India - Fourth Population Project

Documet of The World Bank FOR OMICIAL USE ONLY Report No. 13785 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (CREDIT 1623-IN) DECEMBER 12, 1994 Population and Human Resources Operations Division Country department II South Asia Regional Office This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  Currencv Equivalents Name of Currency = Indian Rupee (Rs) Currencv Exchanze Rates Rupee Appraisal Year Average (1984) 12.0 Completion Year Average (1994) 31.0 Weights and Measures 1 meter (m) = 3.28 feet (ft) I kilometer (km) = 0.62 miles (mi) Abbreviations ARI Acute Respiratory Infections ANC Antenatal Coverage CPR Contraceptive Prevalence Rate CSSM Child Survival and Safe Motherhood DOHFW Department of Health and Family Welfare GOI Government of India GOWB Government of West Bengal IAS Indian Administrative Service IEC Infonration. Education and Communication MCH Maternal-Child Health NGO Non-Governmental Organization PHC Primary Health Center PWD Public Works Department RTC Research and Training Centre SIHFW State Institute of Health and Family Welfare TFR Total Fertility Rate Government of India Fiscal Year - April I - March 31  FOR OFFICIAL USE ONLY THE WORLD BANK Washington, D.C. 20433 U.S.A. Office of Director-General Operations Evaluation December 12, 1994 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SUBJECT: Project Completion Report on India Fourth Population Project (Credit 1623-IN! Attached is the Project Completion Report on India-Fourth Population Project (Credit 1623-IN) prepared by the South Asia Regional Office. Comments were received from the Government of India and are included as Annex B. This project provided assistance to the family welfare program of the state of West Bengal. Components to construct and equip health facilities and training schools, and to support information, education and communication (IEC), population education programs, pre-service and in-service training and program management were included. Implementation of the civil works component was delayed but finally completed two and a half years late. Since most targets were achieved or surpassed, the project outcome is rated as satisfactory. But institutional development is rated as modest and sustainability as uncertain (inter alia because of inadequate maintenance arrangements). 'he Project Completion Report is of acceptable quality. An audit, along with other population projects, is planned. Attachment This document has a restricted distrlbution and may be used by reciplents only In the performance of their official duties. Its contents may not otherwise be disclosed wlthout World Bank authorizatlon.   FOR OFFICIAL USE ONLY PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (CREDIT 1623-IN) TABLE OF CONTENTS PageNo. Preface ............................................................ i Evaluation Summary ........................................................ iii Part I: Project Implementation Assessment Project Objectives ..................................................... 1 Achievement of Project Objectives ......................................... 1 Implementation Record and Major Factors Affecting the Project .................. 3 Project Sustainability ................................................... 7 Bank Performance ..................................................... 7 Borrower Performance .................................................. 9 Assessment of Outcome ................................................. 9 Future Operation ..................................................... 9 Key Lessons Learned .................................................. 10 Part II: Statistical Annexes Table 1. Summary of Assessments ........................................ 15 Table 2. Related Bank Loans/Credits .................................... 17 Table 3. Project Timetable .............. .............................. 19 Table 4. Loan//Credit Disbursements: Cumulative, Estimated and Actual .... ...... 20 Table 5. Key Indicators for Project Implementation ......................... 21 Table 6. Key Indicators for Project Operation .............................. 22 Table 7. Studies Included in the Project .................................. 25 Table 8. Project Costs ................................................ 27 Table 9. Economic Costs and Benefits .................................. N/A Table 10. Status of Legal Covenants ...................................... 28 Table 11. Compliance with Operational Manual Statements .................. N/A Table 12. Bank Resources: Staff Inputs ................................... 30 Table 13. Bank Resources: Missions ...................................... 31 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  Appendices: Appendix A. Aide Memoire ............................................. 33 Appendix B. Summary of West Bengal Project Completion Report ..... ........... 37 Appendix C. Cofinancier Contribution to the ICR (N/A) ..................... N/A Appendix D. Miscellaneous Appendices: 1. Family Planning Acceptors, West Bengal: Selected Years .... .......... 47 2. Coverage of MCH Services, Project Districts vs. Rural West Benga9 ..... 49 3. Subcenter Coverage, Rural West Bengal: 1985; 1994 ................. 51 4. West Bengal Health & Family Welfare Management Information System . 53 5. Evaluation of In-Service Training of Auxiliary Nurse-Midwives .... ..... 55 6. 'A Case Study of Two Pairs of Subcentres' ......................... 57  i PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (CREDIT 1623-IN) PREFACE This is the Project Completion Report (PCR) for the Fourth (West Bengal) Population Project in India, for which Credit 1623-IN in the amount of SDR51.5 (US$51.0) million equivalent was approved on July 23, 1985 and made effective on December 20, 1985. The Credit was closed on March 31, 1994 compared with the original Closing Date of August 31, 1991 and should be fully disbursed by July 31, 1994. Preparation of this PCR was begun during the Bank's final supervision/completion mission from January 18-24, 1994 . It is based on material in the project file. The Borrower contributed to preparation of the PCR by preparation of a state project completion report, a summary of the state project completion report, and comments on a draft of the PCR that have been incorporated into the final report.   iii PROJECT COMPLETION REPORT Evaluation Summary FOURTH POPULATION PROJECT (Credit 1623-IN) INDIA Introduction 1. India's early recognition of the threat to development posed by rapid population growth led to the establishment of a national family planning program in the mid- 1960s. External assistance was sought, resulting in a series of IDA-supported population projects to provide support to the family welfare (family planning and maternal-child health) program on a state-by-state basis. The first project became effective in 1973 and the ninth will go to the Board in July 1994. The fifth and eighth projects are urban projects, the others are rural. Their common objectives are to support achievement of fertility reduction through increased contraceptive prevalence and reductions in infant, young child and maternal mortality through improved coverage and quality of MCH services. They have evolved from assistance limited to specified districts in a state to support for entire state programs. Project Objectives and Components 2. Objectives. The Fourth Project provided assistance to the family welfare program in the state of West Bengal. The Staff Appraisal Report anticipated that in the four project districts the following increases in coverage would be achieved: contraceptive prevalence to about 50 percent; acceptors of temporary contraceptive methods to 25 percent of new acceptors; deliveries assisted by trained persons to 60 percent; and antenatal and immunization coverage to 85 percent. Infant mortality was expected to fall, although no numbers were specified. It was expected that if in addition to the provision of physical inputs, the quality of service delivery could be improved, achievement of project objectives would be feasible. 3. Components. A service delivery component comprised construction of health facilities including training schools and furnishing, equipping and staffing of constructed and rented facilities. Service delivery was supported by components for information, education and communication (IEC), population education, pre-service and in-service training, and program management. Implementation Experience and Results 4. Achievement of obiectives. The project's objectives were by and large achieved. Numbe,rs of sterilization and temporary method acceptors rose by 37 and 581  iv percent, respectively, and in consequence the contraceptive prevalence rate increased to approximately the targeted 50 percent while the proportion of temporary method acceptors reached almost 50 percent, far exceeding expectations. Project goals for antenatal coverage and delivery attendance by trained persons were reached, and immunization progress was considerable although goals were not quite fully achieved. Infant morta!ity in rural W. Bengal fell to less than 70 per 1000 lives births. In general, the project districts progressed significantly more rapidly than did the rest of the state. 5. Sustainability. There are three major sustainability issues. First, a state apex research and training institute constructed with project support was not operationalized by the end of the project, raising serious concerns as to whether an effective institution would be developed and the major investment in the physical facilities justified. Second, the maintenance of more than a thousand health facilities constructed with project support is not assured, and experience in previous projects suggests that in West Bengal as well adequate funds for the purpose will not be allocated. Third, provision of drugs and supplies by the state government is not satisfactory. While supply of those subcenter items currently supported by the central government is relatively reliable, state provision is essential to effective functioning of referral facilities and a variety of health programs, including the excellent management information system (MIS) developed with project support. 6. Implementation timetable and costs. Implementation of the civil works component was delayed at the outset of the project and was completed only because the Credit Closing Date was extended by two and a half years, to March 31, 1994. Civil works costs exceeded the original estimate by almost a third, while expenditures for incremental staff were substantially lower than originally anticipated because of delayed appointment or failure to sanction the posts. Total project costs in rupees were higher than the original estimate by about 8 percent. 7. Key factors affecting achievement of obiectives. Key factors in effective project management were (i) the appointment of senior officers from the Indian administrative service (IAS) as project coordinators and the long tenure of the first coordinator; (ii) direct involvement of senior program officers in project management and implementation; and (iii) ability of managers to learn from implementation experience and research results. These were linked with key program improvemnents, resulting in successful project implementation as well as significant program impact. 8. Bank Performance. Project preparation was abbreviated and the Bank appraised on the basis of an inadequate proposal. The most serious appraisal shortcomings were failure to require creation of an empowered project Governing Board to avoid having to obtain clearance of individual project expenditures by the state Finance Department; and incomplete appraisal of a proposed state apex training institute, which resulted in long delays and ultimate failure to operationalize the institute by the end of the project. Bank supervision was adequate in terms of frequency and was able to provide useful technical support on a number of occasions.  v 9. Borrower Performance. India, who is the Borrower under the legal documents, made the proceeds of the credit available to West Bengal, the implementing state of the project. and played only a minor role in project implementation. Participation in the appraisal process by GOWB did not go smoothly, and little was done to carry out pre-project activities. However, after appointment of a project coordinator by GOWB, project management was competent and effective, and virtually of the project's physical targets were achieved. Management of procurement, project accounts and submission of disbursements applications were all satisfactory, and with one exception, concerning the apex training institute, there were no covenant compliance issues. 10. Assessment of proiect outcome. Based on the success of the project in achieving its demographic and health objectives, project outcome can clearly be rated 'satisfactory.' Failure to operationalize the apex training institute and other sustainability concerns prevent a rating of highly satisfactory,' which might overwise be indicated. Summarv of Findin2s, Future Operations, and Kev Lessons Learned 11. Important findinEs of the project implementation experience. The chief negative findings concern the Bank's continuing inability to deal with civil works problems in the population projects, inciuding improper siting of subcenters and failure to ensure maintenance late in the project period as well as subsequently. On the positive side, the achievement of project objectives demonstrates that a combination of good management and key program improvements can result in significant program impact. The accomplishments of the project's in-service training and MIS components in particular provide models that could profitably be utilized by other states in India. 