India - Malaria Control Project

Document of The World Bank Report No. 16571-IN PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT IN THE AMOUNT OF SDR 119.2 MILLION TO INDIA FOR A MALARIA CONTROL PROJECT May 15, 1997 Population and Human Resources Operations Division Country Department II South Asia Region  CURRENCY EQUIVALENTS Currency Unit = Indian Rupee (Rs.) US$1.00 =Rs. 35.0 (Projected average for 1996) GOVERNMENT FISCAL YEAR April I to March 30 ABBREVIATIONS AND ACROYMNS ABER Annual Blood Examination Rate APDR Annual Program Development Review BA Beneficiary Assessment BHC bi-hennal-chloricarbidate CAS Country Assistance Strategy DALY Disability Adjusted Life Year DDC Drug Distribution Center DDT dichloro-diphenyl-trichloroethane EA Environmental Assessment FTD Fever Treatment Depot FY Fiscal Year GOI Government of India IEC Information, Education and Communication IDA International Development Association MLF Malaria Link Functions MMN Medicated Mosquito Nets MOHFW Ministry of Health and Family Welfare MPW Multipurpose Worker MRC Malaria Research Center NGO Non-Governmental Organization NMP Directorate of the National Malaria Eradication Program PIP Project Implementation Plan PHCF Primary Health Care Facilities SDR Special Drawing Rights SPR Slide Positivity Rate WHO World Health Organization Vice President Mieko Nishimizu Country Director Robert S. Drysdale Division Chief Richard Skolnik Task Manager Prabhat Jha  INDIA MALARIA CONTROL PROJECT Contents Page No. BLOCK 1: PROJECT DESCRIPTION ................................................ 2 1. Project development objectives ................................................ 2 2. Project components ................................................ 3 3. Benefits and target population ................................................ 4 4. Institutional and implementation arrangements ................................................ 5 BLOCK 2: PROJECT RATIONALE ................................................ 6 5. CAS objectives supported by the project ............................... ................. 6 6. Main sector issues and Government strategy ................................................ 6 7. Sector issues to be addressed by the project and strategic choices ...........................7 8. Project alternatives considered and reasons for rejection ...................................... 8 9. Major related projects financed by the Bank, lessons learned and reflected in the project design ...................................... 10 10. Indications of borrower commitment and ownership ...................................... 11 11. Value added of Bank support ...................................... 11 BLOCK 3: SUMMARY PROJECT ASSESSMENT ...................................... 12 12. Economic Assessment ...................................... 12 13. Financial Assessment ...................................... 13 14. Technical Assessment ...................................... 14 15. Institutional Assessment ...................................... 15 16. Social Assessment ...................................... 17 17. Environmental Assessment ...................................... 17 18. Participatory Approach ...................................... 19 19. Sustainability ...................................... 20 20. Critical Risks ...................................... 20 21. Possible Controversial Aspects ...................................... 21 BLOCK 4: MAIN CREDIT CONDITIONS ...................................... 21 22 Effectiveness Conditions ...................................... 21 23. Other ...................................... 21 BLOCK 5: COMPLIANCE WITH BANK POLICIES .................. .................... 24  Page No. TABLES 1 Estimates of costs by component ....................................................3 2 Demographic indicators in districts with severe malaria ....................................................4 3 Stakeholder analysis of the enhanced program ..................... .............................. 19 4 Level of participation in the enhanced program by various groups ......................... ............. 19 5 Summary of risks, ratings and minimization measures ................................................... 22 FIGURES 1 Possible scenarios for average annual costs of NMP activities ..............................................9 2 Annual expenditures by the NMP under the Eighth five year plan ................................................... 13 3 Epidemiological profile of malaria in India, 1961-1994 ................................................... 16 ANNEXES i IDA Credit Design Summary 2A Detailed Project Description 2B National Policy Letter and Revised Insecticide Guidelines 3 Estimated Project Costs 4 Economic Assessment 5 Financial Summary 6 Procurement Arrangements 7 Project Processing Budget and Schedule 8 Documents in the Project File 9 Statement of Loans and Credits 10 India at a Glance  INTERNATIONAL DEVELOPMENT ASSOCIATION Country Department II South Asia Region Project Appraisal Document India Malaria Control Project Date: May 15, 1997 a Draft s Final Task Manager: Prabhat Jha Country Manager: Robert S. Drysdale ProjectiD: IN-PA-10511 Sector: Health Lending Instrument: Credit PTI: 0 Yes Q No Project Financing Data O Loan 0 Credit Q Guarantee O Other [Specifyl For Loans/Credits/Others: Amount (US$M): 164.8 Proposed Terms: C To be defined Q Single currency Grace period (years): 10 ED Standard Variable a Fixed C] LIBOR-based Years to maturity: 35 Commitment fee: 0.50% Service charge: 0.75% ................