India - Fourth Population (West Bengal) Project

Document of The World Bank FOR OFFICIAL USE ONLY CR . 16 2 3 -r Report No. 5523-IN STAFF APPRAISAL REPORT INDIA WEST BENGAL - FOURTH POPULATION PROJECT June 17, 1985 Population, Health and Nutrition Department This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its centents may not otherwise be disclosed without World Bank auhorization.  CURRENCY ZQUIVALENT US$1.00 = Rupees (Rs) 12.00 GOVERNHENT OF INDIA FISCAL YEAR April 1 -March 31 MEASURE (METRIC SYSTEM) 1 meter (m) = 3.28 feet (ft) 1 kilometer (km) = 0.62 miles (mi)  FOR OMCIAL USE ONLY ABBREVIATIONS ADIED Assistant District Health Education Officer AIIEPH AU-India Institute of Hygiene and Public Health AIR All-India Radio A1( Auxiliary Nurse Midwife B.Ed. Bachelor of Education Degree BEE Block Extensiou Educator CBR Crude Birth Rate CDR Crude Death Rate CHC Cobumity Health Center CKD Chief Medical Officer CMS Central Medical Store CTI Central Training Institute DHEO District Health Education Officer DES Director of Health Services EPI Expanded Program of Imminization &NM General Nurse-Midwife GOI Goverzmmnt of India cm GDnvermet of West Bengal EAF Health Assistant (Female) EHAM Health Assistant (Male) EED Health Education Officer HFWTC Health and Family Welfare Training Center ICE International Competitive Bidding ICDS Integrated Child Development Services IEC Information, Education and Comnimication IUD Intra-Uterine Device LCB Local Competitive Bidding mCm Maternal and Child Health nEs Managenent Information and Evaluation System mH Ministry of Health MOHFP Ministry of Health and Family Planning 1I)FW Ministry of Health and Family Welfare ENM Multipurpose Worker Female mPWm Multipurpose Worker Male 11T Medical Termination of Pregnancy NIElCi National institute of Health and Family Welfare NRR Net Reproductive Rate OTC Orientation Training Camps PHC Primary Health Center PWD Public Works Department RH Rural Hospitai SBHI State Bureau of Health Intelligence SFWO State Family Welfare Officer SHC Subsidiary Health Center SHTO State Health Transport Organisation SIHNW State Institute of Health and Family Welfare SRS Sample Registration System SwO Social Welfare Officer TFR Total Fertility Rate T&V Training and Visit VHG Village Health Guide This document has a resticd distibuion and nmy be used by repients only in the prformance of teir official duties. Its contents may not otherwise be didosed without World Bank authorization.  DEFINITIOS Current Contracep- Proportion of eligible couples estimated to be currently uslng a tive Prevalence method of (modern) contraception. Effective Contracep- Current contraceptive prevalence adjusted for the relative effec- tive Prevalence tiveness of contraceptive methods (sterilization and oral con- traceptives are assumed to be 1OOS effective, IUDs 951 and con- ventional contraceptives 501); abays somewhat lower than current prevalence. Crude Birth Rate Number of live births per year per 1,000 population. Crude Death Rate Number of deaths per year per 1,000 population. Rate of Natural Diff rence between crude birth and crude death rates; usually ex- Increase preased as a percentage. Rate of Population Rate of natural increase adjusted for (net) mdgration, expressed as Growth a percentage of the total population in a given year. Age Specific Number of live births to women in a given age group per 1.000 women Fertility Rate in the saoe age group, in a given year. It is usually calculated for five-year age groups. Total Fertility The average number of live children that would be born per moan if Rate she were to live to the end of her childbearLng years, and bear children according to a given set of age-specific fertility rates. The Total Fertility Rate often serves as an estimate of the average number of children per fatdly. Net Reproduction The number of live-born daughters a cobort cif femles would bear Rate under a given fertility schedule and a givenT set of survival prob- abilities, from birth to the end of the childbearing years. Infant Mortality Annual number of deaths of infants under one year per 1,000 live Rate births during the sae year. Maternal Mortality Number of msternal deaths attributable to pregnancy, childbirth, or Rate puerperal complications (i.e., within six weeks following child- birth), per 10,000 live births. Life Expectancy Average number of years expected to be lived by children born in a given year if mortality rates for each age/sex group resin the same in the future. Age Dependency Ratio of population 14 years and under plus population 65 years and Ratio over to population aged 15 to 64 years. Equivalent An index of overall family planning performace calculated by adding Sterilizations the number of sterilizations performed over a period of tin., one- third the number of IUDs inserted, one-eighteenth the musier of equivalent conventional contraceptive users (condoms, diaphragms, etc.), and one-ninth the number of equivalent oral contraceptive users. These weights are derived from an assessoent of numbers of births averted by different contraceptive methods in India. Equivalent For oral contraceptives and condom, the tmubers of equivalent users Acceptors are calculated as the number of oral contraceptive cycles distributed divided by 13 and the number of condom divided by 72; used by the GOt to report achievements for these methods, rather than the numbers of individual acceptors. Dai Traditional Birth Attendant. Panchayat A local government body usually covering a large village or several ssaller villages Tehsil/Taluk Subdivisions of districts.  INDIA STAFF APPRAISAL OF A FOURTH POPULATION PROJECT - WEST BENGAL BASIC DATA1/ Total Area 3,287,263 km2 Total Population (March 1981) 685.2 million Density per km2 (March 1981) 216 Rate of Natural Increase of the Population (1971-81) 2.25%/annum Crude Birth Rate (1982) 34/1000 Crude Death Rate (1982) 12/1000 Life Expectancy at Birth (1982) 55.0 Infant Mortality Rate (1981) 110/1000 Maternal Mortality Rate (1972) 50/10,000 Urban Population as Percent of Total Population (1981) 23.3% Adult Literacy Rate (1981) Males 47Z Females 25% Primary School Enrollment (1980) Males 100% Females 66% Age Structure (1981) 0-14 39% 15-60 55% 60 and over 6% Population per Physician (1977) 3,135 Population per Nurse (1976) 6,320 Current Contraceptive Prevalence (1984) 32.3% Effective Contraceptive Prevalence (1984) 29.2% Per Caput Gross National Product (1982) US$260 'I Latest official GOI estimates.  INDIA FOURTH POPULATION PROJECT - WEST BENGAL CREDIT AND PROJECT SUMMARY Borrower: India, acting by its President. Beneficiary: The State of West Bengal. Anount: SDR 51.5 million (US$51 million equivalent). Terms: Standard. Relending As part of Central assistance by the Government of Terms: India (GOI) to the State for development projects on terms and conditions applicable at the time. At present, Central assistance for health and family welfare activities is provided on a grant basis. GOI will bear the exchange risk. Project The project would have as its major objectives a Description: reduction of fertility and infant, child and maternal mortality in the State of West Bengal. It would assist the Government of West Bengal (GWB) in ac- celerating the development of its family welfare program generally in the State and specifically in four selected districts with a total population (1985) of approximately 12.2 million. It would comprise the following major components: (a) service delivery; (b) demand generation, including informa- tion, education, and comzmnication activities and population education; (c) training; (d) monitoring and evaluation; and (e) project management. Project risks pertain to the difficulties of persuad- ing some 2 million couples to change their attitudes toward the acceptance of family planning and maternal and child health practices aimed at improving the health of children and limiting family size. In view of the experience gained from previous Bank Group projects in India, and th2 project support to be pro- vided by GWB and GOI, risks associated with project implementation are expected to be minimal. With the strengthening of GWB's ability to design and implement more effective operational strategies, together with the considerably expanded demand generation, achieve- ment of projected levels of contraceptive prevalence should be possible.  Estimated Costs: Local Foreign Total -( (US$ Millions) -- Service Delivery 44.1 4.4 48.5 Demand Generation 4.7 0.3 5.0 Training 8.7 0.8 9.5 Monitoring and Evaluation 1.1 0.1 1.2 Project Management 4.0 0.2 4.2 Total Base Cost 62.6 5.8 68.4 Physical Contingencies 1.9 0.2 2.1 Price Contingencies 18.2 1.2 19.4 TOTAL1/ 82.7 7.2 89.9 Total net of taxes and duties 77.2 7.2 84.4 Financing Plan: Local Foreign Total -===- (US$ Millions) IDA 43.8 7.2 51.0 GOI Grant/ GWB Contributionsi/ 38.9 - 38.9 TOTAL 82.7 7.2 89.9 Estimated (US$ Million) Disbursement: FY 86 FY 87 FY 88 FY 89 FY 90 FY 91 FY 92 Annual: 1.0 3.9 8.4 12.8 15.0 8.9 1.0 Cumulative: 1.0 4.9 1S.3 26.1 41.1 50.0 51.0 Rate of Return: Not applicable. 11 Includes about US$5.5 million of taxes and duties.  STAFF APPRAISAL OF A FOURTH POPULATION PROJECT - WEST BENGAL Table of Contents Page No. I. POPULATION CHARACTERISTICS 1 A. All-India Trends 1 B. Project State and Districts 3 II. NATIONAL FAMILY WELFARE PROGRAM 4 A. Background, Current Policies and Future Prospects 4 B. Fandly Welfare Program Organization 6 C. Delivery of Family Welfare Services 7 D. Program Support Activities 9 E. Program Constraints 10 F. Financial Resources 15 G. Bank Group Role and Strategy in India's Population Sector 16 III. THE PROJECT 17 A. Concept, Design and Objectives 17 B. Summary Project Description 21 C. Detailed Description 22 IV. PROJECT COST, FINANCING, DISBURSEMENT AND PROCUREMENT 39 A. Costs 39 B. Financing 41 C. Procurement 42 D. Disbursements 44 E. Accounts and Audit 44 V. PRWECT IMPLEMENTATION 45 A. Organization and Management 45 B. Mbnitoring and Reporting 46 VI. PROJECT BENEFITS AND RISKS 47 VII. ASSURANCES AND RECOMMENDATIONS 48  Table of Contents (Continued) MNS 1. Schematic Representation of Block-Level Health Services Model to be Implemented by the Year 2000 2. Strategy Paper 3. Illustrative Performance Indicators 4. Criteria for Location of Health and Family Welfare Facilities 5. Illustrative List of Evaluation and Operational Research Studies 6. Project Policy and Steering Committees 7. Selected Documents and Data Available in the Project Files TABLES 1. Selected Demographic Data 2. Population Projections, 1985-2025 3. Selected Socio-Economic and Demographic Data for Project Districts, West Bengal and India 4. Population Projections under Two Assumptions of Fertility Decline 5. India and West Bengal : Family Welfare and Maternal and Child Health Service Statistics, 1979/80-1983/84 6. Project Districts : Family Planning Service Statistics, 1979/80-1983/84 7. Health Facilities : New Coustructions 8. Health Facilities : Improvement/Upgrading 9. Project Districts : Projected Requirements for and Availability of NPWFs, 1984/85-1990/91 10. Implementation : Information, Education and Communication 11. Implementation : Population Education 12. Estimated Costs by Component and Year; Estimated Costs by Expenditure Category and Year; and Estimated Costs by Expenditure Category and Component 13. Estimated Disbursements Schedule CHART 1. Project Management Organization 11 Implementation Chart - Construction MAP IBRD 18664 - India, Showing Location of Project Districts  I. POPULATION CHARACTERISTICS A. All-India Trends Population Size and Growth 1.01 India's 1981 census population was 685.2 million (Table 1), second in the world only to China's. After adjustment for the estima- ted undercountl/, the figure was close to 700 million and by mid- 1985, according to World Bank projections, will rise to 765 million. Although the 2.25Z intercensal growth rate for 1971-81 is modest com- pared to that of many developing countries, the sheer numbers added each year (an estimated 16 million annually over the 1980s) represent a serious constraint for India's development effort. The 1984 World Bank projection indicates that, assuming fertility will fall to re- placement level by 2010, the population will rise to over 1.36 billion by 2025 (Table 2). Fertility 1.02 The best estimates indicate that India's total fertility rate (TFR) declined slowly from something over 6.0 during 1951-61 to around 5.8 in 1972 and since then has declined more rapidly to about 4.8 in 1983. Rising female age at marriage has made some contribu- tion, but a fall in marital fertility is primarily responsible for the decline; this can be attributed in large measure to the family plan- ning program, which has been instrumental in increasing effective con- traceptive prevalence from 11% in 1971 to 291 in 1984. The national figures mask substantial variations among the States: reported TFRs ranged from 3.0 in Kerala to 5.8 in Uttar Pradesh (1980), while effec- tive contraceptive prevalence varied from 15Z in Uttar Pradesh to 47Z in Maharashtra (1984). The crude birth rate (CBR) is estimated to have fallen to about 34 by 1982, although decline In the CBR has in- evitably slowed in recent years as a reduced number of births has meant that women of childbearing age have constituted a larger propor- tion of the total population. Mortality 1.03 The long-term decline in mortality in India has slowed over the last several decades, with the crude death rate (CDR) about 13 and life expectancy edging towards 55 (1982). Infant mortality was esti- mated at about 135 in the early 1970s, although by the latter part of the decade the Sample Registration System (SRS) reported fairly sig- nificant declines in mortality, including infant mortality, which fell to around 110 by 1981. The chief causes of infant mortality are known to include respiratory and diarrheal diseases and neo-natal tetanus. Greater attention to specific maternal and child health (MCR) inter- ventions is required if mortality declines are to be sustained. 1I Census of India 1981, Report on Post Em ration Cbeck, Paper 4 of 1982.  -2- Age and Sex Distribution 1.04 The population of India is a youthful one, with about 40Z of the population currently under the age of 15. India is one of the few countries In the world still characterized '6y higher mortality rates for females at every age until about 40, with the result that there are more males than females In the population (Table 3). Traditional preferences for sale offspring as well as discrimination against females in terms of access to food and medical care appear to under- lie this phenomenon, which is more pronounced in the northern than in the southern States. Urbanization 1.0i The population was 232 urban in 1981 (Table 3), up from 20% in 1971, and projections Indicate that urbanization will exceed 30% by 2001. Although this is not a particularly rapid rate of urbaniza- tion for a developing country, In absolute terms it Implies a doubling of urban numbers, from about 165 million in 1981 to 330 million by 2001. For India's cities and towns, whose infrastructures are already strained, providing for this additional burden represents a task of staggering proportions. Consequences of Population Growth 1.06 The links between rapid population growth in India and cur- rent difficulties in the areas of urbanization and housing, pressure on natural resources, and literacy and education are discussed In Vol. II, Chapter 4 of Situation and Prospects of the Indian Economy - a Medium Term Perspective (Report No. 4962-IN dated April 16, 1984). The consequences of future population growth for India can be con- sidered from a variety of soclal and economic perspectives. Table 4 illustrates the consequences for three groups of particular concern to the family welfare program: young children 0-4, women 15-34 (the prime childbearing ages) and elementary school children (6-11). Two alter- natives for the achievement of replacement fertility (NRR-1) are con- sidered, by 2000 and by 2010; the first approxisates the current Government of Indla (GOI) goal whlle the second represents the World Bank's present "best guess' projection. The results indicate that If through program and related efforts replacement fertility could be achieved 10 years earlier than anticipated In the World Bank alterna- tive, the consequences would be substantial. Achievement of replace- ment fertility by 2000 rather than 2010 would mean reductions of 6, 21, and 10 millions in the numbers of young children, women of prime childbearing ages and elementary school children respectively.  -3- Compared to current (1985) numbers, replacement fertility by 2000 would mean that by 2015 the number of children 0-4 would fall by 12% and the number of elementary school children by 2Z, while if replace- ment fertility were not reached until 2010 the number of young chil- dren would fall by only 6X and the number of school children would rise by 7Z. Even under the optimistic GOI assumption the number of women 15-34 would rise by 50%, but under the World Bank alternative the increase would be more than 80X. The World Bank alternative would also mean that by 2015 India would have to construct and staff approx- lmately 85,000 additional family mlf are subcenters to achieve the current target of one per 5,000 population coverage, while only 71,000 new subcenters would be required under the G00 projection. B. The Project State and Districts 1.07 The project will be Implemented in West Bengal. West Bengal Is India's fourth most populous State (population 54.6 million in 1981), although In terms of area It ranks only eleventh among the 22 States (Table 3). The resulting high population density (average 615 persons per sq. km in 1981) is second only to Kerala (655) among the States. Although Calcutta, the capital of West Bengal, is India's largest city, the proportion of urban population in the State in 1981 (26%) was only slightly greater than for all-India (23Z), and the growth of urban population between 1971 and 1981 (32X) was substan- tially less than that for all-India (46%). Overall literacy and female literacy (41Z and 30% in 1981) are somewhat higher than in India as a whole (36% and 25Z in 1981). According to the census, 33Z of females 5-9 were enrolled in school in 1981 (32% for all-India). Crude birth and death rates for 1982 were reported as 34 and 11 respectively, both slightly lower than the comparable all-India rates. Reliable estimates of fertility are not available for West Bengal, although a decline in the child-woman ratio between 1971 and 1981 suggests that fertility has fallen over the period. Census figures indicate 38% of the popu- lation of West Bengal was below the age of 15 In 1981, as compared to 39% for all-India. 1.08 The State's family welfare program (Table 5) has achieved a level of effective contraceptive prevalence (28X in 1984) close to the all-India average (29Z) despite poor subcenter coverage (47% of the estimated requirements as against 64% for all-India in 1982). The Indian family planning program has relied heavily on sterilization in recent years (para. 2.18), and this is especially true in West Bengal: in 1984 sterilization accounted for 94% of effective prevalence and 64% of new/equivalent acceptors In West Bengal, as against 86% and 43% for all-India.  -4- i.0^ Four districts - Bankura, Birbhum, Bardhaman, and Puruliya - have been selected for infrastructural strengthening under the project (para. 3.05). They form a contiguous block in Bardhauan Division bordering Bihar State and together constitute 20% of the State's popu- lation. Three of thm are overwhelmingly rural (about 92X); only Bardhaaan has a substantial urban population (29%). All four districts have proportions of scheduled caste and scheduled tribe populations (average 35Z) higher than the State average (28%), while female liter- acy is exactly the State average. Effective contraceptive prevalence in these districts ranged from 31X to 38% in 1984, somewhat higher than the State average (Table 6). As in the State as a whole, the family planning program in the project districts relies heavily on sterilization, with 95Z of effective contraceptive prevalence and 64% of new/equivalent acceptors in 1984 due to sterilization. Existing subcenter coverage varies widely, from about 26% of requirements in Bardhaman and Puruliya districts to 54% and 89% in Bankura and Birbhum districts respectively (average of 46% for the four districts). Never- theless, the number of equivalent sterilizations per thousand popula- tion achieved in the four districts in 1983/84 was quite similar: about 8.5 in Bankura, Birbhum and Bardhaman districts and 6.5 in Puruliya district. II. NATIONAL FAMILY WELFARE PROGRAM A. Background, Current Policies and Future Prospects Background 2.01 India was the first developing country to recognise a poten- tial population problem and in 1952 inaugurated a national family planning program aimed at slowing population growth. Serious efforts to implenent a nationwide outreach program were begun in the mid-1960s but encountered a series of setbacks. Neither a campaign to popular- ize intra-uterine devices (IUDs) nor a mass vasectomy camp effort achieved sustained success, and when family planning emerged as a political issue in the aftermath of the 1975-77 Emergency period, it was widely feared that the program had been seriously comDromised. However, all of India's governments since 1977 have reiterated support for the program's basic goals, and lost momentum has been recovered. Since 1977 family planning and MCH have been combined under a redesig- nated Department of Family Welfare with the objective of integrating the delivery of family planning and MCH services. Numbers of new fam- ily planning acceptors are currently at record levels, and over the last three years (1980-84) effective contraceptive prevalence has ris- en an encouraging average of 2.2 percentage points per year to 29.2%.  -5- Although the program continues to rely on sterilization (para. 2.18), figures for 1983/84 indicate that government efforts to promote use of temporary methods have had a discernable effect. Population Policy 2.02 The GOI clearly and firmly supports a national population policy, the goals of which are the reduction of fertility through the implementation of a family planning program and the support of social strategies known to contribute to fertility decline. Family planning is an essential part of the Governaent's overall health strategy "Health for All by 2000 A.D.". The strategy calls for the restruc- turing and reorientation of the health care system to achieve objer- tives that include the integration of family planning and basic health services; emphasis on promotive and preventive rather than curative care, particularly those aspects designed to protect and promote the health of mothers and children; emphasis on provision of services to those currently underserved, particularly in rural areas; and the in- volvement of local communities. 2.03 With respect to family planning, the Government supports the adoption of contraception on an entirely voluntary basis and the equal promotion of all contraceptive methods, male and female, the choice to be left to individual couples. The National Health Policy document (1984) calls for the program to achieve the following demographic targets by 2000: Crude Birth Rate 21 (per 1000 population) Crude Death Rate 9 (per 1000 population) Infant Mortality Rate below 60 (per 1000 live births) Life Expectancy 64 (years) Net Reproduction Rate 1 (female child per woman) Immunization Coverage above 85% Effective Contraceptive Prevalence Rate 60Z 2.04 The GOI is currently utilizing international assistance to undertake family welfare projects (based on a "Model Plan" derived from the experience gained from the first Bank-assisted population project) in selected districts of 14 States ("Area Projects") that are intended to achieve targeted levels for facilities, staffing and training within five years. These projects are designed to bring about measurable improvements in health status and rintraceptive prevalence as well as to provide insights into program improvements that might be more widely adopted.  -6- Future Prospects 2.05 The progress of the family welfare program over the past several years, while quite encouraging, provides no grounds for com- placency. On the one hand four States (Maharashtra, Gujarat, Punjab and Haryana) have achieved effective contraceptive prevalence of at least 40%. There is as yet no sign of the 'plateau' phenomenon that has slowed the rise of contraceptive prevalence in some developing countries, and if everage 1980-84 achievements can be maintained, the GOI goal of 60% effective contraceptive prevalence can be reached by 1998. On the other hand, the northern band of States (Bihar, Uttar Pradesh and IRajasthan), which constitutes 30% of India's population, continues to lag far behind the rest of the country. The constraints responsible for the current low levels of effective prevalence of these States (15X-18% in 1984) constitute the largest stumbling block to continued overall program progress. Many of these constraints can be identified (paras. 2.16-2.25). The GOI and the Government of Uttar Pradesh will undertake a management survey in May/June 1985 that will focus on these difficulties in the State and recommend possible reme- dial measures. 2.06 While it is clear that in the short term it is contracep- tive prevalence that will determine the pace of fertility decline, planners recognize the potential longer term effects of other social measures. The most important of these are the education of females and population education. The well-documented correlations between female education on the one hand and age at marriage, contraceptive use and infant mortality on the other, suggest that immediate efforts to increase female school enrollment could have a significant impact on these factors, and through them on fertility, that would begin to become apparent in 10 to 15 years. Population education is the natural complement of the more narrowly targeted information, education and communication (IEC) efforts within the family welfare program. The Government has recognized the importance of including population education within regular school curricula in all the States and is currently utilizing UNFPA assistance for this purpose. College and university students, especially future teachers, as well as adults participating in non-formal education programs constitute additional target groups that also should be reached by population education efforts (para. 3.41). B. Family Welfare Program Organization 2.07 Policy-naking for the family welfare program is the joint responsibility of the States and the Central Government, while program implementation is primarily the responsibility of the States aud Union  -7- Territories. Since the family welfare program is considered of high national iiportance, it is funded entirely by the Central Government. The central Ministry of Health and Family Welfare (MOHFW) is respon- sible for overall program direction, guidance and evaluation. Within the Ministry, the Department of Family Welfare is headed by an Addi- tional Secretary to the GOI. In each major State there is a Regional Director for Health and Family Welfare responsible to the Centre for coordinating with and advising State governments on program implemen- tation as well as feeding back information. 