12. Future proiect operations and sustainability. The Government of West Bengal operates under severe financial constraints, and in addition funds for facility maintenance are controlled by the Public Works Department, not by the Department of Health & Family Welfare (DOHFW). Nevertheless, DOHFW expects to absorb staff appointed under the project and has given commitnents concerning operationalization of the apex training institute as well as ongoing support for program activities strengthened under the project. The round of in-service training begun under the project will be completed, and further training will be provided subsequently on a regular basis as well. Similarly, the IEC (information, education and communication) program is planning for more effective use of diminished resources. Support for family welfare services will also be available to the state through the IDA-supported national Child Survival and Safe Motherhood (CSSM) Project. 13. Lessons for future proiects. Like its predecessors, the Fourth Project was only part of a state family welfare program and consequently an even smaller part of the national program. The project was not designed to have an impact on the underlying problems of the national program identified in reviews of the earlier projects, which included weak and overcentralized national program planning and management and emphasis on sterilization for the sake of national population goals at the expense of a balanced and integrated family  vi planning/MCH program. The focus on achievement of sterilization and other targets, which continues to distort program implementation in India, was less evident in this project than in earlier ones, due to positive program results combined with relatively flexible program management. However, target problems were by no means absent, and the good project experience in West Bengal should not obscure the need to support major policy and implementation changes in the Indian family welfare program. The CSSM project represents a beginning for Bank assistance to the national MCH program. A corresponding project of national scope on the family planning side, rather than further investments limited to particular states, would appear to offer the best prospect for enhanced Bank influence on the future directions and effectiveness of the family welfare program.  1 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (Credit 1623-IN) Project Objectives 1. The Fourth (West Bengal) Population Project was one of a series of related projects intended to provide IDA assistance to India's family welfare (family planning and maternal-child health) program on a state-by-state basis. The staff appraisal report (SAR) states that the objectives of the project were to support the efforts of the family welfare program in rural West Bengal to achieve fertility reduction through increased contraceptive prevalence and reductions in infant, young child and maternal mortality through improved coverage and quality of maternal-child health (MCH) services. More specifically, the SAR indicates that by the end of the project it was expected that in four selected project districts' contraceptive prevalence would increase to about 50%, the proportion of acceptors of temporary contraceptive methods to 25% of new acceptors, the proportion of deliveries assisted by trained persons to 60%, and the level of antenatal and immunization coverage to 85%. The infant mortality rate was expected to fall, although no numbers were specified. It was anticipated that if in addition to the provision of physical inputs, the quality of service delivery could be improved, achievement of project objectives would be feasible. Achievement of Project Objectives2 2. In assessing project results, it is useful to bear in mind overall demographic trends in West Bengal in recent years. Fertility and infant mortality, the two key indicators, have declined consistently since at least the early 1980s: figures for rural West Bengal indicate a fall in the total fertility rate (TFR) from 4.8 in 1981 to 3.9 in 1990, while infant 1/ In contrast to the Second and Third Projects, where all project districts were 'backward,' only one of the four West Bengal districts was clearly backward and average contraceptive prevalence was higher than the state average, thus "mak[ing] it possible to expect substantial program achievements, approaching the GOI goal of 60% contraceptive prevalence." (SAR para. 3.06). 2/ Data in paras. 2-6 are from the national Sample Registration System; West Bengal family planning program statistics; project baseline, mid-term and end-of-project surveys (1985, 1989, 1993); and the National Family Health Survey for West Bengal (1992).  2 mortality declined from 98 to 68 over the same period. There has also been a marked shift in contraceptive method mix from sterilization to temporary methods. 3. To what extent the family welfare program has been responsible for these trends is difficult to quantify. However, it is generally accepted by observers that in rural areas the expanded availability of family planning, maternal-child health, and other health services has been the single most important factor. The goals specified for the project districts were by and large achieved, and these districts clearly progressed more rapidly than did the rest of the state. 4. The contrast between project and non-project districts is apparent in numbers of family planning acceptors, which are in turn reflected in contraceptive prevalence rates (CPRs). In the project districts, numbers of sterilization and temporary method acceptors rose from 1985 to 1993 by 37 percent and 581 percent, respectively, in contrast to 7 percent and 324 percent increases in the rest of the state (Appendix 1). CPRs increased by 19 Contraceptive Prevalence Rates, West Bengal: 1984, 1993 Pct. 1984 1993 Change Chanze (percents) State 28 37 9 32% Project Districts 33 52 19 58% Non-Project Districts 26 33 7 27% percentage points (58%) between 1984 and 1993, while the corresponding increase in the non-project districts was only 7 percentage points (27%). 5. In 1984, sterilization accounted for about 90 percent of all new acceptors in West Bengal, but by 1993 the proportion had fallen to about 50 percent. The experience in the project and non-districts was along similar lines. Thus, the project goal of reducing the sterilization proportion to 75 percent was more than achieved. 6. There are no data available for infant mortality or other MCH outcomes which would permit a direct comparison between project and non-project districts. In the project districts, project surveys indicated substantial progress in immunization and antenatal (ANC) coverage, from about 25 percent in 1985 to more than 70 percent in 1993 for DPT and polio immunization, and from 75 percent ANC coverage in 1988 to 84 percent in 1993. Although immunization goals were not fully achieved, levels for immunization and ANC coverage in the project districts appear to be consistently higher than those for the state as a whole (Appendix 2).  3 7. The project surveys reported an increase in institutional deliveries from 26 to 40 percent in the project districts. Data on how many additional deliveries were attended at home by either health workers or trained dais are not available, but the total figure for deliveries attended by trained personnel may approach the 60 percent mentioned in the SAR. Implementation Record and Major Factors Affecting the Project 8. The project, which was implemented by the West Bengal Department of Health & Family Welfare (DOHFW), got off to a slow and unpromising start. It became effective in December 1985, more than a year after appraisal, and a project coordinator was not appointed until about that time. Few pre-project activities were undertaken, which particularly affected the civil works component. However, after initial difficulties project management improved. Extension of the Credit Closing Date from August 31, 1991 to March 31, 1994 (para. 32) permitted completion of the civil works component, and all of the project's physical targets were by and large achieved. The original project budget was exceeded by about 8 percent because of cost escalations in the civil works component. 9. Two general factors which affected project implementation can be noted at the outset. First, a very competent senior officer from the Indian Administrative Service (IAS) was appointed project coordinator and then allowed to retain the post for more than five years. The project had only three coordinators, all IAS officers, in contrast to coordinators from the technical side and/or a rapid turnover of coordinators which occurs in most states in IDA-assisted projects. Second, senior program officers were directly involved in project management and implementation, and there was good liaison between the Directorate of Health Services and the project coordinator's office. Thus, a project team developed but a project-program split was avoided. 10. Project support for civil construction and associated furniture, equipment and vehicles was limited to the four designated project districts. However, the other project components were assisted on a state-wide basis. The following paragraphs review the implementation record of the individual project components. 11. Service Delivery. A project strategy paper annexed to the SAR elaborated how project objectives were to be achieved, mentioning the importance of contraceptive method mix, demand generation, in-service training, program management at all levels, and community involvement. The paper was entirely a Bank production, produced after the appraisal without any input from the state, and was consequently ignored. Nevertheless, as the review of project implementation in the following paragraphs makes clear, because projectlprogram managers reached similar conclusions about the measures necessary to improve program effectiveness and impact, the approaches taken over the course of project implementation were similar to those of the strategy paper.  4 12. One of the major objectives of the project was to enable West Bengal to approach national norms for rural subcenter coverage (1:5000 population; 1:3000 in hilly, tribal or backward areas) in the project districts. This goal was to be achieved through recruitment and training of field workers and provision of constructed or rented subcenter facilities. Coverage in the project districts, initially about 9,000 population per subcenter, improved to about 5,800 by 1994, which, while still higher than the norm, represented substantial progress (Appendix 3). In addition, through construction and staffing of primary health centers (PHCs) covering 30,000 population, availability of referral facilities was greatly expanded. 13. After the mid-term review, program/project managers, drawing on the recommendations of Bank expert consultants, decided to use project assistance to address the major treatable causes of infant mortality in rural West Bengal, which were identified as diarrheal diseases, acute respiratory infections (ARI) and low birth weight. Provision was therefore made for training of trainers and for suitable additions to in-service training curricula. This pioneering child survival initiative never really took hold, because ARI drugs were not available and medical officers did not give it adequate emphasis or backup. However, the work already undertaken increases the possibility that child survival objectives will be achieved through the IDA-supported Child Survival and Safe Motherhood (CSSM) project currently being implemented in all states. 14. Field workers in the project districts were trained in IUD insertion early in the project period and supplied with IUD kits. This is reflected in the much greater increase in the number of IUD acceptors in the project districts compared to the non-project districts-- 586% vs. 182% (Appendix 1). When the training evaluation carried out in 1991 (para. 22) emphasized that some antenatal procedures were not being carried out because required equipment and supplies were not available, project funds were used to provide them to all subcenters in West Bengal; however, they were supplied too late in the project for assessment of impact. 15. Supervision of field workers is conceded by managers to remain inadequate despite project training efforts. It is expected that the situation will gradually improve with the retirement of older supervisors who lacked field experience; all supervisory positions are now filled through promotion and training of existing field workers. 16. Civil Works. Failure to carry out planned pre-project site selection and design activities, combined with an engineers' strike at the beginning of the project, resulted in substantial delays in the civil works component. These were subsequently compounded by procurement difficulties and failure of the state government to provide funds on some occasions. Nevertheless, some 1,130 constructions, essentially all that were originally planned (Table 6), were undertaken. Quality of construction was judged to be generally satisfactory by successive supervision missions. As of January 1994, some 96 percent of constructions had been completed, 94 percent handed over to DOHFW, and 91 percent were  5 functional. On account of delays and greater cost escalation than anticipated, the total cost of civil works exceeded the original budget by almost a third. 17. The civil works component involved a number of difficulties. The end-of- project survey indicated that almost 40 percent of subcenter sites, which were limited to donated land, were outside the main inhabited area of the village. Arrangements for supply of furniture and equipment to completed constructions were not satisfactory, and this, combined with delays in recruiting and posting staff, resulting in delays in making new facilities functional. Provision of electricity, which is riot unde; the control rf DOHFW, was also much delayed in many cases. No provision was made for maintenance of facilities constructed early in the project, some of which now require major repairs. 