~~~............................................................................................................................................................................................................ Financing plan (US$m): Source Local Foreign Taxes Total GOI 28.7 0 10.3 39.0 IDA 114.6 50.2 0.0 164.8 Boffower: India, acting by its President Guarantor: N/A Responsible agencies: MOHFW and NMP Estimated disbursements (Bank 1998 1999 2000 2001 2002 2003 FY/US$M): Annual 12.6 28.1 41.9 38.7 31.3 12.2 Cumulative 12.6 40.7 82.6 121.3 152.6 164.8 For Guarantees: z Partial Credit z Partial risk Proposed coverage: Project sponsor: Nature of underlying financing: .................... ............................................................................................................................_ Terms of financing: Principal amount (US$) Final maturity Amortization profile ....................................................................................... _.................................................................................................................I......... Financing available without guarantee?: C Yes Q No If yes, estimated cost or maturity: Estimated financing cost or maturity with guarantee: Expected effectiveness date: September 30, 1997 Closing date: September 30, 2002   Project Appraisal Document Page 2 Country: India Project Title: Malaria Control BLOCK 1: PROJECT DESCRIPTION 1. Project development goals and objectives (see Annex I for key performance indicators): Malaria, a parasitic disease transmitted by certain mosquitoes, causes substantial death, morbidity and social and economic losses in India, especially among the rural poor. The Directorate of the National Malaria Eradication Program (NMP) estimates that there were nearly three million reported cases of malaria and more than one thousand related deaths in 1995. These estimates are likely to understate actual figures.' Malaria is mobile and localized: it varies with temperature and precipitation, the level of immunity in the human population, the degree of in-migration from other communities, vector density, and social, economic and cultural factors. Malaria is a disease most common to the rural poor, especially tribal and indigenous peoples. The medium-term objective of the International Development Association (IDA) credit is to help India create an enhanced and more effective malaria control program (hereafter "enhanced program") that uses a better mix of effective malaria control interventions responsive to local needs; and strengthens NMP and modifies its orientation. The long-term objective is to reduce death, morbidity and social and economic losses from malaria. First, the enhanced program would represent a better mix of effective malaria control interventions by: (a) adopting a malaria control strategy currently recognized as optimal2; (b) shifting the focus from vector control of the mosquito to prevention and treatment of human cases; (c) reducing reliance on indoor residual spraying, the success of which has diminished recently; and (d) using multiple interventions at local levels. Key benchmarks would be total spending on the mix of interventions, coverage with infonnation, education and communication (IEC) messages, and degree of adherence to up-front policy commitments from Government of India (GOI) to IDA (the National Policy Letter and the Revised Insecticide Guidelines; attached in Annex 2B). Second, the NMP will be strengthened and its orientation modified at all levels. Nationally, technical leadership, supervision, evaluation and financing of malaria control will be strengthened. Districts will assume more responsibility for local malaria control by using newly developed guidelines for district implementation plans. States will strengthen supervision and training functions. In the past, NMP used military-command approaches to eradicate mosquitoes and dealt only minimally with the human environment of malaria. The enhanced program will emphasize community involvement and ownership of malaria control. The key benchmark will be the success of the district implementation plans. Third, the enhanced program should help to reduce death, morbidity and social and economic losses from malaria in the long term. Key benchmarks will be the reduction in malaria cases and the stabilization of fatal malaria. To enable a flexible enhanced program that can deliver effective malaria control, the IDA Credit relies on: (a) the up-front policy commitments; (b) a detailed project implementation plan (PIP); and (c) a focus on structured and regular evaluation (the annual program development reviews). IThe Global Burden of Disease estimates for India (Murray and Lopez, 1996) report about 26,000 deaths in 1990 from malaria (i.e., 0.3% of all deaths and 1.0% of deaths due to infectious and parasitic diseases). Malaria was responsible for the loss of about 1.2 million disability adjusted life years (DALYs) in 1990 (i.e., 0.4% of all DALYs lost and 1.4 % of DALYs lost due to infectious and parasitic diseases). These estimates are indirect, and may under- or over-estimate the true burden. The World Declaration on the Control of Malaria (1992); Indian Prime Minister's Expert Committee on Malaria (1995); and WHO Revised Malaria Control Strategy (1995).  