam: 1000) 1994: 41.2 1999: 21.4 (NFHS) Karnataka: Data not avaiable 1994 23.3 1999: 19.3 (NFHS) Rajasthan: Data not available Rajashthan: 1994: n.a. 1999: 37.6(NFHS) Reduce Maternal Mortality Ratio (MMR) (Per Assam: 20 State and nationa data not found to be 100,000) live birtis Kamataka: 20 reiable. Rajasthan: 20 Source: National Family and Health Survey (NFHS) 1998-1999. Reproductive Child Project - Household Survey (RCH) 1999. 1/ Endline Survey data: based on a very small sample and need to be interpreted carefully. - 20 - Output Indicators: Indlcator/Matrix Projected In last PSR Actual/Latest Estimate No. of fadlMes complted/renovated and State of Assam: All planned fadlities In Assam have been handed over. 800 new sub-centers; 50 renovated completed and have been handed over. The sub-centers; 100 PHCs upgraded State regbnal drug warehouses has also been Dispensaries; 88 ANM quarter at PHCs completed, but Is yet to be fumished. The 75 Grade IV quarter at PHCs.; 76 FRUs quality of completed works has been good. UpgradhIg/Renovations State of Kamataka: In Kamata, an average of 93 percent of 1,133 new sub-centers and PHCs; 2,587 pinned fadilIes have been completed and renovated sub-oanters/PHC/CHs; are fully functioning. These indude 932 271 Medical Offlcers quarter at PHCs sub-centers (new), 1,264 (renovation), 90 72 FRUs Upgrading/Renovations PHCs (new) 464 (upgraded) and 19 upgraded CHCa, and 250 Medical Officer Quarters. Based on an independent survey, the quality of completed works has been found to be generally satisfactory. State of Rajasthan: In Rajasthan, out of 810 sub-centers 860 sub-centers; 100 labour Room; 30 planned, 808 were completed and 804 have delivery room;31 Dnrg Ware House; been handed over to PWD. The water and 10 upgradatlon of PHCt to CHC electrdty connection for some of works are stUIl to be completed. No. of mobile clinics planned Data not avalable In the State of Kamata, 12 NGOs are currently providing mobile Reproductive and ChUd (RCH) services. This is more than 4 planned. In Rajasthan, 318 mobile health camps were organized by India Red Cross Society. 25,775 persons have accessed the services provided through these camps. Success of community based vdunteer Data not available The project had dedded In the early years not scheme. to continue this activities In Assam, due to the law and order situation prevailing in the State. Hcowver, In Karnataka, 25,000 Angawadi Workers were appointed as link workers, and miUlon population reached through conmunity linkages. In Rajasthan, health camps have been organized in 25 districts where the RCH services are not available. These camps were held on fixed dates and places. Dunng the project period, 5,026 camps have been conducted and RCH services and treatment of RTUSTD have been provided. No. of trained staff and faculty in posIton State of Assam: Assam has signflfcantly expanded trainin,g 9,835 Health Worker FemaUANM; 1,507 and exceeded all planned training target Health Asstant F/LHV; 2892 General During the project period a total of 96,739 Nurse; 170 Bbck Extnesion Education; 250 health personnel inCluding MSS, WHP, training faculty; 4,305 medical officers; 3,000 TBAs and vilage laders have been trained. pMvt med pracL 590 Sr. Physidcans/ Superv; 30,000 TBAs; and 78,000 Women Health Promotor. Kamnataka decided to revise the trining State of Kamataka: miodules based on RCH guideflnes. This 23,580 Health Worker FemiaiANM; 2,958 caused a slowing down of the training Health Assistant FemnaWLH/V and 13,413 activIides. Hmowver, the training of functional male; 669 General Nurse; 2,954 Sr. Heath e O Inspector, 1530 Block Extion Education; - 21 - PHCs were achieved on an average of 87 306 training faculty 9,172 medical offiars percenL The training of community based 3,000 pvt mfed pract. 590 Sr. Physicians/ functionaries has been slow. Supervisors; 93 000 TBAs; and 370,000 various Health Promotor and school teachers. All district trainrng faciliies in Rajasthan have trained faculty in position. The critcal faculty State of Rajashan: has to be peced In the SIHFW. However, 21.960 MPW (M/F); 2.130 Sector the quality of training needs to be assessed. SupervAsors;2520 SMO/MO; 300 CHMO/Dy CH-MO; 114 State Officials; 535 Training Faculty; 90 equip. operators; 453,915 joint training ANM/TBA/AWW No. of training faclities upgraded, State of Assam: In Assam, 22 district training centers along constucted and fully equipped and handed 2 training centers; 17 ANMWGNM training with four 100 bedded nurses hostels, five 20 over as per training strategy centers/school building; 4 hostels bedded nurses' hostels and 16 hostels for (100-student) and 5 hostels (20-student) field practice area were constructed as 1 office building planned. State of Kamataka: In Kamataka, as per the plans, 27 training 19 training centers facilities have been upgraded and fully 1 LHV/ANM school and 1 HFWTCs equipped. 1 office building State of Rajasthan: In Rajasthan, out of 15 ANM training centers 15 District Training Center (DTC) have been upgraded as distict training I New HFWTC centers to facilita in service training. Of the 2 updradation of existng HFWTC 14.628 various levels of training. 13.427 have 1 SIHFW been completed. No. of NGOs contracted and % of populabon Data not avaibable Involvement of NGOs has only begun in the covered past year in Assam. 10 NGOs have been contracted. The coverage of 7 low performing and inaccessible districts Is commrendable. In Kamataka. 14 NGOs have been conbacted to provkie RCH services though innovative mneans to naccessble and tibal populabtons. NGOs have also been ontracted to take over 2 PHCs and provide RCH services through them. In additon. Unk Workers, and Mobile Medical Units were also implemented. In Rajasthan NGOs contracted for carrying out faclity survey for 138 First Referral Units (FRUs) for ldentication of their needs. The FRUs were upgraded based on the assessment NGOs have also been ivolved in conducbng RCH camps described above. It has been estimated than 47,835 population have been covered and benefited. No. of IEC actvities planned Data not available IEC acivity has been caried out in Assam. Evaluaton on effectiveness of IEC actvities wivl be assessed under the planned end Une survey. Earty Involvement of the NGOs in IEC actvities including trianing In all the disticts produced better impact in RCH service delivery. In Kamataka, against 10.986 planned actvites, 7,115 were conducted. However, the effectiveness of IEC activities wiN be evaluated under the panned End Une survey. A private communication firm has also been contacted to develop and implement the IEC plan. - 22 - Improved Management Capacity through Create additonal posts: The HMIS Is In place as planned In Assam. upgraded facility, Installed systems, and Assam - 90 It has helped in monitoring and evaluation of provided technical assistance Kamataka - 163 the project activities. A similar facility (LMIS) RaJasthan -228 Is being Impemented In the Drug Warehouses/ Logistics component. In Kamataka, faclity upgrading has been done according the plan. Computr instaabtion, MIS training and PMIS software for cvil works and procurement were also completed. (-Check the end-line survey for Evaluation of Implementation of MIS) Out of 228 planned positons for Raajasthan, only 93 in posidon (41% achieved). Computer system strengthened In the family welfare department at state and distict level. % of tribal and special population being Data not avaglable Most of the districts under the project in covered and reiving health services. Assam have a trbal and underserved population. The seven districts with NGO Involvement In RCH have them providing services among the tribal populabtion. % of population reached through the Data not avaiable In contrast, the Kamataka has a small tribal Innovative Schemes and Investment populabtion which is receivng health services. Preparation Fund The services are provided by NGOs which were contracted by the project There also 8 innovative schemes were imopemented under the project period. And 14 NGOs particpated in the investment preparation fund schemes in which population coverage was estimated as 716,783. 