18. Information. Education and Communication (IEC). DOHFW's IEC unit was one of the stronger among the states. Additional IEC activities supported under the project were carried out along planned lines, in the areas of community education, mass media, traditional folk media, workshops and conferences, and innovative programs including village health fairs (Table 6). After the mid-term review, mass and folk media activities were reorganized to concentrate on poorly performing areas, and special programs for backward and tribal blocks were developed. The IEC unit also used project funds to support very successful programs for prevention and control of diarrheal diseases in blocks reporting high numbers of diarrheal deaths and to develop IEC materials for expanded MCH interventions. IEC orientation/training was provided for program managers, IEC staff, and field staff, although feedback from the latter indicated a need for additional training in interpersonal communication techniques. The project surveys indicated significant improvements over the project period in the proportion of respondents recalling some family welfare communication in the recent past and in knowledge of the program. These results were achieved despite failure to appoint more than a few of the agreed incremental staff. There is no doubt that availability of additional staff, particularly on the administrative side, would have enabled the unit to function more effectively. 19. Population Education. With project support, population education programs were implemented by four departments other than the Health Department: Higher Education, Mass Education, Panchayats and Labour. Orientation in population-related subjects was provided to faculty and students of teacher training colleges; Mass Education staff and extension workers; panchavat (local council) members; and trade union leaders and workers at Labour Welfare Centres. Numbers planned to be trained were roughly achieved. However, no evaluation of the programs' impact was carried out. 20. Management Information System. Prior to the project, health and family planning reporting in West Bengal was disorganized and non-functional. The state took a decision to use project resources to introduce a state-wide unified management information system. Goals were to implement a system that would (i) collect, collate and feed back data accurately and rapidly; (ii) avoid duplication and require minimum staff time; and (iii) be used at all levels of the program for monitoring, management and planning purposes. The  6 svstem was developed through a careful process of investigation of existing systems in other states, consultation with concerned program officers and staff, pre-testing of forms and registers before their general introduction, and training in their use. The goals were achieved to a surprising extent (Appendix 4). The end-of-project survey reported that the basic register was available in 96 percent of subcenters and that almost 75 percent were found up to date. Timely submission and completeness of monthly subcenter and PHC reports were also good. Additionally, mission field observations indicated that field workers used the register for household prioritization and that the availability of register-generated subcenter prevalence rates had noticeably improved local program management. By contrast, systems in other states often do not collect data effectively and are infrequently used for local management purposes. 21. Evaluation and Research. A series of surveys and research reports, including baseline, mid-term and end-of-project surveys, were carried out with project support, some externally and others by DOHFW (Table 7). An evaluation of in-service training (para. 22) proved particularly helpful. There has been little appreciation of the potential usefulness of research results in the India population projects. The attitude of managers in West Bengal was different; many improvements in program implementation can be traced directly to research findings. 22. Training. The pre-service training of incremental field workers was carried out at the beginning of the project period as planned, as was management training of medical officers. In contrast to previous projects, the Fourth Project placed major emphasis on in- service training of all staff. The development of in-service training in the course of the project is instructive. In 1989, about half-way through the project, several studies indicated that the performance of field workers who had received in-service training was significantly better than that of untrained workers, but that substantial gaps in the knowledge and skills of even the former remained. The training strategy and curricula were therefore revised and particular emphasis was placed on making the training more skills-oriented and more practical. It was also decided to expand in-service training to cover the entire state. By the end of 1991, about half of the state's some 8,000 ANMs had been trained under the revised curricula, and a further evaluation was conducted. It was found that levels of knowledge and skills, although improved, were still unsatisfactory in some areas (Appendix 5). In consequence, the training period was extended, the training was made even more practical, and the attention given to interpersonal communication was expanded. 23. State Apex Traininz Institution. Strengthening of DOHFW's in-service training capacity was one of the Bank's primary concerns in developing the project. The preparation mission concluded that a state institute of health & family welfare (SIHFW), to serve coordinating, planning, monitoring and research functions, was needed. In the absence of a suitable existing institution that could be strengthened. creation of an SIHFW from scratch would be required.  7 24. Establishment of an SIHFW was characterized by a series of delays stemming originally from an incomplete appraisal. The SIHFW as appraised was subsequently judged by the Bank to be overly ambitious. Extended discussions among the Bank, DOHFW and the central Ministry of Health & Family Welfare were followed by a feasibility study, which supported the establishment of a state apex training institution, renamed the state Research and Training Centre (RTC), but recommended further reductions in its scope. Approval by GOI and GOWB, as well as Bank approval of drawings, all required additional time. Ultimately construction was not completed until the very end of the project, at which time staff had not yet been appointed. Proiect Sustainability 25. At completion, the project faces three major sustainability issues. First, the failure to operationalize the RTC during the project (para. 24) raises serious concerns as to whether an effective institution will be developed and the major investment in the physical facilities justified. 26. Second, the maintenance of the some 1,130 health facilities constructed with project support is by no means assured. The report of the project completion mission indicates that buildings constructed early in the project are already beginning to deteriorate from lack of maintenance (para. 18). In this, as in the three prior IDA-supported population projects, the state government is legally committed to provide post-project maintenance; in practice, the situation in West Bengal appears little different from that in other states. Maintenance is seldom a priority for financially pressed state govermunents. Any allocation made will be under the control of the PWD, and even if funds are nominally available the PWD has proved reluctant to use them for the maintenance of small facilities in widely scattered rural areas. This problem is no closer to being addressed systematically at the end of the Fourth Project than it was when the completion reports for the earlier population projects noted the same problem in other states. 27. Third, it is evident that the ability of the state's family welfare and health programs to provide services is crucially dependent on the availability of contraceptives, vaccines, drugs, ORS, other supplies and equipment (e.g. para. 13). While supply of those items supported by the central family welfare program has been relatively satisfactory, there is no guarantee of continued central support. The current supply of drugs by the state is unsatisfactory, with no prospects of improvement. Failure of the state to provide support for the printing of MIS registers and reporting forms, to cite another example, would seriously undermine the excellent system that has been developed with project support (para. 20). Bank Performance 28. The Fourth Population Project was developed in 1984, in quick succession to the Third Project the previous year. A fourth project was first discussed with GOI in January/February 1984, and it was agreed that because of a mutual wish to process the  8 project as rapidly as possible the project would be confined to the single state of West Bengal. The Bank took a conscious decision to put through a fourth state project along the lines of the previous three and continued to defer discussion of previously identified national program issues. 29. Bank participation in project preparation was limited to one preparation mission in July 1984 and a subsequent meeting with senior officials in Delhi in September. The project proposal was first seen by the appraisal mission at the time of the mission in November. The appraisal team did not deal adequately with either the development of a state apex training institution or a service delivery strategy (paras. 23;11). 30. However, the most serious appraisal shortcoming concerned a means to avoid the necessity of obtaining line-by-line clearance of project expenditures by the state Finance Department. This problem had proved to be a major bottleneck in the Second Project and had been addressed in the Third Project through the creation of project Governing Boards empowered to take decisions that were not subject to review by individual departmnents. At the time of the appraisal, the then Secretary of DOHFW made an alternative proposal that was accepted by the mission although never formally incorporated into the project documents. After project effectiveness, it emerged that the alternative could not be implemented. As a result, obtaining Finance Department clearance for project expenditures became as much of a problem in the Fourth Project as it had been in the Second Project. 31. Bank supervision of the project was by and large adequate in terms of frequency and appropriate technical expertise. Supervision suffered initially from lack of continuity due to the retirement of the original project officer and the disruptions associated with the reorganization of the Bank in 1987. Late in 1987, the newly appointed PHN officer at the resident mission in Delhi became the task manager for the project and remained so for four years. The establishment of an informal working relationship between the task manager in Delhi and the project coordinator facilitated several aspects of project management and implementation. A mid-term review carried out in 1989 provided a productive opportunity to assess project progress and introduce a number of modifications and innovations. The provision of expert consultant advice in the area of child survival gave the state a valuable headstart for the CSSM project (para. 13). The IEC component would have benefited from stronger Bank technical support, particularly in the first half of the project, when it became apparent that project resources were being used to support a variety of expanded activities without an appropriate framework or strategy. 32. The Credit Closing Date was extended as part of a 'restructuring' of the Third, Fourth and Fifth Population Projects that was carried out in February 1990 on the basis of a memorandum to the Board submitted in December 1989. This was done to allow GOI to draw down the unexpended balances of these Credits resulting from changes in exchange rates. Under the restructuring, the project was formally extended to all of the state's districts, thus permitting additional disbursements. However, there was essentially no impact on project implementation.  9 Borrower Performance 33. India, the Borrower under the legal documents, made the proceeds of the credit available to West Bengal, the implementing state of the project, and played only a minor role in project implementation. Preparation of a project proposal and participation in the appraisal process by the GOWB did not go smoothly. The proposal given to the appraisal mission proved to contain many errors, and it became apparent that the Secretariat and the Directorate of DOHFW were not cooperating. As a result, the appraisal was completed only with great difficulty. 34. A condition of negotiations required GOWB to establish a Voluntary Agency Cell in the Directorate of Health Services, in order to foster greater participation of NGOs and private practitioners in the family welfare program. To fulfill the condition, responsibility was assigned to an existing officer. However, the Cell was never established and staffed per the SAR because DOHFW felt that an existing voluntary organization coordinating committee was sufficient. 35. Little was done by GOWB to carry out agreed pre-project activities, which slowed the implementation of the civil works component in particular (para. 16). However, subsequent management of the project, aided by the long tenure of the first project coordinator (para. 9), was good. Management of procurement, project accounts and regular submission of disbursement applications were all satisfactory. With the exception of a covenant relating to staffing of the SIHFW, there were no covenant compliance issues. Assessment of Outcome 36. Based on the success of the project in achieving its demographic and health objectives (paras. 2-7), project outcome can clearly be rated 'satisfactory.' Failure to operationalize the Research and Training Institute during the project period and other sustainability concerns (paras. 25-27) prevent a rating of 'highly satisfactory,' which might otherwise be indicated. Future Operation 37. The project completion mission (January 1994) discussed project sustainability concerns (paras. 25-27) and the future of West Bengal's family welfare program with DOHFW. DOHFW is lirnited by the severe financial constraints under which GOWB operates, as well as control of funds for facility maintenance by the PWD. Nevertheless, no difficulties concerning absorption of staff appointed under the project are expected, and the mission received commitments concerning operationalization of the Research & Training Centre as well as ongoing support for program activities strengthened under the project. The round of in-service training begun under the project will be completed for all workers in the state (Table 6); subsequently, refresher training will be given at training institutions at intervals of three years; and in the interim years ongoing training will carried out locally on  10 a regular basis. Similarly, the IEC program is planning for the more effective use of diminished resources, by inter alia more targeted selection of audiences and messages as well as coordination of media use. Support for family welfare services will also be available through the IDA-supported CSSM project (para. 13). Continued support for MIS, however, remains a concern (para. 27). 