2.08 In West Bengal the Director of Health Services (DES), who is ex-officio Secretary to Government, is the technical head of the health and family welfare program. He is assisted by the State Family Welfare Officer (SFWO) supported by Assistant Directors. There are 16 districts in West Bengal, but two have been split for administrative purposes because of their large populations, resulting in 18 health and family welfare districts. At district level, health and family welfare services are under the charge of a Chief Nedical Officer (CMO) assisted by district family welfare officers. C. Delivery of Family Welfare Services 2.09 The draft Seventh Plan calls for a pattern of infrastruc- ture and staffing, to be implemented uniformly in all the States, which continues Sixth Plan efforts to expand and strengthen service delivery in rural areas (see Annex I for a schematic representation). The pattern will be India-wide, although the extent of the implemen- tation of the norms in different States will depend on existing pat- terns of service delivery, which are uneven. Overall, however, the pattern represents a rationalization and expansion both desirable and feasible. Even so, it does not approach levels which could be regard- ed as entirely satisfactory, particularly at the peripheral level where coverage will be only half that regarded internationally as ideal for effective service. A three-tiered structure of (a) sub- centers, (b) new primary health centers (new PHCs), equivalent to old subsidiary health centers (SHCs), and (c) old PHCs, of which two in four will be upgraded to community health centers (CHCs), will serve approximately 5,000, 30,000, and 100,000 population respectively. (Smaller populations will be covered in hilly, tribal or sparsely populated areas.) Old and new (Seventh Plan) terminology are summarised below:  -8- Population Old New (Seventh Plan) Coverage Terminology Terminology 5,000 Subcenter Subcenter 30,000 Subsidiary New Primary Health Health Center Center (New PHC) (SHC) 100,000 Primary Health Old Primary Health Center (PHC) Center (Old PHC) Community Health Community Health Center (CHC) Center (CHC) (1 in 4) (1 in 2) The supervisory ratios therefore will be approximately five separate subcenters under one new PHC and two new PHCs under one CHC/old PHC. A subcenter will be staffed by one female and one male multipurpose worker (MPWF/MPWM). A new PHC will be under the charge of a medical officer and staffed by male and female health assistants (HAMs/HAFs) responsible for the supervision of the multipurpose workers posted at the subcenters under the new PHC2/. An old PHC will be staffed by three medical officers, three nurses, a block extension educator (BEE), pharmacist, laboratory technician, statistical clerk, male and female health assistants and male and female MPWs. CHCs will provide specialist services in pediatrics, surgery, and obstet-rics/gynecology. 2.10 Under a GOI program int-roduced in 1975 (although still im- perfectly implemented), the delivery of family planning and MCH servi- ces is integrated at all levels and is carried out primarily by male and female M4PWs. Female MPWs are the linchpin of the family welfare program, providing MCH services to mothers and children in their homes and at subcenter clinics, conducting deliveries, conveying family planning information, providing conventional contraceptives, and re- cruiting acceptors for IUD insertion and sterilization. MPWs support village health guides (VEGs) and trained dais (traditional birth at- tendants) at the village level. VHGs are selected by their comimni- ties, given training by CHC/PHC staff in basic preventive and promo- tive health care, and paid an honorarium by government to treat minor ailments, report communicable diseases and vital events, provide basic health education and promote family planning acceptance. The draft Seventh Plan calls for enhanced dai training that will expand the role of dais in the provision of pre- and post-natal services as well as family planning promotion. 2/ In West Bengal multipurpose subcenter workers are referred to as health assistants and field supervisory workers are referred to as health super- visors.  -9- D. Program Support Activities 2.11 The delivery of family welfare services in all States is supported by three major sets of activities: IEC efforts, pre-service and in-service training, and monitoring and evaluation. Information, Education and Communication 2.12 At CHCIPHC level, information education and comumnication (IEC) efforts are organized by the BEE_/. The BEE works under the technical direction of the Assistant District Health Education Officer (ADHEO) at sub-district level who in turn reports to the District Health Education Officer (DHEO). IEC efforts in the past have largely been confined to use of the mass media, although it is now recognised that interpersonal communication is an essential component of success- ful demand generation. A variety of constraints must be overcome if IEC is to realize its potential contribution to the program (paras. 2.24-2.25). Training 2.13 Medical officers are trained in India's extensive network of public and private medical schools, largely along conventional western lines with emphasis on curative rather than public or preventive health care and with little consideration of the management functions required of doctors in government service. General Nurses and Public Health Nurses are trained in hospital-based schools; they staff hospi- tals and form the nurse-tutor cadres. The fpmale MPWs (formerly known as Auxiliary Nurse-Midwives (ANKs)) receive their basic 18-month training at female paramedical training schools. Male MPWs received training specific to the vertical program (malaria, leprosy, etc.) for which they were recruited and have been given conversion courses to enable them to adapt to the multipurpose program. New recruits are now given an 18-month basic training course at male paramedical schools. Supervisors are promoted from the male and female MPW cadres and given a six-month upgrading course. 2.14 Under the family welfare program, a number of training institutes have been established. The National Institute for Health and Family Welfare (NIHFW) in New Delhi is the apex institution for health and family welfare training. Seven existing institutions throughout the country have been designated as Central Training Insti- tutions (CTIs). There is need to promote better linkages between the NIHFW and the CTIs to enable them to utilize the professional skills available at the NIHFW more widely and effectively. Within each State, from three to five Health and Family Welfare Training Centers (HFWTCs) are responsible for a wide range of in-service and trainers' training. 3/ In West Bengal the BEE is termed Social Welfare Officer (SWO).  -10- The UFWTCs have carried out iuch of the retraining entailed by the conversion to the MPW scheme. However, there is need to make the refresher training, intended to maintain and upgrade skills or intro- duce new ideas, more systematic. A recent Bank mission examined the situation of in-service training at national and State levels and identified a number of problems (para. 2.22). Monitoring and Evaluation 2.15 Responsibility for nonitoring and evaluation rests with the Evaluation and Intelligence Division of the Family Welfare Department at the Center, and at State l%vel with the Demographic and Evaluation Cell. The primary function of this cell is the compilation of family planning and MCH service statistics. These are collated from sub- center reports at the CHC/PHC level, further consolidated at the dis- trict level, and then forwarded to the State Cell; figures for the en- tire State are subsequently sent to the central MO0FW. Other health statistics are collected in a parallel fashion and compiled at State level by a vital statistics unit within the Health and Family Welfare Department. Approach Papers prepared in the process of formulating the Seventh Plan indicate the need to strengthen and integrate these systems, supplemented by regular surveys and studies. Almost all evaluation projects carried out by the State Demographic and Evalua- tion Cell are organized by the Central Evaluation and Intelligence Division, which also contracts for evaluations with other organiza- tions, primarily the 16 DemDgraphic Training and Research Centers around the country. These are attached to universities and are wholly funded by the Government. Important program evaluation work is car- ried out by an evaluation unit in the Planning Commission. E. Program Constraints 2.16 Although India has achieved a basic consensus about popula- tion policy and encouraging family planning results over the past several years, there is general acknowledgement that the program has major constraints. This judgement is supported by the substantial variation in contraceptive prevalence among the States (from 47Z ef- fective prevalence in Maharashtra to 15% in Uttar Pradesh in 1984). Whilst socio-economic factors underlie these differentials, there is increasing evidence that program management factors also play a major role. Some of the difficulties, such as the management of peripheral services, have parallels in other Indian development program; others arise from the special circumstances of the family planning effort. The nost important include inadequate coverage of services, over- reliance on sterilization, and weaknesses in management, training, monitoring and evaluation, and IEC capacities, all of which are evident in West Bengal.  -1l- Coverage of Services 2.17 The development of rural health and family welfare infra- structure in India since Independence is, by any standards, a remark- able achievement for a large, poor and mostly rural country: from vir- tually nothing In 1947 to 7,400 old PHCs, 4,000 new PEC. (old SHCs) and 83,000 subcenters in 1985. However, the proportion of the popula- tion using a facility or reached by subcenter workers falls off rapid- ly with increasing distance and with only 64% of subcenters required to meet the coverage goal (one per 5,000 population) established by 1982, the need to expand infrastructure and service availability con- tinues. Subcenters are often located in sub-standard rented premises, and equipment and vehicles are, all too often, old and unusable. Sub- center coverage is particularly unsatisfactory in West Bengal (para. 1.08), where only 47% of required subcenters had been established by 1982. Contraceptives, supplied free to clients from central supplies, are generally well distributed, although in some areas IUDs and oral contraceptives have been in short or intermittent supply in recent years. A program for the subsidized co mercial narketing of condoms has operated successfully since the 1960. and is about to be expanded with USAID assistance (para. 2.27). Reliance on Sterilization 2 * 18 Since the early 1970., the Indian family planning program, and in particular the program in West Bengal (para. 1.08), has relied almost entirely on sterilization. The emphasis is now largely on female sterilization (85X of all sterilizations in 1984), a shift from the opposite proportions a decade ago. In term of effectiveness and the most efficient use of scarce resources, sterilization has been an appropriate choice for the program. However, at the program's current stage of development, continued emphasis on sterilization alone is a serious constraint to the achievement of rapid increases In contracep- tive prevalence. If couples who have no or only one child, or wish to delay adoption of a permanent contraceptive method, are to be brought into the program, it uast be as users of temporary methods. 2.19 The use of temporary methods has increased significantly since 1982 (Table 5), primarily because of the high priority vhich the GOI has accorded their promotion. However, particularly at field level, many staff have still not perceived the Importance of tempo- rary methods for Individual clients or for the achievement of con- traceptive prevalence goals. The orientation of these workers has largely been towards sterilization. Temporary methods are also not well-known among the target population; the aid-term survey (1983) in the second population project districts of U.P., for example, showed that altbhoigh more than 80 of eligible couples were aware of steri- lization, only about 35% knew of condoms, oral contraceptives and/or  -12- IUDs. Although sterilization will continue to be an important part of the national program, promotion of temporary methods must continue to be actively fostered at all levels. Management 2.20 Management deficiencies are particularly apparent at dis- trict and block levels where management is the responsibility of medical doctors whose professional training provides little or no preparation for this function. Staff vacancies and frequent transfers, the need to respond to emergencies and personal problems of housing and children's education are some of the real problems which doctors face in rural areas, all of which inhibit effective management. In West Bengal, large district populations, low subcenter coverage (para. 1.08) and the frequency of serious flooding and associated epidemics add to program management difficulties. Management prac- tices also need improvements that would enable more effective res- ponses to client and program needs. Management support systems, particularly IEC and monitoring and evaluation, need to be improved and systematized. Program performance targeting as a planning and monitoring tool has long been a feature of the Indian family welfare program. Although previously it has been a mechanical exercise, the .-OHFW has introduced improvements in the last two years by determining targets on the basis of the long-term demographic goals of each State, after suitable consultation. Each State has then allocated targets to districts which, in turn, have set them for lower administrative units. But this process is still largely mechanical and done with little or no consultation. As a result, field staff are unable to understand the rationale behind target setting and view targets as imposed from above, which in turn leads to an emphasis on quantity. There is need to redefine the targeting system and extend the con- sultative process to lower program levels so that all staff use the system constructively to improve program performance. Training 2.21 In view of the generally poor health status of the popula- tion, India needs a medical professiou oriented towards public and preventive health care rather than urban-based clinical work. A re- orientation of medical education will be required to achieve this, a long-term national task widely recognized to face many and difficulc obstacles. Pre-service training of nurses and field-workers is gen- erally well organized, although field-worker training needs a more practical focus, with more field practice, and should include comr munication skills and concentration on priority tasks and clients.  -13- 2.22 Attention needs to be paid to developing systematic train- ing and retraining programs which take particular account of existing levels of skills and knowledge, the need for professional management and IEC skills, and future program directions and strategies. Con- comittantly, existing training potential, in terms of both human and physical facilities, should be determined. The linkages between the various levels of training (para. 2.14) require review in order to strengthen them. The NIBFW, as the apex institution, should function, with policy guidance from the MOHFW, as the coordinating focus of the national training effort and as the primary vehicle by which training capabilities at lower level are strengthened. At all levels, the training provided should be seen by the participant to have a direct relationship to career prospects and relevance to work situations. In addition to improved facilities and training equipment, the quality of the staff assigned to State HFWTCs should be significantly improved. There is a critical need for State-level training institutions to develop well-defined strategies and programs, to supervise their im- plementation, and to provide systematic continuing education. These improvements require planning and coordination so as to reflect local needs and priorities as well as overall strategies, to be carried out as close to work locations as possible, and to be related to other activities within the framework of integrated service delivery. West Bengal provides a good example of the problems connected with training (para. 3.50). One of the CTIs, the All-India Institute of Hygiene and Public Health (AIIHPR), a post-graduate medical institution in Calcutta, provides some inservice training for State health and family welfare staff, but these activities are not of central concern to the AIIHPH nor does it provide planning or coordination for program train- ing activities. An advisory committee, chaired by the GOI's Health and Family Welfare Secretary, has recently been appointed to strength- en AIIHPH's contribution to the program. The Government of West Bengal (GWB) is implementing plans to improve the functioning of the three HFWTCs in the State. Monitoring and Evaluation 2.23 The compilation of program performance information at the subcenter level has typically been a cumbersome and time-consuming burden that occupied an inordinate amount of field-workers' time with- out providing data in a form fully useful to either administrators or the workers themselves. To address this issue, the first Bank-assisted project developed a management information and evaluation system (MIES) designed to provide accurate information quickly to program managers, who could then use it to monitor performance, and provide subordinates with appropriate feedback and plan future activities. Project experience has been mixed: in Andhra Pradesh the system has functioned well both as a reporting system and a management tool;  -14- however, in Uttar Pradesh while it works well as a statistical device, its management potential has yet to be realized. The GOI has recom- mended that a MIES be introduced by all the States, but response has been uneven and the implementation throughout India of such system, linked to operational research focused on program coverage and qual- ity, is far from being achieved. The collection, collation and analy- sis of statistics in West Bengal has not been systematized in line with GOI recommendations. Program research and evaluation in India has tended to be demographic rather than operational in orientation. The population centers established under the first project have made some valuable operational studies, as have academic research centers. The GOI has recently analyzed research findings and will provide Directors of research institutes with guidelines to produce more operationally-oriented program studies. Information, Education and Conamication 2.24 While IEC efforts in India have led to widespread aware- ness of family planning, there is still a considerable gap between awareness and practice. IBC has tended to rely on the sas media and on centrally produced materials that are often unsuitable in local circumstances. Advertising and marketing skills, highly developed in the private sector in India, have rarely been used. The GOI now recog- nizes that demand generation requires an interpersonal comumication approach, although usny State and district-level program managers still have little notion of the contribution that IEC is capable of making to program performance. The second 3ank-assisted project has demonstrated that decentralized development of IEC strategies and related materials is possible by a fully staffed and appropriately trained (or retrained) IEC cadre. The use of orientation training camps (OTCs) for local leaders to promote understanding and acceptance of fimily planning is proving particularly effective. 2.25 However, the replication of such IEC approaches elsewhere Is constrained by a shortage of staff and lack of professional leader- ship. Many sanctioned IEC posts at State, district and block levels go unfilled or are filled by individuals with no IEC background or training. What is more, TEC staff are under the administrative control of medical officers who often use them for a variety of non-IEC func- tions. Lack of suitable staff is particularly felt at State level where IEC strategies to directly support priority program interven- tions ust be planned and managed. If IEC efforts based on campaign strategies and oriented towards interpersonal coumnication are to be successfully implemented, the twin problems of poorly trained and or- ganized staff and failure by program managers to appreciate the poten- tial of IEC uust be addressed. In West Bengal the direction of IEC activities is more professionally competent than that of most other States. The major gap is at district level, where IEC officers to plan and coordinate activities and supervise block level staff have not been appointed (para. 3.39).  -15- F. Financial Resources 2.26 The family welfare program is considered of national impor- tance and expenditures for family welfare incurred by the States are, therefore, met almost entirely from GOI funds, derived from both Five Year Plan and non-plan annual budgets. Plan budgets are the source of funds for incremental staff and new programs, whilst non-plan budgets cover the maintenance of existing staff and programs. Expenditures on family welfare Increased from US$92 million in 1978/79 (actual) to US$330 million in 1983/84 (revised estimates) at an average annual rate of about 252 in real terms. They have also been increasing as a percentage of the total consolidated expenditures, but even in 1983/84 the percentage (0.8x) was insignificant compared to the total, and family welfare represented only some 14Z of the total expenditures on health and family welfare. As a percentage of GOI total expenditures, the proportion spent on health and family welfare in 1983/84 (5.7%) was similar to that in Bangladesh (5.3Z) and higher than that in Nepal (4.5% in 1982) and Pakistan (3.9% in 1980). However, in per caput terms GOI expenditures on health and family welfare in 1983/84 amount- ed to only about US$3.23. In West Bengal, the proportion of the State budget spent on health and family welfare is the same as the average for all States (about 10Z); and although in 1978 West Bengal had the lowest per caput spending on family welfare of the 15 major States, family welfare spending since then has quintupled, whereas health spending has risen at only half that rate. 2.27 International assistance has supported population activities in India since 1967. In the Sixth Plan, external assistance was estimated to be about US$205 million or about 19% of the family welfare budget. Support has core from the UNFPA, UNICEF, WHO, and IDA, as well as the governments of the United Kingdom (ODA), Norway (NRAD), Denmark (DANIDA), Sweden (SIDA) and the United States (USAID). The Area Projects program (para. 2.04) is being assisted by UNFPA, IDA, ODA, DANIDA and USAID. NORAD is assisting in expanding the postpartum family planning program to 400 sub-district hospitals. USAID is providing US$20 million to fund the family welfare activities of private institutes and organizations. In addition, the GOI has signed an agreement with USAID to provide US$32 million for a scheme for the commercial marketing of contraceptives. The International Planned Parenthood Federation provides financial support to the Family Planning Association of India, a voluntary organization. Among pri- vate organizations, the Population Council, the Ford Foundation and the Rockefeller Foundation support, inter alia, dewographic and bio- medical research.  -16- G. Bank Group Role and Strategy in India's Population Sector Experience with Past Lending 2.28 The Bank's first, largely experLiental, population project in India became effective in 1973 and was completed in 1980 (Project Performance Audit Report No. 3748, dated December 31, 1981). Cover- ing five districts in Karnataka and six in Uttar Pradesh, it was funded through an IDA credit of US$21.1 million and a SIDA grant of US$10.6 million. 2.29 The second India population project covered six districts in Uttar Pradesh and three in Andhra Pradesh. Supported by an IDA credit of US$48 million, the second project became effective in 1980 and will be completed by December, 1985. The project provides for the exten- sion of services to inadequately covered rural areas and focuses par- ticularly on demand generation through IEC activities, on professional and management training, and on improving reporting and evaluation systems to strengthen planning and manageuent capabilities. In Uttar Pradesh the role of the Population Center, Lucknow, established under the first project to provide a research and evaluation capability, has been expanded to include management training. In the Andhra Pradesh project districts, MIES has been used as a planning and management tool as intended, and the system will be extended to the entlre State. The local development of IEC materials has been Impressive. There has been increased acceptance of non-terminal contraceptive methods, and much improved coverage in key MCH activities in the project districts of both States. 2.30 The third population project, covering six districts in Karnataka and four in Xerala and supported by an IDA credit of US$70 million, became effective in May 1984. The third project moved from a narrow district focus to a broader State perspective with support for demand generation, MIES, and to some extent training activities on a State-wide basis. Experience from the second project was particularly useful in organising pre-project activities, and project implementa- tion is currently ahead of schedule in some areas. Rapid completion of surveys of gaps in the knowledge and skills of paramedical staff has led to proposals for extensive in-service training programs and has pointed the way to a review of basic training for these workers. 2.31 Recent Bank-supported restarh in demography and family planning in India has included a comparative study of fertility in Kerala and Karnataka. The population centers established in Uttar Pradesh and Karnataka under the first population project have carried  -17- out a variety of research and survey projects. The Bank has also sup- ported analysis of data from the Narangwal (Punjab) nutrition and pop- ulation research projects. Other studies have included an overall review of demographic, health and nutritional status as well as the family planning program in India (1978), a summary of experimental health, nutrition and family planning projects in India (1982), and a study of the possibility of adapting the training and visit (T&V) system for family planning, health and nutrition programs (1984). Bank Group Strategy 2.32 Recent discussions with the GOI have resulted in a request for project assistance in each of the next four fiscal years that would expand the basis of Bank support beyond the Area Project frame- work. In addition to the fourth population project in West Bengal, the proposed pipeline includes a metropolitan cities (Calcutta, Bombay and Madras) project, a second project in Uttar Pradesh State, and a national training project. Assistance to West Bengal and Uttar Pradesh will be directed to the entire State program, although available fi- nance and absorptive capacity will constrain infrastructural develop- ment to selected rural districts. The proposed metropolitan cities population project would be the first project to focus specifically on urban areas, a priority suggested by expected urban growth over the next two decades that would almost double the populations of Calcutta, Madras and Bombay. A recent mission that began work on the scope and content of a possible national training project identified weaknesses suggesting that high priority should be given to assistance in this area. At State level, expanded support for training can achieve sig- nificant improvements. Because States differ in needs and resources, there is no universally applicable formula, but the training component of the West Bengal project will provide insights for further develop- ment. In these projects, priority will be given to ameliorating the constraints identified in paras. 2.16-2.25. Substantive work has started on the preparation of all the proposed projects. III. THE PROJECT A. Concept, Design and Objectives 3.01 The proposed project is another in the series of the GOI's Area Projects (para. 2.04) but represents a further shift from the original Model Plan's exclusive focus on strengthening selected dis- tricts to support for the program at State level. Experience with previous Bank-assisted projects has shown that an approach limited to  -18- district level is unlikely to do more than create the necessary infra- structure. If program direction is weak at State level, program ac- tivities in the district will also be weak. In the third project, IEC (including population education) and monitoring and evaluation activi- ties were strengthened at State level. The proposed fourth project takes this approach further and, inter alia, strengtheus these activi- ties not only at State level but also at district level throughout the State. Construction of all facilities and staff quarters required throughout the State, however, cannot be included in the project because of financial constraints and the size and complexity of the civil works program that would be needed. 