22 NGOs In Rajasthan have been provided funds for organirng mobile health camps. Innovative schemes such as the use of Jan Mangal couples and Jan Swastha Kasmi as community based distributors of suppfies and also as agents of change, were implmented under the project. There were 30 NGOs participated in the investment preparation fund schemes and the population coverage was very encouraging. In addition, NGOs have been assodated for carrying out various research studies. Most of mobile health camps Were conducted in the under served area to provide RCH services. These have been Implemented In 1,337 villages. Rt has benefitd at least 27,000 persons. End of project - 23 - Annex 2. Project Costs and Financing Project Cost by Component (in US$ million equivalent) Appraisal Actual/Latest Percentage of Estimate Estimate Appraisal Project Cost By Component US$ million US$ million Strengthen F. W. Service Delivery 50.10 47.83 95 Improve Quality of F. W. Services 22.00 21.23 96 Increasing Demand for F. W. Services 10.30 9.44 92 Management Improvement 8.80 8.78 99 Innovative Schemes 4.10 3.70 90 Emergency Earthquake Assistance for 9.53 Reconstruction in Gujarat 1/ Physical Contigencies 7.70 Price Contigencies 0.80 Total Baseline Cost 103.80 100.51 Total Project Costs 103.80 100.51 Total Financing Required 103.80 100.51 = 1/ A new component, Emergency Earthquake Assistance for Reconstruction in Gujarat was added following the earth quake in Gujarat in 2001. DCA was susquently amended to include the Gujarat component as the part Z of the project. - 24 - Project Costs by Procurement Arrangements (Ap ralsal Estimate) (US$ mllion ulvalent) CIVIL WORKS 36.19 6.60 42.78 (32.57, (.94, (38.51) GOODS Vehcles 3.99 0.30 - 4.29 (3.19) (0.24) (3.43l Mopeds, Bicycles for Field Staff 5.48 5.48 (4.39) (4.39) Furniture - 2.71 0.98 3.69 (2.17) (0.79) (2.96) Equipment & Health Kits - 6.69 2.43 - 9.12 (5.35) (1-94) (7.29) Training Material & Books - 1.67 - 1.67 (1.57) (1.57) Consumables - 1.84 - 1.84 (1.35) (1.35) Medicines & Medical Material - 3.04 - 3.04 (2.22) (2.22) TECHNICAL ASSISTANCE Project Preparation & Implementation 15.67 - 15.67 Support (includes Grants, Innovative Schemes (14.92) (14.92) Project Preparation & Implementation 1.30 - 1.30 Support (Publicity services) (1.04) (1.04) Institutional Development (Includes 3.04 - 3.04 IEC & training) (2.35) (2.35) MISCELLANEOUS Salaries of Additional Staff 4.56 - 4.56 (3.37) (3.37) Honorarium to Community Volunteers 2.83 - 2.83 (2.09) (2.09) T.AJD.A. of staff 0.27 0.27 Civil Works Operation & Maintenance 1.73 - 1.73 (1.24) (1.24) Equipment & Fleet Operation & Maintenance 2.55 2.55 (1.87) (1.87) Total 3.99 45.58 54.00 0.27 103.84 (3.19) (40.09) (45.31 - (88.58) - 25 - CIVIL WORKS= 45.45 7.90 - 53.35 (40.45) (5.45) (45.90) CIVIL WORKS (PART Z) 1/ (9.5__ (9.53) GOODS Furniture, Equipment & Health Kits,Vehcles 1.67 10.18 2.77 - 14.62 (0.98) (9.71) (1.89) (12.58) Training Material & Books 0.75 - 0.75 (0.69) (0.69) Consumables 0.97 - 0.97 TECHNICAL ASSISTANCE Project Preparation & Implementation 5.37 - 5.37 Support (includes Grants, Innovative Schemes (0.89) (0.89) Institutional Development (Includes 9.00 - 9.00 IEC & training) (6.96) (6.96) MISCELLANEOUS Salaries of Additional Staff& TA/DA of staff 4.83 - 4.83 (4.50) (4.50) Honorarium to Community Volunteers 0.56 - 0.56 (0.55) (0.55) Civil Works Operation & Maintenance 0.96 - 0.96 Equipment & Fleet Operation & Maintenance 0.57 0.57 Total 1.67 55.63 33.68 - 90.98 _ (0.98) (50.16) (20.93) (81.60) I / The civil work financed by IDA under the Part Z of the project for the Emergency Earthquake Assistance for Reconstruction in Gujarat. However, the total amount is not reflected by GOI financial report for the India Family Welfare (Assam, Rajasthan and Karnataka) Project. - 26 - Project Financing by Component (in USS million equivalent) Percentage of Appraisal Component Appraisal Estimate Actual/Latest Estimate IDA Govt. CoF. IDA Govt. CoF. IDA Govt. CoF. Strengthen F. W. Service 46.64 8.59 36.30 11.54 77.8 134.3 Delivery Improve Quality of F. W. 20.95 2.81 18.37 2.86 87.7 101.8 Services Increasing Demand for F. 9.05 2.03 6.94 2.50 76.7 123.2 W. Services Management Improvement 8.08 1.53 7,08 1.69 87.6 110.5 Innovative Schemes 3.86 0.30 3.38 0.32 87.6 106.7 Emergency Earthquake 9.53 Assistance for Reconstruction In Gujarat 1/ Total 88.58 15.26 81.60 18.91 92.1 123.9 1/ Emergency Earthquake Assistance for Reconstruction in Gujarat was added following the earth quake in Gujarat in 2001. DCA was susquently amended to include the Gujarat component as the part Z of the project. - 27 - Annex 3. Economic Costs and Benefits No economic costs and benefits analysis was carried out at the time of project appraisal or for the ICR. - 28 - Annex 4. Bank Inputs (a) Missions: Stage of Project Cycle No. of Persons and Specialty Performance Rating (e.g. 2 Economists, I FMS, etc.) Implementation Development MonthNear Count Specialty Progress Objective Identificaffon/Preparaffon/Prea ppralsal 2 Mission Leader, Public Health 02/25/92 - Specialist 03/11/92 04/11/92 - 2 Mission Leader, Public Health 04/26/92 Specialist Appraisal/Negotiation 12/06/93 - 15 Chief, Population and Health 12/12/93 Adviser, Mission Leader, Economist, Public Health Specialist, Consultant/Project Preparation, 2 Consultant/Architects, Consultant/IEC/NGO/Comm unity Participation, Consultant/Management, Consultant/MIS, 2 Procurement and Disbursement Specialists Supervision 11/24/94 - 6 Mission Leader, 2 S S 12/21/94 Architects, 2 Training Specialists, Pharmaceutical 08/30/95 - 7 Mission Leader, IEC, S S 09/23/95 Procurement, Training, Health Specialist, Architect, Pharmaceutical 04/01/96 - 6 Mission Leader, Training, S S 04/15/96 Management, Health Specialist, Architect, Pharmaceutical 11/18/96 - 3 Mission Leader, Community S S 12/06/96 Partnership, Service Delivery 04/28/97 - 5 Mission Leader, S S 05/21/97 Community/Partnership, Training, Management, Civil Works 10/13/97 - 5 Mission Leader, Training, S S 11/17/97 Management, Civil Works, IEC 05/14/98 - 7 Mission Leader, Public Health S S 06/05/98 Specialist, Training, Management, Civil Works, IEC, Community Participation 11/05/98 - 10 Mission Leader, 3 Program and S S 12/15/98 Project Implementation - 29 - Specialists, Decentralized Planing, Community Mobilization, Training, IEC, 2 Civil Works 02/12/99 3 Mission Leader, Economist, S S Public Health Specialist 04/14/99 - 5 Task Leader, Operations Analyst, S S 05/18/99 3 Consultants 11/08/99 - 8 Task Leader, Consultant/Public S U 11/17/99 Health Specialist, Consultant/Architect, Consultant/Monitoring & Evaluation, NGOs, Social Assessment, Consultant/Management Specialist, Consultant/Obstetrics 04/26/00 - 9 Task Leader, 2 Public Health S U 05/22/00 Specialists, Public Health Analyst, Operations Analyst, Training, Bio-engineer, Institutional Management, Consultant/IEC 09/21/00 - 6 Task Leader, Public Health S S 10/04/00 Specialist, Consultant/Training, Consultant/lEC, Consultant/Architect, Team Leader 05/10/01 - 4 Task Leader, Public Health S S 05/30/01 Specialist, Health Specialist, Financial Management Specialist 09/21/01 - 5 Task Leader, Consultant/Public S S 09/23/01 Health Specialist, Consultant/Architect. Procurement, Financial Management ICR 12/10/2001 - 5 Mission Leader, Public S S 12/14/2001 Health Specialist, Financial Specialist, Procurement, Operations Officer - 30 - (b) Staff: Stage of Project Cycle Actual/Latest Estimate No. Staff weeks US$ ('000) Identification/Preparation/Preap 205.30 314.70 praisal Appraisal/Negotiation 143.47 221.12 Supervision 342.00 687.02 ICR 20.00 65.98 Total 710.77 1,288.82 - 31 - Annex 5. Ratings for Achievement of Objectives/Outputs of Components (H=High, SU=Substantial, M=Modest, N=Negligible, NA=Not Applicable) Rating ;Macro policies O H OSUOM O N * NA ?Sector Policies O H O SU * M O N O NA Z Physical OH *SUOM ON ONA 0 Financial OH OSUOM ON ONA z Institutional Development 0 H 0 SU O M 0 N 0 NA FEnvironmental O H OSUOM O N * NA Social O Poverty Reduction O H O SU * M O N O NA M Gender O H *SUOM O N O NA O Other (Please specify) O H OSUOM O N O NA F Private sector development 0 H O SU * M 0 N 0 NA • Public sector management 0 H O SU 0 M 0 N 0 NA O Other (Please specify) O H OSUOM O N O NA NGO development - 32 - Annex 6. Ratings of Bank and Borrower Performance (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HU=Highly Unsatisfactory) 6.1 Bankperformance Rating I Lending OHSOS OU OHU z Supervision OHS OS * U O HU 3 Overall OHS OS * U O HU 6.2 Borrowerperformance Rating I Preparation OHS OS O U O HU I Government implementation performance O HS * S 0 U 0 HU Z Implementation agency performance O HS OS 0 U 0 HU 0 Overall OHS OS O U O HU - 33 - Annex 7. List of Supporting Documents 1. IDA. India, Staff Appraisal Report, Family Welfare (Assam, Rajajasthan and Karntaka)Project, May 26, 1994. 2. IDA. Development Credit Agreement, Credit Number 2630-IN, June 1994. 3. IDA. Project Agreement, Credit Number 2630-IN, June 1994. 4. IDA. ICR Mission Report, December 5-12, 2001. 5. IDA. Mid-Term Review (MTR)/Supervision Mission Aide-Memoire, November 5 to December 15, 1998. 6. IDA. Supervision Mission Aide Memoires, 1994-2001. 7. Government of Karnataka, Mid-Term Review by World Bank Mission, November 15 - 18, 1998. 8. Government of Assam, Mid-Term Review, November 1998. 9. Govemnunet of Assarn, State Report, IPP-IX and Reproductive and Child Health (RCH), November 1998. 10. Econ Design and project Services (P) Ltd., Guwahatai-6. Final Report of Mid-Term Review (CW), Assam Area Project (IPP-IX) 11. Government of Karnataka, Health & Family Welfare Dept. Final Implementation Completion Report (IDA - 2630- IN). The Family Welfare Project (Population-IX) Karnataka. 12. Society for Implemetation of Assam Area Project IPP-IX, Hengrabari, Guwahati. Assam Project Review Status, Project Report, December, 2001. 13. Health & Family Welfare Dept. Government of Karnataka. Implementation Completion Report (Draft) (New Delhi 12th - 14th December 2001) 14. Government of Karnataka, Tribal ANM Report, July 1999 to March 2000. Vivekanananda Foundation. 