38. Another matter discussed with DOHFW concerns utilization of constructed subcenters. The end-of-project survey indicated that less than half of attached quarters were being occupied by the female field workers for whom they are intended. This is partly the result of improper siting of subcenters (para. 17) but also reflects West Bengal's strict recruitment policies designed to ensure that field workers come from the rural areas where they will serve; some workers therefore prefer to live in family homes rather than to occupy government quarters. DOHFW is considering systematic utilization of available subcenter space for IEC and community activity purposes, which is already happening in some locations. Key Lessons Learned 39. Bank. The reviews of the Second and Third Projects noted the need for a consistent mechanism to deal with the problem of large credit balances at the Credit Closing Date. However, procedures have now been worked out that allow cancellation of IDA funds that will not be utilized and 'reflows' of these funds into new lending. GOI has also withdrawn the objection it voiced in dealing with previous population projects to cancellation of any credit balance that may still remain. Thus, SDR 5.2 million was cancelled from this Credit in 1994, and an unexpended balance of more than SDR 5 million will be cancelled.3 40. Project. Of the project design and implementation issues identified in the preceding population projects, the following were successfully addressed in the Fourth Project: (a) It was clear from the earlier projects that limiting project support to selected areas/districts of a state (the 'Area Project' model) was ineffective. Expansion of project coverage was begun in the Third Project and further developed in the Fourth Project. In the Sixth, Seventh and Ninth Projects4 this lesson was carried to its logical conclusion, and state programs are assisted without designation of project districts. 3/ The unexpended credit balance in this project reflects entirely exchange rate changes. The project's original rupee budget of Rs 1079 million was overspent by approximately Rs 90 million. 4/ The Fifth and Eighth Projects are urban projects, with somewhat different circumstances and issues.  11 (b) A program-project split hampering project implementation was noted in earlier projects. This was avoided in West Bengal through good coordination between the project coordinator's office and the Directorate of Health Services and the direct involvement of senior program officers in project implementation (para. 9). 41. The following issues noted in review of the earlier projects, many of which concern civil works, continued to be problems in the Fourth Project: (a) A significant proportion of subcenter sites were not located in conformity with project guidelines (pam. 17). (b) Failure to provide furniture, equipment and electricity to newly constructed facilities, combined with staffing delays, resulted in delays in utilization of the facilities (para. 17). (c) No provision for maintenance of facilities constructed early in the project was made (para. 17). (d) The failure to create an empowered Governing Board was a major source of difficulty for the project (pam. 30). Establishment of such Boards in the subsequent population projects is working reasonably well in some states. (e) Flow of funds problems at state level constrained project progress on some occasions (para. 33). 42. The following additional points can be noted from the implementation experience of this project: (a) The IEC program in West Bengal (para. 18), like those in other states, needs to broaden its focus on inputs and activities to include impact as well. In addition, impact needs to be understood in terms of behavior change as well as knowledge and attitudes. (b) In the Fourth Project, the scope of in-service training was broadened to cover all staff throughout the state. In-service training subsequently became a major focus of the Sixth, Seventh and Ninth Projects. However, unless the states under these projects adopt the skills-based, pmctical approach used in West Bengal (para. 22), it is unlikely that they will achieve comparable results. (c) The importance of MIS was emphasized in previous projects, but despite considerable investment the results achieved do not compare with West Bengal's achievement (para. 20). GOI has developed a computerized district- level-and-above health and family welfare MIS that could profitably be  12 implemented in all states. However, below district level the system developed in West Bengal provides a useful model for the rest of India. (d) The difficulties of establishing new institutions from scratch are well known. The unhappy history of the RTC in West Bengal (para. 24) underlines the importance of a complete appraisal process in such an endeavor. (e) Failure to involve the State's Finance Department at the appraisal stage resulted in the inclusion of unrealistic numbers of incremental staff in the project. Particularly in the case of the IEC component (para. 18), this hampered subsequent approval of more realistic numbers. Project experience also underlines the importance of ensuring the appointment of agreed incremental staff early in the project. (f) The mid-term review of the project, which drew on a survey carried out by an external agency, was useful in irnproving project/program implementation (para. 31). 43. How a project which started so badly was by the time of its completion arguably the most successful of the past and current India population projects is obviously of interest. Several aspects of project/program management can be identified as contributing factors: (a) The long tenure of capable, senior IAS officers as project coordinators (para.9); (b) The direct involvement of senior program officers in project management and implementation as well as good liaison between the Directorate of Health Services and the project coordinator's office (para. 9); (c) The willingness of managers to learn from ongoing implementation experience and evaluation studies (para. 18). These project management factors were linked with a package to improve both coverage and quality of services that included better subcenter coverage, strengthened referral capacity, effective in-service training, a functional MIS and targeted IEC (paras. 12;18;20;21). The result was successful project implementation as well as significant program impact. 44. Program. A 'Case Study of Two Pairs of Subcentres' in the project districts carried out by DOHFW in the last year of the project provides some significant insights into factors contributing to program impact (Appendix 6). The subcenters were selected on the basis of high or low contraceptive prevalence rates (CPR), which were available from MIS records; the results indicated that field work, IEC efforts and community involvement were  13 most clearly associated with high CPRs. Of equal interest, all four subcenters were rated 'poor' for treatment of minor ailments and acute respiratory infections (ARI). This result reflects lack of drugs and perhaps training deficiencies as well. In particular, field workers' inability to deal with common infections and skin ailments in young children, which cause continuing problems for many mothers, represent a lost opportunity that if made good could enable the program to greatly enhance its credibility. 45. Like its predecessors, the Fourth Project was only part of a state family welfare program. The project was not designed to have an impact on the underlying problems of the national program identified in reviews of the earlier projects, which included weak and overcentralized national program planning and management and emphasis on sterilization for the sake of national population goals at the expense of a balanced and integrated family planning/MCH program. The focus on the achievement of sterilization and other targets, which continues to distort program implementation in India, was less evident in this project than in earlier ones, due to positive program results combined with relatively flexible program manazement. However, target problems were by no means absent, and the good project experience in West Bengal should not obscure the need to support major policy and implementation changes in the Indian family welfare program. The CSSM project, which became effective in 1992, represents a beginning for Bank assistance to the national MCH program. A corresponding project of national scope on the family planning side, rather than further investments limited to particular states, would appear to offer the best prospect for enhanced Bank influence on the future directions and effectiveness of the family welfare program.   15 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT ICredit 1623-IN) Table 1: Summary of Assessments A. Achievement of objectives Substantial Partial Negligible Not applicable x x x x Macro policies rn Sector policies 0ZI Financial objectives Institutional development l EZI Physical objectives W ZIZI Poverty reduction W m Gender issues w Other social objectives 11111 m Environmental objectives w Public Sector management [ Private sector development Other (specify) W  16 B. Project sustainbility Likely Unlikely Uncertain x x x C. Bank performance Highly satisfactory Satisfactory Deficient x x x Identificaction W Preparation assistance W Appraisal W Supervision W D. Borrower Highly performance satisfactory Satisfactory Deficient x x x Preparation W Implementation W IIIE Covenant compliance W Operation (if applicable) E. Assessment of Highly Highly outcome satisfactory Satisfactory Unsatisfactory Unsatisfactory x x x x Ow w  17 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (CREDIT 1623-IN) Table 2: Related Bank Loans or Credits Credit No. : 312-IN Title : First Population Project Year of Approval : 1972 Purpose : To support the family welfare program in five districts of Karnataka and six districts of Uttar Pradesh Status : Credit Closed June 30, 1980 Comments : PCR 6/81; PPAR 1/82 Credit No. 981-IN Title N Second Population Project Year of Approval . 1980 Purpose A To support the family welfare program in six districts of Uttar Pradesh and three districts of Andhra Pradesh Status . Credit Closed March 31, 1988 Comments PCR 1/90; PPAR 8/90 Credit No. : 1426-IN Title : Third Population Project Year of Approval . 1984 Purpose . To support the family welfare program in six districts of Karnataka and four districts of Kerala Status : Credit Closed March 31, 1992 Comments : PCR 8/93 Credit No. . 1931-IN Title N Fifth (Bombay/Madras) Population Project Year of Approvalt 1988 Purpose To support the family welfare program in the cities of Bombay and Madras Status . Under implementation Comments NGOs and private medical practitioners are included in the project. Credit No. . 2057-IN TitleNo Sixth (First National Family Welfare Training and Systems Development) Population Project Year of Approval . 1989 Purpose To support the family welfare program in the states of Uttar Pradesh, Andhra Pradesh and Madhya Pradesh Status : Under implementation Comments : Focus on strengthening of training aspects of the program on a  18 statewide basis. Credit No. 2133-IN Title Seventh (Second National Family Welfare Training and Systems Development) Population Project Year of ADoroval 1990 Purpose To support the family welfare prograrn in the states of Punjab, Haryana, Gujarat and Bihar Status Under implementation Comments Focus on strengthening of training aspects of the program on a statewide basis. Credit No. 2394-IN Title Family Welfare (Urban Slums) Project (Population 8) Year of Approval 1991 Purpose To help the Government of India increase the supply of family welfare service in the slum populations of Andhra Pradesh, Karnataka, West Bengal and Delhi. Status Under implementation Comments Focus on reduction of fertility and maternal and infant mortality rates among slum populations by improving the outreach of family welfare services, upgrading the quality of family welfare services through extensive and ongoing personnel training, expanding the demand for health services through expanded information, education and communication activities and improving the administration and management of health care agencies. Credit No. : 2300-IN Title : Child Survival and Safe Motherhood Project Year of ADproval 1992 Purpose To support the Government of India's Maternal and Child Health Program. Status Under Implementation. Comnments Focus on child survival, safe motherhood (prevention of maternal morbidity and mortality) and effective service delivery. Credit No. 2630-IN Title Family Welfare (Assam, Rajasthan and Karnataka) Project (Population 9) Year of Approval 1994 Purpose To support the family welfare program in the states of Assam, Rajasthan and Karnataka Status : Approved by the Board on June 16, 1994. Comments : Focus on reduction of fertility and maternal and childhood mortality by strengthening service delivery including extension and upgrading of infrastructure, strengthening demand generation activities through improved information, education and communication planning and activities, strengthening program management and implementation capacity, and improving service quality including training, improvement of program logistics, promotion of private sector involvement, and funding for innovative schemes.  19 PROJECT COMPLETION REPORT INMIA FOURTH POPULATION PROJECT (CREDIT 1623-IN) Table 3: Project Timetable Step in project cycle Date planned' Date actual/latest l_____________________ estim ate Identification (Executive Project January 1984 January 1984 Summary) Preparation May/June 1984 July 1984 Appraisal October 1984 November 1984 Negotiations April 1984 April/May 1985 Board presentation May 1985 July 23, 1985 Signing September 1985 September 24, 1985 Effectiveness December 1985 December 20, 1985 Midterm review (if applicable) 1988 1989 Project completion August 1990 March 1994 Loan closing August 1991 March 1994 1 As provided, for example, in the Staff Appraisal Report (SAR).  