Project Appraisal Document Page 3 Country: India Project Title: Malaria Control 2. Project components (see Annex 2for a detailed description and Annex 3for a detailed cost breakdown): IDA will finance eighty-five percent, net of taxes, of the incremental requirement of the enhanced program of the NMP over five years. The NMP will oversee investments throughout the country, based upon local needs and the guidelines for district implementation plans, starting in certain rural districts with high malaria burdens. The project will include five components (Table 1): Table 1. Estimates of costs by component Component Cost including Percent of total contingencies (USSA':) Integrated Early Detection and Prompt Treatment 44.7 22 Selective Vector Control 81.2 40 Medicated Mosquito Net Program 23.4 11 Epidemic Response and Intersectoral Collaboration 19.5 1 0 Institutional Strengthening 35.1 17 TOTAL 203.9 100 (a) The integrated early detection and prompt treatment of clinical cases component will improve the quality and accessibility of malaria treatment at primary health units, and in the private sector improve the speed and accuracy of diagnosis of malaria cases, and the treatment of severe malaria. IDA will finance drugs, laboratory supplies and equipment, training and incremental salaries. (b) The selective vector control component will replace widespread indoor residual spraying with more targeted spraying of insecticides determined by epidemiological stratification by village, increase the use of non-insecticide vector control methods, such as larvivorous fish and biolarvicides, and shift the selection of insecticides towards more environmentally neutral options. IDA will finance selected insecticides, vehicles, equipment, training, consultant services, and operational research. (c) The medicated mosquito net program component will carefully increase the use of medicated mosquito nets through grassroots organizations, social marketing groups, and public distribution, including local production and distribution. IDA will finance medicated mosquito nets, insecticides, Non- Governmental Organization (NGO) services, and operational research. (d) The epidemic response and intersectoral collaboration component will strengthen regional offices to identify and control outbreaks and epidemics, monitor resistance, build intersectoral collaboration among national ministries, identify malaria sources from industrial construction or projects, conduct health assessment studies and provide training and malaria control guidelines to industries. IDA will finance insecticides, vehicles, equipment, surveillance, research, and training. (e) The institutional strengthening component will improve management and planning skills of state and district level staff, provide training in new skills such as social assessment, create and disseminate an information, education and communication (IEC) program, support high-quality operational research, prepare future project components and improve management and information systems. IDA will finance civil works, vehicles, a management information system (MIS), and a geographic information system, IEC, training, research studies, and incremental salaries.  Project Appraisal Document Page 4 Country: India Project Title: Malaria Control 3. Benefits and target population. The direct target population is the more than two-hundred million people living in areas endemic for malaria, especially sixty-two million people living in rural areas with severe malaria. The enhanced program will directly benefit tribal and indigenous peoples. However, the human, economic, environmental and institutional benefits will accrue to India's entire population of nine-hundred and thirty million.3 Specific benefits include the following: First, in the long term, the enhanced program will reduce deaths and morbidity caused by malaria. Early in the enhanced program better surveillance and increased public attention may lead to a rise in reported malaria cases, but death and morbidity rates and the percentage of severe cases of malaria should decline by the fifth year. Because malaria is expected to remain a major burden, and the success of the enhanced program depends on many variables, the enhanced program does not set specific targets. In India and elsewhere, eradication of malaria is no longer technically possible; emphasis has thus shifted to control. In recognition of this, the NMP will remove eradication from its directorate name. Second, the enhanced program will increase equity, especially for the rural poor. Malaria is most prevalent