Sri Lanka - Health Services Project

Document of The World Bank Report No. 15466-CE STAFF APPRAISAL REPORT DEMOCRATIC SOCIALIST REPUBLIC OF SRI LANKA HEALTH SERVICES PROJECT November 21, 1996 Population and Human Resources Division Country Department I South Asia Region  CURRENCY EQUIVALENTS Currency Unit = Rupees (LKR) LKRI.00 = US$.018 US$1.00 = LKR55.6 (October 11, 1996) FISCAL YEAR January 1 - December 31 ACRONYMS ADB Asian Development Bank AIDS Acquired Immunodeficiency Syndrome AMC Anti-Malaria Campaign DDHS Divisional Director of Health Services FHB Family Health Bureau GDP Gross Domestic Product GHC Gramodaya Health Center HEB Health Education Bureau HESP Health Economics Study Program (University of Colombo) HIV Human Immunodeficiency Virus IEC Information Education and Communication MCH Maternal and Child Health MDPU Management Development & Planning Unit MOH Ministry of Health MRI Medical Research Institute NCD Non-Communicable Disease NDTF National Development Trust Fund NGO Non-Governmental Organization NSACP National STD/AIDS Control Program PHC Primary Health Care PHI Public Health Inspector PHM Public Health Midwife PHNS Public Health Nursing Sister PMI Planning & Management Information PMU Project Management Unit SLMA Sri Lanka Medical Association STD Sexually Transmitted Disease UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children's Fund WHO World Health Organization Vice President Mr. D. Joseph Wood Director Ms. Mieko Nishimizu Division Chief/Manager: Ms. Barbara Herz Task Manager Ms. Frances Plunkett  DEMOCRATIC SOCIALIST REPUBLIC OF SRI LANKA HEALTH SERVICES PROJECT TABLE OF CONTENTS Page No. Credit and Project Summary ....................................... iii I. SECTOR BACKGROUND, ISSUES AND CONSTRAINTS I A. Introduction .1 B. Background I C. Population, Health and Nutrition Sector Status .2 D. Sector Issues and Constraints 4 E. Sector Development Strategy .8 II. THE PROJECT ..11 A. Objectives and Summary Description .11 B. Detailed Project Description .12 C. Environmental Considerations .28 III. PROJECT COSTS, FINANCING, PROCUREMENT, DISBURSEMENT AND IMPLEMENTATION . .29 A. Project Costs . .. 29 B. Financing Plan .31 C. Procurement .31 D. Disbursement .34 E. Accounts and Audits .... 35 F. Project Management and Implementation .35 IV. BENEFITS, ECONOMIC JUSTIFICATION AND RISKS ................ 38 A. Benefits ......................... 38 B. Economic Justification ..................................... 39 C. Risks ................................................. 42 V. AGREEMENTS REACHED AND RECOMMENDATIONS ............. .. 43 ANNEXES 1. Basic Sector Data and Key Statistics .45 2. Organization of the Family Health Program 47 3. Malaria Component 51 4. STD/AIDS Component .61 5. Nutrition Component .73 6. Health Policy Component: Proposed Link Program Between the Health Economics Study Program, University of Colombo, and the Ministry of Health .88 7. Management Information Systems Component .102  - 11 - 8. Burden of Disease Study ....................................... 108 9. Health Financing . .. ..................... ........... . . .......... 112 10. Cost-Effectiveness of Project Components ........................... 115 11. Project Implementation Plan ....................................... 118 Implementation Arrangements .119 Implementation Schedules .122 Detailed Project Costs .130 Monitoring and Reporting .142 12. Disbursements .146 13. Selected Documents Available in the Project File .148 CHART .......................................... 150 MAP: IBRD 28019 .151 This report is based on the findings of an appraisal mission which visited Sri Lanka in October 1995. Mission members were Ms. Frances Plunkett (Task Manager); Mr. Christopher Walker (Senior Public Health Specialist, EXCQA); Mr. Peter Heywood (Nutrition Specialist, HDD); Mr. James Herm (IEC Specialist, Consultant); Mr. Bruce Geisert (MIS Specialist, Consultant); Mr. Jay Satia (Management Specialist, Consultant); and Mr. Mark Spohr (Health Specialist, Consultant). Peer reviewers for the project were Ms. Judith McGuire (Nutrition specialist, HDD); Mr. Michael Porter (Public Health Specialist, Consultant); and Mr. Jeffrey Hammer (Economist, PRDPE). Mission support was provided by Ms. Homira Nassery and production of the report was supported by Ms. Lydia Maningas. Mr. Paul Blay (Principal Operations Officer, SAIPH) assisted with processing; Ms. Mieko Nishimizu (Director, SA1DR) and Ms. Barbara Herz (Chief, SAlPH) have endorsed the project.  - iii - DEMOCRATIC SOCIALIST REPUBLIC OF SRI LANKA HEALTH SERVICES PROJECT Credit and Project Summay Borrower: Democratic Socialist Republic of Sri Lanka Inplementing Agency: Ministry of Health, Highways and Social Services Beneficiary: Not applicable Poverty: Not applicable Amount: SDR 13.0 million (US$18.8 million equivalent) Terms: Standard, with 40 years maturity Commitment Fee: Standard (a variable rate between 0 and 0.5% of the undisbursed credit balance set annually by the Executive Directors of IDA) Lending Terms: Not applicable Financing Plan: See para. 3.4 Net Present Value: Not applicable Staff Appraisal Report: 15466-CE Map: IBRD 28019 Project Identification Number: LK-PA-10526   SRI LANKA HEALTH SERVICES PROJECT I. SECTOR BACKGROUND, ISSUES, AND STRATEGY A. Introduction -- Project Context 1.1 Sri Lanka is different. Although the country is poor, public health achievements stand out as an impressive success story: life expectancy of more than 72 years, infant mortality below 20 per thousand births, fertility near replacement level, and a population growth rate of less than 1% per annum and falling. Additionally, literacy is almost universal, for females as well as males. Such demographic, health and education indicators are usually associated with much wealthier, developed countries. 1.2 Nevertheless, several public health issues typical of developing countries remain. There has been a resurgence of malaria in recent years, and a third of children under five are malnourished. And, as in the rest of Asia, HIV/AIDS poses the threat of epidemic spread. Programs to address these three public health priorities comprise essential elements of any package of basic health services. 1.3 Additionally, the aging of the population is associated with major changes in the disease pattern of the population as non-communicable chronic and degenerative diseases of adults become dominant. Thus, Sri Lanka has a unique dual morbidity profile that includes both persistent developing country MCH morbidity problems and adult disease patterns that reflect a well-advanced epidemiological transition. 1.4 The Government of Sri Lanka has requested IDA to finance a Health Services Project, to consolidate and expand assistance provided through the IDA-supported Health & Family Planning project that closed in September 1995, as well as to move ahead to new issues and challenges. Specifically, the Government has requested assistance for its malaria, nutrition, and HIV/AIDS programs that address the country's priority public health issues. The project will also help the Government to identify the dimensions of the expanding burden of non-communicable diseases of adults and will support a pilot effort to develop cost-effective approaches to their prevention and treatment. 1.5 Sri Lanka's health services developed when the focus was on prevention of infectious and communicable diseases. The changing disease pattern resulting from the success of these efforts, combined with increasingly constrained public resources and the growth of the private health sector, have raised basic questions of health policy, particularly in the areas of resource allocation in the sector, resource mobilization, and the role of the private sector. The Government recognizes that such policy issues must be addressed. The project will provide a framework that will facilitate the Government's efforts to approach policy concerns systematically, through improved planning capacity, studies, pilot initiatives and a continuing dialogue. B. Background -- Economic and Social Setting 1.6 Sri Lanka has made progress in reducing the incidence of poverty, reflected in improvements in human development indicators as well as in consumption. This progress is due to a combination of three factors: (i) public provision of basic preventive and curative health services as  -2- well as education services, which have achieved excellent results; (ii) income transfer programs that have enabled higher consumption by the poor; and (iii) a relatively good long-term growth performance, with real per capita GDP growth of about 2.5% per year on average for the period 1950- 93.1/ 1.7 However, Sri Lanka is still a low-income economy. Although its long-term growth rate in per capita terms compares favorably with most of the developing world, it falls well short of the growth rate achieved in the last three decades by the high-performing East Asian economies. The main reason for this lag is that Sri Lanka's policies have been less supportive of economic growth. Problems with macroeconomic management have constrained domestic saving and investment and fueled inflation; export growth has been constrained by inward looking trade policies, interventions in the labor market, and, at times in the past, exchange rate overvaluation; and the agriculture sector's performance has been constrained by pervasive controls on land ownership and use, marketing and pricing. Civil strife in the northern and eastern regions has also constrained economic growth. 1.8 In household and individual terms, substantial poverty remains. A recent World Bank Poverty Assessment for Sri Lanka estimated that the proportion of individuals with consumption expenditure below the poverty line was about 22% in 1990. Poverty is still widespread in Sri Lanka, with the proportion of total consumption expenditure accounted for by food, excluding consumer durables, declining steadily from about 80% for the poorest group to about 40% for the richest. The poor devote more than three-quarters of their total budget to food, with rice, the most important item, accounting for about one fourth of their total expenditure. C. Population, Health and Nutrition Sector Status Population 1.9 The demographic transition in Sri Lanka, now virtually complete, followed the classic pattern of initial mortality decline and subsequent fertility decline. From a life expectancy of about 43 years in 1945, death rates have fallen rapidly to developed country levels as the result of the near eradication of malaria, extension of effective health services in the rural areas, and improved nutrition. The excess female mortality characteristic of South Asia has been reversed, and female life expectancy is now about five years higher than male, as is typical of developed countries. Maternal mortality has also been reduced to developed country levels. The decline in fertility to replacement level (total fertility rate of about 2.2 in 1995) has been due in some measure to rising age at marriage but largely reflects declines in marital fertility due to a vigorous family planning program, widespread female education, and improved child health. Significantly, prevalence of modern contraceptive measures in 1993 was only 44%, with traditional methods accounting for another 22%. This indicates the high demand for family limitation that has been generated as well as impressive ability to use traditional contraception effectively, both of which are linked to the high educational levels. The present population of about 18 million is expected to stabilize at approximately 25 million in about 2025. 1/ World Bank, Sri Lanka Poverty Assessment, Report No. 13431-CE, January 1995.  -3- Health 1.10 Mortality declines, led by the reduction of infant mortality to developed country levels, have been achieved through good implementation of immunization programs and an effective primary health care system. Sri Lanka has made excellent progress in the prevention and control of infectious and communicable diseases including tuberculosis and leprosy. However, preventable morbidity in young children, due to diarrheal and respiratory diseases linked to malnutrition, has not been completely eliminated. The major remaining communicable disease is the age-old scourge of malaria. HIV/AIDS has recently emerged as a new threat, although HIV prevalence is still low. 1.11 DDT spraying virtually eliminated malaria in Sri Lanka in the early 1960s. However, after use of DDT was curtailed there were several resurgences, most recently in 1987 and 1991, when the number of cases was probably at least as high as 1.3 million and 800,000, respectively, and malaria was declared to be Sri Lanka's major public health problem. It is particularly acute in the dry zone, where most of the country's agriculture is concentrated. Rates are highest in children but are also high for adults, so that epidemic outbreaks disrupt both schooling and agricultural activities. By 1995, the epidemic levels of 1991 had been reduced by about a third. This can be attributed in large measure to the introduction of a revised malaria control strategy in 1993, but it is likely that variations in rainfall and the natural progression of the epidemic cycle were also factors. 1.12 The first case of AIDS was identified in Sri Lanka in 1987. As of January 1996, a total of 171 HIV-positive individuals had been identified, 146 Sri Lankans and 25 foreigners. Of these, 58 cases had progressed to AIDS and there had been 49 deaths. It is estimated that by 2000 transmission will be almost entirely heterosexual. The true prevalence of HIV is not known; current estimates vary from 500 to 5,000. However, it is generally agreed that, as in a number of other Asian countries, epidemic spread of HIV has not begun in Sri Lanka. In fact, there are a number of factors which suggest that, given the cultural setting and the high educational levels, if present preventive and educational efforts are continued and strengthened, epidemic spread of the virus in Sri Lanka may be prevented. While complacency must be avoided, Sri Lanka's prospects for avoiding an epidemic appear to be encouraging if appropriate steps are taken now. 1.13 Fertility decline coupled with increasing life expectancy means that the population of Sri Lanka is aging: while the number of children under five is declining, the number of adults over 60 is expected to increase from 1.6 million in 1995 to 2.0 million in 2005. This is resulting in an epidemiological transition, that is, a major shift in the disease pattern of the population as non- communicable diseases of adults become dominant. Communicable diseases now contribute only a small part of the total disease burden, a reflection of the good job that Sri Lanka has done in providing health care and controlling these diseases, for example through immunization. Currently, most of the disease burden comes from non-communicable and degenerative diseases of adults (cardiovascular, cerebrovascular and respiratory conditions; diabetes; cancers). However, the prevalence of non-communicable diseases and associated risk factors in the population at present is in many instances uncertain. Nutrition 1.14 Recent data on nutritional status in Sri Lanka indicate that about a third of children under age 5 are malnourished, that is, underweight in terms of weight for age, a surprising level of  - 4 - malnourishment in a country where literacy rates are high and infant mortality and fertility have been reduced to developed country levels. While to some extent, malnutrition reflects the persistence of poverty in Sri Lanka, there are also significant levels of malnourishment at higher socio-economic levels where food availability is clearly not a constraint. Linked to malnutrition at all socio-economic levels are socio-cultural factors resulting in inappropriate breast-feeding and weaning practices that in turn lead to the failure of a child to thrive. Once growth begins to falter, it becomes progressively more difficult for the child to return to the right track, particularly because the child becomes increasingly vulnerable to diarrheal and respiratory infections. However, due to Sri Lanka's excellent health system, these diseases are no longer a significant cause of mortality. I.15 Micronutrient deficiencies are also present in Sri Lanka. A goiter survey in 1987 indicated that iodine deficiency is a public health problem throughout the wet zone, and it is estimated that more than 60% of the total population may be at risk of iodine deficiency. Iron deficiency anemia is also prevalent in Sri Lanka, particularly among pregnant women and pre-school children. D. Sector Issues and Constraints Program and Policy Development 1.16 At the direction of the present Government, the Ministry of Health has prepared a 'Perspective Plan for Health Development in Sri Lanka 1995-2000.' The Plan draws on the 'National Health Policy Sri Lanka' (1992) of the previous government, and the two documents have many similarities. However, the previous govemment took few steps to implement the recommendations of the 1992 Health Policy. The present Government also intends to issue a new statement of its health policy, although it is not expected to differ greatly from that of the previous government. 1.17 The Perspective Plan specifies five major goals for Sri Lanka's health policy in the next decade: (i) prevention and control of communicable and non-communicable diseases; (ii) promotion of health and fostering of healthy life styles; (iii) human resource development in the public and private sectors; (iv) improvement of availability and quality of health services; and (v) decentralization of health administration. Like many such policy documents, the Perspective Plan covers all areas of concern to the Ministry of Health and enumerates many policies to be implemented, but it indicates neither priorities nor, in most instances, mechanisms for moving from policy to planning and implementation. The Ministry's ability to carry out policy development and planning have benefitted from assistance provided through the recent IDA-financed Health & Family Planning Project but requires additional strengthening. Weaknesses in these areas, and additionally in health economics and financing, where the Ministry has virtually no capacity, remain issues of concern. Organization and Management 1.18 The Public Sector. The Government of Sri Lanka provides free health care services to all citizens through well-developed primary health care and hospital systems. With the implementation of the Provincial Councils Act in 1989, the health services were decentralized and responsibility for most health facilities and provision of most health services was devolved to the provincial Departments of Health. The Ministry of Health remains responsible for policy, relations with UN and bilateral agencies, medical and para-medical education, teaching hospitals, medical institutions providing special care, and the bulk purchase of pharmaceuticals, medical supplies, and equipment.  - 5 - 1.19 With the creation of divisional secretariats and the post of Divisional Director of Health Services (DDHS) in 1992, the health services were further decentralized. Under the decentralized scheme, responsibility for comprehensive health care at community and divisional levels as well as administrative authority over the curative institutions in the division was devolved to the DDHS. The DDHS is therefore responsible for all promotional and preventive health activities in a division, which has a population on average of 60,000-80,000, and must coordinate the functioning of the preventive and curative services, which have developed separately. 1.20 Decentralization was implemented and expanded without adequate planning or resources, and the financial and administrative implications are still in the process of being worked out. Decentralization to the DDHS level, in particular devolution of financial powers, has not been fully implemented. It is intended that ultimately the provinces will support their health services through their own revenues, but in practice the provincial Health Departments have been financed largely through block grants from the central Ministry of Health. These funds are not earmarked for particular purposes or programs. The provinces have not been consistent about reporting on their utilization to the Ministry, and there is a question as to whether they are under any constitutional obligation to do so. 1.21 While in theory decentralization could make significant contributions to the efficiency and effectiveness of the health services, the actual consequences are still far from clear. Planning and management capacities in the provincial Health Departments are weak, nor do they have the resources to support needed staff and infrastructure for the divisional directorates; what has been done in this regard has been supported largely by extemal assistance. The provision of the resources required to support effective functioning of the decentralized health services is a major issue for the Government. 1.22 An additional unresolved issue concerns the provision of health services to underprivileged estate populations.2/ The Ministry of Health has indicated that it intends to take direct control of estate medical facilities and integrate their management and staff into the existing system, a measure recommended by the World Bank's recent poverty assessment for Sri Lanka. However, a plan of action has not yet been developed. 1.23 The Private Sector--for Profit. Although most hospital facilities in Sri Lanka are public, the provision of private outpatient care has expanded rapidly in recent years. In 1986/87, private expenditures for health-related goods and services represented close to 40% of overall national health expenditures, and by 1992 the private sector provided over 50% of outpatient care. These trends, combined with current public sector resource constraints and changing epidemiological patterns, suggest that the public sector should focus on preventive care, support of services for the poor, health education, and communicable disease control, leaving to the private sector the curative services that are of most interest to them. A number of key steps are needed to further facilitate expanded private sector participation. These include provision of a regulatory framework and a supportive climate for private investment, both domestic and external, in health services. Additionally, efforts to encourage the private sector should be linked to exploration of health insurance options. While these points are 2/ Workers on tea estates, most of whom are of south Indian origin, comprise approximately 5% of the population of Sri Lanka.  -6 - included in recent policy documents, concerted measures by Government to implement them are needed. 1.24 The Private Sector--Non-Profit. Sri Lanka has a strong NGO sector that plays an important role in a variety of development and community-oriented programs, which often include health and nutrition activities. There are several large organizations, notably the Sarvodaya Rural Enterprise Program and the Woman's Development Federation, which are island-wide in terms of their coverage, but most NGOs are locally based and active only in their own areas. The extent of NGO activity and potential in Sri Lanka is illustrated by the large number of NGOs, probably more than a hundred, that are active in AIDS work or were interested in becoming so. Coordination between government health programs and NGO activities at local levels is often weak, although when it does occur both public and NGO programs are strengthened at minimal cost. The Ministry of Health could assist the situation by clarifying its intention to improve NGO coordination and cooperation and systematically reviewing the situation of individual programs. Service Provision 1.25 Provision of services through effective hospital and primary health care systems has been the strength of public health care in Sri Lanka. Both systems, however, have come under increasing stress in recent years, and sustaining their capacity to provide quality services will require adequate resources and policy initiatives to respond to changing circumstances. Major issues include the overcrowding of tertiary hospitals, insufficient community outreach, and the erosion of the service ethic that has sustained the public provision of health care in Sri Lanka for many years. 1.26 The hospital system faces substantial efficiency problems, most clearly reflected in the "by-passing" phenomenon, that is, tertiary care hospitals are overcrowded while secondary and primary facilities are underutilized, reflecting the more experienced staff and better availability of drugs at major hospitals. Local maternity homes in particular go virtually unutilized, because women prefer to deliver at facilities where a doctor is available. 1.27 Primary health care achievements have been based on the availability of facility care at divisional level, referral to higher level hospitals, and twice monthly maternal-child health (MCH) clinics organized in the community at the most convenient location available (Annex 2). MCH clinics are conducted by several public health midwives (PHMs) from the area and the divisional-level doctor (DDHS). Although community outreach (that is, visiting households in the community, particularly those with pregnant women, newborns and young children) is part of the job description of PHMs, outreach is often inadequate, because PHMs are unable to find housing in the communities to which they are assigned and transportation is difficult. To improve this situation, a strengthened model for primary health care has been adopted which calls for the construction of village (gramodaya) health centers (GHCs) that combine living quarters for PHMs and clinic space. Where GHCs have been constructed, the resident PHMs report that their coverage and general effectiveness have improved many fold. Preventive and promotive health services provided by paramedical workers resident in the community is a more cost-effective service delivery strategy than reliance on health facilities, and it will become increasingly so as life expectancy continues to rise and care for the elderly at home becomes widespread. However, the GHC model requires considerable resources, and thus far only about 20% of PHMs have purpose-built facilities, mostly financed by external assistance.  1.28 There is remarkable consensus that the basic challenge to sustaining Sri Lanka's public health achievements stems from erosion of the "ethic of service" that has supported the public health system for many years. Typically, medical officers and field staff have worked conscientiously in poor, often appalling, conditions, and yet have managed to achieve excellent results. It is unrealistic to expect that, given rising expectations and increasing economic pressures, the quality of the system can be maintained indefinitely without additional resources. Staffing and Training 1.29 A shortage of physicians in the late 1980s resulting from unsettled conditions in several areas of the country and consequent disruption of medical education has been rectified. However, the creation of the post of Divisional Director of Health Services (DDHS) as part of the decentralization of the health services, which substantially increased the number of government postings in rural areas, has raised several related issues. 1.30 DDHS posts are being filled to a large extent by new medical graduates, who lack requisite administrative and MCH experience and are often dissatisfied with rural postings. It is reported that it has now become common for DDHS doctors to conduct an after-hours private practice as well. It is generally recognized that new graduates appointed to DDHS posts should receive MCH and management training before being allowed to take up their posts. The IDA-assisted Health & Family Planning Project supported the development of a management training course for DDHSs, which the Ministry is continuing. However, there has been too little effort to relate course content to the actual problems faced by DDHS doctors or to evaluate the effectiveness of the training. Informal feedback indicates a high level of frustration because of the difficulty of applying what is taught given the resource constraints that confront most DDHS doctors, as well as a need for more technical MCH training. Expenditure and Financing 1.31 Public sector health expenditure for 1990-94 was about 1.6% of GNP (Annex 9). This is about average for most south and east Asian countries. In real terms, health expenditure has risen about 135% over the last 15 years. The increase is due primarily to substantial capital investment in tertiary hospitals at several points over the period. While the growth of investment undoubtedly reflects changing epidemiological patterns, it has been based on little systematic analysis of needs. As could be expected under such circumstances, expenditure on recurrent costs, although also rising over the period, has not kept pace with investment. New tertiary facilities have tended to absorb increased recurrent expenditures, while recurrent budgets for primary and secondary facilities have become increasingly inadequate. 1.32 The epidemiological transition underway in Sri Lanka has major implications for health expenditure. The pressures for additional spending on health care are likely to increase as chronic and degenerative diseases become more important, because these diseases cost more to treat and require longer term care than the relatively simple diseases of childhood. The complexity of health care services required will increase considerably; health personnel will need to be more highly qualified and more specialized, and the technology for diagnosis and treatment will become more sophisticated. The greatest effect will be seen in increased demand for hospital bed capacity. In sum, the more expensive mix of interventions implied by the epidemiological transition will put increasing pressure  - 8 - on government health resources, and the cost of providing for the health care needs of the population will rise. If the enhanced needs for health services are translated into effective demand, total health expenditure (public plus private) would rise considerably in real terms and as a percentage of GDP, as has happened in developed countries. The prospects, therefore, are that public sector health expenditure as a percentage of GDP is likely to rise, unless the private sector assumes greater responsibility. Financial sustainability is thus emerging as a key issue. E. Sector Development Strategy Government Strategy 1.33 As reflected in the new Perspective Plan (para 1.16), the Government is aware that measures to address increasingly constrained public resources and the changing disease burden resulting from the epidemiological transition are now required. Five key strategies have been identified: (i) improving equity through concentrating on underprivileged and underserved groups; (ii) making better use of existing resources through improvements in the efficiency of services and accountability of management; (iii) strengthening community participation; (iv) developing managerial and information systems; and (v) promoting private sector (both for-profit and NGO) involvement in service delivery. These steps would promote efficiency and help limit demands for public financing of health care. But more needs to be done, and the Government is exploring possibilities. 1.34 In the politically sensitive area of cost recovery, the Government is extremely cautious. This must be seen in the light of the strong public health sector in Sri Lanka and the belief, strongly held by many, that the state has a moral obligation to provide free health and education services. Consistent with this context, the Government's current proposals for cost recovery are limited. Nevertheless, the Government intends to expand pay wards in tertiary and secondary hospitals and to study other possible cost recovery measures. 1.35 The Government's private sector strategy is much broader. To protect the public interest, a regulatory framework for private medical practitioners is in the process of enactment. To encourage private sector growth, Government proposes, among other steps, to: make provision for concessional loans for establishment of private practices, especially in rural areas; lease available spare capacity in public sector facilities to private practitioners; permit foreign providers of private medical care to operate in Sri Lanka; and encourage the development of private health insurance. IDA's Strategy and Role 1.36 The project is fully consistent with the Country Assistance Strategy (CAS) for Sri Lanka, discussed by the Board on June 13, 1996, which indicates that IDA expects to respond to Government requests for assistance in addressing key public health issues through the project. IDA's health sector strategy in Sri Lanka has two complementary goals: to support Government's efforts to sustain present achievements; and to assist Government to move beyond the undoubted accomplishments of the health services to address "second generation" issues concerning resource allocation in the public health sector, efficiency and effectiveness of the health services, financial sustainability, and the private sector. These concerns must be given priority in view of the well-advanced epidemiological transition in Sri Lanka as well as increasing pressures on scarce public resources.  