15. Government of Karnataka, Evaluation of ANM Trainingfor Tribal Girls under India Population Project IXInnovative Scheme. Population Centre, Bangalore, March 1999. 16. Family Welfare (Assam, Karnataka & Rajasthan) IPP-9 Project, Implementation Completion Report (IDA Credit No. 2630-IN) June 24, 1994 to December 31, 2002. Medical, Health & Family Welfare Department (IPP-IX), Jaipur (Rajasthan). 17. IPP-IX - Mid-Term Review (November 1998) Rajasthan, Family Welfare Project. 18. IPP-IX - Mid-Term Review (May 14-15, 1999) Jaipur. 19. Decentralized Planning in Reproductive Health. The Indian Experience of Policy Reform. Nirmala Murthy, December 2000. 20. Mid-Term Review of IEC and Training Programme Implemented under Assam Area Project IPP-IX, Final Report, Population Research Centre, Department of Statistics, Gauhati University. 21. Mid-Term Review. India Population Project IX (K). Government of Karnataka. Centre for Research in Health and Social Welfare Management, March 1999. 22. Mid-Term Review of Training Under IPP-IXProject, Rajasthan, A Report, Indian Institute of Health Management Research. 23. Action Plan for Remaining Training Activities in IPP-IX Project (From 01.07.2000 to 31.12.2001). Review on Training Progress upto July 2000 & Targets upto 2001. - 34 - Additional Annex 8. Government's Contribution to ICR IMPLEMENTATION COMPLETION REPORT, INDIA POPULATION PROJECT - IX IDA CREDIT - 2630-IN Department of Family Welfare Ministry of Health & Family Welfare New Delhi 1.0 INTRODUCTION Area development projects have been taken up under the National Family Welfare Programme with financial assistance from external funding agencies in different States with a view to increase outreach and coverage, while aiming to bring about reduction in maternal and child mortality and morbidity, in birth rate and increase in the couple protection rate. These projects have contributed greatly towards the development of the physical infra-structural facilities in the project states, and improved the quality of health & family welfare services to the people. T he project has also been instrumental in bring down the birth rate, death rate, infant mortality rate and increase in couple protection rate. The World Bank assisted DCth India Population Project (IPP-IX) has been implemented since June 1994 in the three states of Assam, Karnataka and Rajasthan. The project in Assam covers the entire state, in Karnataka 13 Districts and in Rajasthan only 10 districts are covered The World Bank committed an IDA credit of SDR 62.7 million for the project. The original cost of the project was Rs. 335 crores. The joint Mid-Term Review by the World Bank and GOI of the project in November-December 1998 recommended an additional provision for civil works to provide for escalation and cost over-runs to complete the number of buildings originally planned and also to meet the additional activities consistent with the project objectives. Accordingly, the cost of the project was enhanced to Rs. 414.06 crores in May 2000. Again, in January, 2001 the cost of the project was enhanced to Rs. 422.59 crores from the earlier approved sum of Rs. 414.06 crores primarily to meet the additional cost of Rs 8.53 crores for civil works in Assam. The entire additional cost over and above the original approved cost was adjusted against the savings that became available due to exchange rate variations. The project was implemented by the respective project organisations in the three States, with the overall responsibility resting with the State Heath & Family Welfare Departments. The project ended on 31st Dec 2001. 2.0 PROJECT OBJECTIVES, SCOPE AND STRATEGY The specific objectives of the project were * To provide area specific health and Family welfare services to the rural population in the Assam, Karnataka and Rajasthan. * To assist the three States to achieve reduction in birth rate, matemal and infant mortality rates. 2.1 Strategies The project had adoptedfive broad strategies to achieve the desired objectives. I. Expand the health andfamily welfare service delivery system)in the three states. Creation - 35 - of additional facilities, up-gradation of existing facilities, provision of need based services and introducing appropriate area specific ways of service delivery, construction and rehabilitation of sub-centers, primary health centers and operation theatres, establishment of mobile clinics for inaccessible area, furnishing and equipping of the health centers etc were planned. II. Increase the demandforfamily welfare services through (a) an expanded program of information, education and communication (b) increased participation of private voluntary orgaiization, private medical practitioners and the community in the family welfare programme. HI. Improve the quality offamily welfare services being providing to the rural population. It was planned to (a) up-grade the supervisory, managerial, technical and inter-personnel skill at all levels among new and existing medical and para-medical workers through pre-services, in-service and on the job training (b) establish and upgrade facilities available for training in the three States. IV. Implement innovative scheme covering a wide range of additional services including community based contraceptive depots, service delivery through NGOs in under served areas, construction of sub-centres by NGOs, formation of health advisory committees etc. V. Strengthening the Management Information System and Project Management Structure 3.0 ACHIEVEMENT OF PROJECT OBJECTIVES Overall Achievement * The precise impact of the project has been viewed in a much longer time frame than only during the project implementation period. Most of the activities have been completed. The assessment is based on the input and process indicators, supplemented by outcome indicators based on the data available from the Base Line Survey, Mid-Term Review (MTR), End Line Evaluation and State Reports. * The project substantially achieved its development objectives, especially those relating to training systems and infrastructure development and paved the way for enhancing quality of service delivery and care in FW and MCH. The experience, however, has been uneven for the individual States. * The IPP - IX provided for an expansion in the health and family welfare service delivery system in the three States through construction and equipping of buildings for sub-centers, PHCs, training institutions and drug warehouses and by upgrading existing health facilities. The project envisaged inter alia including a total of 2655 sub centers, 125 PHCs, 433 staff quarters, 3 State level training institutes and 29 drug warehouses. The status of the civil work at the end of the project is annexed in Table 1.0. It can be observed from the table that most of the planned civil works have been completed as per the plan. The State of Karnataka has repaired and renovated an additional 108 CHCs/PHCs and achieved 99.36% of targeted construction of SCs and PHCs. Whereas the State of Rajasthan and Assam have achieved nearly 100 percent of targeted construction of SCs and PHCs respectively. - 36 - Expand the health and family welfare service deliverv system The stated project objective of "expand the supply offamily welfare services " has envisaged increased coverage. The staff was already in place in most of the cases providing outreach services, either from rented or makeshift premises before the launch of the project The constructed sub-centres and PHCs under the project enhanced the working environment of the outreach workers by providing a facility from which they could operate, maintain stores and records, and conduct clinical sessions. Similarly the add-on OTs at PHCs/ FRUs enabled sterilization operations to be done in a proper facility and not in makeshift camps'. This component was allocated more than a half of the project resources. The objectives were substantially accomplished, through support to the construction, upgrading and functioning of a large network of rural health facilities/institutions. Altogether, more than 4,800 outreach facilities received new or upgraded infrastructures. The facilities constructed, inter-alia, included about 2,511 Sub-Centres (SCs) - with residential accommodation for the ANM. Similarly, about 1514 SC's were renovated whereas about 137 Primary Health Centres (PHCs) were upgraded, and 40 FRU's got the Operation Theatres (OTs). Drug ware houses and training institutions were constructed in addition to these facilities. Karnataka achieved about 99.36% of targeted construction of SCs and PHCs. 993 SCs out of 1000 SCs and 100 out of 100 PHCs have been constructed and handed over to Taluka Health Officers for operationalisation. The standard scales of sub-centres and PHCs furniture & equipment have been supplied to them. 4250 existing SCs and 802 existing PHCs also have been supplied with augmented supply of instruments and furniture. As per End Line Survey Facility utilization is 77.6% for SCs (clinic portion utilization) though only 64.4% of ANMs have occupied the residential part of SCs. 88% of SCs are within village limits. 