20 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (Credit 1 623-IN) Table 4: Credit Disbursements: Cumulative, Estimated and Actual (US$ Millions) EXFY E8 EI Y89 ELY EX91 Yf2 YE93 FYgA Appraisal Estimate 1.0 4.9 13.3 26.1 41.1 50.0 51.0 51.0 51.0 Actual 3.0 3.9 6.3 16.7 32.3 42.1 47.0 50.9 49.9 Actuai as % of Estimate 300 80 47 64 79 84 92 100 98 Date of final disbursement /1 /1 The Credit should be fully disbursed by July 31, 1994.  21 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (Credit 1623-IN) Table 5: Key Indicators for Project Implementation Key implementation indicators in SAR1 Estimated Actual2 1. Contraceptive prevalence approx. 50% approx. 50% 2. Proportion of acceptors of 25% 48% temporary contraceptive methods to all new acceptors 3. Proportion of deliveries 60% institutional deliveries assisted by trained 40t; deliveries assisted persons by trained dais not available 4. Antenatal coverage 85t 84% 5. Immunization coverage 85% DPT 74% Polio 72% BCG 66t Measles 49% 6. Infant mortality substantial substantial decline decline 1/All indicators refer to the four project districts rather than the state of West Bengal. 2/All figures refer to 1993.  22 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (Credit 1623-IN) Table 6: Key Indicators for Project Operation A. IN-SERVICE TRAINING In-service training goals were revised following the mid-term review in 1989 and a decision taken to provide all health and family welfare staff in the state with refresher and/or specialized training. The modified goals and achievements as of project completion (March 31, 1994) are given below: No. to be No. Trained trained as of 31/3/94 Multipurpose Workers-Female 8,126 6,430 Multipurpose Workers-Male 8,000 3,067 Medical Officers/ARI 2,000 1,400 Sister Tutors/ARI 220 220 Public Health Nurses 750 584 Health Supervisors-Female 1,764 934 Health Supervisors-Male 1,500 794 Note: Staff not yet trained as of 31/3/94 will be trained with support from the CSSM Project. B. CIVIL WORKS Project No.Con- Target structed Subcenter 752 752 PHC (30,000 pop. coverage) 32 32 Block PHC (100,000 pop.coverage) 3 3 Field Training Annex 23 23 Community Health Center/Rural Hospital 12 11 PHC Improvement/Refurbishment 1 77 76 PHC Improvement/Refurbishment II 171 163 Block PHC Improvement/Refurbishment 67 67 Supervisory Training School, Barddhaman 1 1 General Nurse-Midwife Training School, Purulia I I Research & Training Center, Salt Lake, Calcutta 1 1 Vehicle Workshop 2 Equipment Workshop 2 Cold Store 4 Note: The workshops and cold stores were not constructed because of changes in program strategy.  23 C. INFORMATION, EDUCATION AND COMMUNICATION (IEC) Project Achieve- Target ment Activities originally planned Jatra 3,140 3,275 Oriental Trg. Camp 23,135 15,635 Workshop for Writers & Editors 90 76 Essay & Debate Competition 90 84 Workshop for Folk Troupe 18 13 State IEC Conference 6 6 District IEC Conference 109 105 Block IEC Conference 1,685 1,438 Folk Performance 1,705 1,862 Wall Paintings 3,410 7,008 Hoarding 3,012 437 Bus Board Adv. 500 94 Exhibition Sets 363 163 Newspaper Adv. 2,000 1,430 Yatra Script 9 2 Pm. of SH Literature 20,000 20,000 VHG Kits 42,000 42,000 Metal Tablet 90,000 46,500 VHG Booklet 42,000 42,000 Pm. of FW Literature 210,000 165,000 Pm. of FW Magazine (Qtly) 600,000 127,000 Production of TV spots 10 10 Production of Filmns 10 3 Prints of Video Films 200 80 Purchase of Film from Film Division 200 117 Purchase of Offset Press Equipment: (i) Offset Press Camera 1 1 (ii) Addressograph Machine I I (iii) Graining Machine 1 1 (iv) Jogging Machine 1 I (v) Paper Lifting Trolley 1 1 (vi) Retouching Table 1 1 (vii) Photo Type Setting Mc 1 1 IEC Training: (i) IEC Training for Dy. Demos for 6 working days at Gandhgrarn Institute of R.H. & F.W. 36 32 (ii) IEC Training for Dist. Level Officers, Trainers of HFWTC & Lecturers of PP Units, selected BMOHs & SWOs at Indian Instit. of Health Management, Jaipur 60 27 (iii) IEC Training SWOs 60 60  24 Activities added subsequently Project Achieve- Target ment Copies of Yatra scripts 9,000 2,000 Group discussions with mothers 14,000 12,300 Printing of ARI folders 200,000 200,000 Printing of ARI posters 50,000 50,000 Village health fairs 9 8 Special IEC prograrn on ORT 31 blocks 31 blocks Estbl. of Mahila Swastha Sangha (MSS) 1,200 MSS 1,200 MSS Maintenance of MSS 150 MSS 150 MSS  25 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (Credit 1623-IN) Table 7: Studies Included in the Project The SAR (Annex 5) includes an indicative list of eight studies/ evaluations concerned with various aspects of project implementation. * Item (a), follow-up study of acceptors of laparascopic sterilization, was carried out as no. 7 below. * Item (d), evaluation of IEC messages on MCH, was partially covered in the mid-term and end-of-project studies (nos. 6, 11 below). * Item (f), an evaluation of the management information system, was carried out for the Government of India by the Administrative Staff college of India. * Item (h), evaluation of in-service training, was carried out as no. 9 below. None of the rest was carried out in the form suggested in the SAR. The following studies were carried out with project support: 1. Baseline Survey. Indian Institute of Management, Calcutta, 1987. The baseline study was too delayed to have significant impact on project planning or implementation. 2. Survey on Gaps in Knowledge, skills and Practices of Health Personnel. Indian Institute of Management, Calcutta, 1987. Provided the basis for in-service training prior to the mid-term review. 3. A Comparative Study of Constructed and Rented Subcentres. DOHFW, 1988. This study shed little light on its nominal subject, because it proved impossible to identify an adequate number of subcenters constructed prior to the project that were not decrepit. However, findings concerning the strong relationship between in-service training and field worker performance were partly responsible for a major restructuring of the project's in-service training component. 4. Feasibility Study for a Research and Training Centre. Administrative Staff College of India, 1989. Provided the basis for the form of the RTC finally agreed by GOI, GOWB and the Bank. 5. Coverage Evaluation Survey on Immunisation Status. DOHFW, 1990. Indicated gaps in the implementation of the immunization program.  26 6. Mid-Term Evaluation Study. MODE, 1989. Contributed to modifications of project in-service training and IEC components in particular; also indicated that the MIS component was on track. 7. Follow-Up Study of Acceptors of Laparascopic Female Sterilization. DOHFW, 1990. Indicated that in some cases more careful follow-up was needed. 8. A Study on the Retention Rate for IUDs. DOHFW, 1990. Analyzed the factors involved in low IUD retention rates in West Bengal. 9. Evaluation of In-Service Training Programme of ANMs. DOHFW, 1992. Indicated that despite progress there were still gaps in in-service training, which inter alia needed to be made more practical. Was in large measure responsible for further modification of the project's in- service training component to address study findings. 10. A Study on the Factors Responsible for Good Performance/Poor Performance in Sub-Centres. DOHFW, 1994. Identified field work, community involvement and IEC as the key factors responsible for superior family planning performance; highlighted lack of necessary association between good family planning and MCH performance; also noted general failure of field workers to deal adequately with either acute respiratory illnesses of minor ailments. Provides DOHFW with important clues for improved program implementation. 11. End-Line Study. MODE, 1994. Documented general success of the project as well as problem areas.  27 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (Credit 1623-IN) Table 8: Project Costs Appraisal Estimate (Rs. M) Actual (Rs. M) Capital Costs Civil Works 473.0 825.1 Furniture, Equipment 73.1 98.7 and Vehicles Subtotal, Capital Costs 546.1 923.8 Incremental Recurrent Costs Salaries 183.2 125.8 Training and Orientation 90.3 125.0 Costs, IEC Materials, and Maintenance Costs Subtotal, Incremental 819.6 250.8 Recurrent Costs Contincencies Physical 26.1 Price 233.3 Subtotal, Contingencies 259.4 TOTAL 1079.0 1174.7 Note: All foreign costs were indirect. US$ equivalents for actual costs are not available.  28 PROJECT COMIPLETION REPORT INDIA FOURTH POPULATION PROJECT (CREDIT 1623-IN) Table 10: Status of Legal Covenants Project Agreement Covenant Original Section Type Status Date Description of Covenant Comments 4 M C Annual Furnish to the Association no later February 1 than two months before the beginning of each financial year, curricula and a timetable for the retraining of staff in Project Districts. 5 (a) M CD April Complete a mnidterm review of the Midterm review 1988 progress of each component of the was carried out by project and of the performance for GOWB in 1989 the Family Welfare Program in WB and discussed with with particular reference to selected Bank mission in districts. September 1989. 5 (b) M C April Furnish results of midtermn review to the 1988 Association for discussion and thereafter take all necessary sections with the Association. 6 (a) Pi NC June 30 Appoint a nucleus of senior staff SIHFW (renamed RTC) 1986 positions for the SIHFW, as agreed construction was with the Association. completed by March 31, 1994 but staff was not expected to be appointed until April 1994. 7 Pi NC December Establish and maintain two committees Committees were 31 1985 to coordinate the functions of (a) the superseded by merger Education and Media Division with the of units mentioned State Bureau of Health Education; and under both (a) and (b). (b) the Family Welfare Demographic and Evaluation Cell with the State Bureau of Health Intelligence, Said comnmittees to have membership, functions and powers satisfactory to the Association.  29 Project Agreement Covenant Original Section Type Status Date Description of Covenant Commn.ts 3.01 (a) A C Annual West Bengal shall maintain separate Dec. 31 records and accounts and submit to the Association copies which are certified by independent auditors, no later than 9 months after the end of each fiscal year 3.01 (b) A C Annual WB shall have accounts and financial Dec. 31 statements audited by independent auditors acceptable to IDA, and furnish copy of Audit to the Association 3.01 (c) A C Annual Maintain separate records for statements Dec. 31 of expenditure, ensure the separate accounts are included in annual audit, and ensure that a separate opinion by the auditors is given which certifies that a proceeds of the Credit have been used for the purpose for which they are provided. Schedule 2 1 M C Annual West Bengal to furnish no later Feb. I than two months before the beginning of its financial year, detailed annual demand generation strategies to the Association for its review and comment. 2 Pi C March WB take all measures to appoint the 31 1986 the required number of Health Assistants (Female). 3 ST C March Complete a survey to identify any 31 1986 significant gaps in the skills, knowledge and practices of family welfare staff as a basis for reorientation of staff in project districts, and fumish results to IDA. A: Accounts/audits C: Covenant complied with M: Monitoring/reviews CD: Complied with after delay PI: Project implementation NC: Not complied with ST: Studies  30 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (Credit 1623-IN) Table 1 2: Bank Resources: Actual Staff Inouts Number of Staffweeks Staae of Proiect Cycle jgW FY84 FY85 FY86 FY87 FY88 FY89 FY90 FY91 FY92 FY93 FY94 Through appraisal 102.1 27.6 74.5 Appraisal to Board 54.9 53.9 1.0 Board to Effectiveness Supervision 110.1 43.6 15.4 13.4 3.6 13.9 7.8 7.1 4.6 0.6 Completion 7.0 7.0 TOTALS 274.1 27.6 128.4 44.6 15.4 13.4 3.6 13.9 7.8 7.1 4.6 7.6 Note: Number of staffweeks on Completion is an estimate. Staffweek data from Board to Effectiveness not captured in the work program system.  