3.02 Project design is based on the approach papers prepared for the Seventh Five Year Plan (1985-1990), which call for sustained program development, improved coordination with voluntary agencies, greater attention to MCH programs, and better and more relevant basic and continuing staff training. Experience with previous projects (para. 2.28-2.30), the socio-economic characteristics of West Bengal and the particular problems of the West BeLal family welfare program (paras. 2.16-2.25) have also been taken into account. On this basis, a project strategy paper (Annex 2) emphasizing qualitative program improvements, particularly in the areas of training, IEC and service delivery, has been prepared. 3.03 There is more emphasis in the proposed project than in pre- vious projects on training. Surveys of the knowledge and skills of field staff, undertaken by Karnataka and Kerala as a preliminary ac- tivity of the third project, pointed to the need not only for sys- tematic retraining but for improvements in basic training as well. A general review of training by the Bank in 1984 indicated a serious gap at State level. Measures included in the proposed project to improve the coverage and quality of training in West Bengal incorporate the results of both investigations. The proposed State Institute of Health and Family Welfare (SIMFW) will be a major training development in India and could serve as a model for the creation of similar insti- tutions in other States. 3.04 Experience has shown that IEC activities are critical to improved program performance and the project is designed to strezgthen them considerably; expenditure on IEC will increase from the present level of US$217,000 to about US$830,000 annually. Under the project, the professional skills of old and new staff will be improved, and both interpersonal communication approaches and the mass media, which are well developed in the State, will be used in support of the pro- gram. The project is also designed to work through existing insti- tutions in the State to initiate broad-based programs of population education for adults as a means of generating community support and translating family planning awareness into prlctice.  -19- 3.05 For strengthened service delivery, four districts have been selected by the GWB vith the concurrence of the GOI and the agreement of IDA. To facilitate implementation and supervision, district selec- tion was focussed on the soutnern part of the State. The four dis- tricts--Bankura, Birbhtiu, Bardhaman and Puruliya-form a contiguous block within the administrative division of Bardhaman. They fall out- side the Calcutta metropolitan area, which is likely to come under the purview of the propouzd metropolitan cities project. As with other States being assisteJ by the Bank, the selected districts form the first phase of infrastructural development. 3.06 Service delivery levels in the districts selected for infra- structural strengthening will follow those recommended in the GOI planning document 'Health for All by 2000 A.D.', wkh'ch are to be in- corporated in the Seventh Five Year Plan. In West Bengal, emphasis since Independence has been on the secondary level of facilities, which includes PHCs and rural hospitals; the subcenter level needs considerable strengthening. Studies in rural ar.-s of West Bengal have indicated that expanded coverage is a key to improved program performance; the project will, therefore, concentrate on the estab- lishment and staffing of subcenters. In support of expanded service coverage, the four districts will receiLe priority in the development of State-wide support activities. These inputs in the selected dis- tricts, which have levels of contraceptive prevalence somewhat above the State average, make it possible to expect substantial program achievements, approaching the GOI goal of 60Z effective contracep- tive prevalence (paras. 2.03 and 3.07). The quality of the program will be carefully matched against the expectations set out in the strategy paper (Annex 2), and family planning anu NCH performance will be monitored in terms of quantitative goals. Given that the GOI's objective of reaching 60Z effective contraceptive prevalence is only 15 years away, project efforts in the selected districts will provide important guidelines for the State program. 3.07 The establishment of specific goals for the project, oo- ever, is difficult. In West Bengal, as in India as a whole, family planning achievements since 1979/80 have been good (paras. 1.08-1.09), but it is not possible on the basis of existing knowledge to relate program inputs to these results systematically. The difficulty stems to some extent from the provision of services such as sterilization and immunization on a camp or mass basis rather than as part of on- going care. In addition, the project emphasizes qualitative as well as quantitative improvements, and these cannot be measured in the same fashion. Nevertheless, it is possible to estimste the numbers that would be necessary to achieve approximately the GOI's goal of 60Z effective contraceptive prevalence. For the four project districtu,  -20- an average annual increase of about 11% in the number of new/equiv- alent acceptors would be needed to achieve 49% effective contracep- tive prevalence by the end of the project (1990) and 57% prevalence two years later (Annex 2). (Since some facilities will not be complet- ed until the final project year, and in any event institutionalization of project strategies will require time, the full impact of the proj- ect in terms of achievements will not be felt until at least two years after the end of the project.) These are ambitious goals, but the fact that the average annual increase between 1979/80 and 1983/84 was about 25% suggests that they are not impossible. For MCE *argets, the situation is even less satisfactory, since it will not be possible to estimate current levels of coverage until the baseline survey (para. 3.53) is completed. Until these data become available, project goals will be set ia terms of the GOI goal of 85% immrnization coverage (para. 2.03), which the GWB believes can be achieved for other MCR services as well. 3.08 The objectives of the proposed project are to: a. reduce fertility and infant, child and maternal mortality in West Bengal by focusing on specific program interventions and generating demand for services; b. ameliorate program constraints by improving ser- vice coverage and quality, management, train- ing, and monitoring and evaluation; and C. provide experience of replicable program improve- ments which will support the national family wel- fare program and the attainment of its population goals. 3.09 The project will achieve these objectives by: At district level: a. providing trained staff and facilities to achieve levels of service delivery consonant with need and with financial and human resources; At State level: b. improving professional, managerial and technical skills to upgrade the quality of service delivery by programe of in-service training and by the establish- ment of a SIHFW to coordinate, upgrade and monitor in- service training;  -21- c. concentrating program strategies on specific interven- tions including non-terminal methods of contraception, identification and treatment of high-risk mothers and babies and young children who fail to thrive, as well as the use of oral rehydration to treat diarrheal dis- eases, in order to accelerate fertility, morbidity and mortality declines; d. developing IEC strategies which will reinforce and support program interventions, leading to an increased demand for services, and strengthening the capability of the State to generate and implement such strategies; e. generating involvement in the family welfare program by comimmity leaders, panchayat (local government) organi- zations, voluntary organizations and private medical prac- titioners, both in terms of demand generation and service delivery; and f. improving the monitoring and evaluation system and strengthening the capability of the State to collect, analyze and provide program managers with timely in- formation. B. Summary Project Description 3.10 The project, which will be implemented over a five-year period from September 1, 1985, will have five major components: a. Service Delivery (US$48.5 million)4/ The construction, refurbishing, or provision of rental accommodation where necessary, of subcenters, new PHCs, old PHCs, CHCs, and maintenance workshops; provision of furniture, equipment and vehicles; costs of incremental staff; and maintenance of equipment and vehicles to extend and improve the coverage of family welfare services in four districts; b. Demand Generation (US$5.0 million) (i) Provision for community education, IEC materials including the production, printing and distribution of films, costs of incremental staff, furniture, and equipment and the replacement of vehicles; staff re- training and study tours to support service delivery activities and generate demand for family welfare services; 4/ All figures in paragraph 3.10 exclude contingencies.  -22- (ii) Provision for allowances for trainers, operating costs of lectures and seminars; costs of materials produc- tion, incremental staff, furniture, equipment and vehicles to introduce population education in B.Ed. and teacher training colleges, workers' educational programs, panchayat organizations and adult education groups in order to involve comunities in the family welfare prograr. and reinforce demand generating ac- tivities; c. Training (US$9.5 million) The construction, furnishing and equipping of one SIHFW, one General Nurse Midwife (GMN) training school, one super- visor (RUF) training school, and 24 field training annexes; salaries of incremental staff; operating and maintenance costs and vehicles to provide basic training for incremental staff and systematic retraining to upgrade professional skills throughout the State; d. Monitoring and Evaluation (US$1.2 million) The introduction of a MIES throughout the State, including costs of incremental staff, equipment and vehicles; provi- sion of funds for longitudinal sample surveys and operation- al research to monitor and evaluate project and program per- formance as well as indicate new approaches; and e. Project Management (US$4.2 million) Provision of furniture, equipment and vehicles and the salaries of incremental staff required to imple- ment the project. C. Detailed Project Description Service Delivery 3.11 Project Facilities. Following the pattern of service de- livery outlined In pars. 2.09, the infrastructure will be expanded and upgraded in four selected districts (Table 7). There are now 872 sub- centers functioning in these districts, 162 in purpose-built facili- ties and 710 in rented accomodation; according to the norms, a fur- ther 1,037 are required to achieve the desired coverage. The panchayat system of local government is well organized in West Bengal, and all gram panchayats (the lowest tier of the system) have their own build- ings which provide a focus for community activities. The project will  -23- provide for the construction of a subcenter at each of the 752 gram panchayat compounds so that services will be available at important community locations and the program will be more readily identifiable with the community. To complete the pattern of coverage needed to ex- tend services to peripheral rural areas, 412 subcenters will be estab- lished in rented accommodation5/ (T8ble 7). Both purpose-built and rented subcenters will be provided with the necessary staff, furniture and equipment. 3.12 To strengthen the referral chain and provide closer supervi- sion of subcenter staff than hitherto possible, existing dispensaries at which a doctor and supporting staff are posted will be converted into new PHCs (old SHCs) to cover an average population of 30,000 and serve about five subcenters. Of the 280 required, 248 are already functioning in purpose-built facilities. However, they lack an operating theater and laboratory and the number of beds available varies considerably. To complete this important tier of services, the project will provide 32 new pur,ose-built facilities, improve 77 by providing a minimum of six beds (following the approved State pat- tern), a laboratory and smell operating theater, and improve a further 171 with a laboratory and small operating theater only (Table 8). Where necessary, incremental staff will be provided together with furniture and equipment. 3.13 Of the 94 blocks in the project districts, three do not have purpose-bilt old PECs because of recent redistribution of block boundaries; new facilities will be provided for these blocks. Because of the concentration on development of facilities at block level in West Bengal, several rural hospitals and old PHCs with 60 beds have been established which correspond to the CHC of the all-India pattern; there are 12 such facilities in the selected districts. At the pro- posed Seventh Plan level of one CHC to two blocks, a total of 47 CHCs would be required. Because of the existing strength of facilities at this level aud the costs of improving 35 old PHCs, the project will upgrade old PHCs to CHCs on the basis of one in four, which will re- quire the upgrading of only 12 old PHCs (Table 8). For this purpose, the old PHCs will be provided with a small operating theater, X-ray facilities, laboratory and facilities for 10 in-patients to bring them to the standard of a CHC. The remaining 67 old PHCs will be improved by the addition of a laboratory, small operating theater, and accommo- dation for IEC and statistical staff. 3.14 Program Quality. In addition to expanding service delivery facilities, particularly at the peripheral level, the project also stresses improvements in the quality of program services. Strategies on which these improvements will be based are summarised in the proj- ect strategy paper (Annex 2); they are built on the concepts of prior- ity activities, priority households, and effective supervision. In 5I Birbbum district has 169 gram panchayats but as the district requires the establishment of only 42 subcenters to meet the norns, 127 constructed sub- centers will replace rented facilities (see Table 7).  -24- terms of family planning, the project will emphasize temporary contra- ceptive methods. In West Bengal, including the project districts, sterilization currently accounts for about 95Z of effective contracep- tive prevalence and 64Z of new/equivalent acceptors (para. 1.09). How- ever, sterilization is not appropriate for about a third of eligible couples: those who wish to delay first pregnancies, space second preg- nancies, or delay sterilization until a second child is at least two years old. Much more attention must be given to promoting the use of temporary methods by such couples if project goals are to be achieved. IEC efforts in the project districts will, inter alia, focus on reach- ing potential users of temporary methods with appropriate messages in order to support the efforts of multipurpose workers. Promising ef- forts to expand the use of oral contraceptives are being made in West Bengal by voluntary agencies with Government support and provision will be made for the introduction of similar schemes in the project districts. 3.15 Under NCR, priority will be given to expansion of pre-natal, post-natal and immunization coverage as well as the proportion of de- liveries conducted by trained dais, Sample surveys conducted in 1981 indicate that the incidence of neonatal tetanus in West Bengal (14.9/ 1000 live births) is high compared with Andhra Pradesh (8.5/1000) and Kerala (2.4/1000). In the project districts, about 701 of deliveries are presently conducted at home by untrained dais. Only about half of the needed dai training has been carried out in the project districts, and the project provides for the remainder on a priority basis. Once trained, dais are equipped with kits provided by UNICEF but there are problems with their supply and refilling. The project proposes to supplement these kits by providing simple pre-sterilized disposable packets containing a blade, cord-tie and antiseptic lotion. The mate- rials will all be supplied to suitable groups such as mothers' clubs to assemble in semll plastic bags which can be sealed and sterilized. Assembly of the packets at mothers' clubs, encouraged by a small hon- orarium, will provide an opportunity for disseminating information about safe birth practices. The packets will each cost about Rs.0.50 (US$0.04) and will be made available to all pregnant women as well as dais. 3.16 Priority will also be given to interventions that address diarrhea and pneumonia, which account for most of the preventable deaths of infants and young children. Emphasis will be on oral rehy- dration therapy and on measures that mothers can take to lessen the risk that common colds will develop into serious respiratory illness. Ongoing child care by multipurpose workers will be based on periodic weighing and the use of growth charts; children who fail to thrive will be identified and referred if necessary. Child care efforts will be coordinated with the Department of Social Welfare's Integrated Child Development Services (ICDS) program in those blocks where it is  -25- being implemented and full use made of the ICDS supplementary feeding component. In order to strengthen the ongoing Expanded Program of Im- munization (EPI), the project makes provision for refrigerators at new PHCs. Until now, they have been available only at old PHCs, which cover approximately 120,000 people. Storage at a center covering a population of about 30,000 will enhance the potential life of vaccines and reduce the distance between storage point and immnization center. 3.17 The identification of priority households and individuals will be based on the updating of the eligible couple registers main- tained at subcenters so that multipurpose workers will be able to identify those who should receive priority attention and thus make more efficient and effective use of their time and resources. The key to this approach is the incorporation of family planning motivation into the cycle of MCH care, which will shift the focus of family plan- ning efforts to younger, more fertile women and will also increase the use of temporary methods. Identification of priority households/indi- viduals is also essential to the reduction of infant and young child mortality, so that high-risk pregnancies and/or malnourished infants and young children can be assured of special attention. 3.18 If the strategies discussed in these paragraphs and sum- marised in the project strategy paper (Annex 2) are to be successfully implemented, strong support from supervisors at all levels will be re- quired. Emphasis will be on supervision in the field rather than in offices and on supportive and listructlve rather than critical super- vision. The project provides for launch workshops (para. 3.57) that will acquaint all project managers and supervisors, from the highest levels down to field supervisors, with the content and rationale of project strategies and will discuss the role of supervisors in their implementation. The strategy paper will be discussed at these work- shops and widely disseminated in English and Bengali to ensure that all staff are fully acquainted with the project's objectives and strategies. 3.19 By extending basic coverage and developing the three-tiered system (para. 2.09), with its concomitant strengthening of superviso- ry staff, the provision of referral services will be improved. At present, the equipment at peripheral facilities for the care of new born babies with complications is inadequate. In support of the pri- ority to be given to high-risk pregnancies (para. 3.17), the project makes provision for a mucous aspirator and crib at each subcenter and an incubator at each old PHC and CUC where feasible. 3.20 The GWB provides subventions for the support of the family welfare program by a variety of voluntary agencies, such as the Red Cross, Ramakrishna Mission, and several service-oriented organiza- tions. Such projects provide good examples of community involvement,  -26- cross-sectoral coordination and low-cost service delivery in urban and rural areas. The GWB has recently established a Voluntary Agency Cell, headed by the Additional Director (Administration) Health Services, which will be responsible for planning and coordinating voluntary agency assistance (including private practitioners from all medical disciplines), monitoring activities, ensuring service quality, im- proving financial support and payments, and coordinating innovative schemes which agencies develop. 3.21 The various elements which comprise the multipurpose worker scheme are not completely integrated within the Directorate of Health and Family Welfare. Consistent with GOI policy, the Directorate should be reorganized to permit the effective direction of a rural health program integrating family planning and MCH. The GWB has issued an Order which will transfer existing responsibilities within the Direc- torate for MPWMs, EPI and nutrition to the Additional Director (Family Welfare). 3.22 Mobility. In addition to extending and improving service coverage, the project also addresses the problem of mobility, which has a direct bearing on referral and supervision. The State Health Transport Organization (SHTO) of West Bengal is responsible for the operation and maintenance of health and family welfare vehicles. Of the Health and Family Welfare vehicles in the State, 35% are not serviceable; in the project districts, 31% of vehicles are unusable. Many of the remaining vehicles are old, costly to maintain and un- reliable. The Directorate has prepared proposals for the reorganiza- tion of the SHTO with UNICEF assistance, and the provision for vehicles, workshops and staff in the project is consonant with that proposal. The 12 old PHCs to be upgraded to CHCs will each be provid- ed with one four-wheel drive vehicle and one ambulance. For each of the 67 improved old PHCs and the three newly constructed old PHCs, one four-wheel drive vehicle will be provided. The new PHCs form an impor- tant supervisory focus and need transport for referral cases. In the third population project in Karnataka, motorcycles were provided for the medical officers. In West Bengal, however, because of the heavy monsoons and extensive flooding which often follows, motorcycles are unsuitable and four-wheel drive vehicles will be provided for the 32 new PHCs which are to be constructed. The project provides for the operating and maintenance costs of the new vehicles as well as the salaries of drivers as required. 3.23 Maintenance. The proposal to reorganize the SHTO calls for new workshop and storage facilities in Calcutta and regional workshops at Bankura, Murshidabad and Siliguri to provide a State-wide network. In addition, each district in West Bengal will have a mobile workshop. The project will contribute to the reorganization by constructing new workshop facilities at Bankura and Murshidabad which will be equipped  -27- by UNICEF and staffed from existing resources. The workshop at Bankura will cover Bankura and Puruliya districts, and that at Murshidabad will service Birbhum and Bardhanan. Each workshop will be provided with a four-wheel drive vehicle and a breakdown vehicle. 3.24 The Central Medical Stores (CMS) in Calcutta is responsible not only for the procurement of drugs, supplies and equipment but also for equipment maintenance. At present there are no regional equipment workshops, but these will be established in conjunctLon with the vehicle maintenance workshops. The project will provide for construc- tion, furniture, equipment and vehicles for equipment maintenance workshops at Bankura and Murshidabad serving the same districts as the vehicle workshops. Their initial capability will include the service of refrigerators, sterilisers, and operating theater equipment as well as IEC equipment. Demand Generation 3.25 Despite an effective prevalence level of 28% for West Bengal as a whole and 33% for the selected districts, the task of changing age-old attitudes to gain acceptance of a two-child family must still be accomplished. Not only have services to be made more readily avail- able, but a much greater emphasis than hitherto must be placed on de- mand generation. In West Bengal, as recently as six years ago a sur- vey of rural areas around Calcutta showed that about one third of all married women 15-49 years were unaware of family planning, and that a further third, although aware of family planning, did not wish to practice contraception. Among the latter, the most often expressed reason was a desire to have more children, followed by spouse dis- approval and belief that family planning was inconsistent with reli- gious beliefs. The average desired family size was 3.5 children, although this varied with the sex composition of the family since a desire for sons is very strong. 3.26 The project would use two separate but complementary ap- proaches to stimulate demand for family planning and MCH services throughout West Bengal. Firstly, it provides for an intensification of the existing IEC program, developing strategies which support priority service interventions (paras. 3.14-3.17 and Annex 2) and addressing them to specific community groups. Secondly, the project will provide for the introduction of population education in selected influential groups and organizations throughout the State. Existing organizations will be strengthened to enable them to carry out both approaches effectively. Maximum use will be made of existing re- sources and of the distinctive features of Bengali culture. To pro- vide the necessary flexibility required by programs which seek to change attitudes, strategies will be developed on an annual basis.  -28- Assurances have been obtained during negotialons that the GWB will furnish detailed, annual demand generation strategies to the Associa- tion for its review and comments no later than two months before the start of each financial year (para. 7.01(a)). Demand Generation - Information, Education and Communication 3.27 The overall objectives of this component are to: a. generate demand, through mass media, community education and community involvement techniques, for the immediate acceptance of family welfare services and ultimate acceptance of a two-child family norm; b. develop positive attitudes towards the family welfare program on the part of formal and in- formal opinion leaders which will lead to their support of the program; c. ensure the integration of family planning communi- cation activities within the broader content of MCH care; and d. coordinate the activities of government departments and voluntary agencies in a cohesive, well-directed and well-supported demand generation program. 3.28 The component addresses acknowledged barriers to comunica- tion in West Bengal, including low literacy levels, resistance to change, low penetration of mass media, and social and linguistic di- versity. To counteract these barriers, messages will be simple, di- rected to specific target audiences and delivered in the appropriate language or dialect. Messages to be given priority are specified in the project strategy paper (Annex 2). A combination of approsches - co"mmnity education, community involvement, and mass media - will be used to convey them, and their effectiveness will be monitored and evaluated. 3.29 Community Education and Involvement. The primary tactic to reach communities through their leaders and provide basic information about family welfare goals and services will be the OTCs that are being employed successfully in the second and third projects. Partic- ipants will be selected from panchayat officials, school teachers, private medical practitioners, religious leaders, leaders of coopera- tive societies and other village notables. The project provides for holding 16,500 OTCs and 6,600 follow-up camps throughout West Bengal.  -29- OTCs will be supplemented by family welfare advisory committees de- signed to Involve communities in the program. Although such commitees have been a feature of national pollcy, little effort has been made to establish them in West Bengal. The project makes provision for the development of committees at subcenter, block, district and State level; their objectives will be to stimulate organized community in- volvement, develop links with family welfare staff, provide feedback for program managers, and create a broad-based constituency favouring small family norms. 3.30 Tape recorders, filmstrip projectors and public address systems are essential to IEC staff, but not all the SWOs have been adequately equipped. The project makes provision to supply equipment that is currently lacking. 