464 PHCs, 22 CHCs and 1277 SCs in project area and 1460 facilities in non project area have been rehabilitated fully, 58.12% of which are quality audited and certified that rehabilitation work has been carried out satisfactorily. Assam achieved 100 percent of targeted construction, up-gradation and renovation of SCs and PHCs. Further, 90 State dispensaries were renovated. The new facilities and a large number of existing SCs and PHCs, were fully equipped and furnished, and provided with essential supplies ranging from daily consumables to blood pressure measuring instruments etc. About 150 generators were supplied to PHCs and BPHCs in Assam. The fiuniture was supplied to 669 PHCs, 800 SCs, 100 upgraded PHCs and 50 Dispensaries have been supplied as per the norm where as in Karnataka, furniture was supplied to about 833 SCs, 460 PHCs/ MCWCs, training Institutes. Similarly the aforesaid facilities in both the States were equipped with requisite equipments needed under the project. About 90 MTP suction apparatus were provided to FRUs/PHCs/CHCs in Assam. 193 vehicles were purchased and replaced, strengthening the referral and supervisory process. In Rajasthan the procurement under service delivery inter alia included supply of furniture and equipment to 833 SCs, 414 PHCs/ MCWCs, 138 FRUs and 2941 beds for the sub centres. However, the necessary furniture and equipment could not been procured for HFWTC, Jodhpur and SIHFW, Jaipur, Rajasthan. As a result, the overall physical and operational facilities were improved to render quality clinic based and domiciliary services to the rural population, Increase the demand for family welfare services The Project envisaged achieving this objective in several ways - creating quality infrastructures with well - 37 - trained service providers and adequate equipment and supplies; orienting non-health functionaries and opinion leaders at the community level to FW and MCH services; and finally, promoting Information, Education and Communication (IEC), and Non-Government Organizations (NGOs). These two later components were also centrally administered by the MOHFW throughout the country as part of GOI's ongoing national health programs. Approved activities were carried out in the three implementing States. Although the Project utilized over Rs. 157 crore for IEC activities, the precise impact of the investments made under this component is difficult to quantify, since the Project resources were combined with the GOI funds and programs for nationwide coverage. It has been observed based on National Family Health Survey, Mid term / End line evaluation reports and various RCH surveys that the knowledge and awareness of the community and demand for the services has increased since beginning of the project towards achieving project objective. However, the funds allocated for promotion of NGOs and build up-partnerships with them to achieve project objectives were under spent. It indicates limited role the NGOs have played in the project implementation across three states. The IEC strategy in all the three States emphasised on broader reproductive health and multi-sectoral approach while focussing the attention on spacing, delayed age of marriage, enhanced women's status, counteracting male-child preference and involving women's groups. In this context, the IEC Cell was created in Assam under the project. Project funds were used to develop innovative materials together with strengthening all media channels, emphasis on inter-personal communication, audience segmentation and area specific strategies. The activities were planed and implemented at State, district and block levels in co-ordination with State health Bureau / Wing/ IEC personnel. Community based distribution of contraceptives has been introduced in the State of Rajasthan, with launching of innovative scheme, namely Jan Mangal in the year 1992 in Udaipur and Alwar districts. Since then, it has spread to all the districts of the State. It aims at promoting and popularising the use of spacing methods of birth control, to ensure success of family welfare programme. Under the Project, Jan Mangal activities are being financed in 25 districts of the State, whereas, rest of the seven districts were covered under Integrated Population and Development Project of UNFPA. In these 25 districts, 8697 Jan Mangal couples have been selected, against a target of 11065. Training has been imparted to 7754 couples, of which 7396 are functional in the field. In Karnataka, market segmentation of population groups into unmarried women, currently married women with nil / one child, with two or more children, old women, married males and opinion leaders like PRI members, teachers, anganawadi workers, TBAs and health workers was done based on the findings of [PP-IX communication needs survey. Twenty need-based messages specifically needed for each group were designed. A revised IEC action plan was prepared and got approved at midterm joint WB and GOI IPP-IX progress review meeting at Jaipur in May 2000. A reputed advertisement firm-OGILVY & MATHER was involved in developing a media plan and its implementation. State family planning offset press was made functional again and the departmental newsletter "KUTUMBA" was restarted. State IEC officers' communication planning capabilities were strengthened. As on Dec 2001 all the district health education officers of respective districts were supplied with new IEC vans fitted with rear screens, state of the art video projectors and sound systems. TVs, VCRs, Video cassettes of Family Welfare Tele-films, TV spots, 2 sets of panel exhibition sets with enough POL from IPP-DC funds to tour 25 days / month to screen video shows and organize exhibitions quarterly in open air theaters of 100 outreach villages in each District were ensured. The Van has facilitated 6791 shows. In Assam, awareness generation activities like Baby Show, Quiz, Essay competitions, Seminars, Workshop etc. were held at State, district and Block level. IEC activities through Radio spots, Quickies, telecast - 38 - through Doordarshan and local theatres were done. NGOs were involved to generate awareness among the adolescent boys and girls and pregnant women on material and child health. The State revived the health bulletin and its bi-monthly publication -'SWASTHYA SANBAD'. In additions to these major activities many LEC interventions were done to enhance the awareness level of different stakeholders. Improve the quality of family welfare services Setting up improved institutional and management capacity was the principle strategy toward achieving enhanced service quality and working environment. The focus was on training and skill development as the pivot of operational efficiency at all levels. The Project was conceived within the broad framework of the National Family Welfare Progrdm, with an emphasis on "quality" of services and as a step toward a "program" approach - as distinct from the earlier "project" approach. The main thrust for quality was on upgrading the knowledge and skills of the staff, with focus on training as a core activity. In addition to training, several strategies were pursued to improve quality - strengthening the supply dimension; upgrading physicalfacilities, equipment and vehicles; increasing the demandfor services; and revamping the managerial processes. The satisfactory progress has been made in all these areas. Under training, the goal was to create 48 training facilities and train service providers and related persons viz. medical, paramedical and trained birth attendants etc. The Project was successful in developing a network of training infrastructure - a total of 46 institutions were built/renovated; and about 1.83 lac persons were trained. The present status of the training sector achievements is given in Table 2 in the annexe. Despite overall significant achievements, gaps have been observed between the targets and actual output in some of the categories. The new SIHFW building were constructed in each of state of Karanataka and Rajasthan. In Assam, SIHFW building was renovated with the project fund with added classrooms. Four RHFWTC/ HFWTC and 43 DTC were constructed/extended in three project states. Under the project in Assam TOT was completed and skill training undertaken to forrn part of ongoing RCH programme. Training curriculum was prepared as per the project objectives in consultation with the State Health Department. The Trainees were selected category wise and were trained at state, district and block level. The trainings emphasised on retention of knowledge, skill and behavioural change of trainees. The above indicators are reported to be good on evaluation that was also reflected in the Project indicators. It is expected that there will be further improvement in the indicators if the training activities are continued periodically in future also. During the Project period a total of 96,739 medical and para medical personnel including MSS, WHP, TBAs and village leaders