31 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (CREDIT 1623 IN) Table 13: Bank Resources. M,ssions __________________ _____________________________________ _ ) P er ',r -a oce R al rgI Month/Year Number of Persons D )ays in hield f Specialized Staff Skills Represented Imple-ntaion Sutus | ating r.. 4ircr c |s Fcpes ot Problems THROUGH APPRAISAL AND EFFECTIVENESS Jan-Feb/84 I - Mg Jun-Jul/84 7 8 Ar, Dm. Ec, ]EC, Mg, PE, Tr Sep/84 2-- Mg, PH Nov/84 7 17 Ar, Dm, IEC. Mg, PE, Pli, Tr SUPERVISION Sep-Octl85 5 7 Ar, Dm, Mg, PH. Tr 3 3 M, T luon, 6 9 Ar, Dm, IEC, Mg, PE, Tr 3 F, M, T Nov/86 4 7 Ar, iEC. Mg, M&E 3 3 F, M, T Jun/87 3 - Ec. Mg. Tr 1 I ,T Dec/87 3 8 Ar, Dm. Ec 3 3 F, T Jun/88 4 10 Ar, Ec, IEC, Tr 2 T Dec/88 2 14 ArEc r2 r Sep/89 6 15 Ar, Dm. Ec, PH(3) 2 2 T Jun903 4 4 Ar, Dm, Ec. PH I Jarn/91 2 6 PH(21 I I Jan/92 3 5 Ar, Dm, PH I I Jan/93 4 3 Ar, Dm, PH, SA . | COMPIETION Jan/94 | 4 7 Ar, Dm, BEC, PH 7 1/ Spec,aheud sutfskills Ar . architect Dm: demographer IEC: iniformation, education and communication specialist Mg management specalist PE population education specialist PH: public healLh specialist SA . sysems analyst Tr . uaining speciaist 2/ Performance rutinx I problem-tree or minor priolems 2 moderate problens 3 rttlor problems 3/ Types of problems F finainil M : managerment T technical   33 APpendix A FOURTH POPULATION PROJECT - PROJECT COMPLETION MISSION January 19-25, 1994 Aide Memoire 1. A World Bank mission visited West Bengal from January 19-25, 1994 to carry out the project completion mission for the Fourth (West Bengal) Population Project. The mission comprised Mrs. F. Plunkett (mission leader), Dr. K.B. Banerjee (public health specialist); Mr. S. Chakravarty (consultant architect); and Mr. P. Kakkar (consultant IEC specialist). The mission was joined by Mr. P.C. Datta, Under Secretary, and at the wrap-up meeting by Mrs. Jayashree Gupta, Deputy Secretary, Ministry of Health & Family Welfare. The mission would like to thank the Government of West Bengal, the Department of Health & Family Welfare, and the entire project team, both in Calcutta and the project districts, for the courtesy, cooperation and assistance extended to the Bank missions throughout the project. The mission's field visit was particularly useful in providing a fuller understanding of project achievements and impact. West Bengal Project Completion Report 2. The mission would like to congratulate the project unit on the excellent, very complete and useful project completion report that has been prepared. The PCR, together with the end-of-project report prepared by MODE Research Ltd., have provided the mission with much of the material needed for preparation of the Bank's own project completion report. The excellent 'Case Study of Two Pairs of Subcentres' carried out by the Department of Health & Family Welfare also provides important insights into factors affecting program effectiveness; the mission recommends wider dissemination and/or publication of this study. Credit Closing 3. The Credit for the project will close on March 31, 1994. The Department of Health & Family Welfare is reminded that all project expenditures must be incurred on or before that date. A period of four months is provided to close out accounts and submit final disbursement applications; applications must therefore be submitted to the Bank on or before July 31, 1994. The Department may retain skeleton project staff for the wind-up period. Project Status and Impact 4. As the project comes to an end, the mission notes from the end-of project report that the project's physical goals have been met almost entirely and that project impact  34 objectives have also been by and large achieved. After a difficult start, the management and accomplishments of this project have been impressive. Through the provision of a package that included better subcenter coverage, strengthened referral capacity, effective in-service training, a functional MIS and targeted IEC, the coverage and quality of services has been significantly improved and family planning and MCH achievements have increased substantially over the project period. Coverage levels in the project districts appear to be consistently higher than those in the rest of the state's districts. The Departmnent of Family Welfare, the project coordinator, and all of those associated with the project, past and present, deserve sincere congratulations for their hard and dedicated work and their accomplishments. Project Issues 5. The end-of-project report and the mission's field observations raise several questions concerning the construction of subcenters. A substantial proportion of subcenters are reported to have been located outside the populated area of the village, in violation of project guidelines. An even larger proportion of quarters are not being occupied by the ANMs for whom they are intended, reflecting both unsuitable location as well as the strict West Bengal policy designed to ensure that ANMs come from the rural areas where they will serve; some ANMs therefore prefer to live in family homes rather than to occupy the quarters. The mission recommends that the Department systematically pursue the utilization of non-occupied quarters for IEC and community activities, as was observed at one subcenter visited by the mission. 6. It does not appear to be possible to address the question of the contribution of constructed subcenters to project achievements on the basis of available information. Clearly, many ANMs using rented facilities are able to achieve excellent results. An attempt to assess this was made early in the project, but the lack of functioning constructed subcenters at the time prevented a useful comparison. The mission recommends that the Dept. undertake such a study at this time, to obtain a better understanding of the role, if any, of constructed subcenters in program accomplishments and to guide possible future state investment in the construction of additional subcenters. 7. After the history of delays, the mission was pleased to learn that the construction for the Research & Training Centre (RTC) is essentially completed. However, it is distressing to learn that despite the recommnendations of previous missions furniture and equipment have not yet been procured, nor has anything been done to sanction posts and establish at least a nucleus for the institution that now needs to be developed. The failure to operationalize the RTC during the project period is a matter of serious concern to the Bank and represents a regrettable exception to an otherwise impressive record of achievement. Continuing Support 8. The mission is glad to record that no difficulties concerning absorption of staff appointed under the project are expected. The Dept. expects to complete the round of in-  35 service training begun under the project for all workers in the state and subsequently expects to provide refresher training at training institutions at intervals of three years; in the interim years ongoing training will be carried out locally on a regular basis. The IEC program is planning for more effective use of diminished resources, by inter alia more targeted selection of audiences and messages as well as coordination of media use. Support for family welfare services will also be available through the Bank-supported Child Survival and Safe Motherhood (CSSM) Project Sustainabiliti' 9. The mission raised three major sustainability issues with GOWB and GOI at the wrap-up meeting. First, as noted above the failure to operationalize the RTC during the project puts into question the future of the institution and the justification for the major investment in the physical facilities. The mission notes the assurances given by the Health Secretary that staff positions will be sanctioned and filled in 1994-95 and that the institution made functional as soon as possible. 10. Second, the maintenance of the facilities constructed with project support appears to be in question. The mission's architect reports that facilities constructed early in the project already require maintenance, and within several years the maintenance requirements will be substantial. The mission also notes the Health Secretary's assurances in this regard. However, past experience in other Bank-supported population projects concerning maintenance of facilities is not encouraging. Funds for the purpose are controlled by the PWD rather than by the Health Dept., and even if funds are nominally allocated, the experience has been that the PWD is reluctant to use them for maintenance of small, scattered rural facilities. The mission therefore would like to suggest to GOWB and GOI that this matter deserves special attention and that a concerted and sustained effort is likely to be necessary to achieve results. GOWB might also wish to explore the possibility of involving the panchayats in facilitating maintenance, especially since some of the subcenter construction was handled by the panchayats. 11. Third, the mission's field observations, as well as discussions with paramedical staff and doctors, reinforce the conclusion that the state's ability to provide quality health and family welfare services is crucially dependent on the availability of contraceptives, vaccines, drugs, ORS, other supplies, and equipment. While supply of those subcenter items supported by the central family welfare program has been relatively satisfactory, and will be supported, at least for several years, under the Child Survival and Safe Motherhood Project, there is no guarantee of continued central support. The current supply to subcenters and referral institutions by the state is unsatisfactory. Given the financial constraints under which GOWB operates, continued support for activities begun or strengthened under the project may also be at risk. To cite a specific example, failure of the state to provide support for the printing of MIS registers and reporting forms would seriously undermine the excellent system that has been developed with project support.  36 Lessons Learned 12. The Bank's conclusions concerning project and program lessons learned from the experience of this project will be included in the Bank's project completion report. Nevertheless, the mission would like to take this opportunity to record its appreciation of the discussion of lessons learned in the West Bengal project completion report. The ability of project/program managers to learn from experience and make appropriate changes in program management and implementation is clearly one of the factors that has contributed to the success of this project, and it bodes well for the future of the family welfare program in West Bengal.  37 ARpendix B PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (CREDIT 1623-IN) SUMMARY OF WEST BENGAL PROJECT COMPLETION REPORT 1. India Population Project IV, a project in the series of Area Projects taken up by the Govermnent of India with the help of World Bank assistance, becarne operational in West Bengal on Septernber 1, 1985. Project design was based on the approach papers prepared for the Seventh Five Year Plan (1985- 90) which called for sustained development of Primary Health Care, Family Planning and Maternal And Child Health Programmnes, improved coordination with cormunity leaders, basic and continuing staff training. The project strategy was formulated taking into account the socio-economic characteristics and status of the current Family Welfare Programmne of West Bengal. Emphasis was on qualitative improvements in the areas of service delivery, training, monitoring, evaluation and information, education and communication. PROJECT AREA 2. The four contiguous districts of West Bengal - Burdwan, Birbhum, Bankura and Purulia - were selected as the project area. Total population of the project area was 111.60 lakhs as per 1981 Census out of a total population of 545.8 lakhs in the State as a whole. However, monitoring, evaluation and IEC components of the project were taken up in the entire State right from the beginning of the project, while the training activities of the project were extended to the entire state from 1989-90. Project support for service delivery, other than civil works, was also extended to all the districts of the State during later stages of the project. OBJECTIV 3. The objectives of the project were to: (a) Reduce fertility and infant, child and maternal mortality by focussing on specific programme interventions and generating demand for services; (b) Ameliorate programme constraints by improving service coverage and quality, management, training and monitoring and evaluation; and (c) Provide experience of replicable prograrnme improvements which will support the National Family Welfare programme and the attainment of its population goals.  38 ACHIEVEAIENTS UNDER DIFFERENT CONIPONENTS OF THE PROJECT Civil Works 4. One of the basic strategies of the project was to improve the delivery of services by expanding the health infrastructure and extending the services as near to the doorstep as possible. The project provided for construction of 752 sub-centres, 35 PHCs (old and new) and 11 CHCs. There was also provision for refurbishing of some 306 units of the existing PHCs and BPHCs. For improvement of training facilities in this State, construction of one GNM Training School, one Supervisors' Training School, 23 Training Annexes and one Research and Training Centre was also taken up under this project. In all 1,130 Health Care Units were taken up for construction. 5. P.W. (CB) Dte, PHE Dte., PWD and Zilla Parishads were the executing agencies for the construction work. Besides, W.B.S.E.B. was also engaged for providing electrical service connection to these health care units. 6. All the sites of the Health Care Units except for the site for Research and Training Center at Salt Lake were either donated by village community or situated on public land. These sites were selected by the District Committees headed by Zilla Sabhadhipati. 7. At the initial stage there were some difficulties in regard to selection of sites, procurement of cement and steel, finalization of design, etc., and the process was slow. The initial difficulties were overcome and the project gradually gained momentum. From the third year onwards the progress was very satisfactory and by the end of the project period almost all the proposed units were completed. 