9- 1.37 IDA's comparative advantage is based on the ability to bring to bear relevant cross- country experience in the health sector, particularly in the areas of helping Government to assess priorities within the sector, develop more cost-effective ways of providing health care, and explore issues relating to sustainability and non-government options for delivering health care. In anticipation of the need for data and analysis addressing health policy questions, the recently completed IDA- supported Health & Family Planning Project included a major Health Strategy and Financing Study. Drawing on the study's recommendations, which are by and large consistent with those of the Government's Perspective Plan (para. 1.16), IDA has initiated policy discussions with the Ministry of Health as part of project preparation. The result has been an agreed program of studies and initiatives to be carried out as part of the project, supported by an annual review to carry the process forward (para. 2.66; Annex 6). Improved quality and efficiency of the health services, generation of additional resources for tertiary care, and achievement of an appropriate public-private mix in the health sector are among the first areas that will be addressed. External Support 1.38 WHO has a long-standing relationship with the Ministry of Health and provides technical assistance and other support to many of the Ministry's programs. UNICEF and UNFPA provide assistance to the Ministry's MCH and family planning programs, respectively. These donors, together with UNDP, USAID, and NORAD, have sustained the AIDS control program since its inception. However, assistance from UN and bilateral sources is expected to be substantially reduced in the coming years, and these agencies have cooperated fully in project preparation. In addition to IDA, the Asian Development Bank (ADB) is also a major source of loan support for the health sector. ADB currently supports a health project that concentrates on health facilities at primary and secondary levels. The content of the IDA-supported project has been discussed with ADB, and care has been taken to ensure that the two are complementary. IDA is therefore in a favorable position to assist Government with donor coordination and to act as the lender of last resort. Lessons Learned 1.39 The only IDA-assisted social sector project that has been completed in Sri Lanka is the Health & Family Project (Cr. 1903-LK), which closed on September 30, 1995. This project experienced major implementation difficulties in its early phases, due primarily to lack of "ownership" by the implementing ministry and poor project management. After a very critical mid-term review by the Borrower, project management was modified and implementation improved substantially. On the basis of this and other country experience in the social sectors, the following lessons can be drawn: (i) the politically sensitive nature of many aspects of health policy, given the widely held view that the state has a moral obligation to provide free health and education services to all citizens; (ii) the importance of "ownership" of a project by the ministry responsible for implementation; (iii) the need to ensure that senior program managers understand and support the strategies underlying project assistance to specific programs; (iv) the crucial role of project management in coordinating project activities and monitoring progress; (v) the useful role that a thorough mid-term review carried out by the Borrower can play; (vi) the need to ensure that Bank practices and procedures are understood by those responsible for project management by the time the project becomes effective; and (vii) the importance of drawing on regional and international experience to strengthen project and program design. The preparation team drew on experience in other countries to help the  - 10 - Government identify cost-effective strategies in the nutrition and STD/AIDS areas, and the pilot NCD effort is expected to make extensive use of developed country experience in developing NCD options.  - 11 - II. THE PROJECT A. Objectives and Summary Description Project Objectives 2.1 The objectives of the project are to strengthen Government's ability to address (i) remaining major public health problems (malaria, malnutrition and HIV/AIDS); (ii) new challenges raised by the epidemiological transition and the increasing importance of non-communicable diseases of adults; and (iii) key health policy and financing issues. Summary Description 2.2 To achieve these objectives, the project will comprise the components described in the following paragraphs. 2.3 The malaria component will support expanded implementation of WHO's revised malaria strategy, focusing on six high-prevalence districts. The revised strategy emphasizes the cost- effective options of personal protection through use of insecticide-impregnated bed nets, prompt diagnosis and treatment for suspected cases, and the substitution of selected residual spraying for widespread spraying. Mobile clinics for immediate diagnosis and treatment will be phased out when prevalence falls below specified thresholds. Initial implementation of the revised strategy, which has reduced the amount of insecticide used by some 65%, appears to have achieved good results. The annual incidence of malaria cases in the six high-prevalence districts is expected to fall from more than 40 detected cases per thousand population in 1994 to less than 10 per thousand by 2001; this would mean 125,000 fewer detected cases in 2001 as compared to 1994. 2.4 The STD/AIDS component will support the -efforts of the National STD/AIDS Control Program (NSACP) to prevent the epidemic spread of HIV in Sri Lanka. The program has moved promptly to take the medical and educational steps necessary to contain HIV. A major focus will be improvement in the diagnosis and treatment of STDs in both public and private sectors, since STD cases are a major HIV risk group. Education/communication efforts to promote knowledge of STDs and HIV/AIDS and avoidance of high-risk behaviors will continue to be carried out by NGOs with external support parallel to the project. If present efforts are expanded and strengthened, it may be possible for Sri Lanka to avoid an AIDS epidemic and remain a low HIV-prevalence country. 2.5 The nutrition component will support the reorientation of the Health Ministry's existing clinic-based growth monitoring program to a community-based growth promotion program utilizing NGOs and community volunteers. This shift results from examination of altemative approaches in Sri Lanka and elsewhere. Since inappropriate breast-feeding, weaning and feeding practices rather than food availability constraints underlie much of infant and young child malnutrition, the program will focus on reaching pregnant women and mothers to promote behavior change. Micronutrient deficiencies (iron and iodine) will also be addressed. The percentage of malnourished children below age 5, which was about one third, or more than 500,000 infants and children, in 1993, is expected to be reduced to less than 20% by 2001, The percentage of low-weight births, which was about 20%, or roughly 80,000 newboms, in 1993, is expected to be reduced to less than 15% by 2001. Iodine  - 12 - deficiency is expected to be virtually eliminated and iron-deficiency anemia significantly reduced by 2001. 2.6 The pilot non-communicable diseases component will support an effort to identify the dimensions of non-communicable diseases in Sri Lanka and develop cost-effective strategies for prevention and treatment. 2.7 The program support component comprises three subcomponents. A health policy component will support strengthening and institutionalization of Government's currently weak capacity for policy analysis and planning in the health sector. It will assist Government to address issues conceming efficiency and effectiveness of health services; resource mobilization; financial sustainability; and the role of the private sector. It will include an agreed program of policy-related studies and linked pilot initiatives. A management information systems component will support increased capacity of MOH to organize, analyze and utilize information for management and planning purposes. A health education component will support enhanced quality, effectiveness and coverage of health education activities coordinated by the Ministry's Health Education Bureau (HEB) as well as improved ability of the HEB to carry out an expanded program of training in interpersonal communication. B. Detailed Project Description COMMUNICABLE DISEASES AND NUTRITION Malaria Component (US$3.6 million; 17% of base costs) 2.8 Background. In the aftermath of the recent resurgence of malaria in 1991 (para. 1.11, Annex 3), in order to strengthen the Ministry of Health's Anti-Malaria Campaign (AMC) a decision was taken to adopt WHO's revised Global Malaria Control Strategy. Funds from the IDA-supported Health and Family Planning Project (Cr 1903-CE) were made available from 1993 to support the revised strategy in four of six high-prevalence districts (Matale, Polunnaruwa, Kurunegala and Anuradhapura). By 1994, the epidemic levels of 1991 had been reduced by about a third and continued to decline through 1995. The decline in the incidence of malaria since the introduction of the new strategy is encouraging. However, it is likely that variations in rainfall and the natural epidemic cycle have also been factors. 2.9 Objectives. The objective of the Anti-Malaria Campaign is to sustain and increase recent reductions in the incidence of malaria in an environmentally acceptable manner. Specifically, the goal is to reduce the annual incidence of malaria in the high-prevalence districts from more than 40 detected cases per thousand population in 1994 to less than 10 per thousand by the end of the project period. Once this level is achieved, the program can be sustained on a maintenance basis and resource requirements will be considerably reduced. 2.10 Strategies. The revised WHO strategy adopted in 1993 includes: (i) early detection and prompt treatment of malaria cases; (ii) selective application of sustainable malaria control measures including vector control; (iii) development of mechanisms to forecast/prevent malaria epidemics and outbreaks; and (iv) regular assessment of the implementation and impact of the program. In consequence, the focus of the program has shifted: there is now much less emphasis on spraying with  - 13 - insecticides and more stress on protective measures and treatment through insecticide-impregnated bed nets, mobile clinics, and better diagnosis and treatment at health facilities. The change in the spraying program has been dramatic. Since 1993, two new insecticides have been introduced in addition to the malathion previously used in order to minimize development of resistance, and the amount of insecticide used has been reduced by 65%. Coverage of targeted houses has improved, since the new insecticides are more acceptable than malathion. 2.11 Content. The project will provide continued support of the revised AMC program nationally as well as expansion of support to the two remaining high-prevalence districts (Puttalam and Moneragala). Program content that will be supported by the project is summarized below; details are given in Annex 3. (a) Program management--improved coordination among regional (district) malaria offices and the AMC Directorate; preparation of annual district plans incorporating annual targets; computerization of data collation and analysis at district level supported by training and improved data reporting to the AMC. (b) Early diagnosis and prompt treatment of malaria cases--mobile clinics to take blood films from all fever cases in a local area, diagnose malaria on the spot and provide immediate treatment; recruitment and training of microscopists to be posted to medical facilities, thus reducing the level of presumptive treatment; improved identification and follow up of drug-resistant cases; training of field health staff to enable their expanded participation in malaria control activities at the community level. Project support for ambulances for transport of falciparum malaria cases and other medical emergencies would be conditional on a review of transport aspects of the health system that would indicate the justification in cost-effectiveness terms for the type and number of vehicles needed and address sustainability issues. (c) Selected and sustainable malaria control methods--strengthening of entomological and parasitological surveillance; improved targeting of house spraying through better parasitological and entomological parameters; expansion of the impregnated bed net program. (d) Regular assessment of malaria status and prevention of epidemics--improved tracking of drug resistance; regular prevalence surveys; establishment of an early warning system for potential malaria epidemics based on entomological, parasitological, epidemiological and climatic data. (e) Community awareness and particivation--program orientation for NGO/community volunteers; educational activities focused at the community level emphasizing use of impregnated bed nets and the importance of seeking diagnosis and treatment for fever, to be coordinated by the Ministry of Health's Health Education Bureau and the provincial health education units. (f) Operational research--small-scale trials of additional physical and biological controls to expand vector control while minimizing environmental risk; other applied research as appropriate.  - 14 - 2.12 The AMC program receives limited support from WHO in the form of technical assistance. Project support for the activities indicated above will allow the AMC to complete introduction of the revised WHO strategy nationally and especially in the high-prevalence districts. 2.13 lnputs. The project will support equipment, computers, vehicles, in-service training, information, education and communication (IEC) activities and materials, and incremental operating costs including insecticide for the treatment of bed nets. 2.14 Monitoring. The AMC monitors a set of program indicators on a monthly and annual basis, including the number and results of blood slides, malaria treatment provided by mobile clinics and at health facilities, and hospitalization and mortality figures from health facilities. Program impact will be monitoring through the trends in slide results as verified by baseline and follow-up prevalence surveys (Annex 1 1). STD/AIDS Component (US$8.2 million; 43% of base costs) 2.15 Background. Following the first diagnosis of an AIDS case in Sri Lanka in 1986 (para. 1.12; Annex 4), GOSL moved promptly on a number of fronts to deal with the threat of an HIV/AIDS epidemic. It was recognized early on that AIDS prevention and control was a behavioral as much as a medical concem and would require a national focus. Consequently, a multi-sectoral, multi-disciplinary National AIDS Committee reporting to the National Health Council, chaired by the Prime Minister, was established and now meets quarterly. With support from WHO and other donors, a first Medium Term Plan for HlV/AIDS control and prevention was adopted in 1991 and a second developed in 1994. Primary responsibility for HIV/AIDS control has been assigned to the STD Control Program of the Ministry of Health, which has been redesignated the National STD/AIDS Control Program (NSACP). To date, with donor support NSACP staffing, management and capacities have been strengthened and the security of the blood supply has been enhanced. Additionally, donors have channeled substantial support for educational and counseling activities to NGOs, which have succeeded in greatly increasing knowledge about HIV/AIDs in the general population, although corresponding understanding of other STDs is still low. A national secretariat for NGOs has been established in the Ministry of Social Services. However, much remains to be done, particularly in terms of the diagnosis and treatment of other STDs, which is especially important because persons with STD infections are at higher risk of HIV infection than any other group. 2.16 Objectives. Although there is uncertainty about the current level of both HIV prevalence and STD incidence in Sri Lanka, it is generally agreed that at present HIV prevalence is relatively low and that epidemic spread has not yet begun. Given that avoidance of HIV infection is at present the only way to prevent AIDS, the NSACP has recognized the urgency of taking cost-effective measures while the prevalence of HIV is still low, to prevent the epidemic spread of HIV infection. The objective of the program, therefore, isto -ensure that Sri Lanka remains a low HIV prevalence country. 2.17 Strategies. To achieve this objective five key strategies have been adopted. The spread of HIV is being addressed through: (i) improvement of the capacity of the public and private health sectors to diagnose and treat other STDs; (ii) ensuring the safety of the blood supply; (iii) promotion of knowledge about HIV/AIDS and avoidance of high-risk behaviors through targeted educational efforts; (iv) increased emphasis on multi-sectoral and inter-ministerial involvement and strengthening  - 15 - of the institutional capacity to deal with HIV/AIDS and other STDs; and (v) monitoring of HIV prevalence through annual sentinel surveys as well as other behavioral and epidemiological studies. 2.18 Content. The project will support aspects of the expanded National STD/AIDS Control Program not supported from other external and government sources (para. 2.30). The content of this support is summarized below; details of the program are given in Annex 4. 2.19 Improved capacity of public and private health sectors to diagnose and treat other STDs. At present, the National STD/AIDS Control Program functions from three separate buildings in Colombo, including clinic and laboratory facilities that are dilapidated and completely inadequate for current needs. Support will therefore be provided for construction of a new headquarters for the NSACP in Colombo that will: (i) serve as the headquarters for the national program; (ii) serve as a training center; and (iii) provide clinical and laboratory services and function as a national referral center. The new facility will allow much more satisfactory examination, treatment and counseling of both male and female patients and will strengthen laboratory services for diagnosis, surveillance systems and testing programs. STD and HIV/AIDS data will be computerized, thus facilitating tracking of STD, HIV and AIDS cases reported by other STD clinics and the private sector. Provision is made for the supply of equipment, computers, furniture, supplies, and a vehicle. The Govemment has provided to the Association confirmation that it has title to the site designated for construction of a headquarters facility of the STD/AIDS Control Program in Colombo. and that plans for the facility have been approved by an architect acceptable to the Association (para. 5.2(a)). together with approved bidding documents for construction of a headquarters facility for the STD/AIDS Control (para. 5.3(a)). 2.20 The capacity of existing STD clinics in the nine provincial hospitals to diagnose and treat patients, including laboratory work, will be strengthened through modest inputs including physical improvements, provision of equipment, furniture, supplies, training, and a vehicle. In ten base hospitals located in appropriate areas, STD clinics will be established. These will be supported through upgrading of existing hospital space and provision of equipment, furniture, supplies, and training. Improved reporting of STD cases to the NSACP in Colombo from both provincial and base hospital STD clinics will be emphasized. 2.21 The NSACP, in cooperation with the Family Health Bureau (FHB), will undertake an extensive in-service training program (Annex 4, Attachment 1). Since even with the expansion and improvement of public sector STD facilities, it is expected that a majority of STD patients will continue to use the private sector, the training program includes STD/HIV/AIDS orientation for private sector physicians, who see most of the STD cases. Also provided is management, technical and counseling training for NGO members. 2.22 Since the target populations of the STD/AIDS and family health programs both include women in the reproductive age groups (ages 15-49), coordination between the two programs in order to enhance reproductive health care is a goal of the NSACP. All staff of facilities that provide care to women will be trained in the NSACP/FHB training program, which will cover female reproductive health including increased used of modem contraception, linking of condom distribution for family planning and STD prevention purposes as appropriate, infection control at delivery, and early identification of congenital STD infection in newborns through symptoms such as eye discharge. In  - 16 - cooperation with NGOs active in AIDS work, joint FHB and NSACP programs for at-risk groups such as out of school youth and youth in tourist resort areas will be organized. 2.23 Security of the blood supply. Support will be provided to the National Blood Transfusion Service for continued improvement of blood screening security. At the present time, there is an unknown number of unregulated private blood banks. The Govemment has provided assurances to the Association that by December 31. 1997 private blood banks will be required to follow Ministry of Health standards for the safetW of the blood supply (para. 5.2(fl). 2.24 Improved AIDS awareness and increased avoidance of high-risk behaviors. Continued efforts to improve levels of AIDS awareness and knowledge and to promote avoidance of high-risk behaviors by means of targeted education and communication efforts as well as condom promotion and distribution are essential to the effort to prevent the epidemic spread of HIV. AIDS awareness also needs to be linked to information about other STDs to the extent possible. NGOs, which will continue to take the lead in contacting at-risk population groups, are also active in the establishment of counseling programs and caretaking procedures for HIV positive and AIDS individuals. Some 50 NGOs are currently working in these areas, and others have expressed interest in participating. Adequate extemal support for NGO activities is considered to be available (para. 2.30). The project will support a mass media program coordinated by the Health Education Bureau that will supplement interpersonal communication efforts being undertaken by NGOs. Condom vending machines to be placed by NGOs working with high-risk groups to further their efforts to promote behavioral change will also be supported. 2.25 Strengthening of program management capacity. WHO will support additional technical staff to improve the capacity of the NSACP to plan and implement the program as well as management training for program staff. The project will support computerization of the program's record keeping, which should greatly improve the recording of all HIV/AIDS and other STD cases reported from both public and private sectors and the analysis of program data. 2.26 Research. monitoriny and evaluation. Three HIV sentinel surveys have been carried out using WHO methodology, which identifies female commercial sex workers and STD patients as high- risk groups (Annex 4). The forthcoming 1996 survey will cover additional risk groups including armed forces members, prisoners, and injecting drug users. Support will be provided for technical assistance to review survey sampling design and procedures and to carry out annual surveys. 2.27 Additionally, provision is made for other epidemiological and behavioral research as needed. STD surveys linked to HIV surveillance will be supported, and parallel behavioral surveys to monitor progress in promoting behavioral change will be introduced. The Sri Lanka Medical Association will cooperate in following up the STD orientation training provided to private sector physicians and developing further approaches to strengthening their contribution to the diagnosis and treatment of STDs. The extent of injecting drug use in Sri Lanka and its potential role in the spread of HIV is a topic that needs to be explored. 2.28 Inputs. The project provides support for civil works, equipment, computers, supplies, vehicles, in-service training, technical assistance, IEC activities and materials, pharnaceuticals, contraceptives, salaries and other incremental operating costs.  - 17 - 2.29 Monitoring. The impact of the STD/AIDS Control Program will be monitored through the results of annual HIV and behavioral sentinel surveys, which will indicate whether the goals of preventing epidemic spread of HI-V and reducing the occurrence of high-risk behavior are being achieved. However, given the difficulty of ascertaining current prevalence/incidence rates of HIV and other STDs, process monitoring including improved reporting of STD cases from both government facilities and the private sector will be emphasized (Annex 11). 2.30 External support. A large proportion of the expanded STD/AIDS Control Program has been funded by donors (UNDP, NORAD, UNICEF, UNFPA and WHO). In 1995 donor assistance provided about 70% of the program's funding; in addition USAID provided substantial funding directly to NGOs. However, this level of donor support will not be available in the coming years. UNDP plans to continue to support the program to some extent, primarily through NGOs. WHO plans to provide some funding, at least through 1997, for office rental, technical assistance and management training. UJNAIDS will also provide limited support for 1997. The project will therefore provide support for that portion of the program that is funded by neither Govemment nor donors. It is anticipated that, at least for the first half of the project, adequate NGO support will be available from UNDP and other sources. Funding requirements for NGOs in the latter half of the project will be reviewed carefully as part of the mid-term review. Nutrition Component (US$2.8 million; 14% of base costs) 2.31 Background. The potentially harmful effects of low birth weight, malnutrition, and micronutrient deficiencies in infants and young children on their health and future productivity are well documented. The persistence of high levels of these problems in Sri Lanka (paras. 1.14-15; Annex 5), despite very low infant mortality, good control of most communicable diseases, and high literacy rates, has received considerable attention from the Government in recent years. Recognizing that malnutrition is a multifaceted problem that cuts across sectors and that a number of government as well as NGO programs are concerned to improve nutritional status, in 1992 the Government established a high-level National Steering Committee for nutrition as well as coordinating committees at provincial, district and divisional levels. 2.32 Lead responsibility for implementation of programs to improve nutritional status has been assigned to the Ministry of Health. For more than two decades, MOH has attempted to deal with child malnutrition, iron-deficiency anemia and low birth weights through a programn that is in principle a growth promotion program incorporating growth monitoring by public health midwives (PHMs), a food supplement (thriposha), and nutrition education. In practice, however, the program has become a limited growth monitoring effort linked to thriposha distribution. The training of many PHMs in growth promotion is deficient, and the inclusion of growth monitoring in crowded MCH clinics, where a variety of other activities must also be carried out, has constrained the quality of services and made nutrition education activities difficult if not impossible. Community outreach, which is also essential to a growth promotion program, is not adequate in many areas. Additionally, there is no evidence from any of several studies that the expensive and poorly implemented thriposha program (Annex 5) has had any sustained impact on the nutritional status of intended beneficiaries. The Government has provided assurances that by June 30. 1998. the Ministry of Health will carry out, under terms of reference satisfactory to the Association, an evaluation of the impact of the thriposha supplementary feeding program and furnish to the Association the findings and recommendations of the evaluation: and (ii) the Ministrv of Health will carry out agreed recommendations of the study (para. 5.2(g)).  - 18 - 2.33 Community-based nutrition and integrated rural development programs are supported by UNICEF, UNDP, a number of bilateral donors, and NGOs such as Sarvodaya. The most extensive of these is the nutrition component of the IDA-supported Poverty Alleviation (National Development Trust Fund) project (Annex 5).3/ The objective of the NDTF nutrition component is to reduce malnutrition among young children and low weight births, with emphasis on reaching the poorest and most deprived populations. Initial indications are that the 'In-Depth Approach' of the NDTF nutrition component is achieving significant reductions in malnutrition. These results have been achieved without any food supplementation. The failure of the thriposha program to achieve results, and the demonstrated effectiveness of the alternative approach being utilized in the NDTF nutrition component, together suggest that the Family Health Bureau's current approach to malnutrition should be reoriented. 2.34 UNICEF has taken the lead in supporting the iodization of salt in Sri Lanka, primarily through the supply of equipment to salt producers and promotion of legislation. Legislation mandating iodization of salt became effective from July 1, 1995, but experience elsewhere indicates that a purely legal strategy is inadequate to eliminate production and sale of non-iodized salt. The low quality of most salt produced in Sri Lanka makes it more difficult to iodize and also makes more likely a substantial price differential between iodized and non-iodized salt. 2.35 Objectives. The objectives of the Ministry of Health's nutrition programs are, by the end of the project period, to reduce protein-energy malnutrition among infants and young children under five to less than 20%, or roughly half of current levels, and virtually eliminate severe malnutrition; reduce the proportion of low-weight births to less than 15%; reduce levels of iron- deficiency anemia among pregnant women and children substantially; and essentially eliminate iodine deficiency diseases. 2.36 Strategies. Recognizing that inappropriate breast-feeding, weaning and feeding practices, rather than household food shortages, underlie much of infant and young child malnutrition in Sri Lanka, the Family Health Bureau will reorient and broaden its growth promotion program to emphasize maternal nutrition, anemia prophylaxis, and prevention of growth faltering by infants and young children rather than cure (i.e. food supplementation) after faltering has begun. The present clinic-based focus will shift to a community-based, interpersonal communication approach, which is expected to be more cost-effective in Sri Lanka's circumstances where literacy rates are high and weaning foods are relatively available. The growth promotion effort will be supplemented by mass media campaigns, which provide an essential complement to interpersonal communication; pilot efforts to revitalize the health and nutrition education program in the schools; and broadening of the UNICEF-supported salt iodization program. 2.37 Content. Project support for Ministry of Health nutrition programs is summarized below; details are given in Annex 5. 2.38 Institutional strengthening. The project will support strengthening of the Maternal-Child Health (MCH) unit of the Ministry of Health (also called the Family Health Bureau), whose 3/ The Poverty Alleviation Project (Cr. 2231-CD) became effective in September 1991, and the credit is scheduled to close in December 1996.  - 19 - responsibilities include nutrition. A post of Director Nutrition will be created and supporting office establishment provided. The Government has confirmed that a post of Director Nutrition (Ministrv of Health) has been created (para. 5.2(b)); and that by March 31. 1997 a candidate whose gualifications and experience are acceptable to the Association will be appointed to the post of Director Nutrition (Ministry of Health) (para. 5.2(h). 2.39 Divisional Health & Nutrition Committees. Divisional Health & Nutrition Committees have been nominally organized in all divisions but are reported to be effectively functioning in only some. With project support and monitoring, these committees are expected to become fully functional and to take an active role in the implementation and coordination of nutrition activities in their respective divisions. Participation in the committees will be widened to include more of the field officers of various govemrnent departments working in the division as well as representatives of the NDTF, other development programs and NGOs active in the division, and the new national development (Samurdhi) program. 2.40 Program/project orientation. Provision is made for program/project orientation in the first project year for all FHB and provincial staff concerned with nutrition programs, including senior officers of the Health Ministry and provincial Departments of Health and members of the divisional Health & Nutrition Committees. The orientation will cover current nutrition problems in Sri Lanka, the strategies being adopted to address these problems, especially the reorientation of the growth promotion program, and coordination with other govemment departments and nutrition programs. 2.41 Growth promotion program. Experience indicates that successful and cost-effective growth promotion programs emphasize interpersonal communication and community participation. A national growth promotion program focusing on infants, young children and pregnant women and reoriented along these lines will be implemented through existing infrastructure and staff of the Family Health Bureau and the provincial Health Departments. It will aim to reduce growth faltering in infants and young children through promotion of behavior change, particularly concerning breast-feeding and weaning practices. Low birth weight will be addressed through promotion of better maternal nutrition and anemia prophylaxis. However, for some women whose short stature is a reflection of childhood and adolescent undernutrition, underweight births are difficult to avoid; this problem can be overcome only in the next generation through ensuring that daughters receive the adequate nutrition that their mothers were lacking. To achieve reorientation of the growth promotion program, the project will support in-service training of all PHMs and supervisors in program strategies, technical nutrition knowledge and interpersonal communication skills. 