have been trained. The project in Assam has not only expanded the training facilities through construction of district training centres, expansion of RHFWTC and SHFWTC, Hostel facilities and supply of essential materials but has also systematically organised training at State, district and block level and has thereby established a good system of training. In Rajasthan, the extensive training infrastructure that was established included State, regional and district-level institutions. The most important achievement is the establishment of State Institute of Health and Family Welfare (SIHFW), Jaipur, as an Apex Training Institution. Also a Regional Health and Family Welfare Training Centre has been established at Jodhpur. Besides, 15 ANM Training centres have been upgraded as District Training Centres, to facilitate In-service training to the Pam medical staff for ensuring up-to-date knowledge and skill required for better and effective service dispensation. In addition, existing two HFWTCs at Jaipur and Ajmer have also been provided inputs to strengthen them. - 39 - In Karnataka, skill based training to ANMs/ LHVs/ MPWs/ HAs/ BHEs was introduced both under IPP syllabus under the first round as well as under RCH in the second round to improve quality of family welfare services. Nearly 55,000 comnnunity volunteers were trained to support ANMs in family welfare service delivery in linkage systems. A total of 14253 staff of both medical and para-medicals was trained. The other major achievements included construction of one SIHFW, one HFWTC, 5 ANMTCs and 17 DTCs. All the training facilites constructed and upgraded have been fully equipped. A significant number of trained managers, supervisors and service providers as well as non-health functionaries are now available to provide and support effective and quality service delivery in all the three states. During the Mid-Term Review, different categories of health personnel observed and interviewed in the clinical and outreach settings received generally satisfactory ratings on most counts. A large number of functionaries in PHCs and SCs and their supervisors were found to have received in-service training, acquiring necessary skills in health and FW programs, such as: anti-natal care (ANC), post-natal care (PNC), the "five cleans" (clean surface, hands, blade, cord tie and cord stump), signs and symptoms of pregnancy, conduct of delivery, managing birth complications, immunization, family planning, record keeping, IEC, management and supervision. Efficiency Improvement This objective was envisaged to be achieved through human resource development and by earmarking funds for improving the management and operation of the FW program by: (a) strengthening administration and management; (b) developing Human Resource Development Cells (HRDCs); (c) improving Management Information Systems (MIES); (d) undertaking research on Program Management and Evaluation, and Human Resources Development; (e) setting up Technical Advisory Committees; and (g) instituting regular Monitoring and Evaluation Mechanisms to follow up implementation progress and bottlenecks. The Project Management Unit of the respective States of the project facilitated implementation of various project activities, by ensuring co-ordination between various project executing authorities and agencies. The project management also provided regular feed back to the higher authorities of the State, MOHFW and World Bank, regarding status of implementation and difficulties experienced in execution of project activities etc., to find solutions of the difficulties and hindrances. The project management made timely persuasions with the executing departments to ensure timely and quality implementation of various project activities. In order to improve management capacity by gathering, processing and taking quick data based decisions in Karnataka, the MIES cell of Family Welfare Department has been strengthened by additional supply of computers coupled with a new CNA software platform. Large number of community volunteers approximately 55,000 has been trained to support ANMs in Family Welfare service delivery linkage systems. Similarly under the project in Assam a computer unit has been established at the project headquarters. It has helped in timely monitoring and evaluation of the project activities and data processing in relation to the health services delivery. The computer system was freely used for flow of information. It streamlined / quickened the administrative activities and its implementation. Similar facilities were proposed for Drug Warehouses. Under programme management in Rajasthan, the project has funded comprehensive contact and survey drives in the State, which have facilitated smoothening of record keeping at the health institutions and enforcing community needs assessment approach for RCH in the State. These contact and survey drives, which were organised every year in all the villages of the States are unique, as these provide comprehensive - 40 - database required for successful implementation of Family Welfare Programme and RCH Programme in the State. The other inputs inter alia included strengthening of computer system in the department at State and district levels. The project management unit in Rajasthan facilitated implementation of various project activities, by ensuring coordination between various project executing authorities and agencies. The project management also provided regular feed back to the higher authorities of the State, MOHFW and World Bank, regarding status of implementation and difficulties experienced in execution of project activities etc., to find solutions of the difficulties and various hindrances. The project management made timely persuasions with the executing departments to ensure timely and quality implementation of various project activities. The regular and periodic visit of World Bank Mission and technical experts to the project states has contributed in enhancing the quality as well as the efficiency. 4.0 PROJECT COSTS AND EXPENDITURE Total project cost and expenditure is depicted in the following table. Rs (in Crores) State Total Cost Expenditure Rajasthan 124.94 103.01 Assam 144.37 144.06 Karanataka as on 31/3/2002. 150.84 137.08 Total 422.58 384.17 The component wise cost and expenditure in the three states is as follows: Rs in Lakh Category Civil Work Equip. Vehicle Books & IEC rg ConsuL & Incremental Total Furniture Trg. Mat Fellowship Salary ___________ ~~etc._ _ _ _ _ 1 2 3 4 5 6 7 Rahasthan 5354.40 970.68 41.01 47.58 1567.57 358.39 1962.04 10301.67 Assam 8742.89 3495.85 6.89 33.14 1164.05 49.00 915.17 14406.99 Karnataka 8822.03 1841.44 653.12 164.06 1161.61 126.47 940.11 13708.84 22919.32 630797 701.02 244.78 3893.23 533.86 3817,32 38417.59 5.0 MAJOR FACTORS AFFECTING THE PROJECT The regular joint GOI-WB periodical review, Mid Term Reviews and End Line Survey observed number of factors which affected the desired pace of implementation. Some of them are as under:- The neeative factors included the followinn: -41 - (a) Preparedness in the Beginning of the Project: This was a challenge to all the States as quantified monitoring indicators were largely in abeyance in the beginning of the project. The State's knowledge of the Bank's procurement procedures was highly deficient; and staffing and delegation of powers to the project authorities / implementing units was inadequate, especially with respect to civil works, procurement, and financial management. (b) Management and Staffing: The State Empowered Committees were set up with delayand meetings of the same were not held regularly, resulting in delay in decision making process and delayed implementation. Further, the Project Director was also not delegated administrative and financial powers. Staff appointment and frequent transfers was also a perpetual problem. Rajasthan and Karnataka had eleven and nine Project Directors during the project period respectively. Nearly perennial vacancies in many operational and training positions, coupled with concurrent holding of several positions by an individual arising out of financial difficulties of the States have been observed. The states' concern to avoid pernanent liability beyond the project period also proved debilitating e.g. procurement and MIS sections were totally vacant for two years in Karnataka, which affected functions of both these units for the period. The project was implemented with head of IEC wing vacant for most of project life and even up to the end of project period. The same is the case in the state of Rajasthan. (c) Monitoring: Lack of a systemic and regular monitoring mechanism at the State & District levels coupled with inadequate field visits affected the implementation of the project adversely. (d) Co-ordination: Project Management Unit (PMU) was created and made responsible for the implementation of the project in each state. PMU has remained separate entity from the State's Family Welfare Directorate during the project period. Linkages and coordination levels/ points between the Directorate and PMU has not