8. The service units under the project were provided with transport, equipments and furniture for improving their service facilities. Some incremental staff were also provided to extend and improve the coverage of F.W. and M.C.H. services. (a) Sub-Centres. The sub-centre is the health unit at the grassroot level to cater for about 5000 population. It consists of a clinic with provision for consultation. examination and space for waiting patients. It also has the provision for residential accommodation of Auxiliary Nurse-cum- Midwife. It has a covered area of 60 sq.m. There was provision for construction of 752 sub-centres in four project districts. Initially the sanctioned cost for each unit was Rs.1,37,800/- but this estimate was subsequently revised as Rs.2,03,080/- for normal soil and Rs.2,39,660/- for cracky type of soil. (b) New P.H.C. A new PHC serves a population of about 30,000. Provision was made for construction of 32 new PHCs in four project districts. The following facilities have been provided in this unit - operation theatre, laboratory, six-bedded ward for medical and maternity patients, inner waiting space for patients, outer waiting space, dispensary, store, office room, doctors' exarnination room, garage, staff quarters for medical officers and staff, etc. Initially the sanctioned cost of new PHC was Rs.24,33,400/- which was subsequently revised. (c) New Old Primarv Health Centre. An old PHC will serve a population of more than one lakh. There were three such units proposed to be  39 constructed under the project. All of them have been completed. Each unit has the provision for OT complex having operation and delivery suites, 10-bedded ward for medical and maternity patients, dispensary, three rooms for examination by doctors, multipurpose space, inner and outer waiEing space, etc., besides the staff quarters. Sanctioned cost of each unit was Rs.37,69, 100/- which has subsequently escalated. (d) UDgradation of Old PHC. Each CHC s required to serve more than 4 lakhs of population. This is a referral hospital. Eleven PHCs have been upgraded to CHC by creating additional facilities like wards for 20 patients, O.T. complex, laboratory, x-ray units, etc. Provision has also been made for aseptic OT, aseptic delivery, recovery room attached to OT complex, staff quarters for medical and para-medical staff, etc. Sanctioned cost for each unit was Rs.53,54,000/- which was subsequently enhanced. (e) New PHC Imp.I. Under this scheme, the new PHCs were improved by providing 6-bedded ward for medical and maternity patients, OT room and delivery room, laboratory, garage, etc. The covered area of the new input building is 292 sq.m. Against the provision of 77 units, the construction of 76 units were taken up and completed. Sanctioned cost for each unit was Rs.9,94,294/- which was subsequently revised. (f) New PHC Imp.II. Under this scheme, provision was made for creation of additional facilities in 163 units by providing OT complex and laboratory, covered area of the new building is 153 sq.m. Sanctioned cost for each unit was Rs.7,45,922/-. (g) Improvement of Old PHC. 67 such units were provided with OT complex and laboratory by constructing an input building having an area of 226 sq.m. Sanctioned cost for each unit was Rs.7, 10,000/- which was subsequently enhanced. (h) Multipurpose Health Worker (Female) Training Annex. For training of multipurpose workers (female), provision was made for construction of training annexes attached to each of the rural hospitals (CHC) under the project by providing classroom, laboratory, office equipment, store, dormnitory type hostel, instructor's room, etc. Each unit has a covered area of 235 sq.m. Construction of 23 such units were completed against the provision of 24 units. Construction of one unit was, however, dropped due to a court case. Sanctioned cost for 16 units was Rs.6,68,900/- and the cost was revised to Rs.11,82,100/- for 8 units. (i) Trainine Schools. One Supervisors' Training School at Burdwan and one GNM Training School at Purulia were constructed at an estimated cost of Rs.42,19,195/- and Rs.1,61,36,312/- respectively. The built up area of the Supervisors' Training School is 1256 sq.m. while the total covered area of the GNM Training School is 5172 sq.m.  40 (j) Research and Training Centre. As an apex body to plan and guide the training programme of the State, construction of a Research and Training Center at Salt Lake has been taken under the project. The revised cost for this institute is to the tune of Rs.280 lakhs. It has the following structures: (i) Two storied Institute block; (ii) Three storied Hostel block; (iii) Utility block and residential quarters; and (iv) Ground reservoir, external water supply, roads and drains, compound fencing with gate, etc. The construction of the Institute is complete. Demand Generation 9. In order to generate demand for MCH and FW services and also to convey new information and teach new skills to the workers, IEC strategies were developed and implemented under the project. Annual action plans were prepared keeping in view the strategy plan and priority areas. These action plans, strategies and approaches were reviewed from time to time on the basis of experience, feedback received from field functionaries, findings of mid-term evaluation and reconmnendations of the World Bank missions and modified accordingly. Some area specific innovative programmes were also taken up under the project. Training courses on IEC were organized to improve the knowledge and skill of the workers playing the key role in organizing the IEC activities. The major activities under the IEC progranune were as below: A. Comrnunity Involvement and Communitv Education: (i) Orientation training camps for opinion leaders were organized for community education and community development; (ii) Family Welfare Advisory Commnittees were formed at the sub-centre, block, district and state levels with members from Panchayat, other development agencies, staff of the Health and FW department and other government departments; (iii) A variety of educational materials for community education have been produced and distributed. B. Mass Media. Wall paintings, hoardings and bus board advertisements with different messages have been made under this programme. Exhibition sets have been produced and distributed to different units for participation in local exhibitions, fairs, melas, etc. Metal tablet sets have been produced and distributed for permanent display at PHCs and Sub-Centres.  41 One feature film on Family Welfare with 40 prints was produced and 117 prints of different films were purchased from Films Division and distributed to District A.V. Units for regular exhibition. C. Jatra Performance and Traditional Folk Media. For organizing Jatra performance at the block level local professional troupes and youth or village welfare organizations having experience in performing open air drama or jatra in villages were selected. Such programmes were however replaced by traditional folk programmes later on in the light of the feedback. D. Workshop and Conferences. Workshops for Writers and Editors, ANMs, SWOs, Dy.Demos, Artists and Projectionists were organized. E. Innovative IEC Programmes. (i) Village Health Fair. The purpose of holding a health fair in a selected block is to extend education on Health and Family Welfare, provide Health Care Services and entertainment in the form of evening cultural programnrnes. Seminars and discussions, exhibitions, debate and quiz contests, distribution of literatures, extending health care services, evening entertainment, etc. are different components of this health fair. A number of such fairs were organized under the project. The unique feature of these fairs was a huge procession of people from all walks of life to mobilize public participation. (ii) Mahila Swastha SanEha (M.S.S.). One M.S.S. is formed for a village of about 1,000 population. A Sangha has 15 members with ANM, AWW, CHG, TBA, etc., as members. The members are oriented in a one-day camp immediately after selection and they meet every month to review the programme and health problems of the village. Better family welfare acceptance could be demonstrated in the selected blocks after the fornation of M.S.S. (iii) Essay and debate competitions, mothers' discussion group. IEC programmne on prevention and control of diarrhoea] diseases were other innovative programmes organized under the project. Population Education 10. Training to Grain Panchayat members, Trade Union Leaders, workers of Labour Welfare Centres, Project Officers, Assistant Project Officers, Extension Officers of Mass Education Department, key persons of colleges and Teachers' Training Colleges, students of Degree Colleges, etc., were organized under the Population Education Programme through different Departments of Government. Training 11. The project provided substantial support for institutionalization of inservice training. It also helped in creating additional training facilities including a state level Research and Training Centre. A working group was constituted to coordinate and guide the training activities.  42 12. Indian Institute of Management. Calcutta, conducted a study to find out the gaps in knowledge, skills and practices of some key category workers. This helped in developing purposeful training strategy for different categories of workers. 13. Mode Services Pvt. Ltd. conducted the mid-term review of IPP-IV, which inter alia reviewed the ongoing training programnne. This also helped in revision of training curriculum and identifying priority areas. An evaluation of inservice training programme of ANM was also conducted by MIES branch. This helped in reorganizing and improving further the training programmes of ANM. The following categories of training programrnes were organized under the project; (i) Inservice training programme of ANMs. (Initially the progranmme was of 6 days duration. It was extended to 11 days. A separate course of 4 days' duration was organized for those who had earlier undergone training for 6 days; (ii) Inservice training of Health Supervisors. (Originally it was planned for six working days, but the same was extended to 11 working days); (iii) Inservice training of P.H.N. for 11 days; (iv) Reorientation Training of Dais for two days; (v) Training of Medical Officers and Teachers of Nursing Training Schools in ARI of 4 days' duration; (vi) Inservice Training of Medical Officers for 5 working days; (vii) Inservice Training of Multipurpose Workers (male) for 11 days; (viii) Inservice Training of Supervisors (male) for 11 working days; (ix) I.U.D. training of ANMs; (x) Inservice Training of ANMs. 14. A training calendar was developed for each category of worker for each year. The existing training facilities like Nurse's Training School, Health and Family Welfare Training Centres, P.S.M. Department of Medical Colleges, PHN Training School, etc., were utilized as far as practicable. Maximum stress was given on practical aspects and on the job training. MIES (i) A single reporting form was introduced at sub-centre, sector and PHC level. Now, normally no other report needs to be submitted from these units. The new PHC monthly report and sub-centre monthly report contained informnation on essential inputs like staffing, training status, cold chain position;  43 (ii) Eligible couple registers were redesigned, printed and supplied to all the workers at the sub-centre level. The new eligible couple register renamed as eligible couple and children register (ECCR) contains information of immunization status of all children in the age group of 0-5 years along with information about F.P. status of the couples. Provision to record and update follow up particulars in respect of couples and children was also made in the ECCR. Every printed ECCR now contains a detailed instruction in Bengali as to the procedure of maintaining the register. A summary sheet for consolidation of the records contained in the register was also provided in the register. A module has been prepared on utilization of ECCR for planning house visits on priority basis, monitoring and evaluation of work of a sub- centre. (iii) Record keeping at the sub-centre level has been standardized and total number of registers has been reduced to a great extent. (iv) A system of monitoring and feedback at the district, block and sector levels has been introduced through some standardized format and instructions. The check list for supervisors, analytical report for review of programmes, formats for writing resolutions of review meeting etc., have been introduced; (v) The new system was introduced only after imparting necessary MIES training to all staff from sub-centre to district level. The PHC computers, because of their important role in MIES has been included in the curricula for basic and inservice training programme for all nursing and para-medical staff. 89 workshops were organized throughout the state with MPWs on MIES in general and utilization of ECCR in particular; and (vi) One P.C. with printer has been installed at the D&E Cell of SFWB for better analysis of information generated through MIES. IMPACT OF IPP-V 15. The project document clearly laid down the priorities of the project on the basis of a detailed analysis of the pre-project status of the State and the project districts. The achievements of the project have been examined from this point of view in the following paragraphs: 16. Overall decline in fertilitv. mortality and infant mortality in the State. The primary object of the project was to promote a Family Welfare Program with greater emphasis on MCH Care in the State in general and in project districts in particular. A comparison of the basic vital rates (Samnple Registration System) - birth rates, death rates and infant mortality rates in the pre-project year of 1984 with the same rates in 1992 in the table below shows that there has been substantial progress in this direction in West Bengal. The corresponding rates for India are also shown in the table below:  44 West Bengal India 1984 1992 1984 1992 Birth Rate 30.4 24.6 33.9 29.0 Death Rate 10.7 8.3 12.6 10.0 Infant Mortality Rate 82.0 64.0 104.0 79.0 17. Increase in Effective Couple Protection Rate. There has been significant increase in couple protection rate (CPR) in the State as a whole during the period from the year 1984 to 1992. However, the rate of increase was much more in project districts presumably due to investments in a service deliverv component which was limited to the project districts only and priority attention received by these districts in other components. Couple Protection Rate As Of 03/31/1984 03/31/1993 Project Districts 33 52 Non-Project Districts 26 33 State 28 37 18. Increase in Acceptance of Temporary Methods. The project has taken up the strategy of increasing the use of temporary methods while continuing efforts to promote the adoption of permanent methods. In fact use of temporary methods lagged in the project districts (as in all West Bengal) when IPP-IV was taken up. The project had set up a goal of proportions of temporary acceptors as 50% of all new acceptors. There has been substantial increase in proportion of temporarv acceptors in the project districts and in the State at the end of the project period as shown below: Percent of Total New Acceptors 1983-84 1992-93 Proiect State Goal Proiect State Sterilization 64 64 50 35 31 IUD 4 8 20 19 16 CC User 29 24 25 33 36 Oral Pill User 3 3 5 13 17 19. The project had its emphasis on reach and quality of MCH Care. There has been significant improvement in MCH coverage in the state during the last few years as already indicated by deciine of Infant Monality Rate in West Bengal. In fact near 100 percent achievement of targets (all infants and pregnant women) of universal immnunization programmes was possible in the last few years in the project districts.  