2.42 To move away from the current over-emphasis on growth monitoring, growth promotion will be shifted from crowded MCH clinics to community centers, where growth promotion, nutrition counseling, and community nutrition activities will be carried out by local volunteers with the support and guidance of PHMs. In those areas where community-based nutrition programs, for example the NDTF in-depth nutrition component, are currently being implemented, the focus will be on coordination between such efforts and the MOH growth promotion program. Where there is no such program, once supervisors and PHMs have completed in-service training they will utilize local health committees (or organize such committees if they do not already exist) to establish community nutrition centers and recruit local volunteers, preferably village mothers, who will be given training. The resources and experience of existing NGOs will be utilized in identifying community volunteers, and their cooperation will be solicited in setting up community centers and carrying out community-based  - 20 - nutrition activities. The training of health staff and community volunteers will draw on the experience and materials of the NDTF in-depth nutrition component and other community-based nutrition programs to the extent possible. Similarly, the growth promotion, nutrition counseling and community nutrition activities of the community centers will draw on the NDTF experience. In view of questions concerning roles and capacities of NGO and other community workers that have been raised by health staff, it is necessary to clarify the potential participation of community workers in the growth promotion program. The Government has provided assurances to the Association that growth monitoring and other growth promotion activities may be carried out by trained community volunteers under the general guidance of health workers (para. 5.2(i)). 2.43 A parallel growth promotion program will be carried out in the estate sector, focusing on the creches provided for infant and child care while mothers are working. The creches make nutrition education for mothers and on-site nutrition supplementation, when required, considerably more practical on the estates than in other areas. 2.44 The communications strategy for the growth promotion program, which will be coordinated by the Health Education Bureau (Ministry of Health) and the provincial health education units, will focus on basic pregnancy, breast-feeding, weaning and micronutrient messages. To the extent possible it will draw on nutrition communications already developed, particularly by UNICEF with the support of the IDA-assisted Health & Family Planning project, and by the nutrition component of the IDA-assisted Poverty Alleviation project. Interpersonal communication by PHMs and volunteers to convey key messages concerning pregnancy, breast-feeding, weaning and micronutrients and associated nutrition counseling will be the core of the growth promotion effort. Mass media campaigns will provide an essential complement to interpersonal communication. In Sri Lanka, where literacy is almost universal and the reach of the mass media is extensive, mass media efforts are a cost-effective way of conveying and reinforcing key messages to the general population as well as specific audiences. Health staff will be inforned about the content and media for upcoming campaigns, so that they are able to reinforce and validate local interpersonal efforts. Provision is made for technical assistance to support the development of the program's communications strategy. Coordination to ensure that the various nutrition programs convey consistent messages is the responsibility of the national Nutrition Steering Committee, which will convene workshops as needed. 2.45 Health and nutrition education program in the schools. The Ministry of Health has a nutrition education program in the schools, but it is largely inactive. The Divisional Health & Nutrition Committees will be asked to adopt one elementary and one secondary school in their respective divisions for the development of model school health and nutrition programs, including school medical inspection and follow up as well as health, nutrition and environmental education. School gardens will be included. The secondary school programs will be directed particularly at health and nutrition education needs of adolescent girls. These model programs will provide the basis for the expansion of health and nutrition education activities in the schools at a later stage. An experimental health and nutrition education scheme in schools in Kurunegala district will be evaluated and expanded with project operational research support if warranted (Annex 5). 2.46 Basic (Pre-Service) Training. Basic training for public health staff is undertaken at the National Institute of Health Sciences (NIHS) Kalutara and at nine other Public Health Training Centers (PHTCs). The NIHS takes the lead role in the preparation of curricula for basic training of public health staff and will be closely associated with the development of curricula for in-service nutrition  - 21 - training of health staff. The content developed for in-service training will also be incorporated into the basic (pre-service) training curricula for all categories of public health staff. Of the nine PHTCs, four have been strengthened by the current Asian Development Bank (ADB) project. The project will support IEC and office equipment as well as upgrading of library facilities for the other five. 2.47 lodization of salt. lodization of salt is widely accepted to be the most cost-effective way to prevent iodine deficiency disorders (IDD). To broaden the UNICEF-assisted salt iodization program, the project will support technical and financial planning assistance to the salt industry, which will permit the industry to produce better quality salt. Such salt is easier to iodize, and its more efficient production will make possible reduction of the price differential between iodized and non- iodized salt. This supply-side assistance will be complemented by support for social marketing to enhance the demand for iodized salt. Provision is also made for baseline and follow-up surveys of household use of iodized salt and IDD status, and for training of health staff responsible for monitoring compliance with the legislation mandating iodization of salt. 2.48 Research. Coordination of a program of operational and technical research will be the responsibility of the Nutrition Division of the Medical Research Institute. The Nutrition Division has adequate staff for this purpose; provision is made for support of office and computer facilities and a vehicle. The Nutrition Working Group (para. 2.51) will develop a list of research proposals and establish priorities for implementation. Additionally, the Nutrition Division will establish a screening and technical review process and will invite proposals from outside the Ministry of Health; these could be submitted by individuals, academic or other research organizations, NGOs, etc. A number of operational research proposals have already been made (Annex 5). 2.49 Inputs. The project will support equipment, vehicles, computers, technical assistance, in- service training, IEC activities and materials, and incremental operating costs. 2.50 Monitoring. Growth monitoring results and other growth promotion activities will be routinely monitored through a system of monthly reports. The impact of the program will be specially monitored through the designation of at least one sentinel division in each province, where baseline surveys and special efforts to ensure completeness of growth monitoring and program reporting will make it possible to track program progress continuously. Baseline surveys will also be carried out in matched divisions for control purposes. Overall program impact will be monitored through project support for continuation of the series of national nutrition surveys that extends back for more than 20 years. 2.51 Management. A Nutrition Working Group in the Ministry of Health, chaired by the Director Nutrition and including representatives from the Health Education Bureau and the Medical Research Institute, will be constituted to provide policy and implementation guidance. The Director Nutrition will invite the participation of others working in the nutrition field from within government, academic institutions and other organization. The Working Group will meet at least once a quarter to review the progress of the component. Two long-term national consultants will be supported for the duration of the project to assist the development and implementation of the growth promotion program.  - 22 - NON-COMMUNICABLE DISEASES AND EPIDEMIOLOGICAL TRANSITION Pilot Non-Communicable Diseases Component (US$0.4 million; 2% of base costs) 2.52 Background. The health services in Sri Lanka have developed in circumstances in which the clear priority has been control of communicable diseases. However, Sri Lanka is now well advanced in the epidemiological transition, that is, communicable diseases have been largely controlled and the burden of non-communicable diseases (NCDs) is increasing as life expectancy rises and the population ages. This situation has been well documented by a burden of disease study (Annex 8). Although recent Ministry of Health policy documents call for increased attention to NCDs, in practice little attention has been given to systematic efforts to address these diseases. Particularly at primary care levels, health professionals are inadequately prepared for effective patient care, nor at community level is there any provision for preventive and promotive NCD strategies linked to health and nutrition education efforts. 2.53 Over the last 15 years, there has been a very substantial increase in investment in hospital facilities (para. 1.31), undoubtedly driven in good measure by the increasing burden imposed by NCDs. However, it is clear from international experience that preventive and promotive measures that prevent or reduce morbidity, disability and mortality are far more socially desirable as well as cost- effective than subsequent hospital-based efforts to treat disease and disability. For example, it is known that: appropriate control can prevent or delay the onset of diabetic complications; early recognition and appropriate control of hypertension will prevent cardiovascular disease and cerebrovascular disease (stroke); regular physical exercise and appropriate nutrition will reduce the incidence of cardiovascular disease; and avoidance of smoking will reduce the incidence of cardiovascular disease, stroke and several cancers. 2.54 Objectives/Strategies. To assist Sri Lanka to effectively address increasing NCD concerns, the project will support a small pilot NCD component. The objectives of the component will be to develop an NCD strategy for Sri Lanka, based on compilation of an NCD data base, development of recommendations in NCD-related areas of food and tobacco policy, and, on a pilot basis, development of cost-effective programs for the prevention and control of selected NCDs. Implementation will draw largely on the existing infrastructure and staff of the Ministry of Health but will also utilize resources available in the universities, the NGO sector and the private for-profit sector. The knowledge and experience gained from implementation of the pilot component are expected to provide the basis for subsequent expansion of cost-effective NCD programs nationally. 2.55 Content. The component will undertake the following activities on a national basis: (a) assessment of the prevalence of diabetes, hypertension, cardiovascular disease, cerebrovascular disease, cancers, and other NCDs as well as obesity, smoking and other predisposing conditions and behavior through a National Risk Factor Prevalence survey; (b) assessment of the care and treatment currently provided for NCDs in the public and private sectors;  - 23 - (c) development of best practice NCD guidelines for health care professionals and health educators reflecting cost-effective approaches. The resulting manuals will be presented to health care professionals in the public and private sectors at a series of workshops; (d) development of national communication strategies for NCD prevention including national mass media campaigns. Such campaigns will be coordinated by the Health Education Bureau of MOH; (e) establishment of an NCD data registry in cooperation with the epidemiological unit of MOH; and (f) development of recommendations linked to NCDs in the areas of food and tobacco policy. Expertise available with the Sri Lanka Medical Association (SLMA), the universities and the NGO community will be utilized in this regard. 2.56 The project will also support a pilot program to address prevention and control of diabetes, which, on the basis of existing experience, has been recommended by the SLMA as the first priority for a pilot program. The Government has provided assurances that by June 30. 1997 an operational plan for a pilot diabetes program acceptable to the Association will be prepared and furnished to the Association for its concurrence, and that the plan will be carried out taking into account the Association's comments (para. 5.2(i)). The pilot program will include: (a) establishment of a core team including a physician, nurse-educator and dietician at a selected medical facility to develop and test approaches to diabetes prevention, treatment and control, including communications and outreach aspects; (b) establishment of a network of specialists in a variety of fields (e.g. endocrinology, ophthalmology, neurology, nephrology, etc.) to provide specialized advice and support to the core diabetes team as needed; (c) development of an outreach program through the primary health care system to train PHC staff and orient community members conceming prevention and control of diabetes and other NCDs, including the development of educational materials; (d) organization of a workshop in the latter half of the project to present the experience and recommendations of the pilot diabetes program. 2.57 If the experience of the pilot diabetes program is good, a second NCD program may be implemented in the second half of the project. 2.58 Provision is made for support of operational research on prevention and control of NCDs, as assessed by the Standing Committee on NCDs of the SLMA. NGOs, academic centers, etc. will be encouraged to submit proposals for support. 2.59 Inputs. The project will support equipment, computers, vehicles, training, technical assistance, IEC activities and materials, and incremental operating costs.  - 24 - 2.60 Evaluation. Evaluation of the impact, cost benefit, cost effectiveness, and replicability of all interventions supported by the component will be carried out in cooperation with the Management Development & Planning Unit (MDPU) of the Ministry of Health, drawing on assistance available to the MDPU from the Health Economics Study Program (HIESP) of the Department of Economics, University of Colombo (para. 2.69). 2.61 Management. The component will be managed by the Research and Training Unit, under the Deputy Director General, Research and Training, of the Ministry of Health. The DDG will seek the assistance of the Standing Committee on Non-Communicable Diseases of the Sri Lanka Medical Association and the NCD interest group at the University of Colombo Medical School which already has experience in the prevention and management of NCDs. A long-term national consultant will be contracted to manage implementation of the component. PROGRAM SUPPORT Health Policy Development Component (US$1.3 million; 6% of base costs) 2.62 Background. The earlier IDA-assisted Health & Family Planning project (para. 1.37) financed a Health Strategy and Financing Study (HSFS) to identify health sector issues and provide guidance on policy development and planning in the sector. The study documented the expanding role of the private sector in the provision of health care and identified as issues, among others, the need to improve the quality and efficiency of services through strengthening the referral system, determining altemative uses for types of facilities known to be ineffective, and addressing inefficiencies in the pharmaceutical sector, and the need to provide additional resources through expansion of cost recovery in the tertiary hospital sector. 2.63 The Prospective Plan for Health Development (1995-2004) recently published by the Ministry of Health is comprehensive in scope and constructively addresses, among others, most of the issues identified by the HSFS. The Plan recognizes that while Sri Lanka has made notable public health achievements, in view of changing demographic and epidemiological circumstances combined with increasingly constrained resources, efforts to deal with efficiency, effectiveness and financing issues in the sector are now required. However, the means to move from identification of policy requirements to effective planning and implementation need to be strengthened. The Government has provided a Letter of Health Development Policy acceptable to the Association. The Letter summarized the Government's intentions with reference to future policies. strategies and priorities for the overall development of the health sector. including specific steps which the Government intends to take in the areas of pharmaceutical policy, improvement of the efficiency and effectiveness of the health system. and resource generation in tertiarv health facilities (para. 5.1). The Letter is included in Annex 6. 2.64 Objectives. The objectives of the component are to support strengthening and institutionalization of Government's currently weak capacity for policy analysis and planning in the health sector; and to support further research and analysis of health policy and financing issues linked to implementation of associated pilot activities. 2.65 Strategies. To accomplish these objectives, the project will support (i) an agreed program of policy-related studies and pilot activities; (ii) a process of health planning and capacity  - 25 - development; and (iii) strengthening of analytic and planning capacity in the Ministry of Health and the Ministry of Finance & Planning. 2.66 Content. The development of an agreed program of policy-related studies (Annex 6) was begun as a part of project preparation. Five major areas for policy-related studies were agreed: (i) improved quality and efficiency of the health services; (ii) generation of additional resources for tertiary care; (iii) appropriate public-private mix in the health sector; (iv) addressing NCD morbidity and disability; and (v) other significant health policy areas, including mental health, violence against women, and environmental health. Prior to the end of each project year, IDA and the Ministry of Health will review the status of the studies program and jointly agree on the program for the subsequent year. The Government has provided assurances to the Association that under terms of reference and in accordance with a time schedule agreed with the Association, a program of policv- related studies will be carried out: that the results and findings of the studies will be reviewed annually with the Association: and that the recommendations will be timely implemented. taking into account the Association's comments (para 5.2(k)). 2.67 To strengthen understanding of the significance of health economics and financing issues and their role in health planning, the project will support a process of health planning and capacitv development conceming various health economics and financing issues and options. The process will comprise one-day orientation seminars for senior managers; one-week workshops for managers at provincial, divisional and medical institution levels; and orientation meetings for consultants, matrons and nursing sisters at major hospitals. The program will be managed by the Director Training. 2.68 To strengthen the development of analytic and planning capacity for the health sector within the Govemment, the project will support (i) three masters level fellowships in the Planning unit of the Ministry of Health; and (ii) one masters level and one short-term fellowship in the Ministry of Finance & Planning. 2.69 To provide access to additional analytical and planning resources to the Ministry of Health, the project will support a link program between the Ministry and the Health Economics Study Program (HESP) of the Center for Economic Research and Analysis at the University of Colombo. The link program will include development of policy and analysis capacity at HESP, close involvement of HESP in agreed programs of research and training for the Ministry of Health, and direct advisory support to the Ministry in health economics, financing and evaluation of programs. The link program will be established through a contract between the Ministry of Health and HESP (Annex 6), which will include provision for computers and other equipment and supplies as well as one masters level and one short-term fellowship to strengthen the capacity of the HESP. Additionally, support will be provided to the Department of Census and Statistics to include a health costs module in one or more of the periodic national surveys undertaken by the Department. 2.70 The Ministry of Health recognizes that there is a need to strengthen planning capacity at the provincial level, particularly in the areas of cost-effective health interventions based on epidemiological and burden of disease analysis, as well as quality and efficiency improvement. The project will therefore support development of such planning capacity in selected provinces through: (i) training of provincial health staff with planning responsibilities and staff of the district health teams; (ii) development of planning methodologies appropriate for provincial-level planning; and (iii)  - 26 - assistance for two cycles of annual planning including provision of computers, software and training required for the purpose. 2.71 Inputs. The project will support equipment, computers, technical assistance, in-service training, and incremental operating costs. 2.72 Management. The component will be managed by the Deputy Director General Planning. Management Information Systems (MIS) Component (US$1.6 million; 8% of base costs) 2.73 Background. More accurate information on health status and services, as well as improved availability of information, are both essential to increased effectiveness of the health services provided by MOH. Data collection and reporting systems are basically in place in the Ministry, but compliance with reporting requirements and availability of data in useful and usable forms both need to be improved. 2.74 Objectives. The objective of the component is to support increased capacity of the Management Planning and Development Unit (MDPU) of MOH to organize and utilize information for management and planning purposes. 2.75 Strategies. The project will support the development of a management information unit under the Director Planning & Management Information (PMI) as a part of the MDPU. This unit will be the integrating unit for management information in the Ministry and will review and coordinate all information-related activities. Through training and information technology inputs, some support to provincial and district levels will also be provided. 2.76 Content. The PMI unit will be responsible for: (a) coordination of all information technology within the Ministry of Health; (b) development of plans for improvement of the use of information in the Ministry; (c) support for the development of inter-office connections within the Ministry (LANs) as well as e-mail connections to allow interministry communications and to provide a gateway to internet communications in support of MOH activities; (d) support for the development of existing information systems such as that used by the Family Health Bureau for collection of information from the provinces and review of all plans for MIS systems at provincial, district and DDHS levels; and (e) development of training courses in the use of information for management purposes. The necessary software and related requirements will by developed through local consultancy in the first two years of the project (Annex 7).  - 27 - 2.77 The current ADB-assisted project includes support for pilot development of information management at divisional and district levels which is complementary to the MIS development supported by the project. The project will also provide support to the Human Resources Information System (HRIS) developed with support from the IDA-assisted Health & Family Planning project. 2.78 Inputs. The project will support equipment, computers, technical assistance, in-service training, salaries and incremental operating costs. 2.79 Management. The component will be managed by the Director Planning & Management Information. Health Education Bureau Component (US$2.5 million; 12% of base costs) 2.80 Background. For more than half of the goals of national health policy as identified in recent MOH policy documents, the primary determinant of improvement is individual and/or household health behavior, underlining the key role played by health education in achieving health objectives. Promoting behavior change through health education plays a major role in all programs supported by the project. 2.81 The effectiveness of communication efforts that have been undertaken in Sri Lanka, both interpersonal and through the mass media, is reflected by, for example, the successful promotion of contraception, resulting in the virtual achievement of replacement fertility, and the very high proportion of births in health facilities; recently, a mass media campaign concerning leprosy was considered to have reached a wide audience and effectively communicated the intended messages. It is generally agreed that both the high level of literacy in Sri Lanka as well as the capacity of the Health Education Bureau have contributed to the significant impact of health education efforts. 2.82 Objectives. The objectives of the component are to (i) support enhanced quality, effectiveness, and coverage of the health education activities of the Health Education Bureau; and (ii) improve the ability of HEB to carry out an expanded program of training in interpersonal communication. In contrast to the situation in some developing countries, the demonstrated competence of HEB makes it realistic to support expansion of its scope and activities. 2.83 Strategies. HEB will adopt a new approach emphasizing in-service training of primary health care staff in interpersonal communication skills. In other countries where similar training strategies have been adopted, the results in terms of improved primary health care performance have been both evident and cost-effective. To achieve improved quality and coverage of health education activities, the Bureau's planning, management and technical capacities, health education (HE) capacity at health facilities, and HE staffing at divisional level will all be strengthened. 2.84 Content. Management and technical skills of HEB headquarters staff will be upgraded through national and international training. Planning and management systems will be strengthened through the acquisition of computer capacity supported by systems analysis and data entry capability. Actual production of materials and development of media campaigns will continue to be largely contracted to the private sector, taking advantage of good private sector capacity in the advertising and related fields in Sri Lanka.  - 28 - 2.85 The coverage of HEB activities will be expanded through the provision of HE technology to upgrade existing hospital HE units, whose ability to function has been constrained by lack of equipment and materials. Feedback from those HE units which were assisted in three districts under the IDA-supported Health & Family Planning project indicates that inputs have been put to effective use. Additionally, MOH will support the appointment of 50 Health Education Officers a year at divisional level over the next five years from its own resources, with the goal of ultimately providing a Health Education Officer at each of the 259 divisional headquarters (DDHS). Existing Public Health Inspectors (PHIs) and Public Health Nurses (PHNs) are eligible for promotion to these posts; promotee training for those selected will be supported by the project. 2.86 HEB will provide in-service interpersonal communication training to all field staff as a part of the training for the nutrition component. Training to be provided under the malaria and STD/AIDS components will provide additional opportunities for review of communication skills as well. To enhance the capacity of HEB to provide training at headquarters, including training of trainers, the project will support the construction of an HEB hostel in Colombo. The Government has confirmed to the Association that it has title to the site designated for a Health Education Bureau hostel in Colombo. and that the plans for the building have been approved by an architect acceptable to the Association (para 5.2(d)). It has provided to the Association approved bidding documents for construction of a Health Education Bureau hostel in Colombo (para. 5.3 (b)). 2.87 Inputs. A long-term consultant will be contracted to assist HEB with the management and implementation of the greatly increased training and activities load that the project will entail. To strengthen HEB, the project will support civil works, furniture, equipment, computers, vehicles, technical assistance, in-service training, incremental staff, and incremental operating costs. The health education activities and materials in support of individual programs are included as part of those programs. C. Environmental Considerations 2.88 The proposed project was determined to be in screening Category C, which includes projects that are expected to have no significant negative environmental impact. No environmental analysis has been prepared for this project. A positive environmental impact is expected from the revised malaria control strategy that the project will support, since the amount of insecticide used annually for spraying has been reduced by 65%.  - 29 - III. PROJECT COST, FINANCING, PROCUREMENT, DISBURSEMENT AND IMPLEMENTATION A. Project Cost 3.1 The total cost of the Project is estimated at LKRI,4890 million or US$22.6 million equivalent, including contingencies (Table 3.1). Project costs at appraisal were estimated at October 1995 price levels. Physical contingencies of 10% for civil works, equipment, furniture, materials and drugs and 5% for vehicles are included in the total project cost; price contingencies that vary from 2.4% to 3.4% per year for foreign expenditures and from 6.5% to 11.0% per year for local expenditures during the implementation period are also included. Price contingencies are estimated at US$0.56 million, or 3% of base costs; physical contingencies are estimated at US$1.33 million, or 6% of base costs. Total contingencies add about 9% to total base costs. The foreign exchange component is estimated at US$8.23 million including contingencies, or about 36% of the total project cost. The total project cost includes taxes and duties of about LKR130.4 million (US$2.0 million). Table 3.1 Project Costs - Summary by Component (LKR Million) (USS Million) Total Foreign Base Local Foreign Total Local Foreign Total Exchange Costs A. Malaria 153.33 47.87 201.20 2.70 0.84 3.55 24 17 B. STDIHIVIAIDS 265.12 196.79 461.91 4.68 3.47 8.15 43 39 C. Nutrition 113.97 47.17 161.15 2.01 0.83 2.84 29 14 D. Non-Communicable Diseases 16.30 8.38 24.68 0.29 0.15 0.44 34 2 E. Program Support Health Policy Development 43.31 30.42 73.72 0.76 0.54 1.30 41 6 Management Information Systems 65.25 25.43 90.67 1.15 0.45 1.60 28 8 Health Education IEC 89.28 54.76 144.03 1.57 0.97 2.54 38 12 Subtotal Program Support 197.83 110.60 308.43 3.49 1.95 5.44 36 26 F. Project Management 13.72 2.89 16.62 0.24 0.05 0.29 17 1 Total BASELINE COSTS 760.28 413.70 1,173.98 13.41 7.30 20.71 35 100 Physical Contingencies 42.54 33.13 75.67 0.75 0.58 1.33 44 6 Price Contingencies 149.31 90.96 240.27 0.21 0.35 0.56 63 3 Total PROJECT COSTS 952.13 537.78 1,489.91 14.37 8.23 22.60 36 109 3.2 Table 3.2 provides an estimate of the total project costs, investment costs and recurrent costs including taxes and duties. The project investment base costs of US$13.6 million include support for civil works, office equipment and furniture, computers, laboratory equipment, vehicles, technical assistance, training and fellowships. Estimated recurrent base  - 30 - costs of US$7.1 million cover incremental operating costs directly attributable to the project during the five-year implementation period. These include salaries, operational and maintenance expenditures for facilities, laboratory supplies, drugs and medical supplies as well as operational allowances for staff. Drugs, medical supplies and laboratory supplies will be financed through the IDA credit. Table 3.2 Project Costs - Summary by Expenditure Category (LKR Million) (USS Million) Total Foreign Base Local Foreign Total Local Foreign Total Exchange Costs I. Investment Costs A. Civil Works 66.84 66.35 133.19 1.18 1.17 2.35 50 11 B. Equipment 18.75 56.13 74.88 0.33 0.99 1.32 75 6 C. Comp. Hardware & Software 9.24 27.68 36.92 0.16 0.49 0.65 75 3 D. Furniture 1.61 4.84 6.46 0.03 0.09 0.11 75 1 E. Vehicles 68.86 68.50 137.35 1.21 1.21 2.42 50 12 F. Materials 3.24 9.67 12.91 0.06 0.17 0.23 75 1 G. Activities 102.97 5.38 108.35 1.82 0.09 1.91 5 9 H. National Training 74.96 - 74.96 1.32 - 1.32 - 6 I. International Training - 24.40 24.40 - 0.43 0.43 100 2 J. TA - National 49.46 - 49.46 0.87 - 0.87 - 4 K. TA - International 3.12 17.53 20.65 0.05 0.31 0.36 85 2 L. RM & E 56.74 35.73 92.47 1.00 0.63 1.63 39 8 Total Investment Costs 455.79 316.20 771.99 8.04 5.58 13.62 41 66 11. Recurrent Costs A. Salaries 11.72 - 11.72 0.21 - 0.21 - 1 B. 0 & M 264.69 13.80 278.49 4.67 0.24 4.91 5 24 C. Drugs 28.08 83.69 111.77 0.50 1.48 1.97 75 10 Total Recurrent Costs 304.49 97.49 401.98 5.37 1.72 7.09 24 34 Total BASELINE COSTS 760.28 413.70 1,173.98 13.41 7.30 20.71 35 100 Physical Contingencies 42.54 33.13 75.67 0.75 0.58 1.33 44 6 Price Contingencies 149.31 90.96 240.27 0.21 0.35 0.56 63 3 Total PROJECT COSTS 952.13 537.78 1,489.91 14.37 8.23 22.60 36 109 3.3. Sustainability. Successive governments in Sri Lanka have been fully and firmly committed to support public health services. Continued priority support for the programs that address major public health problems--malnutrition, malaria control, STD/AIDS--can be expected. The recurrent cost implications of the project are modest, reaching about 1.8 % by the final project year (Annex 9). Of the incremental recurrent costs, the project will finance only drugs, medical supplies and laboratory supplies. For the malaria and nutrition components, with the completion of project-assisted intensive phases of these programs it is anticipated that after completion of the project the resources required to sustain progress will be significantly lower than the level of project inputs. STD/AIDS requirements, however, are likely to continue to increase for the foreseeable future. Altogether, it is estimated that in the first post-project year, project-related recurrent costs would decline to about 1.6% of the projected recurrent budget for Health (Annex 9), a necessary and sustainable public health outlay.  - 31 - B. Financing Plan 3.4. The proposed IDA credit of US$18.76 million equivalent will finance about 83% of total project costs, comprising 100% of total foreign exchange costs and about 85% of total local costs. Government is expected to finance about US$3.84 million equivalent of total project costs, including US$2.02 million of taxes and duties. Table 3.3 shows the financing plan. Table 3.3 Financing Plan LocallForeign/Taxes by Financiers (US$ million) IDA Government Total Amount % Amount % Amount % I. Foreign 8.23 100.0 0.0 0.0 8.23 36.4 II. Local (Excl. Taxes) 10.52 85.2 1.83 14.8 12.35 54.6 Ill. Taxes - - 2.02 100.0 2.02 8.9 Total Project 18.76 83.0 3.84 17.0 22.60 100.0 3.5. Retroactive Financing. Provision for retroactive financing estimated at US$500,000 has been included. These funds will be used for support of the Project Management Unit office, baseline surveys in the Malaria and Nutrition components of the project, support for district (regional) malaria control offices and other activities that will facilitate start-up prior to project effectiveness. C. Procurement 3.6. The procurement of all items funded from the IDA credit will be governed by the World Bank Guidelines of January 1995 (revised January and August 1996). For International Competitive Bidding (ICB), IDA's standard bidding documents will be used. For National Competitive Bidding (NCB) bidding documents acceptable to IDA will be used. Procurement arrangements are summarized in Table 3.4, and details of the procurement plan are given in Annex 11. The General Procurement Notice has been issued. 3.7. All procurement will be carried out by the Project Management Unit in the Ministry of Health (para. 3.19), except for procurement of condoms, condom vending machines and contraceptives, which is expected to be carried out by UNFPA. Procurement information will be collected and recorded as follows: (a) prompt report to IDA of contract award information by the Borrower; and (b) comprehensive semi-annual reports to IDA by the Borrower indicating: (i) revised cost estimates for individual contracts; (ii) revised timing of procurement actions, including advertising, bidding, contract award, and completion time for individual contracts; and (iii) compliance with aggregate limits on specific methods of procurement.  - 32 - Table 3.4 Summary of Proposed Procurement Arrangements (US$ million equivalent) Procurement Method Intemational National Competitive Competitive Other N.l.F. Total Bidding Bidding A. Works AIDS/STD Complex 0.86 - - - 0.86 (0.80) (0.80) Hostel Construction - 0.28 - - 0.28 (0.26) (0.26) Minor Civil Works (diff. locations) - 1.47 - - 1.47 (1.37) (1.37) B. Goods Fumiture - 0.13 - 0.13 (0.10) (0.10) Computer Hard- and Software 0.64 - 0.11 - 0.75 (0.51) (0.091 (0.60) Misc. Equipment and Materials 0.92 0.30 0.32 - 1.54 (0.74) (0.28) (0.29) (1.31) Lab/Med Equipment/Consumables 0.45 - - - 0.45 (0.36) (0.36) Medical Supplies, Drugs and Contraceptives 4.00 - 0.38 - 4.38 (3.80) (0.36) (4.16) C. Vehicles 2.55 - - - 2.55 (1.91) -(1.91) D. Consultancies Intemational TA - 0.39 - 0.39 (0.39l (0.39) National TA - 0.88 (0.84) (0.84) E. Training National Training - 1.40 - 1.40 (1.33) (1.33) Fellowships & Study Tours - - 0.47 - 0.47 (0.47) (0.47) F. Miscellaneous RM & E - - 1.97 - 1.97 (1.88) (1.88) Health Education Programs - - 1.83 - 1.83 (1.74) (1.74) Incremental Salaries - - - 0.22 0.22 Operation & Maintenance - - 1.355 1.65 3.00 (1.24) - (1.24) Total 9.42 2.05 9.25 1.87 22.60 (8.12) (1.91) (8.73) - (18.76) Note: Figures in parenthesis are the respective amounts financed by IDA. N.I.F. - Non-IDA financed / Furniture will be procured through NS; small computer items and special supplies will be procured through NS. / Small office equipment and other items (US$0.24 million), except for condom vending machines, will be procured through NS; condom vending machines (USS0.08 million) will be procured through UNFPA. / Small amounts of drugs and medical supplies (USSO. 10 million) will be procured through NS. Condoms and contraceptives (US$0.28 million) will be procured through UNFPA. / TA for Health Policy Development (US$0.35 million) is expected to be contracted to an academic institute; MIS Development and Architectural Design (USS0.42 million) are expected to be contracted to firns; the remaining TA is expected to be contracted to individuals. / Spare parts and small maintenance equipment for vehicles, medical lab equipment, and computer hardware.  - 33 - 3.8. The civil works included under the project (estimated cost of US$2.6 million) comprise: (i) construction of an STD/AIDS complex; (ii) construction of a hostel for the Health Education Bureau; (iii) construction of five incinerators at urban health care centers in Colombo; and (iv) minor refurbishment and upgrading of provincial and base hospital STD clinics. These construction activities will be undertaken during the first, second and third project years. The civil works contract for the STD/AIDS complex (estimated cost of US$0.86 million) will be procured through ICB. All other civil works contracts will be for less than US$400,000 and will be contracted using NCB procedures. With the exception of the HEB hostel (estimated cost of US$300,000), the other contracts are expected to be for less than US$60,000 each, in scattered locations. Because of the low value of these contracts and/or the remote location of the construction sites, it is not expected that they will attract international bidders. 3.9. The gooda to be financed from the IDA credit include office and laboratory equipment, furniture, consumables, computer hardware and software, medical supplies, drugs and contraceptives. To the extent possible, these items will be grouped into several procurement packages. For two packages of computer hardware and software of US$0.32 million and above, procurement will be through International Competitive Bidding (ICB). One package of specialized laboratory equipment, furniture and consumables totaling US$0.45 million will be procured through ICB. Drugs and medical supplies with a value of US$4.0 million will be grouped into suitable procurement packages and procured through ICB. Condoms, condom vending machines and contraceptives totaling about US$0.36 million will be procured through UJNFPA. Miscellaneous equipment and supplies with a total value of US$0.92 million will be grouped into two packages and procured through ICB. About US$0.30 million of miscellaneous equipment and supplies will be grouped into suitable contracts and procured through NCB. The balance covering furniture, miscellaneous small office equipment, small computer hardware items and office items, and small amounts of medical supplies, not to exceed a total value of US$0.58 million, will be procured through National Shopping (NS). Spare parts and small maintenance equipment items for vehicles, medical lab equipment, and computer hardware totaling US$1.35 million will be procured through NS. 3.10. All vehicles totaling about US$2.55 million will be procured through ICB and will be grouped into suitable procurement packages. Procurement of ambulances for transport of falciparum malaria cases and other medical emergencies would be conditional on a review of transport aspects of the health system that would indicate the justification in cost-effectiveness terms for the type and number of vehicles needed and address sustainability issues. 3.11. All consultants for technical assistance (TA) will be selected in accordance with the "Guidelines for the Use of Consultants by the World Bank Borrowers and by the World Bank as Executing Agency" (August 1981). Contracts for architectural design and supervision for the STD/AIDS complex and the Health Education Bureau hostel, which will require an estimated 12 person-months, and the TA for the design and implementation of management information systems, which will require an estimated 156 person-months, are expected to be awarded to firms. Additionally, a contract with the Health Economics Study Program, Department of Economics, University of Colombo, for support to the Ministry of Health in the areas of health economics and financing is expected to provide for approximately 30 person-months over five years. Technical support to be provided by individuals to the STD/AIDS, Nutrition, NCD, HEB and project management components for the duration of the project is expected to result in approximately 700 person-months of individual TA. International training in the form of international fellowships and training courses, which will total an estimated 100 person-months,  - 34 - will be provided by academic institutions or training institutes. These will be contracted on the basis of Direct Contracting. Production of health education materials will be procured by NCB or NS, depending on the value of the package. In-service training of Ministry of Health staff, including development and production of course materials and travel and subsistence costs for trainers and trainees, will be carried out departmentally by the Ministry of Health. Surveys and studies will be carried out departmentally by the Ministry of Health with some technical assistance from other government departments. 3.12. All bidding packages procured through ICB and other packages for civil works and goods estimated to cost US$200,000 or more will be subject to prior IDA review. In addition, there will be a prior IDA review process for the first package of each procurement category (civil works, goods, etc.) procured through NCB. International fellowships and study tours will be reviewed by IDA to ensure that they are in accordance with Association guidelines. Terms of reference (TOR) for consultant contracts will be subject to prior review by IDA, regardless of value. In addition IDA will review short lists, letters of invitation, and consultant contracts higher than US$100,000 for firms and US$50,000 for individuals. The Government has provided to the Association confirmation that acceptable sample procurement documents for International Competitive Bidding (ICB) and National Competitive Bidding (NCB) are available (para. 5.2(e)). D. Disbursement 3.13. Preparation of disbursement applications will be the responsibility of the Ministry of Health. The Project Management Unit (para. 3.19) will be responsible for preparing and maintaining all documentation. 3.14. The Project is expected to be completed in five years, by December 31, 2001, and the Credit is scheduled to close on June 30, 2002. Expected disbursement from the IDA credit over a five-year period and disbursement against specific categories are given in Annex 12. Care has been taken to plan procurement of virtually all civil works, vehicles, and equipment in the first half of the project. 3.15. Disbursements will finance: (i) 85% of the costs for civil works; (ii) for goods 100% of foreign expenditures, 100% of local expenditures ex-factory cost and 85% of local expenditures for other items procured locally; (iii) 100% of the cost for foreign and local consultancies and training; (iv) 100% of the health and nutrition and research, monitoring and evaluation activities; and (v) 100% of foreign expenditures, 100% of local expenditures ex- factory cost and 85% of local expenditures for other items procured locally for health and nutrition education materials. 3.16. To facilitate project implementation, the Borrower will establish a Special Account on terms and conditions satisfactory to IDA to cover IDA's share of expenditures. The Authorized Allocation will be US$500,000, representing about four months of average expenditures made through the Special Account. During the early stages of the project, the initial allocation to the Special Account will be limited to US$250,000. However, when aggregate disbursements under the Credit have reached the level of SDR3,500,000 equivalent, the initial allocation may be increased up to the Authorized Allocation of US$500,000 by submission of the relevant withdrawal applications. Applications for replenishment of the Special Account will be submitted monthly but not less than quarterly or when one third of the  - 35 - amount has been withdrawn, whichever occurs sooner. Documentation requirements for replenishment will follow standard IDA procedures as described in the Disbursement Handbook, Chapter 6. Monthly bank statements of the Special Account which have been reconciled by the Borrower should accompany all replenishment requests. 3.17. Disbursement for civil works contracts valued at more than US$200,000 and goods at more than US$200,000 will be made against full documentation. Similarly, disbursement for contracts to consultancy firms valued at more than US$100,000 and for individual consultants valued at more than US$50,000 will also be made against full documentation. Disbursement for contracts for civil works, goods and consultancy services valued below these thresholds may be made on the basis of Statements of Expenditures (SOE). Supporting documentation for SOEs will be retained by the implementing agency for at least two years after disbursement. Direct payment applications will be accepted for minimum amounts of US$50,000 when the initial deposit is US$250,000 and US$100,000 when the initial deposit is increased to US$500,000. E. Accounts and Audits 3.18. Procedures for accounts and audits will follow the Bank's "Guidelines for Financial Reporting and Auditing of Projects Financed by the World Bank." The Project Management Unit will maintain a consolidated account of all expenditures under the project. The Borrower will provide to IDA within six months of the end of each fiscal year an audit report. The project accounts will be audited annually by auditors satisfactory to IDA in accordance with appropriate auditing principles, with terms of reference approved by IDA. The audit reports should include a separate opinion on the adequacy of SOEs and on the Special Account. Govemment has provided assurances that: (i) independent auditors acceptable to IDA will be appointed in a timely manner to undertake annual audits and to prepare audit reports of the Pro_ject Accounts. Special Accounts and SOE : and (ii) certified copies of the audited project accounts and the Special Account statements. together with the auditor's report and opinion thereon. and a copy of the auditor's report and opinion on SOEs will be provided to IDA within six months of the end of each fiscal year. 3.19 Overall guidance for the project will be provided by a Project Steering Committee. The Steering Committee will be chaired by the Secretary Health, with the project coordinator as secretary. Members will include project component managers and representatives of the Economic Resources Department, the National Planning Department and the Department of Budget. F. Project Management and Implementation 3.20. Overall project management and coordination will be the responsibility of a Project Management Unit (PMU). The PMU will be headed by a full-time project coordinator, who will report to the Secretary of the Ministry of Health. The Project Coordinator will be assisted by a computer analyst, a project accountant and office staff. The PMU will be responsible for coordination of annual project reviews, preparation and submission of semi- annual project reports, procurement for the project, and preparation of disbursement applications. Since the PMU will carry over from the previous IDA-supported Health & Family Planning  - 36 - Project, the unit will have practical experience in IDA procurement, disbursement, supervision and reporting procedures from the start. 3.21. The components of the project will be implemented as part of ongoing programs by the unit of the Ministry of Health concerned, as indicated in the table below. The organization chart of the Ministry, which shows these units, is at Chart 1. The ability of these units to successfully implement the project components for which they will be responsible is indicated generally by the excellent achievements of the health services in Sri Lanka and specifically by the effectiveness to date of the AMC, NSACP, and Family Health programs. The MDPU was created with assistance from the IDA-supported Health & Family Planning project and is now functioning along the lines envisioned in the project. The Health Policy and Management Information Systems components will further strengthen and expand the capacities of the MDPU. Component Ministry of Health Unit Malaria Anti-Malaria Campaign (AMC) STD/AIDS National STD/AIDS Control Program (NSACP) Nutrition Family Health Bureau (FHB) Non-Communicable Diseases Research and Training Unit Health Policy Management Development and Planning Unit (MDPU) Management Information Systems Planning & Management Information Unit (PMI Unit) Health Education Health Education Bureau (HEB) 3.22 Monitoring and impact indicators for the respective project components are summarized in Annex 11. The PMU will be responsible for ensuring that baseline and other studies that will be required for impact assessment are carried out. The implementing units of the Ministry of Health will be responsible for ensuring that input and program monitoring data are obtained and submitted to the PMU on a regular basis. The Government has provided assurances that it will maintain policies and procedures adequate to enable it to monitor and evaluate on an ongoing basis, in accordance with benchmarks and indicators satisfactory to the Association. the implementation of the project and the achievement of the project obiectives. 3.23 The PMU will submit to IDA for review and comment not later than one month following the period under review semi-annual reports summarizing project progress and problems for the period under review and cumulatively. Government will carry out a mid-term review of the project, and additionally Government will submit a project completion report to the Association within six months of the Credit Closing Date. The Government has provided assurances to the Association that (i) a Project Management Unit (PMU) within MOH. which will be headed by a Project Coordinator with qualifications and experience acceptable to the Association and responsible for the overall management and coordination of the project. will be maintained; (ii) by November 30, 1997 and each November 30 thereafter. an annual action plan for the project will be prepared and furnished to the Association for review and comment: (iii) by April 30. 1999 a mid-term review of the project will be carried out by Government. and by June 30. 1999 the recommendations of the review will be discussed with the Association: and (iV) on the basis of guidelines acceptable to the Association. a plan for the future operation of the project will be furnished to the Association by the Government within six months of the Credit Closing Date (para. 5.2(f)).  - 37 - 3.24 IDA Supervision. A supervision plan for the project is given in Annex 11. It is anticipated that the annual IDA supervision requirement will be approximately 10 staff weeks.  - 38 - IV. BENEFITS, ECONOMIC JUSTIFICATION AND RISKS A. Benefits 4.1 The expected benefits of project assistance as well as the negative consequences of non- availability of support are as follows. (a) Lack of support for the revised malaria control strategy would mean curtailment of the mobile clinic and impregnated bed net strategies that have proved effective. Additionally, project resources would make possible improvements in surveillance, early warning and management aspects of the program, all of which are expected to make significant contributions to sustaining and accelerating current declines in prevalence. Without continued support for the revised strategy, malaria prevalence could again be expected to rise. (b) The importance of taking measures to control transmission of HIV before epidemic spread begins is evident. Support is required for key strategies to improve diagnosis and treatment of STDs and to reduce high-risk behaviors through education/ communication efforts. Implementation of these measures would mean reasonable prospects for prevention of an AIDS epidemic in Sri Lanka in a cost-effective manner; without these measures, the chances that epidemic spread could be avoided are poor. (c) Without reorientation of the Ministry of Health's ineffective growth promotion program, there are no prospects for significant national reduction of malnutrition levels in the shorter tern. The nutrition component of the project would provide the framework and the resources necessary to accomplish the needed reorientation and improve nutritional status through program interventions. (d) It is clear that the disease pattern in Sri Lanka has shifted from childhood communicable diseases to non-communicable diseases (NCDs) of adults and that the resulting burden on the health system is distorting resource allocation. The pilot NCD component would assist the Ministry to systematically define the issues, identify policy measures, and develop cost-effective prevention and treatment programs, steps which the Ministry would be unlikely to undertake without project initiative and resources. (e) The project support components would enhance the ability of the Ministry of Health to plan, manage and implement its programs, thus benefiting the entire public health system. The health policy component would support development of policy measures that would enable the health system to maintain and improve its good performance under changing circumstances. The management information systems component would strengthen the capacity of the Ministry to analyze and utilize data for planning and monitoring purposes. Through strengthening of the Health Education Bureau, the effectiveness of education/communication aspects of all health programs would be improved. 4.2 For the strengthened malaria and nutrition programs, it is possible to estimate improved program impact by the end of the project period. The annual incidence of malaria cases in the six high-prevalence districts is expected to fall from more than 40 detected cases per thousand population in 1994 to less than 10 per thousand by 2001; this would mean 125,000 fewer detected cases in 2001  - 39 - as compared to 1994. As a result of the reorientation of the growth promotion program, the percentage of underweight infants and young children below age five (i.e. below two standard deviations of the weight-for-age standard), which was about one third, or more than 500,000 infants and children, in 1993, is expected to be reduced to less than 20% by 2001. The percentage of low- weight births, which was about 20%, or roughly 80,000 newborns, in 1993, is expected to be reduced to less than 15% by 2001. Iodine deficiency is expected to be virtually eliminated and iron-deficiency anemia significantly reduced by 2001. The goal of the STD/AIDS program is to reduce the incidence of STDs other than AIDS and to ensure than Sri Lanka remains a low HIV-prevalence country. B. Economic Justification Justification for Public Sector Involvement 4.3 There is a clear economic justification for public sector involvement in all of the programmatic areas supported by the project. For the malaria program, there are positive externalities from the early detection and prompt treatment of malaria cases, which reduces transmission. Moreover, in the terminology of welfare economics, malaria vector control is in the nature of a public good. Interventions to prevent and treat STDs also have positive externalities, as is the case with measures to prevent the spread of HIV/AIDS. The nutrition component addresses imperfect information on the part of households which leads to inadequate maternal nutrition and inappropriate breast-feeding, weaning and feeding of young children. Such information deficiencies cannot be addressed through market mechanisms, since there is no effective demand for this type of information services. Similarly, the health education component would strengthen the public sector's ability to convey important health-related information to households on a wide variety of topics. And health policy development is of course an important public sector function. 4.4 The case of the NCD component is more complex. To the extent that prevention is an important, cost-effective means of reducing the prevalence of some of these diseases (e.g., those which are tobacco-related), there would be a clear rationale for public sector intervention in the form of health education, and related policy measures, such as taxation, may also be in order. Since the public health services presently provide care and treatment for NCDs, and in the short term will continue to do so, there is also justification for support for cost-effective improvements in such services. The NCD component in the proposed project would focus on the development and dissemination of best practice guidelines for the treatment of NCDs, which would address an important information gap for both public and, increasingly, private health care providers. The proper role of the public sector conceming the treatment of NCDs in the longer term is a complex issue which would need to be examined as part of the ongoing policy dialogue. Cost-Effectiveness Aspects 1/ 4.5 Malaria. The revised WHO malaria control strategy introduced in 1993, which the project would support, was adopted to improve the cost-effectiveness of malaria control in Sri Lanka following resurgences in 1987 and again in 1991. The revised strategy emphasizes selective residual spraying using several insecticides in rotation as opposed to the old strategy of blanket spraying with one insecticide, malathion. It also uses mobile clinics for early detection and treatment in high- prevalence districts and promotes the use of insecticide-impregnated beds by households. 1/ For further details, see Annex 10.  - 40 - 4.6 It is likely that the revised strategy is averting a significantly higher number of malaria cases per year than the old strategy. The number of cases detected was about 400,000/year in 1991 and 1992, declined in 1993 to 363,000, still basically under the old strategy, and declined further in 1994 to 274,000 under the revised strategy; from January through June 1995, only 106,000 cases were detected. While other factors such as weather and the natural malaria cycle may have been partly responsible for the sharp decline in cases, the switch to the revised strategy is likely to have been the major factor. In addition, the new strategy has a lower cost. In the aggregate, total annual program costs nationwide declined by about 17% in real terms following the change in strategy. Moreover, the new strategy imposes lower costs in terns of environmental degradation, because the amount of insecticide required has been reduced by about 65%. 4.7 STD/AIDS. Calculations of cost-effectiveness of the STD/AIDS control program (e.g., cost per disability-adjusted life year saved) are difficult because current levels of STD and H1V incidence and prevalence are not known with any precision; estimates vary widely. The balance of the evidence suggests that HIV transmission in Sri Lanka has been fairly limited so far. However, complacency must be avoided. 4.8 The Government's program for prevention of epidemic spread of HI in Sri Lanka was developed with technical inputs from WHO and other donors and draws on accumulated international experience to identify the most technically appropriate as well as cost-effective strategies. It emphasizes: (i) diagnosis and treatment of other STDs, since STD patients are a major HIV risk group; (ii) orientation of private sector physicians, who see a large proportion of STD cases; and (iii) information, education and communications (IEC) efforts directed at appropriate target groups to promote avoidance of high-risk behaviors. IEC activities in the program are carried out by NGOs, which is believed to be more cost-effective than implementation by public sector agencies. 4.9 Nutrition. At present, Government's efforts to reduce malnutrition among pregnant women and young children center on the thriposha program, a supplementary feeding program (thriposha is the name of a food supplement; for further details, see Annex 5). Expenditure on the program is currently about US$4.5 million a year. None of the studies of the program that have been carried out indicate that the program has been consistently successful in improving the nutritional status of beneficiaries. Possible reasons are that the supplement may be consumed by the entire family rather than the target beneficiary; that the mother may reduce the child's regular food when the child is given the supplement, resulting in no net increase in nutrient intake; and that mothers fail to obtain the supplement with enough regularity to have an impact. Since there is apparently no significant impact on the nutritional status of intended beneficiaries, it can be concluded that the thriosha program has a very low degree of cost-effectiveness (i.e., a very high cost per case of malnutrition averted). 4.10 The nutrition component of the project would support a shift to a more cost-effective strategy to reduce malnutrition among pregnant women and young children. Available data strongly suggest that inappropriate breast-feeding, weaning and feeding practices are responsible for much of the malnutrition. This, in tum, suggests that the focus of the nutrition program needs to shift from the present emphasis on the supply of thriposha to a growth promotion program promoting good nutritional practices for pregnant women and young children. Such a program should be particularly cost-effective among Sri Lanka's population, where primary education levels are high. This shift would be supported by the proposed project. The marginal cost of the growth promotion program would be low. No incremental staff would be required. Public health midwives (PHMs) would lead the growth promotion efforts in their communities but would rely heavily on NGOs and community volunteers to assist in these efforts. Total incremental cost of the growth promotion program over five  - 41 - years, largely for training, IEC materials and activities, and surveys/studies, is estimated to be US$3.5 million. The subsequent annual incremental costs of the program would be about US$100,000 in 1995 prices. Based on these cost figures, and the projected increase in the number of cases of malnutrition in young children averted (para. 5.2), the cost per case averted under the new strategy in the period 1996-2000 would be about US$5. (The cost per case averted would be lower if a longer period were considered.) This unit cost estimate does not take into account any additional food costs borne by households, however. 4.11 As part of the proposed project, an impact evaluation of the thripos program would be carried out (para. 2.32), and a special effort would be made to monitor the ongoing progress and the impact of the reoriented growth promotion program (para. 2.50). It is hoped that positive results of the new approach will provide additional evidence to support phasing out of the thriposha program. 4.12 Non-Communicable Diseases. The NCD component is a pilot component, and only the broad principles of its design have been specified so far. Hence, it is not possible to be specific about cost-effectiveness aspects, except to save that cost-effectiveness of any prevention, control and/or treatment strategies supported would be carefully assessed and would be a key factor in any recommendations based on the results of the pilot. Fiscal Impact and Cost Recovery 4.13 The fiscal impact of the project would be very small. Incremental recurrent costs arising from the project would represent about 2% of the total health recurrent budget by the year 2000. This projection assumes that the total health recurrent budget would increase in real terms at the same annual rate as projected GDP (about 5%; see Annex 9). 4.14 There would be no cost recovery associated with interventions supported by the project. Most households would not be willing to pay for various types of health/nutrition education services, and some of these services are also in the nature of public goods (e.g. use of mass media), which would make user fees infeasible in any case. Interventions addressing malaria and STD/AIDS have strong positive extemalities, and it is in the public interest to encourage individual households to take fill advantage of existing services; the imposition of user fees might contribute to higher prevalence of these communicable diseases. However, it may be desirable for the Govemment to impose user fees for treatment of NCDs in public facilities This is an important issue for future policy discussions with the Govemment. Poverty Impact 4.15 The poverty impact of the interventions supported by the project is difficult to establish because of the lack of data relating disease prevalence rates to household income or consumption. For malnutrition, there is evidence from household surveys indicating that the proportion of malnourished children under 5 years of age declines as per capita household consumption increases. For example, in the early 1980s, it was found that the proportion of children who were stunted declined from 49% for children in the lowest quintile of the household expenditure distribution to 22% in the highest quintile. For wasting, the decline was from 15% to about 9%. Hence, it can be expected that nutrition interventions supported by the project would benefit a greater proportion of children in the lowest quintile of the household expenditure distribution than in higher quintiles. For malaria and STDs, however, the benefits of program interventions are likely to be more uniformly spread out among all income classes.  - 42 - C. Risks 4.16 The chief risks associated with project implementation concern the following. (a) The unsatisfactory experience of the first half of the IDA-assisted Health & Family Planning project raises questions about the implementation capacity of the Ministry of Health. In developing the project, care has been taken to avoid the lack of 'ownership' and the project management problems (para. 1.39) which led to previous difficulties. The Ministry has taken the lead in project development, thus enhancing their sense of ownership. Care has been taken to strengthen the Project Management Unit and to provide national technical assistance for project-supported programs, in order to ensure that adequate support for both project management and program implementation will be available. Good performnance in the second half of the Health & Family Planning project provides grounds for expecting continued good performance. (b) Provincialization of the health services raises the possibility that previous levels of support for services would not be maintained. It is not yet possible to assess this risk, because decentralization is an ongoing process and the central Ministry of Health still provides most funds. Thus far, the quality of services does not appear to have suffered, and some examples of excellent provincial initiatives can be cited. The implications of decentralization are being examined as a part of a comparative WHO study (Annex 6), and issues that may emerge would be addressed in any future lending. (c) The nutrition and the STD/AIDS components of the project depend to a significant extent on the involvement of NGOs. Although the NGO sector in Sri Lanka has substantial capacity, the Ministry of Health's record of cooperation with NGOs is not strong. For the STD/AIDS program, this issue has been and will continue to be addressed by channelling donor assistance to NGOs directly. Additionally, a unified donor community has represented strongly to the Ministry that coordination and cooperation between the medical and the behavioral aspects of the national AIDS control program is essential to its success. For the nutrition program, the focus will be on organizing cooperation between the health system and available NGO resources at the divisional and community levels to achieve common health and nutrition objectives. Progress in achieving locally effectively NGO coordination will be monitored by the project. 4.17 The project's health policy dialogue must contend generally with complacency concerning the need for policy changes in the health sector on the part of some senior managers in the Ministry, who cite Sri Lanka's outstanding public health achievements, and specifically with the Government's reluctance to consider wide-scale introduction of politically sensitive cost-recovery measures. These difficulties will be addressed through a continuing dialogue linked to an agreed program of studies and pilot initiatives. The recent publication by the Govemment of a ten-year Prospective Plan for Health 1995-2000 that addresses many of IDA's concerns in a positive fashion will support the dialogue. However, some of the more controversial policy and financing issues may have to be deferred to any future lending. 4.18 Civil unrest in the northem and eastern regions of the country continue to disrupt provision of services in those areas and to pose the threat of other disruptions as well. The Government has coped with these difficulties well over more than a decade. Given the Government's excellent primary health care achievements, sustained support for the project-supported programs that address major public health problems is not considered to be a potential issue.  - 43 - V. AGREEMENTS REACHED AND RECOMMENDATIONS 5.1 A letter of Health Development Policy, acceptable to IDA has been received. The letter summarizes the Government's intentions with reference to future policies, strategies and priorities for the overall development of the health sector, including specific steps which the Government intends to take in the areas of pharmaceutical policy, improvement of the efficiency and effectiveness of the health system, and resource generation in tertiary health facilities (para. 2.63). 5.2 The Government has confirmed to the Association: (a) that the Government has title to the site designated for construction of a headquarters facility of the STD/AIDS Control Program in Colombo, and that plans for the facility have been approved by an architect acceptable to the Association (para. 2.19); (b) that a post of Director Nutrition (Ministry of Health) has been created (para. 2.38); (c) confirmation that the post of Director Planning & Management Information (Ministry of Health) has been filled (para. 2.79); (d) that the Govemment has title to the site designated for the Health Education Bureau hostel in Colombo, and that the plans for the building have been approved by an architect acceptable to the Association (para. 2.86); and (e) that acceptable sample bidding documents for Intemational Competitive Bidding (ICB) and National Competitive Bidding (NCB) are available (para. 3.12). (f) that by December 31, 1997, private blood banks will be required to follow Ministry of Health standards for the safety of the blood supply (para. 2.23); (g) that: (i) by June 30, 1998, the Ministry of Health will carry out, under terms of reference satisfactory to the Association, an evaluation of the impact of the thriposha supplementary feeding program and fumish to the Association the findings and recommendations of the evaluation; and (ii) the Ministry of Health will carry out agreed recommendations of the study (para. 2.33); (h) that by March 31, 1997 a candidate whose qualifications and experience are acceptable to the Association will be appointed to the post of Director Nutrition (Ministry of Health (para. 2.38); (i) that growth monitoring and other growth promotion activities may be carried out by trained community volunteers under the general guidance of health workers (para. 2.42); (j) that by June 30, 1997 an operational plan for a pilot diabetes prevention and treatment program acceptable to the Association will be prepared and fumished to the Association for its concurrence; and that the plan would be carried out taking into account the Association's comments (para. 2.56);  - 44 - (k) that under terms of reference and in accordance with a time schedule agreed with the Association, a program of policy-related studies will be carried out; that the results and findings of the studies would be reviewed annually with the Association; and that the recommendations will be timely implemented taking into account the Association's comments (para. 2.66); (1) that: (i) a Project Management Unit (PMU) within MOH which will be headed by a Project Coordinator with qualifications and experience acceptable to the Association and responsible for the overall management and coordination of the project, will be maintained; (ii) by November 30, 1997 and each November 30 thereafter, an annual action plan for the project will be prepared and fumished to the Association for review and comment; (iii) by April 30, 1999 a mid-term review of the project would be carried out by Govemment, and by June 30, 1999 the recommendations of the review will be discussed with the Association; and (iv) on the basis of guidelines acceptable to the Association, a plan for the future operation of the project will be furnished to the Association by the Govemment within six months of the Credit Closing Date (para. 3.23). 5.3 The Govenument has provided to the Association: (a) approved bidding documents for construction of a headquarters facility for the STD/AIDS Control Program in Colombo (para. 2.19); and (b) approved bidding documents for construction of a Health Education Bureau hostel in Colombo (para. 2.86). 5.4 Subject to the above conditions, the project provides a suitable basis for an IDA Credit of SDR 13.0 million equivalent on standard IDA terms, with a maturity of 40 years, to the Government of the Democratic Socialist Republic of Sri Lanka.  - 45 - Annex.I Page 1 of 2 SRI LANKA HEALTH SERVICES PROJECT A. Basic Population. Health and Nutrition Data* Population (est.) 17.6 million Crude Birth Rate per 1000 Population 19.9 Crude Death Rate per 1000 Population 5.3 Rate of Natural Increase 1.5 % per annum Contraceptive Prevalence Rate 66.1 % Modern Methods 43.7 % Traditional Methods 22.4 % Total Fertility Rate 2.3 Life expectancy at Birth 72 years Infant Mortality Rate per 1000 Live Births 18 Maternal Mortality Rate per 1000 Live Births 0.3 Under-5 Mortality Rate per 1000 Live Births 19 Low-weight Births (under 2,500 grams) 19 % Under-5 malnourished (weight for age) 38 % Under-5 DPT coverage 87 % Under-5 Measles coverage 80% *Data for 1993 Sources: Annual Health Bulletin Sri Lanka 1994. Demographic and Health Survey Sri Lanka 1993  - 46 - Annex I Page 2 of 2 B. Key Statistics for the Public Health Sector Number of Beds No No. of Beds Teaching Hospitals 12 10,882 Provincial Hospitals 8 6,313 Base Hospitals 22 6,571 District Hospitals 133 12,704 Peripheral Hospitals 116 5,264 Rural Hospitals 123 2,979 Central Dispensary and Maternity Homes 80 807 Other Hospitals 16 4571 Total 510 50091 Number of Beds per 1,000 population 2.8 Number of Inpatients per 1,000 Population 179.3 Daily Average Occupancy 37132 Bed Occupancy Rate 75% Average Duration of Stay (days) 4.2 Number of Maternity Beds 8696 Bed Ratio per 1,000 population 2.8 Average Duration of Stay (days) 4.7 Number of Hospital Midwifes per 100,000 Population 12.4 Number of Pharmacists per 100,000 Population 3.5 Number of Dispensers per 100,000 Population 3.6 Number of Medical Technologists per 100,000 Population 3.5 Number of Radiographers per 100,000 Population 1.4 Number of Physiotherapists per 100,000 Population 0.9 Number of E.C.G. Recordists per 100,000 Population 0.5 Number of E.E.G. Recordists per 100,000 Population 0.1 Source: Annual Health Bulletin Sri Lanka 1994.  - 47 - Annex 2 Page 1 of 4 SRI LANKA HEALTH SERVICES PROJECT Organization of the Family Health Program 1. The matemal and child health (MCH) program is the major health and nutrition intervention strategy of the Ministry of Health. An organized effort to provide MCH services dates back to 1906 with the introduction for trained midwifery services in the Municipality of Colombo. In 1926 the Department of Health initiated a broad scheme for the provision of Public Health Services at Kalutara with the establishment of the first Health Unit. The main activities of the health unit included collection of vital statistical data related to the area, delivery of MCH services, prevention and control of communicable diseases, environmental sanitation, health education and school health activities. By 1950 91 health units had been established and the number was further increased to 104 by 1982. In 1989, the country's administration was decentralized with certain powers devolved to nine Provincial Councils. Each provincial council has a Provincial Director of Health Services assisted by 2 or 3 Deputy Provincial Directors of Health. The latter are supported by a technical teams, comprising of a Medical Officer (MCH), Regional Epidemiologist, Regional technical teams, comprising of a Medical Officer (MCH), Regional Epidemiologist, Regional SPHN, 2-3 Health Education Officers, a Survey Statistical Assistant and a Planning Officer. 2. After the devolution process and the establishment of a system of Provincial administration, the number of health unit areas have increased to 252 and are contiguous with the administrative sub-districts or divisions within the province. This massive increase in the number of health unit (MOH) areas has created a pressing need for providing additional MOH/DDHS offices, in the newly carved out areas. It is from these offices that the management of the entire public services are effected. In addition some of the existing offices are in a very unsatisfactory condition which hardly bears out the practice of public health or the message of preventive health. Each Health Unit is in charge of a Medical Officer of Health, now also referred as a Divisional Director of Health Services (DDHS) who is responsible for all promotional and preventive health activities within the area, as well as the overall supervision of health institutions, ranging from a district hospital, peripheral unit and rural hospital to the central dispensary and maternity home. 3. The DDHS/MOH is supported by a team comprising of Public Health Nurses (PHN), Public Health Inspectors (PHI), and Public Health Midwives (PHM). The Health Unit Area is sub- divided into PHI ranges and still further into PHM areas. Each health unit area has a network of medical institutions and health centers which provide institutional and clinic based MCH services. The estate sector in also serviced by MCH clinics, conducted on estates either by visiting medical officers or by estate health staff. The basic cornerstone of the system rests on the Public Health Midwife, who not only provides services at the level of the home, but also links the mother and child to the next level of health care, namely that provided at the "health center" (field MCH clinic) or at the medical institution. The PHM serves a population ranging from 3,000-5,000, within a clearly defined area, which is the smallest working unit within the health system and the first point of contact between the health system and the households. Having an intimate knowledge of her area and the families she serves, the PHM through a systematic scheme of home-visits provides the necessary domiciliary contact and services to mothers and children. This activity is supported by as  - 48 - Annex 2 Page 2 of 4 system of record keeping that helps her to plan and monitor her activities, as well as report on her performance and the vital events that have occurred in her area, to the MOH/DDHS. 4. Mobility has always been a problem for MCH field staff, who have to rely very often on public transport which can be very time consuming and unreliable. Strategies to overcome this problem will need to be considered if the coverage and quality of the domiciliary services are to be improved. 5. Trained for a period of 18 months, the midwife spends the first year in a school of nursing where she receives an intensive training in midwifery and basic nursing. The next six months of her training is spent at the National Institute of Health Science in Kalutara or in selected public health training centers, where she applies her knowledge and develops her skills in an actual working situation within the community. On successful completion of her training she could be appointed either as Public Health Midwife attached to a health unit or as an institutional midwife. 6. As a consequence of the greater utilization of institutional facilities for confinement (today 98% or more of the deliveries take place in health institutions), the PHM's role in the health system gradually changed from a focus on pregnancy and confinement, to a much broader view of maternal and child care. 7. The present functions of the PHM consists of: (a) Prenatal and natal care which emphasizes early registration of all pregnant mothers in her area, regular home visits and prenatal examination with identification of high risk mothers and referral where needed; linking mothers to clinics conducted in her area at which she also participates; immunization of mothers with tetanus toxoid and ensuring that all mothers receive trained assistance at delivery. (b) Postnatal care - regular follow-up visits during the postnatal period for care of the mother and the newborn. (c) Infant and young child care - Registration of all infants with a view to ensuring that all infants under her care are followed up. Proper advice on infant feeding, weaning and child nutrition (including growth monitoring of infants and preschool children). Immunization of all infants and preschool children. (d) Family Planning motivation, instruction and provision of contraceptives (condoms and oral pills) and facilitating the provision of the other methods of contraception as required and assisting at FP clinics in her area. (e) Health education in the other elements of primary health care, particularly the control of diarrheal disease with emphasis on oral rehydration therapy (and maintaining nutrition during episodes of diarrhoea) and Acute Respiratory Infection. 8. The Public Health Nursing Sister (PHNS):  - 49 - Annex 2 Page 3 of 4 (a) is responsible to the DDHS/MOH for the management of the MCH/FP (Family Health) program and the delivery of the services; (b) provides technical support and performs specific functions as assigned to her at MCH/Fp clinics; (c) assists at school health activities; (d) monitors and appraises the performance of PHM's in the Health Unit/DDHS area; (e) conducts family planning clinics in the area; (f) assists the DDHS/MOH in collecting MCH/FP performance data in the area; (g) is a source of advice on maternal health, child health and family planning in the community. 9. The Public Health Inspector: (a) is responsible for the control of communicable diseases, vector control activities, food safety, environmental health and sanitation, and the implementation of legislative enactments regarding food and sanitation; (b) participates in school health activities and the immunization program; (c) conducts health education programs; (d) provides family planning advice and motivation, particularly to males in the community. 10. At the National level (Ministry of Health), the Family Health Bureau (FHB) is the central organization responsible for planning, coordination, direction, monitoring and evaluation of the MCH/FP program within the country. The FHB works in close collaboration with the Epidemiology Unit, Health Education Bureau and Population Division of the Ministry of Health and also with several UN, International and Non-Governmental organizations. The Family Health (MCHIFP) program covers a wide spectrum of services comprising: (a) maternal care - Antenatal, Natal and Post Natal; (b) infant and child care - including immunization, growth monitoring, with appropriate nutrition interventions, child mental health, control of diarrhoeal diseases and acute respiratory inspections; (c) nutrition; (d) school health; (e) family planning. 11. Another important category of health worker is the Health Education Officer (HEO), attached to the Office of the Deputy Provincial Director of Health Services and to certain Health Divisions. These officers assist the public health staff in improving their communication skills and organizing the community for carrying out health work. They are also responsible for publicity and other IEC activities within the region. The need to equip these HEO's to perform their functional effectively will be an important factor in growth promotion and nutrition related actions in the community. 12. An important aspect of MCH service delivery has been the establishment of health centers or "field" MCH clinics, which serve as first level referral centers in the delivery of MCH services. These centers/clinics are conducted once a fortnight and provide, antenatal care; screening  - 50 - Annex 2 Page 4 of 4 of infants and preschool children; immunization; family planning; growth monitoring and nutritional supplementation (Thriposha) to pregnant and lactating mothers, infants 6-11 months and preschool children on a medically selected basis; and general health education activities. On an average one center serves two PI-IM areas. The PHM herself personally assists at these centers thereby providing a personal link between her people and the health center. The services provided at these centers are provided by the DDHSIMOH or other area Medical Officers. The Public Health Nursing Sister is responsible for the overall management of the clinic and other relevant clinic activities. 13. The health center or field MCH clinics could be held in the smaller medical institutions, local government facilities, newly constructed gramodaya health centers (PH-M quarters plus clinic) or in private buildings. The location of these centers is usually determined by its accessibility to the largest numbers that could be served. Higher levels of care are provided by the larger hospitals that provide in-patient care and specialist services. 14. These health centers in certain situation are in need of some basic fumiture, service items and equipment in order to improve the quality of services. It is at these health centers or field MCH clinics that growth monitoring is carried out together with all the other activities that are conducted at these centers, including the distribution of Thriposha. It may be for this reason that the coverage and quality of growth monitoring has not been what it ought to be, since the other activities such as clinical examinations and immunization may take priority. A mother bringing her child for growth monitoring could well be discouraged sans the inducement of triposha. As aptly described. "A mother brings her child to the clinic, often having walked a long distance, waits for the child to be weighed, picks up her packet of Thriposha and goes home as soon as possible. There is little time for the PHM or PHNS to speak to the mothers. There is little supervision by the MOH/DDHS. Health and nutrition education at the clinic is minimal, if at all." While improving the existing physical needs of these clinics there is also a strong justification to look for alternatives vis-a-vis growth monitoring activities, such as Village/Community based "Weighing Posts" or "Nutrition Centers". This should be feasible if actively pursued, since the growth monitoring cards (CHDR) are with the mothers and the duplicate section with the PHM, which is identified by village. The only problem is the issue of Thriposha for which a scheme would need to be devised. 15. The M/PPI survey of 1993 reported that "50% of mothers are visited regularly (once or twice a month) by the PHM at home during their pregnancy, but close to 25% are never visited by a midwife."" (Including other surveys the range would be 15-25%.) While this calls for closer supervision of home visits, the availability of clinic services in urban areas and PHM vacancies may also contribute to this percentage. The importance of home visits is that the personal family contact provides an ideal opportunity for discussion, advice and encouragement on individual problems as well as on matters pertaining to health. 16. An aspect of matemal care at "health centers"/clinics that needs to be reiterated is the lack of focus on weight gain during pregnancy, which is an important aspect of matemal nutrition. The M/PPI survey of 1993 revealed that "over two thirds of mothers do not know how much weight they gained during their last pregnancy. This was because scales were either not available at clinics or, even when they were, there is no regular monitoring of weight gain during pregnancy." The FH Bureau has now included a basic "weight gain chart" in the "Mothers record", but the focus on weight gain in pregnancy still leaves much to be desired.  - 51 - Annex 3 Page 1 of 10 SRI LANKA HEALTH SERVICES PROJECT Malaria Component A. Background - Malaria in Sri Lanka EvidemioloMy 1. Malaria is a serious public health problem in Sri Lanka. In 1987, the peak year of a recent epidemic, it was the leading cause of hospitalization in the country. In each of the subsequent six years 1988 to 1993, it has been either the fourth or fifth leading cause of hospitalization, and the cause of an average 110 hospital deaths per year. The in-patient admission rate and death rate for the country as a whole have remained relatively constant over the last few years at approximately seven admissions per 1,000 population and 0.05 deaths per 10,000 population. In 1993, 5% of hospital admissions were due to malaria. The low case fatality rate for malaria (currently less than 0.1%) is a tribute to the quality of the Sri Lankan health care system. 2. Malaria transmission is not uniform over the island of Sri Lanka. Incidence is higher in the provinces which are situated in the dry and intermediate climatic zones of the country. Approximately 4 million people live in the malarious part of the country. In six high incidence districts within these provinces, hospital admission rates were all higher than for the country as a whole. Parasitology 3. Data from hospital admissions do not indicate the number of persons infected with malaria in the country, since they do not include all the persons treated as outpatients or those who do not receive any treatment. In theory, all persons who present with fever to medical institutions have a blood slide taken for confirmation of malaria parasites, and the blood slide results are the basis of the statistics collected by the Anti-Malaria Campaign (AMC). However, this procedure may not be followed consistently depending on the clinic workload. In addition, some medical institutions at the periphery do not have blood slide facilities; nor do private physicians who serve an increasing proportion of the out-patient population (currently estimated to be about 50%). It is thought that because of these undocumented cases, the incidence of malaria is underestimated by 2 to 6 times, depending on the district. 4. In Sri Lanka as a whole, the data show that there have been two separate malaria epidemics since 1986 (Table 1). The highest epidemic peak was in 1987 at 42.0 cases/l,000 persons, followed by a smaller epidemic peaking at 23.2 cases/I,000 persons in 1991. During the years 1988 and 1989, civil strife in the country caused a disruption in the health services as well as malaria control operations which is reflected in a decline in the number of blood slides examined during those years. However, it appears that there was a true decline in cases in those years because the slide positivity rate was also lower than in 1987 and 1991. The incidence remained stable at over 20 per 1,000 persons through 1992 and 1993 but appears to have commenced a slow decline in 1994. In  - 52 - Annex 3 Page 2 of 10 both 1987 and 1991, P.vivax predominated over Pfalciparum, particularly in the more recent epidemic, in which P.falciparum was also slower to gain momentum, peaking in 1992 rather than in 1991. At the peak in 1987, the number of cases/1,000 was similar to the numbers experienced in previous epidemics in 1968-70 and 1973, but an order of magnitude lower than the annual incidence of 100-400/1,000 typically seen in the 1930s and 1940s prior to initiation of DDT spraying in 1945. Table 1: MALARIA MORBIDITY DATA Year Population No. Slides No. Slides Total SPR ABER Total Exam. Pos. % % API/1,000 1986 16,127,000 1,469,737 412,521 28.1 9.1 25.6 1987 16,361,000 1,973,320 687,599 34.8 12.1 42.0 1988 16,586,000 1,333,846 383,294 28.7 8.0 23.1 1989 16,806,000 1,124,400 258,727 23.0 6.7 15.4 1990 16,993,000 1,175,123 279,172 23.8 6.9 16.4 1991 17,247,000 1,398,002 400,263 28.6 8.1 23.2 1992 17,405,000 1,558,660 399,349 25.6 9.0 22.9 1993 17,619,000 1,503,902 363,197 24.2 8.5 20.6 1994 17,829,000 1,307,831 273,502 20.9 7.3 15.3 Population per district from Annual Health Bulletin, projected from 1981 census. SPR: Slide positivity rate (percent of slides which were positive for any malaria species). ABER: Annual blood examination rate (number of slides examined per year divided by total population). API: Annual parasite incidence (number of positive slides per thousand persons per year). 5. Basing conclusions about malaria on the average annual incidence can be somewhat deceptive, because in fact transmission is highly seasonal in Sri Lanka. There are usually two peak periods of incidence, the largest one corresponding to the North East Monsoon (November to January) and a smaller peak after the South West Monsoon (April to June). The second peak may be absent altogether, as happened in several districts in 1994. Age/Sex Distribution 6. Since Sri Lanka is an area of unstable malaria, adults do not have high levels of immunity and often suffer from symptoms when infected, unlike the situation in highly endemic areas. However, the highest incidence rates are in children. Over the last nine years the pattern of age- specific incidence in the country as a whole has changed. In 1986 through 1990, incidence rates were lowest in infants <1 year-old, increased sharply to 20-30 per 1,000 in the 1-4 year olds, and then showed a gradual slight decline through the older age groups. In 1992-1994, the flat curve has  - 53 - Annex 3 Page 3 of 10 changed to a bimodal curve with highest incidence rates in the I to 4 year olds and the 10 to 14 year olds. Given the greater likelihood of mosquito exposure in adults (who are more likely to be sitting outside or guarding crops at night) higher incidence rates in children indicate a possible significant role of protective immunity in the Sri Lankan population. It is possible that the recent decreased incidence in 5 to 9 year olds is a result of their having been infected as younger children in the 1987 epidemic. However, differences between age-groups in their (or their parents') tendency to seek medical treatment must also be taken into account. 7. It has long been known that the incidence of malaria is higher in males than females in Sri Lanka, and the explanations proposed for this phenomenon range from greater exposure in males to lower health-seeking behavior in women. While there have been more cases in males than females in the last nine years, the excess has been decreasing since 1987 (when the ratio of cases in men:women was 1.37:1) to a ratio of 1.13:1 in 1994. In the particular districts reviewed in this report, the ratios in the last three years have been close to 1: 1, with the exception of Polonnaruwa where the ratio has increased from 1.32:1 in 1992 to 1.59:1 in 1994. Entomology 8. The intensity of malaria transmission varies within the country and within the year according to the distribution and density of the anopheline vectors which in turn depends on the rainfall. The country is divided into three zones according to rainfall: wet (>2,500 mm per year), intermediate (2,000-2,500 mm per year) and dry (<2,000 mm per year) and conditions are most favorable for anopheline breeding in the dry and intermediate zones. The highest densities of vectors occur towards the end of and after the two monsoon seasons (November-January and April-June), because the river-bed pools which form as the volume of flow decreases are favored breeding sites. 9. There are 22 species of anopheline mosquitoes in Sri Lanka, of which 13 have been shown to be possible vectors of malaria. Only three of these species are thought to play an important role in malaria transmission. Anopheles culicifacies has long been known to be major vector of malaria in Sri Lanka, but recently An. subpictus and An. annularis have been recognized as significant vectors in some seasons and districts. Ecological changes occurring due to major irrigation schemes such as that in the Mahaweli river basin apparently favor the breeding of the latter two species. All sectors in Sri Lanka have relatively low human biting rates (usually less than 10 bites per person per night, although numbers approaching 100 have been recorded) compared to highly endemic areas such as Africa and Papua New Guinea. None of the Sri Lankan vectors shows a high preference for feeding on human rather than animal blood; even the most important vector An. culicifacies takes about half of its blood meals from cattle or other animals. All vectors also prefer to bite outdoors rather than indoors. Where sporozoite rates in mosquitoes have been examined, they have generally have been found to be quite low (less than 1%), but in certain situations very high rates up to 9.6% have been reported. 10. The entomological inoculation rate (EIR) is the key parameter which indicates the risk of malaria infection in humans. It is the number of potentially infectious bites which each person receives per night, and is derived from the product of the sporozoite rate (mosquito infection rate) and the bites per person per night. The generally low biting rate of Sri Lankan vectors means that entomological inoculation rates are also usually low; thus accounting for the marginal and unstable nature of malaria transmission in the country. However, if sporozoite rates in mosquitoes rise to levels  - 54 - Annex 3 Page 4 of 10 of over 1%, then even if a person only receives 10 bites per night he or she will still receive an infectious bite once in every 10 days. Entomological inoculation rates as high as I infectious bite per person per night have been reported in some studies in recent years. This aspect of malaria epidemiology in Sri Lanka deserves much further study. B. The Anti-Malaria Campaign 11. At the level of the Ministry of Health, all preventive health programs including malaria control activities are the responsibility of the Deputy Director General-Public Health Services (DDGPHS). From the time of establishment in 1910 until the introduction of Provincial Councils in 1989, the AMC has been responsible for the planning, implementation and evaluation of all malaria control activities. The network available for the provision of primary health care services did not have any responsibilities for malaria control. For purposes of implementing malaria control activities, the island was divided into 17 "regions", depending on the endemicity and population. Each region had a Regional Malaria Officer (RMO) who was responsible for all malaria control activities of the region, to the Director, AMC. A "region" identified for malaria control usually corresponds with a "district" (administrative unit), with a few exceptions. 12. Provision of health services, including malaria control, became the responsibility of the Provincial Council effective March 1989. Following this major change in the organization of the health services, the responsibilities of the AMC and the staff at provincial/regional level were demarcated, with the bulk of technical and monitoring activities assigned to the Directorate and the majority of implementation/administration and training activities assigned to the provinces. Staffing 13. At present, the staff for malaria control activities are available at: (a) National Level: The staff at the AMC Directorate include: Director, Deputy Director, Medical Officers (3), Entomologists (2) and other technical and non-technical support staff. (b) Regional Level: At regional level, the RMO coordinates malaria control activities and has the following categories of staff to assist in his or her activities: field assistants (FA); microscopists at the Regional laboratory; entomological teams - I entomological assistant, 2 FAs, 5 spray machine operators (SMO) and 1 driver; mobil teams - each team includes I FA, 1 Microscopist, I SMO and I driver. (c) Divisional Level: The DDHS and his staff are responsible to the DPDHS and PD for the implementation of malaria control activities within the health area. The role of the RMO is to coordinate, monitor and provide technical guidance to the malaria control activities in the region which includes a varying number of DDHS areas. 