in rural areas where most tribal peoples reside, and occurs during seasons in which demand for agricultural work is at its peak. Malaria imposes an especially heavy burden on women who provide most of the household care and also contribute to agricultural work. Pregnant and lactating women are especially susceptible to malaria due to lower immunity.4 Districts with the severe form of malaria are more likely to be rural, have lower literacy rates, and a higher proportion of scheduled tribe populations and women (Table 2). The enhanced program should lead to higher absolute benefits for the rural poor, even if relative benefits are equal for poor and non-poor populations. Table 2. Demographic indicators (in percent) in districts with severe malaria5 and other districts Districts with severe Other districts Significance test malaria Scheduled tribe 25 4 <0.001 Rural 77 74 <0.001 Female 49 48 <0.001 Literate 39 44 <0.05 Third, the enhanced program will save money for households, especially poor households. Out-of- pocket spending on malaria treatment is common in India and imposes a heavier burden on the poor than the rich: a recent survey comparing the proportion of household income spent on each episode of communicable disease, including malaria, by poor (annual household income below $500) and rich (annual household income above $1500) households found that poor households spent twice as much as rich households. Fourth, the enhanced program will provide some opportunities for grassroots enterprises by supporting women's cooperatives and NGOs that engage in the production, sale, and distribution of medicated mosquito nets. Local production and distribution will increase awareness and use of these 3There are two major types of malaria in India, P. falciparum which may cause severe cerebral malaria and death and is more prevalent in rural areas, and P. Vivax, which causes uncomplicated malaria. In endemic districts in Orissa, six percent of pregnant women and eight percent of pre-school children suffer from malaria at any one point in time. 5Based upon the 1991 census data. Although the enhanced program has identified 97 districts dominated by severe P. falciparum, the above table refers to only 72 districts. The remainder have other names in the census, but similar malaria patterns. The statistical significance test is based upon a t-test comparison.  Project Appraisal Document Page 5 Country: India Project Title: Malaria Control nets, and provide economic opportunity for the poor. Mass use of medicated mosquito nets is new to India, and the NMP will carefully monitor their use, acceptability, and success during implementation, and ensure cost recovery from those able to pay. Fifth, the enhanced program will reduce unnecessary environmental contamination by reducing indoor residual spraying and shifting to more environmentally neutral insecticides. Although insecticide use for malaria control constitutes only about nine percent of insecticides used in agriculture, the enhanced program will help to eliminate some harmful insecticides and increase the export potential of agricultural goods (see Environmental and Economic Assessments). The enhanced program will also improve satisfaction of households, that are increasingly averse to indoor residual spraying. Sixth, the enhanced program will prepare the NMP for the future. A stronger NMP, a better mix of effective malaria control interventions, and better information systems will allow GOI to respond more effectively to malaria both now and in the future. Better insecticide and drug policies and monitoring of resistance should help avoid the widespread transition to the severe resistant form of malaria common in Southeast Asia. If the resistant form of malaria does develop, however, a stronger NMP will be in place to respond. A strengthened NMP will more effectively deliver promising interventions, such as new malaria control drugs and vaccines currently in development. 4. Institutional and implementation arrangements: The IDA Credit builds on the existing institutional arrangements of the NMP, which has substantial experience in malaria control, but has less experience with use of multiple interventions and community- based approaches. The implementation period for the project will be from 1997 to 2002. The NMP will be the key executing agency and will: (a) provide several inputs, such as insecticides, vehicles, and drugs to all levels engaged in malaria control; (b) strengthen state-level functions in training and monitoring; (c) modify the NMP's regional offices into epidemic response units which will provide additional monitoring; and (d) work directly with districts in creating district implementation plans. The NMP will provide revolving funds to districts with completed district implementation plans and satisfactory accounting, financial, and audit arrangements. The NMP and the Ministry of Health and Family Welfare (MOHFW) will be responsible for project coordination. The management of the enhanced program will be integrated into the overall management structure at the NMP, and will provide IDA with technical, financial and performance data