been established. As a result, at the end of the project, some of the activities of the project have not been budgeted in the yearly state budget (e) Fund Flow: While GOI released the Project funds regularly to the State Finance Departments (SFDs), flow of funds from SFDs to the Project Implementation Unit in Rajasthan was a major constraint. Finance Department and Accountant General in Kamataka were not in favour of authorizing large number of district level officers to draw funds from the State sector project funds. In view of this, there were some delays in funds flow to different field offices for some of the software activities. (f) Civil Works: Lack of the appropriate engineering cells in the Implementation Units and ineffective coordination with the agencies responsible for construction - the Public Works Department (PWD), DRDA in Rajasthan for many activities led to problems of quality control, delayed completion and cost escalation. Undue delays were also observed in handing over and operationalising the completed buildings. In certain cases it was also observed that the States did not include external development work and external civic services like electricity, water, drainage and sewerage in the final estimates which also resulted in delay in operationalising such buildings. In Kamnataka, the implementing agencies in the districts were mostly under administrative control of altogether different departments (Rural Development and Panchayat Raj / PWD) supervision over them was found to be extremely difficult and there were delays in getting requisite information/ support. (g) Procurement: The procurement capacity of the project States was found to be weak. This resulted in delay in procurement and also affected its quality. Due to inadequate co-ordination between the civil works and procurement, many of the completed buildings remained non-operational for some time. -42 - This was because of non-availability of requisite supplies in some cases while in other cases the supplies were procured much before completion of civil works. Procurement in other matters also suffered, especially during the early years, due to inadequate familiarity of the States with IDA procedures and non-delegation of powers to the project authorities. In Rajasthan, the procurement suffered badly due to delay in requisite approval by various committees despite appointment of HSCC as the nodal procurement agency. (h) Public Private Partnership: In Rajasthan the project envisaged construction of sub-centres with the share contribution by NGOs and DRDAs. The share could not be provided by these agencies with the result, there was no construction of sub centers for more than 3 years. (i) Inappropriate Implementation: The activities envisaged in the project design were not implemented as per the approved project schedule. This resulted in accumulation of backlog of activities and under utilization of funds during most of its life. Due to this the States had to revise their targets and were also under pressure to complete all activities and utilise funds towards the end of the project (j) Commitment: The project at district and taluka level is implemented through medical officers. The implementing medical officers at district and taluka level were not public health physicians, but of many surgical postgraduate specialities whose commitment to Public Health and FW programmes was less than to their specialities. Despite the above constraints, the project made significant achievements. The following were some of the positive factors. Positive Factors. * Proactive Initiatives: Committed project directors and top management at the state level did make a difference from time to time. The continuity of the Project Director in Assam and regular meetings of the state empowered/ steering committees facilitated project to achieve its targets. * Visits of the World Bank Missions: Regular visits of the World Bank Missions facilitated identification of weaknesses/shortfalls of the projects with a view to take appropriate remedial action and supplement new activities in line with the project objectives. * Utilisation of External Resources: Experiments of using professional advertisement firms in social marketing of Health and Family Welfare messages brought in greater visibility to the programme. * Involvement of faculty of professional management schools as guest lecturers for imparting management training to health staff undertaken as an innovative policy in Karnataka and the same was received well by trainees and trainers in the State. * Strengthening Management Information System: Computerized tracking and monitoring of Project activities progress by IPP-IX and adopting E-mail Communications greatly improved the efficiency of the project. Installation of Computers in Taluka Health Offices and connecting them by WAN with DBFWO Offices, DTCs and DHFWOs and Project office resulted in more efficient monitoring and faster feed back and enlarge the project stake holders web. -43 - Similarly the computerisation of project offices has also greatly helped in improving their efficiencies. * Appropriate Utilisation of Staff Quarters: Permitting contract doctors to occupy the medical officer quarters have resulted in wider utilisation of these buildings in Karnataka. * Innovative / NGO Schemes: The innovative schemes and the experience of NGOs involvement in the three states demonstrated that such schemes could be taken up at wider scale to enhance the effectiveness of health and family welfare programmes. Rajasthan - Organisation of health camps in remote and hilly areas on fixed day and time, association with the campaign " Prashashan Gaon Ke Sang" has directly benefited over 40 million people. The schemes such as interest free loan for purchase of vehicles, support to implementation of neo-natal tetanus toxide campaign, formulation of HRD/Training Policy, associating NGOs with varying activities e.g. mobile camps, facility survey, Jan Mangal Scheme etc., has contributed towards achieving project objectives. Karnataka - Use of video van for outreach villages on experimental basis, supply of Nirodh through PDS shops, involvement of industrial houses in LEC, non-formal education for girls and young people, community incentives, mobile clinics and clubs for newly married couples are some of the innovative interventions implemented to meet the desired objectives. Street plays tele- serials and radio serials also helped reaching the large section of the population. Assam - Baby show, quiz, essay competitions, seminars, workshops held at State, districts and block levels focussing on breast feeding, birth spacing and ante-natal care have been of much effect. IEC activities through radio, telecast of spots and local theatre have helped a lot in generating awareness in general public. 6.0 PROJECT SUSTAINABILITY The issue of sustainability in the context of the evolving demands of the family welfare program needs to be approached with realism and as a process much beyond the limited horizon of the present project. This needs special attention in the context of relative isolation of project efforts from mainstream activities in health and related areas during the implementation. Nevertheless, significant strides have been made toward setting up a vast network of infrastructure and staff development for enhanced training and service delivery. Their potential contribution is certainly promising. All the States have assured considerable additional investments to bring the investments made under the project tofullfruition to ensure sustainability. All the States have already initiated steps in this direction by making adequate provision in the State budget and by coordinating with the other programme been funded by the State/GOL. The State Government of Karnataka had taken steps to ensure sustainability of 19 DTCs and the SIHFW. A position of Director, SIHFW from a senior grade has been created. Provision of separate budget head for training in SIHFW and DTCs has been made. Salaries and allowances of staff working in DTCs and SIHFW up to March 2002 has already been provided by the Steering Committee resolutions. Budget estimates for payment of salary and allowances, office expenses and POL has been placed under State Family Welfare plan amounting to about Rs 23 million annually. All training institutions were furnished and equipped with training equipment during the current year. Sufficient training modules and materials catering to the needs until 2003 were supplied to the training institutes. Provisions for the maintenance of - 44 - facilities created under IPP-LX has been made by increasing the non-wage-non plan budget for the coming year through the mechanism of the Mid Term fiscal plan. Regarding IEC component, the state decided that Radio and Tele-serials will be broadcast and telecast for three months April to June from 2002 onwards every year under RCH / HNP project. The Government further decided that arrangement made under the project like managing Thithimathi and Gumbahalli PHC by the NGOs would continue for next 10 years. Similarly, the EEC vehicles with the facilities of screening films in 27 districts will continue to cover outreach villages through the funds provided by the RCH budget. PVOs activities like mobile medical units and link workers schemes implemented by local entrepreneurial NGOs will be sustained under RCH / HNP projects. The Goveming Body of the Society responsible for effective implementation of the project decided and proposed to the Govemment of Assam to maintain the health institutions up to the level of PHCs by the community through Panchayati Raj system. The State PWD will maintain rest of the buildings constructed under the project. Similarly, the state also decided to continue training and IEC activities through RCH budget. The Department of Health would pay the salaries of the training institution's staff. All the training institutions were furnished and have necessary equipment desired for the organisation of training programmes with appropriate infrastructure and material such as training materials, books etc. The IEC activities will continue under RCH. The Government of Rajasthan is also in the process of making requisite financial provisions in the state budget to sustain the efforts made under the project. 