14. In a DDHS area, the Public Health Inspector (PHI) is the person who is responsible for the control of communicable diseases, so the malaria control activities come under his purview. However, in most of the DDHS areas, a separate PHI for malaria control activities is available. The other categories of field staff in a DDHS area, namely Public Health Nursing Sisters (PHNSs) and  - 55 - Annex 3 Page 5 of 10 Public Health Midwives (PHMs) also contribute to malaria control activities through their participation in health educational activities and supplying chemoprophylaxis to pregnant women, in clinics and at field level. The field assistants responsible for activated passive case detection and the microscopists working in the institutions of the DDHS area also come under the supervision of the DDHS. A varying number of spray teams, each of which includes I FA and 4 SMOs, are also attached to a DDHS area. Implementation of the Global Malaria Control Strategy 15. In June 1993, the AMC made a policy decision to implement the WHO "Global Malaria Control Strategy," which includes the following: (a) early detection and prompt treatment of malaria cases; (b) selective application of sustainable malaria control measures including vector control; (c) development of mechanisms to forecast/prevent malaria epidemics and outbreaks; (d) regular assessment of the country's malaria control program. The supervision an coordination of the malaria control activities are presently being carried out in the following manner. 16. Case detection and treatment. These are being performed via Activated Passive Case Detection, done by FA/APCD at different levels of medical institutions; Active Case Detection, done by fever surveys and mass blood examinations; and mobile clinics. Case detection program other than APCD are organized and supervised by the RMO, in collaboration with the DDHS. The "incidence" data available from these sources are made available to the DDHS and to the RMO, for monitoring purposes. 17. A treatment schedule has been drawn up by the AMC directorate taking into account the species distribution of malaria cases and other practical considerations. Officers at all medical institutions are informed of the need to adhere to this treatment schedule. With the emergence of drug resistance, it is the AMC policy to prescribe the second line drug, sulphadoxine-pyrimethamine (Fansidar) only to those patients who were shown to have drug resistance. The issue of this drug is presently being "controlled" by the AMC. The RMO has the responsibility of issuing this drug to institutions on request. There appears to have been a marked increase in the level of chloroquine resistance in 1992, and now approximately 40-50% of tested isolates were resistant in vitro, and 16- 17% showed the highest level of resistance in vivo. Resistance to Fansidar, mefloquine and quinine does not seem to have appeared yet. 18. Insecticide spraying. Indoor house spraying with residual insecticides has been the mainstay of malaria control in Sri Lanka for almost 50 years. Spraying with DDT was started in 1945 and continued for 12 years, by which time malaria had fallen to almost non-existent levels. It was restarted in 1968 during a P. vivax epidemic but was phased out after the appearance of DDT resistance and then replaced by malathion by 1978. Selective spraying of insecticides was introduced in mid- 1993. Using the data available, the RMO (in consultation with the DDHS of the area) is expected to identify areas that require perennial spraying, seasonal spraying and focal spraying. The present policy of the AMCs to use different insecticides "in rotation," to minimize development of resistance. Spray teams are a part of the DDHS staff, hence the supervision of spraying activities is the direct  - 56 - Annex 3 Page 6 of 10 responsibility of the PHI (malaria control) or PHI of the area, with DDHS having an overall responsibility. All workers who are involved in spraying of insecticides are provided with protective clothing including caps, masks, etc. Their health is regularly monitored and periodic blood examinations are undertaken. 19. Since the implementation of selective spraying, the amount of malathion used in the country as a whole has declined from over 1,000,000 kg in 1989 to 274,311 kg in 1994, while the coverage of houses targeted to receive malathion has improved from 54% to 63.5%. In 1994, fenitrothion and ICON were used. These insecticides are more expensive than malathion, but acceptance is much greater: 69.7% and 74.2% of houses targeted for fenitrothion and ICON respectively were fully sprayed. Monitoring of insecticide resistance is done on a regular basis by entomological teams who conduct standardized susceptibility tests with different anopheline species to detect the evolution of insecticide resistance. They also conduct bioassay tests in which mortality of mosquitoes exposed to walls in sprayed houses is measured; these tests are designed to monitor the operational activities of the spray teams. 20. Larval control measures. In selected areas especially where there is a seasonal increase in the breeding places, larval control measures are undertaken, the commonest being the use of "Abate" (temephos). The decision to undertake larval control measures is taken by the RMO at the request of the DDHS. 21. Entomological surveillance. The entomological teams based at regional level are responsible for the activities of monitoring the vector density, perfornance of the spraying teams, resistance to insecticides and identifying possible changes in the vector species composition or habits. The teams are supervised and monitored on a day-to-day basis by the RMO. The senior entomologist and his staff at the AMC are responsible for the technical monitoring of the entomological surveillance data, at national level. 22. Promoting personal protective measures through health education and community participation. The activities include: promotion of use of permethrin impregnated bed nets and programs aimed at reduction of breeding places. The PHI is responsible for organization of these programs in collaboration with the other health staff of the area and is supervised by the DDHS. However, in practice the RMO also acts in a supervisory capacity for such programs. Finances of the Anti-Malaria Campaign 23. Malaria control activities always receive priority over all other community health programs in making budgetary decisions. In 1989, the Ministry of Health allocated 62.2% of the total expenditure on community health services and 11.6% of the total health budget for the AMC. From 1990 onwards, however, with the decentralization, a proportion of allocations which were previously made to the AMC is diverted to Provincial Health Ministries. Malaria control activities are now integrated with other community health programs, but the provincial health authorities have not yet been able to develop an accounting system to distinguish expenditure on malaria control from other health activities. Until decentralization, AMC used to spend about 60% of its total expenditure for the purchase of malathion alone. Personal emoluments and traveling accounted for another 20%.  - 57 - Annex 3 Page 7 of 10 C. Project Content 24. With the adoption of the WHO revised malaria strategy in 1993, the Anti-Malaria Campaign (AMC) is moving towards an approach to the malaria problem in Sri Lanka that will utilize all suitable techniques in a coordinated manner to (i) reduce the vector population while protecting the environment; and (ii) improve treatment and promote personal protection. Details of the program to be implemented over the project period are given below. The recommendations of the expert team that carried out a review of the AMC program in July 1995 have been taken into account. 1. Program Management Coordination. To improve coordination and exchange of information and experiences among the regional (district) level malaria programs as well as the flow of data to the central AMC, a meeting of all Regional Malaria Officers (RMOs) will be held twice a year at the AMC Directorate. In addition, a review meeting with the participation of AMC officers and the RMOs of the six high-prevalence districts will be held once a quarter in one of districts, on a rotating basis. Planning. The RMOs have received training, with WHO participation, in the formulation of annual regional (district) plans of action for malaria control. These plans will incorporate annual district targets. Reporting. The regional (district) malaria offices will be provided with computer facilities to facilitate collection, collation and analysis of data. Provision of data to the AMC on a prompt and regular basis will be emphasized. 2. Early Diagnosis and Prompt Treatment of Malaria Cases Mobile clinics. Mobile clinics have already been introduced in four of the six high- prevalence districts (Matale, Polunnaruwa, Kurunegala and Anuradhapura) and with project support will be extended to the two remaining districts (Puttalam and Moneragala). Using suitably equipped vans, mobile teams that include a microscopist cover outlying rural areas systematically. Blood slides are taken from all fever cases in a local area, examined on the spot, and if the results are positive the appropriate drugs are given and the treatment regime explained. The importance of seeking diagnosis for any future occurrences of fever is emphasized. Two mobile teams per district for the remaining high-prevalence districts will be provided. When an annual parasite incidence of 8 cases per thousand population is achieved in a given district, one of the mobile clinics assigned to the district will be reassigned. The remaining mobile clinics will be withdrawn when the annual parasite incidence declines to 4 cases per thousand. However, mobile clinics will continue to function in localities where the P. falciparum percentage is recorded to be more than 10% of the total number of malaria cases and in localities which are identified to be foci of P. falciparum. Support for ambulances for transport of falciparum cases and other medical emergencies would be conditional on a review of transport aspects of the health system that would  - 58 - Annex 3 Page 8 of 10 indicate the justification in cost-effectiveness terms for the type and number of vehicles needed and address sustainability issues. Treatment at health facilities. The program will put increasing emphasis on expanding and improving the treatment available at health facilities. An improved treatment schedule has been provided to all health facilities. Provision for microscopic examination of blood films of suspected malaria cases will be expanded by the recruitment and training of 100 microscopists over the project period, all of whom will be assigned to health facilities rather than regional laboratories. As the number of microscopists increases, it will be possible to work towards the goal of taking blood films from all suspected cases, thus reducing the level of presumptive treatment. During the off-season, when microscopists will have less facility work, they will be utilized to examine blood films taken during special parasite surveys. Identification and follow-up of drug-resistant cases. Monitoring of drug resistance will be increased and organized more effectively. This will be done by designating sentinel facilities to do intensified surveillance of treatment failures and report them to the DDHS and the regional (district) malaria office. The RMOs will be given responsible for monitoring drug resistance in their areas. Quality control. To ensure quality in the case detection system, the cross-checking system will be reintroduced at the regional (district) level, under the technical guidance of the AMC. High-quality binocular microscopes will be supplied for the purpose. Small-scale cross-checking will also be introduced at the AMC Directorate. Role of PHMs. Malaria prophylaxis for pregnant women is already one of the responsibilities of PHMs. Their role in local detection and treatment of malaria cases will be expanded, although it is recognized that they have many duties and that they should not be expected to take on a curative role. Training will be provided to PHMs and their supervisors in the high-prevalence districts to ensure that their knowledge about malaria and the drug treatment regime is up to date and to involve them in promoting the use of impregnated bed nets and community malaria prevention measures. Existing community/NGO health volunteers will also be oriented. 3. Selected and Sustainable Malaria Control Methods Targeting of spraving. With the introduction of the revised WHO strategy, the insecticide spraying program has been drastically modified. With the introduction of targeted rather than blanket spraying, the total amount of insecticide used has been significantly reduced, and this decline is expected to continue as spraying becomes more selective. Additional insecticides have been introduced to supplement malathion, both to reduce the risk of the development of resistance and because the new insecticides are less toxic than malathion. Bed net program. Insecticide-impregnated bed nets are an effective, cost-effective and sustainable method of personal protection that can be promoted with community support. With project support, the program will be expanded and implemented in all six high-  - 59 - Annex 3 Page 9 of 10 prevalence districts. NGO support will be sought for a pilot effort to provide net material at cost and pay community organizations for making the nets. 4. Regular Assessment of Malaria Status and Prevention of Epidemics Entomological surveillance. To enable increased and strengthened entomological surveillance, larger vehicles, capable of transporting at least nine people, will be obtained. At present, the work of the entomological teams is focused on assessing the effectiveness of spraying and the level of insecticide resistance. These activities will continue to be important, but with the reduction in spraying, the time and resources required for them will be reduced. More effort will be given to the use of the entomology teams as part of the early waming system and to gather useful epidemiological information related to incidence data. To accomplish this, the following will be done: * better methods for assessing the biting risk to humans will be developed; * capacity for determining sporozoite rates by ELISA will be established at regional (district) level; * better use of data that is collected will be made, so that the time between data collection and response can be shortened. Early waming system. At present, the system reacts to the incidence of infection, e.g. by sending mobile clinics and entomology teams when an area reports a large number of cases, rather than trying to preempt a potential epidemic. To enable the program to move from cure to prevention, an early warning system for potential outbreaks of malaria will be developed, based on parasitological, clinical and other epidemiological data taken in conjunction with entomological data. The focus for the system will be at regional (district) level, based on inputs from the divisional level. Training at both levels and the hardware and software to handle the volume of data involved will be supported (see above under Management). It is expected that the number of cases will continue to fall for the foreseeable future. However, Sri Lanka will always be at high risk for malaria epidemics, and in fact the risk level will increase as prevalence, and therefore immunity, wanes. Therefore, the early warning system must be developed and sustained even when prevalence is low. Prevalence surveys. Baseline prevalence surveys will be carried out in the six high- prevalence districts in early 1996. Subsequent follow-up surveys will be carried out at two-year intervals. 5. Community Awareness and Participation. As noted above, NGO/community volunteers will receive program orientation as part of the training to be undertaken for the program with project support. IEC efforts will focus on promotion of the importance of personal protection, especially the use of impregnated bed nets, and of seeking diagnosis and treatment as soon as possible for any fever that might be malaria. Promotion of these messages will be particular important as mobile clinics are withdrawn.  - 60 - Annex 3 Page 10 of 10 6. ORerational Research. It may be desirable to incorporate additional physical and biological controls into the program after their usefulness has been tested on a small scale. The project will support such research, which has already been initiated by malaria officers in Matale and Kurunegala districts. Some measures that have proven useful elsewhere may not be particularly suitable for Sri Lanka. For example, larval control using fish is not likely to play a major role because of the large number of temporary breeding sites that develop after the rainy seasons but subsequently dry up. However, the use of BTI (bacillus thuringiensis israelensis) and nematodes for vector control in situations such as gem pits in Matale and Ratnapura districts, will be tested.  - 61 - Annex 4 Page 1 of 12 SRI LANKA HEALTH SERVICES PROJECT STD/AIDS Component A. Background 1. Reports of HIV seropositivity among five prostitutes in Madras in 1985 first alerted the Ministry of Health to the danger of HIV/AIDS in Sri Lanka. The first case of AIDS was detected in a foreign visitor to Sri Lanka in November 1986, and the first Sri Lankan with AIDS was diagnosed in April 1987. As of January 1996, 171 WHV-positive individuals had been identified. Of these, 58 had developed AIDS and 49 had died. The first few detections were mainly homosexuals or bisexuals, but by 1989 it had become increasingly evident that the predominant mode of transmission was heterosexual. Indigenous transmission was first documented in December 1989 and since then has been increased steadily. 2. HIV/AIDS prevention and control were integrated into the existing STD Control Programme in 1985. An AIDS Task Force was established in May 1986 chaired by the Director General of Health Services, comprising mainly Ministry of Health staff with representation from the Tourist Board, the Police and the Ministry of Education. The Task Force was expanded to form the multi-disciplinary multi-sectoral National AIDS Committee in February 1988. 3. HIV/AIDS prevention and control activities commenced in earnest with the assistance of WHO consultants, who developed a Short-Term Plan (STP) of Action in July 1987. Baseline serological surveys were conducted among the high risk groups, and a knowledge, attitude, behavior and practices (KAP) survey was carried out. The blood supply was secured and the laboratory services were strengthened. A first Medium-Term Plan (MTP I) was developed, funded primarily by UNDP. An external review of the program was conducted in November/December 1993, followed by a National Consensus Workshop. 4. The report of the Presidential Task Force on Formulation of a National Health Policy for Sri Lanka (July 1992) specifically identified WHV/AIDS as a major health problem and made recommendations on policies to be adopted to address the potential medical, social and economic impacts. The policies reflect the Government's non-discriminatory attitude and its commitment to a multi-sectoral approach. B. Epidemiology of STDs 5. In 1991 WHO estimated that there are more than 200,000 new STD cases each year, but in fact the incidence of STDs in Sri Lanka is not known. In recent years, the Central Clinic in Colombo has seen about 5,000 new cases of STDs a year and about 18,000 total visits. The provincial clinics, mostly located in provincial hospitals, are thought to see another 5,000 new cases annually, although since the provincialization of the health services in 1989 reporting from the provincial clinics has become irregular and unreliable. If the WHO estimate is accepted, then the  - 62 - Annex 4 Page 2 of 12 government clinics are seeing only about 5% of total cases. 6. Gonococcal infections and chlamydia have shown a downward trend in recent years. Syphilis, herpes simplex infections and genital warts, however, have shown a rise as a percentage of diagnosed cases, as have chlamydia and trichomoniasis. For ante-natal clinic (ANC) attendees in Colombo, the VDRL positivity rate was less than 2%. However, ANC syphilis serology coverage is incomplete. 7. Lower socio-economic groups, such as unskilled workers and street hawkers in Colombo and drivers, sailors, military and police in the provinces, account for a significant number of STD cases. Usually these are unmarried males and females. Female sex workers are about a third of clinic attendees in Colombo. More than 70% of male patients reported female sex workers as the source of infection. About 30% of patients are treated for repeat infections. More than 70% of female sex workers tested had an STD infection, and more than 45% of the them had more than one infection. B. Status of HIV/AIDs 8. Although there is a consensus that HIV prevalence is still quite low in Sri Lanka and that major epidemic spread of HIV has not yet occurred, the true prevalence of HIV is not known. Estimates range up to as high as 5,000. The situation has not been clarified by the sentinel surveys that have been undertaken. Surveys have been carried out in 1991, 1994 and 1995. The results from the 1994 and 1995 surveys are summarized below: 1994 1995 No. No. 1-fV No. No. HIV Tested Positives Tested Positives High Risk Female commercial sex workers 453 - 1,208 1 STD patients 817 - 1,315 1 Medium Risk TB patients 385 - 737 - Low Risk Ante-natal women 600 - 3,711 Blood donors 12,957 - 3,000 - Total 5,212 0 9,971 2 9. The results of the first two surveys reported so few HIV positives that the results were not considered credible, and particular care was therefore taken with the third survey. The low numbers of HIV positives for female commercial sex workers and for STD patients, the two major risk categories in Sri Lanka, do not support high estimates for HIV prevalence. As in other Asian  - 63 - Annex 4 Page 3 of 12 countries where the numbers of persons at high risk of HIV infection are relatively small at present, the sentinel surveys carried out in Sri Lanka have included many individuals not at high risk, and the results have reported only small numbers of HIV positives. In retrospect, it is unfortunate that the survey design was not modified to concentrate on high and highest risk groups. Prior to the 1996 sentinel survey, the survey design will be reviewed, and testing for other STDs as feasible will also be incorporated. 10. It is generally agreed that in Sri Lanka heterosexual transmission, is currently, and will continue to be, the primary mode of the spread of HIV. Other sources of transmission that have played significant roles in HIV epidemics elsewhere include contaminated syringes and needles used by injecting drug users; contaminated blood products; perinatal transmission; and accidental infection of health workers during clinical procedures with HIV-infected patients. However, none of these factors is important in Sri Lanka at present: there is little injecting drug use, the blood supply has been carefully secured, and there are too few HIV-infected individuals to bring the latter two into play. 11. The critical determinant of the spread of HIV and other STDs, therefore, is the sexual practices among the heterosexual community. If only a very small percentage of the population have multiple sex partners, then the at-risk population groups will also be very small and spread of the epidemic will be limited even if the multiple sex partner group is substantially infected. Within the at-risk group, the secondary determinant is "safe sex" practices, primarily use of condoms. 12. The evidence currently available suggests that in fact the proportion of persons with multiple sex partners in Sri Lanka is quite low. A recent studyl/ reached the following conclusions about potential high-risk groups. (a) Free trade zone workers (75,000): not a high-risk group; little evidence of promiscuous sexual behavior; none of the respondents had casual sexual partners; all respondents had heard of AIDS and were generally well informed about different modes of HIV transmission, although much less well informed about other STDs. (b) Overseas retumees (288,000, or about 3% of the potential work force): small but non- trivial risk for HIV infections, primarily because of possible sexual exploitation by employers; 20% reported sexual harassment, a smaller percentage casual partnerships; also well informed about HIV/AIDS and transmission, much less so about other STDs. (c) Commercial sex workers (12,000): high risk of infection and therefore of transmitting it to clients; very few male sex workers or low-class female sex workers reported using condoms regularly; by contrast, nearly 87% of high-class female sex workers reported that they did. (d) Prison populations (20,000): high-risk group because of relatively high level of casual sexual activity, including commercially available sex and homosexual contacts; 1/ David Bloom, Socio-economic Implications of HIV/AIDS in Sri Lanka, Harvard Institute for International Development 1995.  - 64 - Annex 4 Page 4 of 12 condoms generally unavailable. (e) Tourist inflows: unlikely to contribute significantly to transmission of HIV among Sri Lankan nationals. 13. Other behavioral research on STD and AIDs risk-related behaviors in Sri Lanka2/ has concluded that unemployed, unmarried youth are a risk group that should be given additional attention. 14. Although it is not known why HIV has not yet spread extensively in many Asian countries including Sri Lanka, while in others (Thailand, Myanmar, India, Cambodia and perhaps Vietnam) spread is now exponential. However, the relative intensity of high-risk behaviors is clearly a major factor. If multiple partner sexual contacts are low and condom use is promoted, as appears to be the case in Sri Lanka, then the potential for rapid spread of HIV is also low. However, since the opposite is also the case, Sri Lanka must make maintenance and improvement of this situation an immediate and continuing priority. To support this priority, patterns of relevant behavior in the population will be monitored by systematic and routine sentinel behavioral surveys similar to sentinel HIV surveys. C. The National STD/AIDS Control Program 15. The National STD/AIDS Control Program (NSACP) employs three major prevention strategies in its efforts to prevent the spread of HIV infection: (i) prevention of sexual transmission; (ii) prevention of transmission through blood; and (iii) prevention of perinatal transmission, as follows. I. PREVENTION OF SEXUAL TRANSMISSION 16. Interventions increasing awareness and knowledge of STD/HIV and safer sex. General public awareness of HIV/AIDS in 1989 was 14%; since then it has increased dramatically to over 80%. Interventions to increase awareness and knowledge will focus on: (a) increasing the proportion of the knowledgeable population; (b) increasing depth of knowledge; (c) correcting misconceptions about STD/WilV; (d) making available information about all safer sex options; (e) desensitizing sex-related topics, including STD/AIDS and condoms; (f) eliminating any stigma attached to people with STD/HIV infections. 17. The approaches to be adopted will be a mix of mass media communications reinforced by support materials and interpersonal communications methods such as peer education, group discussions, and one-on-one interactions including counselling. Traditional media such as street plays and puppet shows will also be used as appropriate. Determining how and where to communicate which messages will be based on audience research with respective target groups. In 2/ Center for Intersectoral Community Health Studies, University of Peradeniya, Kandy, Sri Lanka.  - 65 - Annex 4 Page 5 of 12 light of past experience, it is critical that communications campaigns be sustained and followed up in order to maximize their effectiveness. Interpersonal communication efforts and counseling will be carried out primarily by NGOs, and mass media campaigns will be the responsibility primarily of the Health Education Bureau (HEB) of the Ministry of Health. The NSACP with the assistance of the HEB will coordinate the implementation and evaluation of STD/AIDS communication efforts which, in addition to NGOs, will also involved several other govemnment ministries and the private sector. 18. Education of in-school youth through use of curricula that are honest, explicit and comprehensive about the options available for preventing STD/HIV transmission is planned. The curricula have been developed for grades 5-12 by the Health Education Bureau and the National Institute of Education, MOE. NGOs such as the FPA have developed sexuality modules targeted at grade 10 and above that have already been used in several districts. In addition, UNICEF will support a project focusing on education of primary school children, youth and adolescents including university students. 19. Education of out-of-school youth, implemented through a collaborative effort between the HEB, MOH and NYSC, will be continued to reach members of more than 5,000 youth clubs. In addition, UNICEF will focus on girls working in Free Trade Zones, youth in the armed forces, and sexually exploited children in "tourist areas". 20. Messages to be pretested include the following: (a) What is an STD and how does it affect the individual? (b) What is HIV/AIDS and how does it affect the individual? (c) Behaviors not/leading to infection (d) Barriers to safer sexual behaviors 21. Interventions promoting safer sexual behaviors. including condom use. As the number of HIV-infected individuals continues to increase, more effort will be required to focus on the adoption of safer sexual practices. This will include communication activities that motivate and sustain behavior changes. These interventions will build on those outlined above relating to strengthening awareness and knowledge. 22. Of those who know that AIDS is transmitted sexually, only 5% report that they intend to change their behavior (or have already done so), and in addition, only 5% report using condoms. 23. Development of interventions will be guided by lessons learned from MTP I, including taking existing lifestyles into account; bringing benefit and pleasure to the individual; linking individual behavior change to changing social norms in the community, and findings about the needs of each target group. A mix of the communication approaches will be employed. Interventions will cover the following areas: (a) providing skills for correct condom use; (b) providing skills for increasing assertiveness and negotiating condom use and/or other safer sexual practices; (c) increasing availability of good quality, low-cost condoms through expanding condom  - 66 - Annex 4 Page 6 of 12 social marketing and work place programs; (d) improving demand for and access to good quality, low-cost integrated STD/HIV services that are acceptable to clients; (e) improving demand for and access to good quality, low-cost reproductive health services (integration of FP/MCH and STD/HIV services). 24. The primary message to be adapted to the needs of the different target groups on the basis of qualitative research is the need to try and sustain safer sexual practices, including condom use, mutual fidelity, non-penetrative sex, and abstinence. 25. During MTP 1, the NSACP and some NGOs implemented pilot interventions to motivate behavior change among male and female sex workers, and condom social marketing undertaken by the FPA has increased condom availability to the general public. The NSACP will now coordinate systematic efforts to increase adoption of safer sex which will be implemented by numerous government and non-government agencies and the corporate sector. 26. Interventions promoting STD care-seeking behavior. Sexual transmission has been identified as the major factor in IfV spread . In Asia, including Sri Lanka, heterosexual vaginal/anal intercourse seems to be the most dominant form of transmission. Available studies indicate that sex workers account for nearly 70% of the infection and that about 70% of sex workers are infected with STDs. Interventions promoting STD care-seeking behavior will on IEC efforts to identify potential clients and inform them about STD care, it importance, and where to obtain quality care. Other interventions will be formulated through a workshop. Methods of promoting appropriate care-seeking behavior include among others, community initiatives, national and local media campaigns, and education targeted at populations with risk behaviors. Since only 5-10% of STD-infected individuals attend public clinics, it is essential that private facilities and physicians be involved in these efforts. 27. Interventions strengthening STD diagnosis and treatment. An effective HIV/AIDS Control Program requires a well-established STD/AIDS care service supported by a well-organized laboratory service. The Central Laboratory in Colombo is capable of performing several diagnostic tests for STDs and HIV infections. The tests available outside Colombo are the venereal disease research laboratory (VDRL) tests and microscopy. 