needed for review. Project oversight will by done by NMP and MOHFW and the annual program development review, described below. Accounting, financial reporting and auditing arrangements: The GOI and NMP will follow IDA guidelines on financial control and reporting. The NMP will ensure that all accounts, financial statements, and audits meet IDA guidelines, and will provide IDA with these documents every six months. The NMP will also ensure that each state or district that receives funds from the IDA Credit has accounting and audit arrangements satisfactory to IDA. Monitoring and evaluation arrangements and annual program development review: The NMP and IDA have agreed on a set of key performance and monitoring indicators (Annex 1): (a) Routine data will be collected by the NMP from all districts every month. (b) State malaria control officers will submit every quarter key monitoring and performance indicators in their regions to NMP, and one staff at NMP will be assigned responsibility for each of the agreed set of key indicators.  Project Appraisal Document Page 6 Country: India Project Title: Malaria Control (c) An independent external agency will review NMP management administrative functions in the second or third year of implementation. (d) The NMP will also receive qualitative feedback from local malaria societies and from informal consultations with Panchayat Raj Institutions (or village councils). The annual program development review permits regular, partial, third-party expert review of the enhanced program; Annex I provides its detailed terms of reference. The committee will comprise six members plus a chairperson. Members will include two experts from outside India, one member drawn from the community, and three members will represent the Malaria Research Center (MRC), the National Institute for Communicable Diseases and NMP. All members will be experts in malaria control and community-based disease control. The annual program development review will evaluate the overall performance of the enhanced program and advise on performance and monitoring goals. The annual program development review will issue a report that will be available to the public, but the recommendations of the report will not be binding on the GOI or IDA. IDA will also monitor the enhanced program by conducting: (a) a separate review of adherence to the National Policy Letter and Revised Insecticide Guidelines; (b) an evaluation of the revised operational guidelines that will be published in the second year of the Credit; the revised operational procedures drawn upon the PIP, guidelines for district implementation plans, and key inputs, such as social and environmental assessments; (c) a desk review of the status of malaria control activities in two to five percent of all districts; and (d) spot visits to certain districts implementing the enhanced program. BLOCK 2: PROJECT RATIONALE 5. CAS objective (s) supported by the project: The World Bank Group's Country Assistance Strategy (CAS) for India (August 15, 1995 update Report No. R96-154/1) seeks to support the efforts of the Government of India in promoting economic growth through strong private sector involvement and the development of human capital resources. The progress report on the CAS (discussed by the Board on September 5, 1996) reaffirms this approach and puts special emphasis on improving the cost-effectiveness of social programs. The Bank's assistance strategy for the health sector in India is consistent with the CAS and is being implemented through a two-pronged approach that aims to: (a) reduce the burden of disease of major diseases by supporting cost-effective priority programs; and (b) strengthen state health systems and promote state health sector reform to provide more efficient and effective health care, particularly for the poor. The proposed project is an integral part of the CAS and IDA's health strategy for India. 6. Main sector issues and Government strategy; Substantive, institutional and financial issues for the health sector and the GOI strategy are several.6 Substantive issues include the fact that human development indicators in India are low, a large percentage of the rural poor are affected by communicable and maternal diseases, and access to quality health services and primary education is poor. Despite being less than one fifth of the global population, 6 This section draws upon: (1) India: New Directions in Health Sector Development at the State Level: An Operational Perspective Report 15753-IN, 1996; (2) India: Policy and Finance Strategies for Strengthening Primary Health Care Services; Report No 13042-IN; (3) Operational Issues in Malaria Control: Report of a Working Meeting of the WHO and World Bank, 1995; (4) World Development Report 1993: Investing in Health; (5) VP Sharma. Community Participation in Malaria Control, MRC, 1991; (6) RS Sharma et al, Epidemiology and Control of Malaria in India, 1996; (7) Institute of Medicine, Malaria: Obstacles and Opportunities, National Academy Press, Washington, DC 1991  Project Appraisal Document Page 7 Country: India Project Title: Malaria Control India accounts for twenty-one percent