7.0 ASSESSMENT OF OUTCOME Taking into consideration the significant achievements, the project can be termed as very satisfactory. The infrastructure created and Human Resource Development in the project period has resulted in improvement of provision of service delivery and its quality. These would now need to be consolidated in order to ensure continued upgrading of the quantity and quality of services that the Project initiated. While the quantifiable outcome indicators on infrastructure and personnel development provide evidence of considerable achievement in capacity building of training and quality service delivery, it is too early to assess the precise impact of the Project in terms of specific behavioural changes among the clients and the providers, and their implications for the family welfare and health indicators. The assessment and impact of the project would be deliberated in detail after the results of the End-line Survey are out. However, based on the available programmatic data the improvements in some of the health indicators are given as under: Indicators Assam Karnataka Raasthan SRS, Endline Baseline Endline Baseline Endline 1997-98 . CBR 28.20 27.19 28.30 20.6 36.89 32.35 TFR 3.20 3.05 3.30 2.2 5.08 4.70 IMR 76.0' 61.61 66.9 40.2 128.66 39.0 CPR 18.8 44.3 49.9 60.8 126.66 41.1 -45 - W of 1996 ' ' of 1997 U Based on a very small sample and need to be interpreted carefully In addition to above indicators, the end line survey in three states provided insights towards the process and other indicators: * The mean age at marriage in case of both men and women * Percentage of children in 12-23 months fully immunised and by antigen * Percentage of expectant women who received Anti Natal care by number of contacts, receipts of TT, receipt and consumption of IFA and % of expectant women registeredfor AN care during the first trimester. * Percentage of births attended by skilled health personnel - doctors or trained midwife excluding TBA (Trained or untrained). * Percentage of women who perceive that clinic hours/days are convenient and % of women in reproductive age with knowledge of location of essential obstetric care services * Percentage of children underfive who sufferedfrom diarrhoea during past 15 days, and % of those with diarrhoea who were referred or received ORS * Percentage of women and men in reproductive age familiar with different contraceptive methods and their availability: * % Couples having unmet need for contraceptive services * % new clients in reproductive age receiving counselling for contraceptives * Screening of FP methods users * Level of satisfaction about the current method among the contraceptive users. * Unmet Need * Percentage of clients informed of timing and sources of re-supply/revisit for contraceptives * the mean age at marriage in case of both men and women is below legal age at marriage in case of Rajasthan as over two third of the men and women are married before the legal age. However in case of Karnataka the mean age at marriage for women is just reaching the legal age and while it is quite above the legal age in Assam. In case of age at marriage for men, the age ranged from 19 in case of Rajasthan to 24 and 27 years for Karnataka and Assam respectively. The mean age for the first pregnancy ranged from 19 years in case of Rajasthan to 20 in Karnataka to 21 in Assam. * Percentage of children in 12-23 months fully immunized and by antigen The status of immunization is an important process indicator that provides benchmark for child health. The end line results of various states show that in increase has been observed in case of children (12-23 months) who had received all the requisite doses in case of vaccines. In case of Rajasthan an increase of 12 per cent has been noticed (19 to 31) while the corresponding increase was about I per cent in case of Karnataka State. In case of Assam when end line results are compared to the second round of National Famnily Health Survey, an increase of 27 per cent has been noticed. In both Rajasthan and Assam where immunization status by antigen has been provided, it can be noticed that BCG continues to be the most popular vaccine, followed by the DPT and OPV respectively. -46 - * Percentage of expectant women who received AN care by number of contacts, receipts of TT, receipt and consumption of IFA and % of expectant women registeredfor AN care during the first trimester More number of women are now registering themselves for ante-natal services and are doing so by the end of the first trimester. About 93 per cent women are now registered for ante-natal care in Karnataka compared with the base line figures of 70 per cent, whereas the corresponding increase is about 16 per cent in case of Rajasthan and over two third are now registering themselves for ante-natal care in Assam. One of the important indicators of ANC is timing of registration for the ANC. It can be seen from Table X that nearly two thirds and over half of the registration are now being done by the end of the first trimester in Karnatak and Assam respectively, while about half of the women are doing so in Rajasthan. The increase in registrations during the first trimester is an important process indicator and it has shown tremendous increase in Rajasthan (from 32 to 49) and in Karnataka states. In case of Assam also compared to NFHS II, a good increase has been registered. * Percentage of births attended by skilled health personnel - doctors or trained midwife excluding TBA An increase in the institutional deliveries has been noticed during the project period but a majority of deliveries continue to be domicillary. In Karnataka, the number of institutional deliveries has doubled while the increase is small in case of Assarn and Rajasthan, where it has gone up 10 and 2 per cent respectively. The percentage of deliveries by a trained personnel has also gone up albeit by a small margin. * Percentage of women who perceive that clinic hours/days are convenient and % of women in reproductive age with knowledge of location of essential obstetric care services An overwhelming majority of the respondents in Rajasthan perceived the clinical hours to be convenient and comparative information is not available from the other states. As far as knowledge of location of essential obstetrics services is concemed, a majority of the respondents (89%) knew about the same whereas the corresponding figures for Kamataka are about 45 per cent. * Percentage of children underfive who sufferedfrom diarrhoea during past 15 days, and % of those with diarrhoea who were referred or received ORS There has been an increase in the number of cases where Diarrhoea was effectively managed during the project period. It has been seen that though reference period for diarrhoea was different in the all states and therefore prevalence of diarrhoea also varied from state to state. The number of cases that were effectively managed has doubled (from 18 to 40%) in Rajasthan and more than three-fourths cases are being referred in Kamataka and Assam. * Percentage of women and men in reproductive age familiar with different contraceptive methods and their availability There is an increase in the knowledge of both men and women regarding contraceptives and their availability during the project. Except in case of Assam where no particular trend has been seen in the absence of a proper base line information, the knowledge regarding various contraceptives and their availability has gone up by 5 to 12 per cent in case of modem methods in Rajasthan and Kamataka. While conducting end-line survey in the state of Rajasthan an effort has been made to collect information on the following vital indicators and the corresponding information is not available from -47 - the other states * Unmet Need As per the end line survey unmet need for spacing was 4.8 per cent while the unmet need for limiting was 13.9 per cent. Therefore a total unmet need of 18.7 was found among the surveyed eligible women living in the project area in Rajasthan. * Percentage of clients informed of timing and sources of re-supply/revisitfor contraceptives Among those who are currently using any modem FP method about 31 per cent mentioned that the health worker made the follow-up visits and 13 per cent of the respondents in Rajasthan also mentioned that they were informed about the timing and sources of revisit. 