28. To strengthen quality of care and maximize coverage, the following interventions, including provision of care at the primary health care level through syndromic approaches, will be adopted: (a) Strenathening diagnostic facilities (i) The Medical Research Institute of the Ministry of Health will provide the services to the NSACP in the form of laboratory support for clinical management of HIV infected persons. The services will include: - HIV culture capability; - viral diagnostic service such as herpes, cytomegalo virus and hepatitis B; - bacteriological service for the detection of opportunistic infections; - diagnosis of parasitic and fungal infections;  - 67 - Annex 4 Page 7 of 12 - PCR on a selective basis; - automated CD4 cell counting with appropriate equipment and training; - establishment of an effective and comprehensive quality assessment scheme to ensure standardized testing at all levels. (ii) The existing facilities and capabilities in the Central Clinic will be improved through the construction of a new facility. Expanded capacities and services will include: - antigen testing for HIV on a selective basis; - confirmatory test for HIV 2; - cervical cytology; - MICs of N. gonorrhoea to be performed on a routine basis; - routine diagnosis of chlamydial infections; - urgent requirement to train a laboratory staff member as a maintenance officer with the assurance that he/she will continue to work in the NSACP after the training. (iii) STD/AIDS diagnostic facilities at the nine provincial hospitals will be strengthened so that they will be capable of performing VDRL, TPHA, gonococcal culture, HIV screening and microscopy. An internal quality assurance scheme for the diagnostic laboratories will be established. (b) Undertaking clinical and laboratory studies focusing on the following - asymptomatic women; - rectal gonorrhoea among persons with STD/HIV, both males and females; - serofast for syphilis; - upper reproductive tract infections and foetal wastage due to STDs; - MIC levels; - plasmid analysis; - HIV and HPV PCR studies. (c) Increasing expertise at all levels to improve counseling, contact tracing, partner notification and where appropriate, provision of treatment. 29. Interventions promoting reproductive health (RH). The definition of reproductive health is broader than STD/AIDS control and prevention. A healthy genital tract is usually required for pregnancy and delivery. Since a diseased genital tract either from AIDS, STD or the complications of these conditions can prevent pregnancy and the reproductive function, the aims of maintaining RH coincide with those of STD/AIDS control. 30. Promotion of RH services will among the areas included in IEC efforts. Potential clients will be informed of what RH care consists of, its importance, and where to obtain quality care. Other interventions will be formulated through a workshop. Methods of promoting appropriate RH care will include community initiatives, national and local media campaigns and education targeted at sexually active women.  - 68 - Annex 4 Page 8 of 12 31. Coordination of RH activities will be undertaken by the NSACP and the FHB, with the support of agencies such as UNFPA, UNICEF and UNDP. Practices such as laboratory examination of cervical smears taken from women having IUDs inserted should be made standard. In addition, the NSACP will support expansion of condom social marketing, especially in rral areas. II. PREVENTION OF TRANSMISSION THROUGH BLOOD 32. Interventions ensuring safe blood. There are 46 outstation blood banks in the country. The Central Blood Bank in Colombo is attached to the National Blood Transfusion Service (NBTS). In addition, there are a few private blood banks operating as part of private hospitals or separately collecting blood for sale. NBTS does not have any control over the activities of the private blood banks. The exact number of these blood banks is not known. 33. No cases of HIV infections have been reported following transfusions. One case of transfusion-associated HIV infection has been reported after transfusion abroad. Strategies adopted by the NBTS for "HlV-safe" blood are: (a) Safer donors - voluntary non-remunerated donors - donor selection, including self-deferral - donor examination (b) Safer blood (and blood components) - confidential unit exclusion - screening blood for HIV antibodies According to the statistics of the NBTS, 99.99% of the blood units donated in the country are screened for WIV antibodies and HBs antigen. 34. About 50% of the blood donations in the country are screened for HIV 1 and 2 in the NSACP Central Laboratory using the ELISA technique. All outstation blood banks perform the Serodia test for HIV 1 only. All HV antibody positive samples are confirmed by Westem Blot in the Central Laboratory of the STD/AIDS Control Program for statistical reasons. 35. Every effort will be taken to sustain and strengthen the existing activities of the NBTS to prevent transmission of HIV infection through blood transfusion and transfusion of blood components. Sustainability of the existing scheme will be ensured by providing training to all categories of staff in the NBTS and continuous supply of sterile and disposable items used for blood collection. Test reagents necessary for the continuous testing of all blood units for WHV 1 and 2 antibodies will be made available. Licensing procedures will be established for all private blood banks to ensure safe practices and blood quality control. 36. The following interventions have been identified: - creating awareness among the medical staff about the risks of transfusion associated infections in order to reduce the need for blood transfusion; - preparing and distributing guidelines for blood transfusion practices to all medical  - 69 - Annex 4 Page 9 of 12 officers; - continuing donor selection strategies, blood testing procedures and training programs at their fullest capacity. 37. The policy for providing clotting factor products to hemophiliacs is satisfactory and will be continued in its present form. 38. Interventions preventing nosocomial transmission and other skin piercing procedures. As an initial step to promote infection control, "Infection Control Guidelines" in the health care setting have been prepared and circulated throughout the country. A total of 120 infection control nurses have been trained in groups and has been posted to all parts of the country. As a result every General Hospital and many base hospitals have one or more trained infection control nurses on their staff. These nurses are responsible for all infection control activities in the hospital. The General Hospital in Colombo has an infection control team headed by the clinical microbiologist in the hospital. No cases of HIV transmission have been reported from patient to health care workers, from patient to patient or from health care workers to patient. 39. Conditions, equipment, reagents and guidelines necessary for the practice of universal safety precautions will be made available to all levels of health care workers. HCWs should be continually made aware that any patient admitted to hospital has the potential to be infected with HIV or any other blood-borne pathogen, irrespective of an HIV test result. Interventions foreseen include the following: adequate supervision, awareness, continuous supply of necessary items, clear guidelines and training available for the practice of universal safety precautions; and guidelines on proper sterilization of endoscopes and other invasive instruments to be made available to all medical officers. While emphasizing the need to manage HIV positive patients in the general wards, isolation facilities for those with TB, severe diarrhea and mental disorders, should be made available when necessary. Facilities for incineration or other method of safe waste disposal will be available. A standard protocol will be developed on the plan of action to be followed in the event of an accidental needle stick or any other injury to a health care women. 40. Interventions promoting adoption of safer injecting drug use (IDU) practices. During the MTP I there were no activities directed towards people injecting illicit drugs. However, it is estimated that there are some 30,000 people in Sri Lanka who use illicit drugs, mainly via inhalation, and there are reports of increased experimentation with injection. 41. The NSACP will: - monitor the situation and encourage research to identify existing or emerging IDU activity and patterns; - begin to include information about IDU as a means of HIV transmission in general HIV/AIDS/STD programs and in drug information and control programs; - initiate dialogue with key government and non-government agencies about appropriate intervention strategies if required including: * abstinence from drug use * harm minimization models * provision of sterile injecting equipment via pharmacies, needle exchange, informal  - 70 - Annex 4 Page 10 of 12 networks * provision of information to IDU about how to sterilize equipment * encourage non-sharing of equipment * collect information about successful IDU, HIV/AIDS/STD programs from other countries (Asian and non-Asian) III. PREVENTION OF PERINATAL TRANSMISSION 42. Perinatal transmission from HIV positive mother to child has not been a problem in Sri Lanka. To prevent future difficulties, the NSACP will take the following steps: (a) upgrade the infection control facilities of the hospitals and matemity homes; (b) emphasize the risk of perinatal transmission in all HIV/AIDS awareness programs, particularly in ANCs; (c) provide counseling services for HILV seropositive women and women at risk; (d) offer voluntary confidential HIV testing service to pregnant women. 43. The policy of medical termination of pregnancy in HIV seropositive women may have to be addressed in the future. D. Project Inputs Incinerators 44. The project will support the construction of five incinerators for medical wastes adjacent to but not attached to medical facilities in Colombo, including the new NSACP headquarters building. For each site, a one cc foot incinerator will be constructed, which will be sufficient to dispose of plastic syringes, some linen and gloves, etc. Firing will be by LPG gas supplemented by air blowers. A 50-foot chimney will carry away exhaust gases, although it is anticipated that due to the high combustion temperature there will be very little smoke. DruRs 45. The project will support drugs for the syndromic treatment of STDs. The following drugs will be procured: Erythromycin Ciprofloxacin Doxycycline Caftriaxone Cotrimoxazole It is estimated that it will cost approximately Rs. 250 to treat an STD case syndromically and that by the end of the project period approximately 10,000 cases a year will be treated syndromically 46. AZT is intended to be used only in those few cases of HIV infection of health staff as the result of needle sticks.  - 71 - Annex 4 Page 11 of 12 Condom Vending Machines 47. Provision is made for procurement of 75 condom vending machines through UNFPA. These machines will be placed at the disposal of and serviced by NGOs active in AIDS education efforts who feel that when installed in appropriate locations the machines would be utilized by groups with which they are working. It is expected that most machines would be located in areas of high tourist interest, urban and industrial areas, and perhaps university areas.  TRAINING PROGRAM FOR NSACP 1996 1997 1998 1999 2000 Funding Agency Key Responsibility Program Managemiient Orientation of program managers at provincial level 2 2 2 World Bank NSACP/PD (PDs, DPDs, Heads of Institutions). 6 programs. STD Prevention & Care Preparation of guidelines for training of GPs in x x World Bank NSACP comprehensive STD care, total number 500. TOT workshops for 20 trainers. x x x x World Bank NSACP/College of GPs/lMPA Training of medical graduates, total numbet to be x x x x World Bank NSACP/College of GUPs trained 800. Training of MLTs in VDRL testing - 10 base hospitals. UNFPA Training ol' I'll field stal:t x x x UNFIPA Training of trainers. x x x UNFPA TOT for training of nursing personnel. 2 2 2 2 World Bank D/Nursing & Public Health Training of 400 ward sisters (20 workshops). 5 5 5 5 World Bank D/Nursing & Public Health Care & Counselling Ministry of Health Orientation of ward staff in general hospitals. Ministry of Health Regional training of health education officers and core x x World Bank HEB group members. Training of NGOs in counselling at provincial and 10 10 20 20 World Bank NSACP district level (60 workshops). Training of nursing midwif'ery personnel (16 4 4 4 4 World Bank MOHJD/Nursing workshops). 'Iraining ol'I ield stair in risk areas on condom x x Youth Service Councils/I-lEB promotion, intfection contrtl. Training of School Counsellors. x x NIE/HEB Training of NGO co-ordinators, managers (2 x x NGO Secretariat/NSACP workshops) i 0.  - 73 - Annex 5 Page 1 of 15 SRI LANKA HEALTH SERVICES PROJECT Nutrition Component A. Nutrition Issues in Sri Lanka Low Birth Weight 1. The weight of an infant at birth broadly reflects the quality of its intrauterine development. Birth weight is an important predictor of the survival of the newbom. Studies have also shown that low birth weight in full-term infants has a lasting deleterious impact on growth, which even good diet and environment may not be able to reverse entirely. From a public health point of view, the mean birth weight in a community may provide a broad indication of the quality of matemal nutrition and ante-natal care that is available. 2. The incidence of low birth weight in Sri Lanka, i.e. below 2,500 grains, is significant and, what is more, does not appear to have declined in recent years. A study of 36,578 pregnant women done by the Ministry of Health/CARE in 1984 gave the percentage of low birth-weight births as 19%. Family Health Bureau data indicated an incidence of 23% for the 1986-89 period, and a fuither study in 1989/90 reported 19% low-weight births, of which three quarters were full term. The low birth-weight figures from the 1993 Demographic & Health Survey and the 1993 Nutrition & Health Survey were 19% and 20%, respectively. The DHS survey also reported that in the estate sector, the incidence of low birth weight was close to 30%. Protein Energy Malnutrition (PEM) 3. The 1993 Demographic & Health Survey reported the following levels of malnourishment (below -2 standard deviations from the median of the reference population) for Sri Lankan children 3-59 months of age: stunted (low weight for age), 23.7%; wasted (low weight for height), 15.6%; and underweight (low weight for age), 37.6%. The National Health Survey, also carried out in 1993, measured only underweight and reported 34.7% underweight (6.3% severely and 28.4% moderately). The results of the two surveys, therefore are reassuringly consistent. 4. The DHS data can also be compared to similar data from the 1987 DHS survey. The two DHS and the NHS survey give the following percentages for underweight for children 3-35 months. DHS1987 38.1% DHS 1993 32.6% DHS 1993 32.0% These estimates suggest, first, that the level of malnutrition has declined somewhat since 1987; and second, that the current level of malnutrition among children 3-35 months in Sri Lanka is close to a  74- Annex 5 Page 2 of 15 third. The estimated levels for children 3-59 months are slightly higher (35-38%), as indicated above. This is significantly lower than the comparable level of malnutrition for children 3-59 months in other south Asian countries (e.g. Pakistan 54%, Bangladesh 67% in recent surveys) but is still strikingly high given the low level of mortality in Sri Lanka. 5. The 1993 DHS data indicate a somewhat lower level of malnutrition (underweight) in urban as compared to rural areas and a particularly high percentage among estate populations. The contrast between wasting on the one hand and stunting/underweight on the other hand (10% vs 53- 54% among the estate populations is far greater than that in urban and other rural populations. The most probably explanation for this phenomenon is that among estate women, almost all of whom work, breast feeding and weaning habits are particularly detrimental, resulting for their infants in a downward nutritional spiral likely to start as early as the second or third month and culminating in stunting. However, because household cash income on estates does not vary much by season, there is less likely to be short-term nutritional stress (wasting) than in other areas of the country. 6. The monotonic decline in the percent of children underweight by increasing educational level of the mother in the 1993 DHS data suggests a clear relationship between malnutrition and poverty, and the same association emerges from analysis of the NHS data. However, the relatively high level of malnutrition among the children of even quite educated women (25% for mothers with more than secondary education in the DHS data) is unexpected and suggests that traditional beliefs and practices and other cultural factors are also likely to play a large role in the persistence of high levels of malnutrition in Sri Lanka. 7. The pattern of increasing malnutrition, which becomes evident soon after birth and becomes progressively greater until it starts to level off at about 18 months, as well as other available evidence, suggests that infant and child feeding practices are in fact far from optimal in Sri Lanka. Studies indicate that nearly 30% of infants are fed complementary liquids and solids within the first four months of life, rather than being exclusively breast feed. But although many infants receive complementary foods too early, 30% of infants over the age of six months are not receiving any complementary foods at all. A related problem arises because for traditional reasons the first complementary food given may be rice water, which is not sufficiently nutritious and is often not taken readily by infants. Micronutrient Deficiencies 8. Iron Deficiency. Iron-deficiency anemia is a serious problem in most developing countries. It leads to impaired capacity for physical work, increased maternal and fetal morbidity and mortality and increased risk of low birth weight. It is due mainly to low dietary intake and absorption of iron and folate and is exacerbated by the increased needs of pregnancy. Most of the iron in Sri Lankan diets is derived from plant sources that contain non-heme (inorganic) iron, which is less well absorbed by the body than iron from organic sources. Absorption of non-heme iron is decreased by consumption of tea, a standard of the Sri Lankan diet. 9. The few available studies indicate that anemia is a major nutritional problem in Sri Lanka as well. Two studies conducted by the Medical Research Institute (MRI), involving 129 and 692 pregnant women, found that 78% and 60% of the women, respectively were anemic, that is, had a hemoglobin level of less than I lg/dl. The results of a national iron deficiency survey are expected  - 75 - Annex 5 Page 3 of 15 to be available shortly. Iron-folate supplements are given to pregnant mothers attending ante-natal clinics, although because of poor compliance due to side effects, the impact of this intervention may be limited. Modification of diet may be an alternative approach, since consumption of ascorbic acid-rich foods and meat or fish, even in small quantities, can significantly enhance iron absorption. 10. Iodine Deficiency Disease (IDD). Iodine is an essential component of hormones secreted by the thyroid gland. A wide spectrum of disorders due to iodine deficiency can occur at all ages, but it is particularly serious for a pregnant women since iodine deficiency during pregnancy can cause stillbirth, congenital abnormalities or cretinism in her child. Goiter, the most common manifestation of iodine deficiency, was not documented as a public health problem in Sri Lanka until the late 1940s, when the Medical Research Institute reported that it was prevalent in the wet zone with areas of high endemicity (more than 10% of the population affected) in Kalutara, Kandy, and Matale districts. Subsequently, a survey in 1987 confirmed that iodine deficiency is a public health problem throughout the wet zone. Based on the current population of the provinces surveyed, over 60% of the Sri Lanka is at risk of iodine deficiency. 11. Legislation mandating the iodization of salt was passed in 1993, but only became effective in July 1995 in order to give the salt industry and the government time to prepare for its implementation. In conjunction with this legislation, UNICEF, the multilateral agency most involved to date in strengthening efforts at control of iodine deficiency, has provided iodization plants for two saltems and has collaborated with the Ministry of Health and the Ministry of Industry to increase capacity to monitor the iodine content of salt through the provision of laboratory equipment and training laboratory staff in various areas of the country. However, the proportion of salt fortified with iodine to date is limited, largely due to problems in the salt industry and low demand for iodized salt by the public. Low consumer demand for iodized salt is largely because the public is unaware of iodine deficiency and its effects, or the efficacy of iodized salt in control of IDD. A substantial price differential between iodized and non-iodized salt is also a potential constraint to increasing demand for iodized salt. 12. Vitamin A Deficiency. Vitamin A is required for normal growth and development of the fetus and the infant. The vitamin A status of pregnant and lactating women is crucial, since severe vitamin A deficiency during pregnancy may lead to miscarriage or birth defects and to vitamin A deficiency in breast feeding infants. During weaning, the child is at risk of developing clinical deficiencies if breast milk is replaced with foods low in vitamin A. The prevalence of vitamin A deficiency in Sri Lanka is not known. The only national survey, carried out in 1975/76, reported the existence of pockets of high prevalence in various parts of the country, the worst affected parts being in the districts of Kegale, Matara, and Ratnapura. The results of a national vitamin A survey are expected to be available shortly. B. The Thriposha Program 13. The Thriposha program was initiated in 1973 by the Ministry of Health, with the assistance of CARE, to combat the high incidence of child malnutrition, low birth weight, and iron deficiency anemia in Sri Lanka. The principal target groups are malnourished children under five and pregnant and lactating women. The program is based on provision a take-home dry food supplement. Beneficiaries are entitled to a packet of Thriposha once every two weeks, which translates into a daily food supplement of 50 grarns. The supplement provides energy, protein, and  - 76 - Annex 5 Page 4 of 15 food supplement of 50 grams. The supplement provides energy, protein, and micronutrients as a pre- cooked, ready-to-eat, cereal and legume-based food--hence the name "Thriposha" (triple nutrient). 14. At the inception of the program, the raw materials were entirely imported, but since then the Thriposha formula has undergone considerable modification. Between 1973 and 1990, the bulk of the raw materials were supplied by USAID through a PL 480 Title II Grant Agreement. The formula currently consists of maize (66%), soybean (30%), full-cream milk powder (3%), and a vitamin- mineral premix (2%). The soybean and milk powder are procured locally, while the other components are imported. Although maize is grown locally, it cannot be utilized by the program due to high levels of aflatoxin. The manufacture of Thriposha is centralized so as to maintain high standards of hygiene and quality control. 15. The cumulative cost of the program has been $US 39.3 million, at an average of $US 1.9 million per annum. In recent years, however, actual expenditure has averaged over $US 3.5 million per annum. The program is funded, managed and implemented by the Ministry of Health, and the bulk of the annual expenditure goes towards production of Thriposha. Up until 1990, CARE played a key supporting role in the implementation of the program, and it is generally agreed that overall program performance was better prior to that date than it has been since. 16. The program currently has about 580,000 'approved' beneficiaries, of which roughly one third are pregnant and nursing women and two thirds are children aged 6-59 months. Children are considered eligible if their weights, as recorded on growth cards, indicate that they are underweight for age, that is, 'below the red line.' Over the years there have been significant fluctuations in the ability of the program to supply beneficiaries on a regular basis. in 1994 and 1995, the production of Thriposha declined sharply due to difficulty in securing raw materials. 17. A number of issues have been raised conceming the program's impact and sustainability, including the following. (a) sharing--the supplement may be consumed by the entire family rather than the target beneficiary; (b) substitution--when the supplement is given for the under-five child, the mother may reduce the child's regular food, resulting in no increase in nutrient intake; (c) distortion of growth monitoring--since Thriposha eligibility is linked to recording of the child as underweight on the growth card, weights may not be recorded accurately; (d) dependency--the free distribution of the food may reinforce a dependent attitude on the part of the recipient; (e) sustainability--the production of Thriposha is dependent on imported commodities and is quite expensive. 18. There is no consistent evidence that the Thriposha program has been effective in improving the nutritional status of beneficiaries. Therefore, the Ministry of Health will carry out an evaluation of the program by June 30, 1998 and will then implement recommendations agreed with IDA (para. 24).  - 77- Annex 5 Page 5 of 15 C. The Nutrition Component of the National Development Trust Fund Project 19. A number of community-based nutrition and integrated rural development programs with nutrition components are currently supported by UNICEF, UNDP, several bilateral donors, and NGOs such as Sarvodaya. The most extensive of these is the nutrition component of the IDA-supported Poverty alleviation (National Development Trust Fund--formerly the Janasaviya Trust Fund) Project. The objective of the NDTF nutrition component is to reduce levels of malnutrition among young children and the incidence of low birth weight, with emphasis on reaching the poorest and most deprived populations. An 'In-Depth Approach' is being implemented in 180 of Sri Lanka's 256 administrative divisions, covering about 10% of the total population. Nutrition activities are implemented by NGOs, known as Partner Organizations (POs), in one village cluster (Grama Niladari Division--GND) per division. Ten of the most deprived village clusters are selected in each division. 20. The In-Depth team at the division level consists of four persons: a project coordinator, nutrition field worker (NFW), accounts clerk, and field assistant. These workers are trained by the NDTF with the NFW receiving 3 weeks training in nutrition and related fields, while the others have a 3-day orientation. Each village cluster also has 7 volunteers, three in basic nutrition (trained for 3 days), and four "scholars" who receive training in their particular specialty--agriculture/animal husbandry (13 days' training), health/sanitation (10 days), preschool teacher (30 days) and child care/family planning (10 days). 21. The In-Depth approach is implemented in stages: (a) Volunteer Nutrition Workers (VNWs) trained -- 3 per GND (b) All children weighed (c) Train VNWs in survey methodology Conduct household poverty survey (d) Meeting with GND elders (if required) Meeting with the 35 most deprived households to discuss problems and identify/develop proposals Finalize community development proposals (e) Implement community action proposals While all under-five children and pregnant/lactating mothers are included in the program, "special care" is provided to those identified as the poorest in the community survey. The same group develops the community work proposals which address the immediate causes of malnutrition in that village. 22. In general, implementation of the nutrition component of the project has gone well. POs had been selected and project-supported activities were underway in by POs in all 180 targeted divisions by 1955. There have been problems conceming monitoring and reporting of project output and impact indicators. Initial indications are that the component is achieving improvements in  - 78 - Annex 5 Page 6 of 15 nutritional levels of children, although rigorous demonstration of impact is not yet possible. Project impact on low birth weight has not been tracked. 23. The component originally included Thriposha, but due to recent unavailability combined with questionable sustainability, Thriposha has now been eliminated from the project design. Instead, the project will support production of a local, low-technology food supplement as an income- generating activity. However, it is important to note that the results that have been achieved thus far have been accomplished without any food supplementation. D. Nutrition Component of the Project 24. The Nutrition component of the Health Services Project will support the programs of the Ministry of Health to improve the nutritional status of the most vulnerable groups in the population: infants, young children and pregnant women. These programs will utilize primarily the existing resources available in the Ministry of Health. The focus will be on reorientation and revitalization of the existing growth promotion program of the Ministry's Family Health Bureau (i.e. the MCH unit under the Director MCH). Since there is no consistent evidence that the Thriposha program has been effective in improving the nutritional status of beneficiaries, MOH will carry out an impact evaluation of the program by June 30, 1998, will discuss the findings with IDA, and will then implement agreed recommendations. This section of the annex provides details about most aspects of the nutrition component, which is summarized in the main text of the Staff Appraisal Report. Institutional Strengthening 25. To provide an organizational focus for nutrition programs and activities in the Ministry of Health and to strengthen the ability of the Family Health Bureau and the health system to plan, manage and implement a national growth promotion program, the project will support the following: 26. Ministry of Health. Administrative and other logistical support will be provided to the Family Health Bureau, which is the focal point for nutrition activities within the Ministry. A nutrition unit will be set up as part of the FHB, and a post of Deputy Director MCH (Nutrition) will be established to specifically be responsible for nutrition activities. A clerk and a statistical assistant with computer training will be appointed to assist the Deputy Director, and office equipment and supplies will be supported. Two national consultants will also be engaged for the duration of the project to assist with project implementation. Two vehicles, for the Deputy Director and for the consultants, will be provided. 27. The Medical Research Institute (MRI) is the technical arm of the Ministry of Health. To enable the Nutrition Division of the Medical Research Institute to take the leading role in the implementation and coordination of survey and operational research work for the project, the project will support strengthening of the Division. Data processing capability will be strengthened through provision of computer facilities and office equipment. In addition, the field capacity of the Division will be strengthened through the provision of a vehicle. 28. Divisional Health & Nutrition Committees. In order to coordinate, promote and strengthen health and nutrition activities at divisional level, Divisional Health and Nutrition Committees will be established if they do not already exist. Members of these committees include the  - 79 - Annex 5 Page 7 of 15 divisional Secretary, the Divisional director of Health Services (DDHS), the Divisional director of Education, the Agricultural Extension Officer, the Assistant Director of Planning, and representatives of NGOs working in the division. Other relevant individuals are invited to join as appropriate. The functioning of these committees has been uneven, but it is clear that they can make a major contribution if they are adequately motivated, supported and mobilized. The project will provide operational support for committee meetings and activities and will monitor their progress. Minutes of committee meetings will be forwarded to the FHB. One of the consultants' major responsibilities will be to coordinate with the Committees and promote their support for project activities. Nutrition Working Group 29. A Nutrition Working Group in the Ministry of Health, chaired by the Director MCH and including the Deputy Director MCH (Nutrition) and representatives of the Health Education Bureau and the Medical Research Institute, will be constituted to provide policy and implementation guidance for the Nutrition component. The Director MCH will invite the participation of others working in the nutrition field from within government, academic institutions and other organizations as appropriate. The Working Group will meet at least once a quarter to review the progress of the component. Program and Project Orientation 30. Orientation to the Health Ministry's nutrition programs and to the project will be provided for all Health staff concerned with nutrition programs. There will be a one-day workshop for senior staff in the first year of the project. This will include the Health Secretary, the Director General Health Services, the Deputy Director General Public Health Services, the Director, National Institute of Health Services, the provincial Health Secretaries, the provincial Directors of Health Services, and the provincial Deputy Directors of Health Services. There will be additional orientation workshops for district and divisional level staff including the members of divisional Health & Nutrition Committees. The orientation will cover current nutrition problems in Sri Lanka, the strategies being adopted to address these problems, especially the reorientation of the growth promotion program and the key nutrition messages to be conveyed, the roles of the various government departments concerned, and coordination with other nutrition programs. National Growth Promotion Program 31. Growth promotion can be defined as activities that promote either normal growth of a normal child or catch-up growth of a malnourished child, including low birth weight infants. Growth monitoring refers to the measurement and recording of a child's weight on the card provided to mothers by the FHB for the purpose. Growth monitoring should be seen as one aspect of growth promotion that serves as an entry point for other aspects of growth promotion, particularly nutrition education. It must be delinked, in the minds of health workers and the general public, from its present close association with thriposha eligibility. Growth promotion, rather than detection of malnutrition, should be understood by all concerned as the basic purpose of growth monitoring. 