3.31 Over 41,000 village health guides (VHGs) have been recruited and trained in West Bengal, and the project makes provision for educa- tional kits and communications material to help them in person-to- person contacts with their fellow villagers. School health is the responsibility of the State Health Education Bureau, but little IEC work has been done to support the activities of the medical officer responsible for school health in each district. The project will provide health education display materials for the 20,000 primary schools in West Bengal, instructional material for use in the schools, and pamphlets to be taken home. 3.32 Traditional folk singers and dancers are an important part of the cultural life of West Bengal. Recent years have seen a re- surgence particularly of jatra, folk plays performed by small troupes that perform anywhere with a minimum of equipment. Jatra and other types of folk media lend themselves to the delivery of family welfare messages, and the project will provide for script preparation, per- formances and worksbops for folk media producers to facilitate the in- troduction of these scripts into their repertoires. 3.33 Mass Media. Specific messages relayed by interpersonal communication and community and extension education will be reinforced through mass media in order to: (a) demonstrate to a wide audience the GWB's commitment to family welfare; (b) extend awareness of the need for family planning and MCl; (c) direct attention to service outlets; and (d) provide a supportive environment for the activities of family welfare staff. The project makes provision for the widespread distri- bution of family welfare messages through a variety of media includ- ing public displays, films and publications. 3.34 Film viewing is one of the most popular forms of entertain- ment in West Bengal and the project makes provision for the produc- tion, printing and screening of ten new commercially produced films.  -30- Sufficient prints will be made to make these film available coumnr- cially, and they vill also be shown by the district audiovisual vans. These vans, however, were supplied 15 years ago and are no longer serviceable; the project, therefore, provides for one new van in each of 17 health districts. (The van in the remaining district was recent- ly replaced.) No provision is made for services, generators or projec- tlon staff since they are available. Film with a family welfare theme which my be appropriate for West Bengal are also produced by the GOX and by organizations In other States. Provision Is, there- fore, made for the purchase of family welfare film produced outslde the State and for dubblig ln Bengall. o engage the lnterest of cor- *ercial flmn makers, provision Is made for an annual seminar of pro- ducers to discuss the possibillty of lncluding family welfare theme in their film, and an annual cash award incentive scheme will be established. Cluema. are required by law to show government slides, and provision is wade for the production of family welfare slides for distribution to cinemas throughout the State. 3.35 In order to spread family welfare wassages In newspapers, magazines and special publications whlch serve local readerships, the project makes provision for workshops designed to make editors and writers knowledgeable about and supportive of the goals and services of the family welfare program. Cash awards will be offered annually for the best treatment of population and fauily welfare themes in these publications. In addition, provision is made for cash awards to wlnaners of writing and debatlag contests. 3.36 There is a need to create and maintain program aw%reness among f8ily welfare staff and also pollcy makers, senior clvil ser- vants, political leaders and lndustrial and commrcial leaders. For thls purpose, the project provides for the production of a quarterly riblicatlon whlch documents program performance, draw attention to current IEC strategles and hlghlights new and innovative develop- ments. It will also be used to reinforce contacts with journallsts and fils producers, encouraglig them to use family welfare events and theme in their film and publlcations. 3.37 Folders and posters with family welfare massages will be produced for use ln schools, OTCe, servlce facilities and panchayat centers. These materials, together with the quarterly publication, are printed departmentally. The State hs an offset press obtained with Swedlih aid ln the early 1970s which now requlres a larger cmamra and a modern compositor with Elndi and Bengall capacity to improve Its operations. These will be provided by the project together with a modern addressograph that will Increase the efficiency of the mass m*illng unlt.  -31- 3.38 IEC Organization and Staffing. Communications activities are now carried out by two units in the Directorate of Health and Family Welfare, the Mass Education and Media Division of the State FaiLly Welfare Bureau and the State Bureau of Health Education. The staff of these units have similar skills, their activitles have much in common, and their roles are complementary. To maximize their ef- fectiveness in planning and implementing IEC strategies, assurances have been obtained during negotiations that, by December 31, 1985, the GWB will establish and maintain a committee to coordinate the func- tions of the Mass Education and Media Division with the State Bureau of Health Education, which will have membership, functions and powers satisfactory to the Association (para. 7.01(b)). 3.39 The project makes provision at State level for essential ad- ditional staff including outdoor publicity, song and drama, and audio- visual specialists. The staff of the offset press and mass-mailing unit will be strengthened and provision made for three audiovisual mechanics to service equipment at the proposed equipment maintenance workshops (para. 3.24). The most serious gap in IEC staffing is at district level where there is no one in position to supervise and direct the existing staff. Provision is, _tterefore, made for 18 IEC program officers. 3.40 The project will also address the need to improve the pro- fessional quality of existing staff, particularly the SWOe at block level, At no level have staff been retrained or exposed to modern comnmications techniques for at least ten years. Training facilities in liest Bengal are inadequate to cope with the proposed training load. Block and district level staff will probably be trained at the Ga=dhigram Institute in Tamil Nadu where IEC training for the second Bank-assisted project was successfully carried out. Provision iB. made for senior staff to visit Gandhigram to assess its suitability and discuss the development of training curricula that will Include na- terial supportive of the program. Provision is also made for study tours within India and to selected foreign countries to obser" suc- cessful IEC program and attend short courses at appropriate iLstitu- tions. In order to provide staff with opportunities to keep up-to- date professionally and to promote dialogue between staff at all levels, the project provides for annual district and State IEC con- ferences. Demand Generation - Population Education 3.41 To complement IEC activities, the project makes provision for the introduction of population education activities as a direct stilmulus to demand generation. Assistance for population education in primary and secondary schools is available through UNFPA. The project activities will be directed at four audiences among adults  -32- who have (or will shortly play) an important part in formulating community opinions - college teachers and students, adult learners, industrial workers, and panchayat members - as follows: (i) Experience from the second project in Axdhra Pradesh has shown among college teachers and studeuts that the levels of awareness of populatior issues and the need for adoption of the small family norm are remarkably low. The project will, therefore, provide for activi- ties in the governaent and private degree colleges in the State with a potential audience of some 100,000 lecturers and students. The 15 teacher training col- leges covering some 15,000 potential teachers will also be included. The Director of Public Instruction would be responsible for these programs; (ii) An additional audience, untapped thus far, is the adult learner, some 200,000 of whom are en- rolled in State Rural Functional Literacy Projects. The project makes provision for the training of about 450 staff of these projects and the intro- duction of population education into the curricula. This component will be impleaented by the Directorate of Adult Education; (iii) West Bengal State has a well established workers' education system for industrial workers, and the project will be implemented by the West Bengal Labor Welfare Board in its 54 Labor Welfare Centers and the Centers of the GOI's Directorate of Workers' Education in the State. Through this component, for which the Secretary for Labor will be responsible, 50 Labor Welfare Officers, 500 worker teachers and 300,000 workers will receive population education; and (iv) In West Bengal the panchayat system is well estab- lished and plays an important role in community life; the lowest tier (gram panchayat level) covers some 45,000 elected paachayat members. The population education program will be directed at the office bearers and mem- bers of the various panchayat bodies. Implementation will be the responsibility of the Director of Panchayats in the Ministry of Community Development. 3.42 For each sub-component, the project provides for a small number of additional staff, furniture, equipment and vehicles as well as provision for training courses, training kits and educational ma- terials such as pamphlets and folders directed specifically at each audience. Provision is also made for the evaluation of activities.  -33- Training 3.43 Basic Training. There are four government schools and a private school in the project districts training MPWFs which will be able to train most of the approximately 1,400 additional MPWFs requir- ee by the establishment of new facilities plus normal attrition (Table 9). Project strategies (Annex 2), including priority approaches, MIES and training in IEC skills, will be incorporated into the training. To improve the practical field content of the training, the project provides for the construction of 24 training annexes with equipment, furniture and caretaker staff to be sited at each of the 24 CHCs. The annexes will provide simple dormitory and classroom accommodation for group of trainees doing field work at village and block-level facili- ties. With the exception of leprosy workers, all male unipurpose workers in the State have been given a one-month multipurpose conver- sion course. 3.44 Some MPRFs in West Bengal have received promotee HAP train- ing to these supervisory posts, but the posts have not been filled be- cause the qualified MPWFs are not willing to assume supervisory duties unless an appropriate pay scale is provided. Assurances have, there- fore, been obtained during negotiations that, by March 31, 1986, the GWB will take all measures to appoint the required number of HAFs (para. 7.01(c)). There is no facility for training HAFs in the proj- ect districts. The project will provide for the construction, equip- ping and furnishing of a school for the training of 60 HAEs annual- ly. The school will be established initially in rented quarters so that additional HAFs will be available as of the end of the first project year. ANMs already retrained as supervisors combined with the output of the new HAW school will be sufficient to staff the 374 new PHCs and old PHCs/CHCs that will have been established by project-end. The GRB has already issued a GovernmenL Order by which the West Bengal Nursing Council sanctioned the objectives, curriculum and administra- tive details of HA training, which are appropriate. Project strate- gies (Annex 2) will also be included. Adequate numbers of male super- visors will be available. 3.45 General nurse-midwives (GNMs) provide clinical nursing ser- vices at new PHCs, old PHCs and CHCs/rural hospitals. Staffing is cur- rently adequate, but only because some ANMs have been diverted into clinical work. It is estimated that the number of such ANKs in the selected districts is about 350. Depending on theLr qualifications, they will go either for training as female supervisors (HAYs) or for a condensed two-year GNM course. In addition to these positions, a total of about 650 GNMs will be needed to staff the new PHC8, old PICs and CHCs to be improved, upgraded or constructed under the project.  -34- Including a leave reserve and allowance for normal attrition, the total number of additional GNMs required during the project will be approximately 1,100. Sanctioned improvement of existing GMN schools in Bardhaman and Bankura districts will proceed immediately, increas- ing the annual output of these schools, now at 65, to 100 by the final year of the project. In addition, the project will construct a 300- place GNM school in Puruliya district. The school will be established initially in rented quarters and will train existing ANKs, allowing an annual out-turn of 150 GNMs from the second project year. The small shortfall of about 50 GUMs under the project will be made up by gradu- ates from schools outside the project districts. 3.46 There is no shortage of physicians, dentists, medical spe- cialists and laboratory technicians to staff the additional require- ments of the project. 