45 20. In the State as well progress was remarkable. A comparison of current achievement levels with those in 1985-86 in the State is shown in the following table: Percentage of Target Achieved 1985-86 1992-93 State Proiect State TT (PW) 64.7 98.9 76.8 DPT 44.1 106.2 87.3 Polio 25.6 107.1 88.4 BCG 56.1 106.6 88.0 Measles 45.9 93.0 70.9 21. End Line Survey. At the end of the project an End Line Survey was conducted through Measrs. Mode Services Pvt. Ltd. The objective was to assess the impact of different components of the project quantitatively and qualitatively. The Survey also highlighted the lessons learned through implementation process of IPP-IV. The findings of the End Line Survey are summarized below: (a) There has been substantial improvements in contraceptive prevalence rate and immunization coverage rates in the four districts covered under IPP-IV project. The rate of increase was higher in project districts than the same in non-project districts. Reach of ante-natal and post-natal care improved considerably in the project districts. The performance of these districts in terms of immunization coverage, institutional birth and utilization of Government health facilities improved steadily during the project period. From the household survey it was observed that there is a general improvement in the level of awareness of the people regarding F.W. Ante-natal Care, Child Survival, Oral Rehydradation Therapy, etc. But in vital issues like attitude regarding age at marriage, breast feeding, ideal family size. etc., there has been no significant change. (b) The training programme was well planned and extended to all the districts of the State under IPP-IV. The coverage of inservice training prograrrme particularly for ANMs has been quite impressive. The quality of training progranune as revealed from the survey was satisfactory. (c) Development of Management Information Evaluation System was another success of the projea. Recording and reporting system was standardized, number of registers reduced and maintenance and utilization of ECCR were introduced in the State under the project. (d) A wide range of IEC activities was attempted under the project including special efforts for specific conmmunity groups. However, greater attention should have been paid to this component under the project. (e) Under the service delivery component a huge amount of civil works was taken up under the project to construct over 1100 health care units (including 752 sub-centres). The building constructinn process was. however. unusually delayed and its impact could not be fully felt during the project. Only at a very later stage the equipment for MCH Care  46 started reaching the sub-centres. Very few of the quarters of ANMs in the sub-centres constructed under the project were being used. Delay in implementation of service delivery has been one major constraint of the project. 22. Lessons Leamt: (a) Infrastructure development should precede the software investment to get the full benefit under a project. Delay in infrastructure development prevents full attainment of project impact during the project period itself; (b) Considering the huge investment required for creation and naintenance of physical infrastructure it would be more cost-effective in the long run to concentrate on upgradation of the existing infrastructure to the extent necessary and give more emphasis on training, IEC and MIES; (c) There is need for more attention in selection of sites for the service delivery units. The system of using donated lands should be reviewed. Such lands are not often ideally located. The Health Care Units should be set up within villages if necessary by purchasing land; (d) Investnent of ANM staff quarters needs rethinking as most of the workers are not utilizing this facility; (c) IEC strategy should be developed on the basis of formative research to be undertaken at the initial stage of the project and studies and evaluation from time to time. Priority areas should be identified before hand and there should be more stress on area specific approach; (f) Investrnent on training proved to be most effective. Training strategy needs to be continuously evolved through training need assessment and regular evaluation; and (g) A good MIES and utilization of information generating through MIES can improve performance of the programrnme qualitatively and quantitatively.  47 ADpendix D-1 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (Credit 1623-IN) Family Planning Acceptors, West Bengal: Selected Years Temp. Oral Ster. Methods1 IUD Contr. Pro_ect Distrists No. of Acceptors 1984-85. 75535 13915 8028 5887 1988-89 93430 49688 33648 16040 1992-93 103316 94758 55103 39655 Pct. Increase. 1985-1993 371 581% 586% 574% Pct. of Total Acceptors 1984-85 84% 16% 9t 7% 1988-89 65% 351 241 11% i992-93 52% 48t 28% 20t Non-Project Districts Numbers of Acceptors 1984-85 196080 57033 38093 18940 1988-89 242443 150748 83216 67532 1992-93 209643 242012 107610 134402 Pct. Increase, 1985-1993 7% 324% 182% 610% Pct. of Total Acceptors 1984-85 77% 23% 15% 7% 1988-89 62t 38t 21% 171 1992-93 46P 54% 24% 30% l/Condoms have not been included in the total for acceptors of temporary methods because of the unreliability of figures for condom acceptance and use. The figure for oral contraceptives represents couple years of protection, that is, the number of cycles distributed divided by 13, rather than the3 number of new acceptors.   49 Appendix D-2 Page 1 of 2 PROJECT COMPLETION RPORT I= FOURTH POPULATION PROJECT (Credit 1623-IN) Coverage of MCH Services. Proiect Districts vs. Rural West Bengal Pct. Lpcation Pate Cglerage SoQLe BCG Barddhaman Dist.* 1990 73 1 Bankura Dist.* 1992 80 2 rural West Bengal 1992 61 3 polio-full immunization Barddhaman Dist. 1990 72 1 Bankura Dist. 1992 76 2 rural Went Bengal 1992 51 3 DPT-full immunization Barddhaman Dist. 1990 71 1 Bankura Dist. 1992 74 2 rural West Bengal 1992 49 3 Measles Barddhaman Dist. 1990 51 1 Bankura Dist. 1992 50 2 rural West Bengal 1992 41 3 No immunization Barddhaman Dist. 1990 2C 1 Bankura Dist. 1992 9 2 rural West Bengal 1992 25 3 TT (pregnant women)- Barddhaman Dist. 1990 88 1 full immunization Bankura Dist. 1992 88 2 rural West Bengal 1992 76 3 Antenatal examination rural West Bengal** 1992 65 3 project distric:s*** 1993 84 4 institutional delivery rural West Bengal** 1990 21 5 project districs*** 1993 40 4 * Barddhaman and Bankura were project d_strcts. ** Based on births in year prior to survey *** Based on births in four years prior to survey  50 Appendix D-2 Page 2 of 2 Sources: 1. Coverage Evaluation Survey, Barddhaman District, 1990 2. Coverage Evaluation Survey, Bankura District, 1992 3. National Family Health Survey for West Bengal, 1992 4. End-of-Project Survey, 1993 5. Sample Registration System (SRS), 1990  51 PROJECT COMPLETIrN REP_Ra INDA FOURTH POPFLATION PROJECT (Credit 1623-IN) Subcenter Coverage. Rural West Bengal: 1985: 1994 1.1.85 Rural Pop. No. of Av. Pop./ tmil.) Subcenters Subcenter Project Dists. 9.8 1,112 8.795 Non-Project 33.7 3,487 9,655 Dists. 1..4 Rural POp. No. of Av. Pop./ (mil.) Subcenters Subcenter Project Dists. 11.2 1,952 5,761 Non-Project 41.1 6,174 6,656 Dists. Sources: Census of India 1981, 1991; Went Bengal Dept. of Health & Family Welfare. Population figures for 1994 are projected.   53 Appendix D-4 Page 1 of 2 PROJECT COMPLETION REPORT nmLI FOURTH POPULATION PROJECT (Credit 1623-IN) West Bengal Health & Family Welfare Management Informtion System The MIS developed in West Bengal with project support is based on a set of subcenter registers and reporting forms that link the subcenter, PHC, district and state. The basic set of subcenter registers is limited to three, which are supplied to all subcenters in printed form: 1. Eligible Couple and Children Register (ECCR) 2. Clinic Service Register 3. Diary These are supplemented by antenatal and immunization cards as well as a few additional supply and related registers. This is a far smaller set of registers than that in use in any other state. The ECCR is used the record the current family planning status of all eligible couples (wife 15-44) as well as services provided, and the immunization status of all children below age 6. The clinic service register and the diary are used to record provision of services by date. The system has greatly reduced duplication in record keeping. Workers can quickly take totals for various services provided from the clinic register and diary in order to fill out weekly or monthly reporting forms. They can use the ECCR, supplemented by the cards, to identify priority family planning and maternity cases as well as needed immunizations. The Indian family welfare program has been noted for its ability to collect monthly sterilization achievement figures, and more recently immunization figures as well, and rapidly forward them from PEC to district to state to Delhi. What distinguishes the West Bengal MIS is the use of the system for a range of management purposes at several levels. Field workera are trained to use the ECCR for prioritization of households and tasks. They are asked to plan their field visits beforehand on the basis of a set of priorities provided to them, with the caution that the priorities are to be used flexibly.  54 Appendix D-4 Page 2 of 2 Once a year, workers use the ECCR to calculate contraceptive prevalence as of the last day of the year, which results in prevalence figures for each village in the subcenter area by method, age, and number of living children. One of the most obvious indications of the development of the MIS is to see on subcenter walls a chart showing the CPR for the subcenter area by village and method for the last several years. It is therefore possible to see at a glance overall progress over time, the relative progress of the different contraceptive methods, and whether any village needs particular attention. Workers are also trained to use CPRs and other figures available to them from their records to assess their own progress in reaching coverage goals. CPRs are now cumulated at block and district level as well. For 1992- 93, CPRs from MIS data were available for 14 of 18 districts in West Bengal. These CPRs represent actual contraceptive use, in contrast to the couple protection rates that the Indian family welfare program calculates from achievement numbers. The two sets of figures correspond fairly well, indicating that the MIS prevalence rates are reasonable and also that the achievement figures for temporary contraceptive methods are not substantially inflated, as in the case in some other states. The major achievements of the West Bengal health & family welfare MIS can be summarized as follows: 1. There is now a standardized system for recording and reporting. Duplication has been avoided as far as practicable, and the workload of the workers for recording and reporting has been reduced to a great extent. 2. A fixed time schedule for reporting of data is now maintained. 3. ECCRs are now used routinely to prioritize house -isits and identify weaknesses and problems. CPRs are available for villages, subcenters and blocks for most of the districts. Village wise and subcenter-wise CPRs and other MIS information are being used for IEC planning and for organizing services. The ECCR has become the basis for planning, implementing and evaluating the work of field workers. 4. The monthly analytical MIS report is now being used at district and block level for monitoring and feedback. The monthly district-level meeting has become more meaningful through the use of the MIS analytical report and other information generated by the system, as well as a standardized MIS checklist. 5. Introduction of the MIS has brought to West Bengal family welfare and health programs a culture of decision making on the basis of information generated by the system.  55 Appendix D-S Page 1 of 2 PROJECT COMPLETION REPORT INDIA FOURTH POPULATION PROJECT (Credit 1623-rN) Evaluation of In-Service Traininc of Auxiliary Nurse-Midwives The following are the conclusions of a field evaluation of in-service training of auxiliary nurse-midwives (ANMs) carried out by the Department of Health & Family Welfare in 1992. 1. On the whole, the in-service training program succeeded in imparting knowledge and skills co a majority of the trainees. However, the evaluation indicated that 20-30' of the trainees lacked adequate knowledge and skills in some subjects even after having attended the training program, indicating that there was scope for improvement. 2. From feedback from the trainees, it was concluded that inclusion of mor practical demonstration in the classroom, hospital and subcenter clinics was needed to improve t;e training course. Modules prepared in Bengali are also required. 3. The training on acute respiratory infections (ARI) was found to be the least effective part of the curriculum. 4. For oral rehydration therapy (ORT), the practice level was high, but there were gaps in knowledge and skills about classification of dehydration and the type of advice to be given to the mother. This aspect of the curriculum needs to be strengthened by inclusion of more practical demonstrations sessions. S. Training in antenatal care (ANC) services was generally effective. But many of the trainees lacked required skills to carry out a urine test, and many were unable to classify or treat clinical anemia properly. It was reported that urine testing, blood pressure measurement, and weighing of pregnant women could not be done in many cases for want of equipment and supplies. As a result, many trained ANMS could not utilize the knowledge and skills acquired during the training program and tended to forget what they had learned. The same is true for detecri.on and management of low birth weight infants. Although the trainees learned different aspects of caring for LBW infants, the practice of weighing all babies at birth was not general and specific instructions to this effect were needed.  56 Agoendix D-5 Page 2 of 2 6. Many ANMs did not have proper knowledge about the type of family planning advice to be given to postnatal mothers. A need for special educational materials for postnatal mothers was indicated. 6. Lack of adequate knowledge and skill in sterilization of syringes and needles during immunization in a good number of cases was a matter of serious concern. 7. In the trainees' opinion, the IEC training did not include much that was new. S. About half of the ANMs evaluated lacked proper IUD insertion skills. They requested more practical sessions on ILU insertion during the training program.