32. The public health midwife (PHM) is responsible for growth promotion activities. However, given her many other tasks, one of the goals of the re-oriented growth promotion program will be to make growth promotion a community-based program and to utilize NGO workers and/or community volunteers to carry out growth promotion activities to the extent possible. The PHM,  - 80 - Annex 5 Page 8 of 15 together with NGO workers and/or community volunteers, will be responsible for the following activities involving pregnant women, the mothers of infants and young children and their children, and the community, as follows. Pregnant Women Provide general pregnancy counseling, including diet and weight gain advice Provide iron-folate supplementation and motivate to consume Monitor weight gain Motivate to give colostrum to newborn Infants/Mothers Motivate to breast feed exclusively for 4-6 months Provide general lactation counseling Counsel about importance of steady growth in infant and role of growth monitoring Monitor growth of infant Ensure referral if initial faltering of growth continues Provide iron-folate supplementation for at least six weeks postpartum and motivate to consume Counsel about treatment of diarrhea Counsel about benefits of iodized salt Young Children/Mothers Counsel about important of steady growth of child Counsel about start of weaning at 4-6 months, appropriate weaning foods and feeding frequency Demonstrate preparation of simple local weaning foods Monitor growth of young child Ensure referral if initial faltering of growth continues Counsel about spacing and family planning as appropriate Counsel about treatment of diarrhea Counsel about benefits of iodized salt Community Promote community awareness of importance of good matemal, infant, and young child nutrition 33. Introduction of the reoriented growth promotion program will follow completion of in- service training of PHMs and supervisors, which will be phased over the first three years of the project. In those areas where the NDTF nutrition component or other community-based programs that include nutrition activities are being implemented, the emphasis will be on coordination between the PHM and NGO workers and/or volunteers who are already active. In those areas where there is only the FHB program, after completing her nutrition training, the PHM, with the assistance of local leaders, local NGOs, her supervisor, the DDHS and the Divisional Health & Nutrition Committee will organize a local Health & Nutrition Committee if one does not already exist. She will discuss with local leaders, local NGOs, and the local Committee the importance of growth promotion and will seek their assistance in recruiting local volunteers (most probably married women). The DDHS will be responsible for providing training to volunteers. The PHM  - 31 - Annex 5 Page 9 of 15 will also seek the agreement of local leaders concerning a location (or locations) for establishment of a community nutrition center as a focus for growth promotion activities in her area. Growth monitoring and nutrition counseling will be carried out at the community nutrition centers, separately from MCH clinics, on a fixed day at a specified time each month. The volunteers will be instrumental in ensuring that children are brought for weighing, and to the extent possible they will carry out growth monitoring and counseling under the supervision of the PHM. They will also make household visits to pregnant women and mothers with infants and young children. Communications Strategy 34. The communications strategy for the growth promotion program will include both interpersonal communications and mass media campaigns. It will be coordinated by the Health Education Bureau (HEB) of the Ministry of Health and to the extent possible will draw on nutrition communications development already accomplished, particularly by UNICEF with the support of the IDA-assisted Health & Family Planning project and by the nutrition component of the IDA-assisted Poverty Alleviation project. Interpersonal communication by PHMs and volunteers to convey key messages concerning pregnancy, breast feeding, weaning and micronutrients and associated nutrition counseling drawing on the information supplied by growth monitoring will be the core of the growth promotion effort. The communications strategy will encompass message development, pretesting, development and testing of materials and media, and modifications of messages, materials and media based on experience as the project progresses. It will be important that the key messages are understood at all levels of the program. Mass media campaiRns will provide an essential complement to the interpersonal communication efforts. The messages featured will also focus on pregnancy, breast feeding, weaning and micronutrients. HEB will ensure that health staff are informed about the media to be utilized and content of upcoming campaigns, so that they can be used to reinforce and validate local interpersonal efforts. Coordination to ensure that the various nutrition programs convey consistent messages is the responsibility of the national Nutrition Steering Committee, which will request the Nutrition Working Group to convene workshops for the purpose as needed. Role of NGOs 35. NGOs would be involved in the growth promotion program, directly and indirectly, in the following ways: (a) Reorientation of the growth promotion program and associated in-service training of health staff as well as training of community volunteers would draw to the extent possible on the experience and materials of the NDTF in-depth nutrition component, which is implemented by NGOs under contract to the Tmst Fund. (b) In those areas where community-based nutrition programs are already being implemented, e.g. the areas covered by the NDTF nutrition component, the reoriented MOH growth promotion program would coordinate and cooperate with ongoing activities rather than trying to replace them or compete with them; thus, in such NDTF areas the program is already being implemented by NGOs.  82 -Annex 5 Page 10 of 15 (c) In other areas, the resources and experience of existing NGOs will be utilized to the extent possible to identify community volunteers, and their cooperation would be solicited in setting up community nutrition centers and community-based nutrition education efforts. Rapid Assessment of Growth Monitoring Activities 36. Prior to undertaking in-service training for FHB staff, a rapid assessment of how growth monitoring activities are currently carried out will be undertaken. The exercise will be coordinated by one of the long-term consultants for the nutrition component, who will report on the results of the exercise. The sample of sites to be visited will include areas where the In-Depth program of the National Development Trust Fund (NDTF) is operating, where other nutrition programs are ongoing, and where only the current FHB program is being carried out. 37. The assessment will elicit through observation and discussion with health workers, volunteers, mothers, etc. knowledge and practice in respect of: (a) General principles of growth monitoring. For example, are mothers and workers aware that the growth chart allows for comparison of a child's growth with that of a reference population; that as long as the child's weight gain is parallel to the reference line the child is gaining weight at the appropriate rate and is not in need of immediate intervention; that a growth curve that is flat or decreasing is a waming signal; that it is also a diagnostic tool to identify the undemourished or those needing nutritional/medical intervention. (b) Carrving out of growth monitoring. Is the weighing being done reliably and accurately; what type of scale is being used; condition of the scale--is it zeroed routinely and checked periodically against standard weights; are weighing pants/trousers in good condition; is the child handled properly during the weighing; is the child's age verified; is the weight read, recorded and plotted on the chart correctly; is the information on the chart being interpreted correctly by the health worker, the mother, and others involved and related to other health information; is the chart used to primarily identify beneficiaries for thriposha: is the information appropriately used for weaning advice; are weights for a given child being recording regularly. The assessment should also try to ascertain what percentage of children in the area covered are being weighted. Development of a Nutrition Guide for Health Workers 38. Also prior to the program of in-service training, a Nutrition Guide for training and reference purposes will be developed. The Guide should be concise and limited to important information and practical instruction. The Nutrition Working Group will appoint a nutrition curricula working group to compile the Guide that will include content specialists from the MRI, FHB, HEB and NIHS, and outside experts, e.g. a sociologist and a home science expert, who will seek the collaboration with the College of Obstetricians and the College of Pediatricians. The findings of the rapid assessment of growth monitoring would also be used in the preparation of this document. After the text is reviewed and finalized, it will be translated into Sinhala and Tamil.  - 83- Annex 5 Page 11 of 15 The Health Education Bureau will be consulted on design and printing. Initial requirements are anticipated to be 2,500 copies in English, 15,000 in Sinhala and 3,500 in Tamil. Development and production of the Guide should be completed in 3-4 months. 39. The nutrition needs and problems of the following groups should be covered by the Guide. (a) Adolescents and Young Women The special concerns and requirements of non-pregnant adolescents and young women. (b) Pregnant and Lactating Women General principles of health and nutrition during pregnancy, including energy requirements, relevant to pregnancy and lactation. (The special concerns of non- pregnant adolescents and young women should also need to be included.) Issues relating to weight gain in pregnancy. Use of the weight gain chart and relevance of regular weight measurement during pregnancy and its interpretation. Dietary advice and instruction with specific reference to locally available nutritious food. (Examples of nutritious diets during pregnancy will assist the health staff to confidently advise mothers.) Prevention and control of anemia in pregnanCv. A comprehensive strategy has already been formulated at a National Consultation on the Prevention and Control of Anaemia in Pregnancy. The sections on dietary modification, iron folate supplementation, and screening for anemia in pregnancy, as well as guidelines for referral of problem cases, should be included. The issues related to poor compliance with iron-folate supplements should be highlighted and stress given to ways and means to deal with this problem. (c) Infants and Young Children General principles of growth and development in infants, young children (1-3 years) and preschool children (3-5 years). Breast feeding: importance of early initiation of breast feeding, feeding of colostrum, exclusive breast feeding through first 4-6 months; common problems and how to deal with them. Weaning: appropriate timing of weaning; appropriate weaning foods that can be prepared inexpensively in the household; feeding requirements of infants and young children; common infant feeding problems and how to deal with them. Nutrition reguirements of different are groups: use of nutritious foods available locally; recommended daily dietary schedules for different age groups, with quantities, etc.  - 84 - Annex Page 12 of 1i Principles of growth monitoring including average weight gain at different ages; uses and limitations of growth charts. Development of Curricula for In-Service Training 40. As an extension of the development of the Nutrition Guide, the nutrition curricula working group will oversee the development of curricula for the in-service training of health staff. Curricula would need to be developed for the following categories of staff to be trained. (a) Public health (MCH) staff viz. PHNs, SPHIMs, PHMs. The Health Education Officers (HEOs) would also be included in this category. Duration of training: four days. This is the crucial category of health worker that would really take growth promotion activities into the community. (b) Public Health Inspeectors (PHIs). As a member of the public health team, this category will be given an orientation with regard to growth promotion activities that are proposed and their role in supporting such efforts. Duration of training: one day. (c) Nursing/midwifery staff attached to matemity and pediatric wards of hospitals. The training would concentrate on particularly relevant areas such as maternal nutrition, exclusive breast feeding, principles of infant and young child nutrition, and appropriate weaning practices, which would help to enlist the support of hospital staff for growth promotion activities. Duration of training: one day. (d) Estate health staff, including medical assistants (RMPs, AMPs, EMAs) and midwives. The curricula for training would be similar to that for MCH staff. 41. In addition to technical curricula, curricula for training in interpersonal communication, to be carried out primarily by staff of the Health Education Bureau, will be developed. As a part of this task, the training methods, materials and experience already being used by the NDTF nutrition component and other nutrition programs will be reviewed and utilized to the extent possible. Training of Trainers (TOT) 42. Once curricula are finalized, training of trainers (TOT) will be undertaken. The first three categories above will be trained by district training teams comprising five selected trainers from each district, which will be trained centrally for six days. TOT will be undertaken in three phases, spread out over the first three years of the project. For estate health staff, core trainers will be selected and trained from within the estates. On the last day of the training course, the respective Deputy Provincial Directors would be invited as resource persons to assist in the planning process for implementation of training in their respective regions. Duration of TOT: six days. Numbers and phasing are indicated in the following table.  - 85 - Annex 5 Page 13 of 15 Trainers No. of Central No. of Trainer No. to be Level Training Project Year No. of Districts Teams Trained Programs 1 4 4 20 1 2 12 12 60 3 3 8 8 40 2 43. A total of 110 core-trainers will be trained in the seven estate regions, namely: Galle 20, Ratnapura 14, Badulla 16, Kegalle 16, Kandy 12, Hatton 12 and Nuwara Eliya 20. Ratnapura 14, Badulla 16, Kegalle 16, Kandy 12, Hatton 12 and Nuwara Eliya 20. The total number of health staff involved in the training would be approximately 630. Duration of training four days. In-Service Training of Staff a. Public health field staff (MCH staff and PHIs). Number to be trained is based on the assumption that each Divisional Directorate of Health Services (DDHS) area has on average 20 FHB staff (PHNs, SPHMs and PHMs) and eight PHI's; 254 DDHS areas are assumed. Duration of training: four days for FHB staff and one day for PHIs. Numbers to be trained and phasing are indicated in the following table. Public Health Field Staff Project No. of DDHS MCH Year Districts Areas Staff PHI's MCH Staff PHI's* 1 4 45 900 360 45 15 2 12 125 2,500 1,000 125 42 3 8 85 1,700 680 85 28 * PMI training of one day's duration will follow immediately after MCH staff training. PHls from three DDHS areas will be trained together at one central location. b. Institutional staff. Ten institutional training programs will be undertaken per district, in selected institutions. Fifteen nurses and midwives attached to obstetric and pediatric wards will participate in each training program. This training will be undertaken by the respective DDHSs, supported by the Regional MO (MCH) and other resource persons as appropriate, up to a maximum of four persons. Duration of training: one day. Numbers to be trained and phasing are indicated in the following table.  - 86 - Annex 5 Page 14 of 15 Institutional Staff No. of Institutional No. of Staff to be Project Year No. of Districts Training Program Trained 2 4 40 600 3 12 120 1,800 4 8 80 1,200 c. Estate health staff. Training of estate health staff comprising medical assistants (Registered and Assistant Medical Practitioners and Estate Medical Assistants), Junior Medical Assistants, and midwives will be undertaken. The seven estate sector regions will have teams of core trainers to undertake the training of other staff. A category of community mobilizer on the estates, called the plantation family welfare supervisor (PFWS), as well as creche attendants will also be trained for two days using a modified curriculum. The numbers to be trained will be approximately 380 PFWSs and 1,510 creche attendants. The training of estate staff would be coordinated by the Health and Women's Division of the Plantation Housing and Social Welfare Trust, which is the central organization involved in health and welfare activities on estates. Monitoring 44. One of the initial activities to be undertaken will be finalization of a monitoring scheme for the growth promotion program, so that it can be incorporated into the in-service training of health workers. A routine monthly reporting system for growth monitoring that gives the percentage of underweight children at a given point in time and the percentage whose growth is faltering, as well as infonnation on household visiting and other growth promotion activities undertaken, needs to be developed. 45. While the overall impact of the component will be evaluated through national surveys of nutritional status, a special effort will be made to monitor the ongoing progress and impact of the growth promotion program. However, reporting of growth monitoring is open to the objection that it is always incomplete, that is, it is not certain that those children weighed one month are the same as those weighed the previous month, or even that those linked over two months are again picked up the following month. This will be dealt with through the designation of at least one division in each province as a sentinel division. Several of the sentinel divisions should be NDTF divisions. It will be necessary, first, to carry out baseline surveys in selected divisions. Special efforts will then be made in the sentinel divisions to achieve high reporting rates. The functioning of the sentinel monitoring scheme will be carefully observed in the first phase of implementation and adjustments made as experience indicates. Baseline surveys will also be carried out in matched divisions, where the program will not be introduced until the last phase, for control purposes.  - 87 - Annex 5 Page 15 of 15 Basic (Pre-Service) Training 46. Basic training for public health staff is undertaken at the National Institute of Health Sciences (NIHS) Kalutara and at 9 other Public Health Training Centers. The NIHS takes the lead role in the preparation of curricula for basic training of public health staff and will be closely associated with the development of curricula for in-service training under the nutrition component of the project. Therefore, the content developed for in-service training will also be incorporated into the basic (pre-service) training curricula for all categories of public health staff. The project will support a meeting of public health trainers from the training institutes to effect the necessary changes. 47. Of the 9 Public Health Training Centers, 4 (at Galle, Kadugannawa, Kurunegala and Tellipalai) have been upgraded to Regional Training Centers (RTCs) and will in addition take on the training of other categories of paramedical workers, for which adequate support has been provided under ADB project assistance. The other 5 training centers (at Panadura, Homagama, Moratuwa, Werallagama and Batticaloa) are in urgent need of support for IEC and office equipment, which will be provided under the project. Provision will also be made to upgrade the library facilities at these training institutions. Operational Research 48. Operational research will be the responsibility of the Nutrition Division of the Medical Research Institute (MRI) of the Ministry of Health. The Nutrition Division will develop a list of research proposals which will be reviewed by the Nutrition Working Group. Additionally, the Nutrition Division will establish a screening and technical review process and will invite proposals from outside the Ministry of Health. Proposals could be submitted by individuals, academic or other research organizations, NGOs, etc. 49. A number of proposals for operational research have already been identified, including the following. On estates, most of the growth monitoring activities are conducted in creches. It is proposed that a pilot program be undertaken involving 10-20 estate creches, where intensive follow-up with parents of children whose growth is faltering would be undertaken by creche and plantation health staff. In Kurunegala district, an experimental scheme has been introduced to use measurement of their height and weight by students as a method of helping to sensitive them to nutritional issues affecting their growth and development. It is proposed that this scheme be evaluated and, if warranted, expanded to areas. It is proposed to evaluate the use of school health cards to improve nutritional status of students.  - 88 - Annex 6 Page 1 of 6 SRILANKA HEALTH SERVICES PROJECT Health Policy Component: Proposed Link Program Between the Health Economics Study Program. University of Colombo and the Ministry of Health Introduction 1. Health policy development, through research into issues central to the provision and financing of health care services and the sensitizing of decision makers, has become an urgent necessity with the tightening of resource constraints that require prioritization and the introduction of altemative strategies. 2. Health economics has grown in stature as a subject of policy importance and relevance. It is an essential tool in the management of limited health care resources to satisfy social objectives, particularly with regard to the provision of adequate health care for the needy and disadvantaged. A knowledge of health economics is also extremely valuable to sensitize health sector decision makers, at both the micro and macro levels, on the complex issues that arise in decision making with regard to efficiency, equity and sustainability in the face of necessary trade-offs and externalities. Further, it can have considerable power to create awareness among officials in other ministries, members of NGO bodies and the general public regarding health issues, altemative funding sources and service provision facilities, and their role in contributing to the development of health care services in the country. 3. The proposed link between the Health Economics Study Program (HESP) and the Ministry of Health can play an important role in such a context by facilitating research and providing training programs that inform and educate a range of personnel, from parliamentarians and policy makers through medical administrators and medical students to grassroot level health workers. 4. HESP, which has been chosen as the link organization, is headed by a Health Economist trained at the London School of Hygiene and Tropical Medicine. He will be supported by other staff members who are currently actively engaged in research and training activities on health related economic issues. The members of HESP are: a. Dr. Nimal Attanayake (Ph.D. London) Sr. Lecturer in Economics/Heal of HESP b. Dr. Harsha Aturupane (Ph.D. Cambridge) Sr. Lecturer in Economics c. Dr. Amala de Silva (D.Phil. Sussex) Sr. Lecturer in Economics d. Mr. Sarath Vidanagama (M.Sc. Stirling) Sr. Lecturer in Eco., Head, Dept. of Eco. 5. Health Economics is already being taught as part of the B.A. Economics Honors Degree at the Department of Economics, University of Colombo. Members of HESP are conducting the Health Economics course in the M.Sc. program in Health Administration. A workshop on Matemal and Child Health Care, for senior officials of the health and finance ministries, was organized under the auspices of UNICEF and the Ministry of Health in February 1995. A session on economic evaluation was also conducted in a workshop on Health and Financing Issues conducted under the IDA/World Bank sector project.  - 89 - Annex 6 Page 2 of 6 6. Research on health sector issues have been conducted primarily by Dr. Attanayake, starting with a study of health sector resource flows in Gampaha district conducted for the Ministry of Health with WHO funding in 1987, followed by one of the earliest HSR studies on resource utilization at medical institutions in the same district and later policy related research funded by WHO/TDR. Other areas of current research by members of HESP include health sector financing, malaria. PHC, hospital autonomy, public-private mix, AIDS and addiction. 7. Dr. Attanayake has been a long-standing member of the HSR committee. Members of the Study Program have attended HSR seminars, as well as other recent seminars on issues such as malaria, public-private mix, health sector financing, AIDS and medical ethics. Members of HESP have also attended inter-country consultative meetings on behalf of the Ministry of Health. Such activities have fostered a close link between the members of HESP and the Ministry of Health. These links are likely to prove helpful in future collaboration. Objectives of the Program 8. The Program envisages the achievement of the following objectives. (a) Creating an appreciation for Health Economics, and awareness of financing issues among senior policy and decision makers; (b) Enhancing the skills for Health Economics, particularly cost and financial analysis, among operating level managers; (c) Sensitizing service providers to cost and financing issues; (d) Developing institutional capacity in the field of Health Economics; (e) Carrying out research programs in the area of health policy development on issues jointly agreed between the Ministry of Health and HESP. 9. In order to achieve these objectives the following strategy will be pursued: (a) The Health Economics Study Program and the Ministry of Health will enter into a long- term agreement in order to establish an efficient and firm foundation for their collaboration. (b) The capacity of the HESP will be developed through the provision of fellowships and training opportunities. (c) A close organizational relationship will be maintained through interactions between the Deputy Director General (Planning) in the Ministry of Health and the Head of HESP. 10. The plans with regard to the programn will be made by two representatives of the Ministry of Health and HESP. A meeting of these representatives will be held at least once every quarter. Three policy advisors will be appointed to advice on this program. A three-week review of the program will be conducted by a local consultant at the end of each year.  90- Annex 6 Page 3 of 6 l. Institutional capacity building will involve the provision of one two-year M.Sc./M.Phil fellowship or two one-year M.Sc. fellowships. Four short-term fellowships are also envisaged. Equipment, hardware, software and supplies will be provided for the maintenance of this link program. Envisared Activities Training and Dissemination - Training programs to be conducted for provincial, district and divisional health staff with the objective of providing planning, management and evaluation; - Workshops to be conducted for groups such as medical consultants, matrons, politicians and hospital development committee members with the objective of sensitizing them to issues related to provision of health services; - Other training and workshops as appropriate. 12. In addition to conducting such training programs for the benefit of the participants, the material prepared and the resource persons trained will be of great benefit in the future. Studies will be undertaken with a view to creating course material and case studies to be used in these dissemination and training programs. The findings of such studies will be disseminated through workshops and briefing of Ministry of Health officials. Curriculum Preparation A curriculum will be prepared in conjunction with the Department of Community Medicine, to be used in undergraduate teaching at the Medical Faculty of the University of Colombo. Research Research will be undertaken in the following areas in the first two years of this program. First Year - Research will involve evaluating policy options for strengthening the financial capability of the tertiary sector - this will involve in-depth analyses of such schemes as paybeds, autonomous hospitals with subsidies, user fees for specific services, cooperative systems within hospitals and other options. Research programs for the subsequent years will be developed in collaboration with the Ministry of Health, taking into account the changing health sector environment and the needs of the Ministry. Postgraduate students and ministry officials could be involved in these research activities on the request of the Ministry of Health. Tentatively, for the second year, a research study is planned on the area of public-private mix in health services.  - 91 - Annex 6 Page 4 of 6 Research findings will be disseminated through reports prepared for the Ministry of Health and seminars conducted for policy makers since the research issues chosen reflect important current policy concerns. An annual workshop will also be organized to disseminate research findings to an audience of important policy and decision makers. Other Support HESP will undertake to build and maintain databases in costs and health sector behavior that can support policy-related decision making. A newsletter will be prepared and circulated (bi-annually in the first year of the program and quarterly thereafter) among health sector policy makers and administrators, and others involved in decision making on the financing and provision of health care services at a central and provincial level. The newsletter will include reports on the ongoing activities of the link program, including summarized reports of research findings as well as news of activities organized by the Ministry of Health and other organizations in the field of Health Economics. HESP will also provide advisory support to the Ministry of Health in the form of an average of seven-person days per month on an agreed time schedule.  - 92 - Annex 6 Page 5 of 6 Policy-Related Studies and Initiatives* Topic Status 1. Improved Quality and Efficiency of the Health Services Efficient utilization of health facilities (by- To be developed in first year of project. passing problem) Drug costs and availability Study completed. MOH wishes to continue with a study of drug leakages and improved control systems. Consequences of decentralization of the health WHO-supported multi-country study on services. decentralization is in progress. Relocation of outpatient operations out of major To be developed as follow-up to by-passing tertiary care hospitals to reduce over-crowding. study. Differential criteria for direct admission to To be developed as follow-up to by-passing facilities to encourage systematic use of referral study. system. 2. Generation of Additional Resources for Tertiary Care Increase in the number of paybeds to enhance To be carried out in first year of project. financial resource availability at facilities. Detailed study of the resource generation Several studies in progress: Autonomy and experience of the Sri Jayawardenapura Hospital Management Structure, by Colombo University in order to assess the desirability and feasibility Economics Department; Revenue Generation of expanding resource generation in the tertiary and Cost Control, by consultants appointed by sector. the hospital; cost recovery as a part of an Assessment of Resource Mobilization in the Health Sector of Sri Lanka, carried out in late 1995 by the Harvard School of Public Health. Policy options for generating additional Various policy options--paybeds, revenue resources for tertiary care. generation, cooperative hospitals, autonomous hospitals--to be examined during the first project year.  - 93 - Annex 6 Page 6 of 6 Topic Status 3. Appropriate Public-Private Mix in the Health Sector Leasing of sophisticated medical equipment Feasibility study to be completed in first project from private sector for public medical year. institutions. Leasing of under-utilized space in public To be developed. facilities to private doctors for outpatient services. Support for development of private sector in- To be developed. patient facilities in rural areas. 4. NCD Morbidity & Disability Assessment of NCD prevalence. NCD National Risk Factor Prevalence Survey to be carried out starting in first project year. Development of capacity for burden of disease Supplementary survey and analysis to be (BOD) analysis undertaken as needed in second half of project. 5. Other Health Policy-related Areas Status of Mental Health Study to be undertaken; policy recommendations to be considered by MOH Assessment of violence against women Study to be undertaken; policy recommendations to be considered by MOH. Coordination between health and other sectors Small project on improved information for (e.g., agriculture, irrigation, industry, managing environmental health involving the environment, municipal government). Ministries of Environment and Health and Colombo Municipal Government, with possible technical assistance from the Environmental Health Project of USAID, to be carried out. * Status as of project negotiations.  Teleph#loneJs 9: 194 - 543I762 v CA/IDA/HC:'/C .. -; _Annex 6 K..,~20436 -: . Attachment MF- va-,e Secrctary 9 our . J P 1 of 83 tr)(..->.