8.0 THE LESSONS LEARNT * There are chronic and persistent operational problems that adversely affect implementation of all family welfare projects in weaker states. These include poor flow of funds to the implementing agency in states that experience fiscal problems, low procurement capacity, persistent staff vacancies and high turnover, and lengthy decision-making processes. These often relate to macro-economic difficulties and problems of governance at the state level, and are beyond the scope of individual project teams to address effectively. Unless resolved at an apex level, they continue to constrain implementation and create problems of long-range sustainability. * GOI needs to consider creating incentives to states through performance-based financing during project implementation. In IPP IX, Government of India released funds regularly to the State Finance Departments (SFDs), but the onward flow of funds from the SFDs to the project units was impeded as result of financial difficulties at the state level. Such a situation would need to be guarded against through performance-based financing referred to above or through reallocation of funds to project states. * The project design from the beginning should clearly incorporate phase-out strategy with the clear provisions of making project interventions sustainable after the project period. It is essential to build in appropriate mechanisms to ensure quality assurance for interventions as well as continuous monitoring systems. The mechanisms to orient various committees and staff members of project and relevant people about the Banks procedures, rules and regulations etc must be a part of project design. * The project design from the beginning should incorporate mechanisms to develop common understanding of the project objectives, approaches, systems and procedures. If new systems have been developed or proposed for the project, it must be made known to every one. At the same time mechanisms must ensure that at the time of change in the leadership of the project, the new person get appropriate induction of project concept and over all project cycle components. * Centralized system of functioning would be useful for hardware component whereas decentralized way of functioning provides better results wherein the software activities are involved. * The newly constructed facilities must be registered at the PWD development register to ensure appropriate maintenance. This is based on lessons from the IPP VII where these properties were not entered in the registers of PWD and were, as a consequence, neglected for maintenance. -48 - * The project should prepare detailed action plan to integrate all the project components with in the existing health system of the state and take the action appropriately. * A person of commissioner rank to minimise the delays must head the Project Procurement Committee. * Computerized tracking and monitoring of Project activities, adopting e-mail communications, installation of computers in Taluka Health Offices and connecting them by WAN with DHFWO Offices, DTCs and DHFWOs and project office have resulted in improving efficient monitoring and faster feed back system. * Use of professional advertisement firms in social marketing of health and family welfare messages, involvement of faculty of professional management schools as guest lecturers for imparting management training is found to be very effective approach. * Inter-sectoral co-ordination was found to be a difficult task and required different area specific approaches. Creative ideas are needed for the better utilisation of newly constructed facilities e.g. permitting doctors who are on contract services to occupy the residential quarters meant for MOs has resulted in wider operationalisation of these buildings in Kanataka. * The tenure of the Project Director and the fund flow mechanisms ensuring timely receipt of funds by the project authority with requisite delegation of financial powers to them are pre-requisite for the success of project. * District and Taluka (Sub-District) health administrations are critical crossover points in delivery of Public Health and Family Welfare Services. It has been experienced that it could be better for project effectiveness if District and Taluka Project Implementation Committees would exist to monitor project activities. * One Project Management Unit that is situated at state level cannot do monitoring of large number of ongoing civil works. The community participation could be more encouraged at Zilla Panchayat level for better effectiveness of project implementation. Zilla Panchayat could take a lead role in monitoring the progress of civil works and regular monitoring could be priority agenda item in its monthly general and subject meetings. * Project Implementation Plan (PIP) should go into all details of implementation. Preferably the persons who were involved in the preparation of PIP should also be involved in the implementation of the project for the first two years at least The funds flow and accounting / audit procedures to be clearly firmed up in the PIP to avoid loss of valuable time on such procedural issues after commencement of the project. * The soft activities of the project should also be initiated from the beginning to have greater and faster impact. -49 - Table 1.0: State-wise Project Targets and Achievements S Activity Assam I Karnataka Rjasthan CIVIL WORKS )Target Achievements Targ et [chi"vementarget |AJhievement N_-, F rt i 10 Y\ 11 14 J\i . Jk'AN N W1\ (Nl SlT1(1T. D1:I JVFRY _ I Sub Centres 800 800 1000 993 855 808 2 Construction of PHC - - 100 100 25 23 3 Upgradation of PHCs to - - - 10 9 CHCs 4 Construction of OT at FRUs - 45 40 5 Staff Quarters for ANMs 88 88 - - - - 6 Quarters for Medical Offtce - - 270 266 7 Staff Quarters for Grade IV 75 75 - - 8 Upgradation of existing State 100 l00 dispensaries to PHCs 9 Renovation of State dispensary 90 90 - 10 Renovation of sub-centres 250 250 1277 1277 - II Constructions of OT at FRUs - - - 45 40 12 Upgradation of 37 37 10 9 PHCs/CHCs/Hospital as FRUs 1 3 Rep. and Renovation of existing 39 39 375 483 - CHCs/PHC I .I _ I _ CONSTRUCTION RELATED TO TRAINING FACILITIES 14 Construction/ Extension I I I I 1 1 SHFWTC/ SIHFW 15 Construction/ Extension of I I I 1 2 2 RHFWTC/ HFWTC _ _ 16 Construction / Extensions / Upgradations of the training Schools a) School building for trg. (DTC) b) l00 bedded hostel for GNM 2 22 6 6 1 5 1 5 _ 4 4 19 19 17 20 bedded Nurses' hostel 5 5 _ - - 18 Constructions of FPDAs _ 15 14 19 Accommodation at Field 16 16 Practice Areas _____ _ 2 Other Remarks _ c) OTHER CONSTRUCTIONS . 21 Construction of Project Directo I I . building with approach road an boundary wall 22 Construction of Central/ Stat I I Level Drug warehouse - 50 - Cont... S# Activity Assam Karnataka Rasthan Target Achievement Target Achievement Target HAchievement 23 Construction of Zonal 5 5 - warehouses 24 Construction of Drug - - - 23 22 warehouse (Minor) 25 Construction of Drug - 5 5 warehouse (Major) 26 Completion of incomplete I 1 - - - work of boys Hostel (SHFWTC) 27 Completion of incomplete 1 I - work of SHTO 28 Institute of Pharmacy (SMC) 1 1 - 29 Completed of incomplete work 1 1 - of boys' hostel (SHFWTC) (i) Repairing and renovation o I girls' hostel for SHFWTC, (ii) Repairing and renovation 1 of SHFWTC 30 Regional Nursing College 0 1 boundary wall etc 31 Computer site preparation - - 32 Upgradation. of Central SHTO I I workshop (with boundary wall, electrification and approach road and water supply and removal and shifting H.T. line) I - 51 - Table 3: Human Resource Development - Training Coverage S # Activity Assam I Karnataka Raj jasthan ITarget [Achievement Target |Achievement Target Achievement Category of Health personnel I Core 10 11 57 67 - - Trainers 2 State Level Officers - - - 114 20 3 District Level Officers 300 92 4 SMOs/ Dy CMHOs - - - - 956 498 5 MOs including Sr. Supervisory 4895 2489 1676 1867 2573 2490 officer 6 DPHN 23 15 - - - - 7 DEMOs and Dy. 46 36 - - DEMOs 8 BEEs / HEs/ 1040 537 527 339 - - BHEs 9 HW (F) / ANMs/ 6720 5636 8741 10835 14628 13427 MPWs I 0 HW(F)/ANM Trained outside - 46 - - - - the state _ 11 HA (F) / LHVs/ Sector 960 540 1000 100 1920 1525 supervisors 12 Basic Training of 1500 788 - - - - GNMs 13 PMAs 4440 5122 - - 14 TBAs 15000 10386 15 Training faculty 250 261 67 57 16 Private Medical 3000 314 Practitioners 17 MSS (IEC) 35,000 21781 - 18 WHP (IEC) 75000 44967 19 OTC (IEC) 4900 3780 1120 523 20 SHAM ___ 3738 2290 21 CVs __ _ 155905 54506 22 IEC Workshops 46 34 . - 52 - Report No.: 23855 Type: ICR