3.47 In-service Training. In addition to project support for basic training, MPWs will be given in-service training to upgrade their professional skills and ensure that program goals and strategies are clearly understeod. To be able to identify significant gaps in the skills, rknowledge and practice of the staff delivering family m2efare services, surveys were carried out at the beglnning of the third population project. The surveys had a simple design and were carried out expeditiously. They showed, inter alia, serious gaps in staff knowledge, poor patterns of supervision, and lack of IEC materials, particularly at subcenters. The project makes provision for a similar survey to be carried out in the selected districts by a teau- coTprising a physician, public health nurse, senior health inspector and trainer chosen for their experience and competence. Assurances have been obtained during negotiations that the GWB will, by March 31, 1986, (a) complete a survey to identify any significant gaps in the skills, knowledge and practices of family welfare staff as a basis for the reorientation of the staff in the Project Districts; and (b) promptly furnish the results of the said survey to the Asso- ciation for its review and comments (para. 7.01(d)). The information from the survey will be used by the Directorate of Health Services to develop curricula for retraining courses and to direct the attention of program managers and supervise-v to areas which noed strengthening (see Annex 2, Section F). Assurances have been obtained during nego- tiations that the GWB will, not later than two months before the start of each financial year, furnish annually curricula and a timetable for the re-training of staff in project districts to the Association for its review and coments (para. 7.01(e)). Apart from the costs of the survey, no incremertal provision for in-service training is required, since the staff involved receive regular salaries and allowances which also apply to training courses.  -35- 3.48 Most interpersonal communication in support of family wel- fare activities is carried out by MPWFs and MPZMs at the subcenter level, but neither they nor their supervisors have been trained in commnications. In-service training for multipurpose workers (para. 3.47) and supervisory training (para. 3.44) will pro'vide for simple training in IEC techniques, and supervisory training will also In- clude emphasis on the importance of providing support for demand generation activities. 3.49 To improve the management skills of doctors in charge of health facilities at district and block (old PUC/CIC) levels, the project will provide management training. The training, which will draw on similar training programs developed in previous Bank-assisted projects, will be based on public health materials and will be problem solving in orientation. The Indian Institute of Management in Calcutta has staff with experience in health services management and will be offered a contract to develop and carry out project management train- ing along the required lines. About 120 doctors, drawn from district and block level staff, will be trained during the project period. 3.50 The present pattern of in-service training is described in para. 2.14 and weaknesses. outlined in para. 2.22. In West Bengal there is no family welfare in-service training facility at State level, which is a serious gap in training resources, nor is there any existing facility in the State which cold be institutionally devel- oped into such a facility. The project, tberefore, provides for the construction, equipping, furnishing and staffing of a SIHFW to be es- tablished in a suburb of Calcutta. The objective of the SlEFW is to provide the State Directorate of Health and Family Welfare with a strong and highly professional capability designed to improve the quality of staff and their services, and provide support for planning, research and information dissemination. To allow for administrative flexibility, the SIHFW would follow precedent and be registered under the Societies Act as a semi-autonomous institution. It would, however, retain strong connections with the GCB and especially the Directorate of Health and Family Welfare, the Director of which would be Chairman of the Governing Body. The SIEFW would be headed by a Director with the rank of an Additional Director of Health Services who would be supported by four deputy directors with the academic rank of profes- sor. Deputy directors would each be responsible for training, re- search, planning and field services and would draw on the services of specialist units including demography, MCR and fanily planning, en- viromnental health, etc. The outreach capacity of the SIHFW will be strengthened on an experimental basis by the establishment of district training units and the addition of training staff at the CHC training annexes in the selected districts. These staff will ultimately be responsible for organizing in-service training requirements, monitor- ing the effectiveness of the training provided, and feeding back their findings to trainers and project managers so that problems can be cor- rected.  -36- 3.51 In the first project year, a nucleus will be established either in rented accommodation in Calcutta or at the Kalyani HFWTC in Nadia district. The SIHFW will be permanently established on a government-owned site at Salt Lake, a suburb of Calcutta. The GWB has prepared plans setting out the objectives, functions, staffing and facilities for the SIHFW. In the first population project, two new Population Centers were established but the development of an institu- tional capability took far longer than anticipated. This experience, documented in the Project Performance Audit Report-India First Popu- lation Project (Report No. 3748 dated December 31, 1981), suggests that it would be unrealistic to expect that the SIEFW will be able to contribute more than marginally to in-service training needs during the project period. By the erd of the project, however, West Bengal will have a well-established SIHFW capable of playing a pivotal role in the planning and development of the State's family welfare program which will serve as a model for replication in other States. Since the completion of the first project, responsibility for running the two Population Centers has been assumed by the respective State Govern- ments. Staff, however, continue to be employed on a temporary con- tract basis, which has led to recruitment and retention problems. Assurances have been obtained during negotiations that the GWB will (a) by June 30, 1986, appoint a nucleus of senior staff positions as agreed with the Association; and (b) by March 31, 1988, fully staff the SIHFW as agreed with the Association and thereafter maintain all the SIHFW staff positions on a regular basis (para. 7.01(f)). Monitoring and Evaluation 3.52 The project will strengthen the capacity of the State to monitor and evaluate program performance along lines developed under the previous projects. Under the first project, a MIES was developed that replaced rumbersome and time-consuming methods of collecting per- formance stacistics and also provided a management tool through use of the data compiled to monitor performance and the prompt feedback of results. Experience in the first and second projects has indicated that the introduction of MIES in only a few districts does not permit the system to function as intended and that responsibility for the system must be clearly located. In this project, as in the third project, MIES will be implemented State-wide in phases; the first phase will include the project districts with the remaining districts to be covered in two subsequent phases. Implementation of MIES will be preceded by a series of training and orientation sessions starting at State level and proceeding down to subcenter level. After approxi- mately six months, refresber training for field staff will be carried out to correct any difficulties in implementation that may arise. The project makes provision for the printing of forms, equipment to aid data collation and analysis at district and State levels, and evalua- tion of the system's effectiveness. Plans for the introduction of a State-wide MIES have been made, and the Statistical Unit of the State's Family Welfare Department (para. 3.55) will be responsible for the implementation and functioning of the system.  -37- 3.53 To make possible quantitative assessment of program achieve- ments, the project makes provision for three surveys-baseline, mid- term and final-to be carried out in the four project districts and a control district. The lack of demographic parameters and related data by district is a major program handicap throughout India. Although performance figures are readily available and are used to calculate contraceptive prevalence rates, there is no basis for the estimation of district-level vital rates or NCH coverage rates; the numbers of eligible couples or young children can only be estimated crudely and a breakdown of eligible couples in terms of age, parity, age of youngest child and family planning status is not possible. Baseline survey results, which will be available by March 1986, will provide estimates of these numbers for the project and control districts and will also make it possible to measure changes in vital rates, health status and attitudes to family planning and health services. The data also will provide more precise values for the project indicators (Annex 3) on the basis of which agreement will be reached with the Bank on this project's quantitative goals; they will also be used for final project evaluation. The Demographic and Evaluation Cell (para. 3.55) will have overall responsibility for implementation of the surveys and dissemination of the results. Survey design, field work and data analysis will be carried out by the Demographic Research Center of the Indian Statistical Institute, Calcutta, which has already been in- structed by the GWB to finalize plans. 3.54 Operational research is an important means of supporting the Implementation of a complex program. It serves to highlight existing problems and to develop alternative approaches for dealing with them. Ongoing operational research is currently being carried out by the Population Centers in Bangalore and Lucknou established under the first project. In this project, research and evaluation will be co- ordinated by the State Statistical Unit. Annex 5 gives a preliminary list of evaluation and operational research topics. The staff of the Statistical Unit will be strengthened to increase its research capa- bilities. The Unit will also eventually coordinate with the research and evaluation section of the new SIHEFW (para. 3.50). In addition, funds are provided to permit some of the research program to be car- ried out on a contract basis by other qualified organizations, of which there are many in the Calcutta area, as appropriate. 3.55 The statistical, monitoring, evaluation and research capa- bilities of the State's Health and Family Welfare Department will be strengthened. There are two units in the Directorate of Health and Family Welfare which deal with statistics. Health statistics are collected, collated and analysed by the State Bureau of Health Intel- ligence. The Demographic and Evaluation Cell is similarly responsible for family welfare statistics and will be responsible for the imple- mentation of the MIES. The monitoring and evalution capabilities of  -38- this cell will be strengthened by the provision of ten statistical staff at State level and one statistical officer in each district together with supporting staff. Essential equipment, including a mini-computer, will also be provided to mBet the requirements of the introduction of the MIES and extend the cell's capacity for operation- al research and evaluation activities. Much of the data, however, are of common literest and value and there is need to improve the coordi- nation of the activities of both units. Assurances have been obtained during negotiations that, by December 31, 1985, the GWB will establish and maintain a committee to coordinate the functions of the Family Welfare Demographic and Evaluation Cell with the State Bureau of Health Intelligence, which will have meabership, functions and powers satisfactory to the Association (para. 7.01(g)). Project Management 3.56 Project activities will be coordinated by a Project Coordi- nator in the Secretary of Health's office. He will be supported by an Additional Director of Health Services to liaise with Directorate Staff and monitor the project's program inputs as well as progran performance and quality in the selected districts. Project officers based in each district have been found to be most useful in previous projects. Drawn from the revenue cadre, they will be responsible for site selection and acquisition and once these functions are complete will be replaced by medical officers to assist with program implemen- tation. The Project Coordinator has been appointed and four officers with administrative and land acquisition experience are being recruit- ed from the State civil service cadre. The project makes provision for the salaries of 52 project management and support staff, including accountants at State and district level, furniture, equipment, vehi- cles and rented office accommodation. 3.57 Project activities will be carried out as part of the on- going program by the various departments of government responsible (para. 5.03). These will be suitably strengthened, as described under each component, to cope with expanded activities on a permanent basis and not merely supplemented by temporary project positions. The civil works program will, however, require the temporary strengthening of the Public Works Department (PWD) and provision is made for 96 addi- tional engineers and architects at State, district and sub-district levels during the construction period of the project. To ensure that the project's objectives are clearly understood, provision is made for project launch workshops at which the strategy paper (Annex 2) will be used as the basis for discussions.  -39- IV. PROJECT COSTS, FINANCING, DISBURSEMENTS AND PROCUREMENT A. Costs 4.01 The total estimated cost of the project is US$89.9 million equivalent of which the indirect foreign exchange component is esti- mated at US$7.2 million, or about 8% of total costs. Taxes included in total costs are esti-ated at about US$5.5 million. Capital costs for construction, furniture, equipment and vehicles account for US$45.5 nillion, or 67% of base costs. Incremental operational and maintenance costs total US$22.9 million, or 33Z of base costs. Cost estimates by expenditure category, detailed in Table 12, are sum- marized in the following table: INDIA : PROJECT COSTS BY EXPENDITURE CATEGORY (In Millions) ROM________ _ 1US$ Zof Z aE Locl Foreign Total Local FoePgn Total Fobe Total Thd! lae (bost L (tal Coss QIvtl Wbns 421.5 51.5 473.0 35.1 4.3 39.4 11 5B Fwei