of global DALYs, a quarter of global maternal deaths, and a quarter of global deaths in children under age five. The under-five mortality rate in India is twenty-one percent, and the probability of death between age fifteen and sixty is thirty-one percent. In contrast, the under-five mortality rate is four percent in Sri Lanka and the probability of death between age fifteen and sixty is eighteen percent. The GOI's substantive strategy involves continuing to focus on key endemic diseases, especially those strongly associated with poverty. The GOI has modernized paradigms for several disease control programs, such as adopting directly observed therapy for tuberculosis and dropping fertility targets. Much more technical and managerial improvement of programs is required, however. Institutional issues include inefficient public sector delivery of social services; India has complex organizational structures that impede reform, and public facilities often lack adequate management and trained staff. The GOI's institutional strategy largely involves strengthening specific centrally sponsored programs and upgrading primary health centers facilities (PHCF) and first-referral hospitals at the state level. The GOI is experimenting with devolution of financial and administrative powers to local village councils as a means of increasing local ownership. Financial issues include low levels of spending on public health, especially preventive care. India spends six percent of its gross domestic product (GDP) on health care (equal to thirteen dollars per capita in 1990) more than that of Nepal, Bangladesh, China and Sri Lanka. The percentage of public health spending on primary care (0.6 percent of GDP or approximately one dollar per capita) is lower than in any of these countries, however. States spend nearly three-quarters of all public funds, but spending in poor states is low in absolute amounts. Eighty percent of all health spending is done by the private sector mainly as regressive and often cost-ineffective, out-of-pocket spending on curative services. The GOI's financial strategy involves prioritizing public spending toward primary health care that benefits households by gradually decreasing spending on tertiary care services and increasing spending on cost-effective priority programs. The GOI has begun limited work with the private sector by contracting out certain hospital services and engaging private groups and NGOs in IEC and mass marketing campaigns (as in IDA-financed Cataract Blindness Control and Tuberculosis Control Projects). 7. Sector issues to be addressed by the project and strategic choices: The enhanced program for malaria control addresses these sector issues in several ways. On a substantive level, the enhanced program provides a cost-effective set of interventions to control malaria with the greatest benefit accruing to the rural poor. These interventions include preventive activities such as IEC about household environmental management and reduction of water sources, vector control to reduce malaria sources, and treatment with simple medications. On an institutional level, the enhanced program improves malaria control at all levels by strengthening the NMP's technical leadership, policy direction, supervision, and evaluation functions. The enhanced program will encourage local ownership of some of the activities through village councils and by increased involvement of NGOs. A strengthened NMP will supplement other central programs supported by IDA financing, such as the National AIDS Control Organization, the Leprosy Elimination Program, the Tuberculosis Control Program, and the Family Welfare Program.  Project Appraisal Document Page 8 Country: India Project Title: Malaria Control On a financial level the GOI has recently increased budgets to the NMP, but spending remains lower than in other countries. The enhanced program will increase total spending on malaria from about eleven cents per capita in 1994 to fifteen cents per capita in 1998. Per capita public spending would remain lower than in other countries with comparable malaria risks, such as Sri Lanka (forty cents), Thailand (thirty-eight cents), Venezuela (twenty-five cents), and Cambodia (twenty cents). Although private provision of malaria services is limited by the large public goods nature of the service and by low individual willingness to pay, the enhanced program will involve private practitioners, engage NGOs and grassroots organizations in small-scale local social marketing efforts, and inform private industries, especially large infrastructure projects, about source reduction and adequate treatment. 8. Project alternatives considered and reasons for rejection: The major alternatives to the enhanced program are to: (a) retain the current program; (b) expand the current program; (b) provide no incremental resources but shift spending toward the mix of interventions proposed under the enhanced program; (d) confine the IDA Credit to areas in which malaria is most endemic; or (e) decentralize malaria control using 'horizontal' primary health care approaches. The first alternative, retaining the current program, was rejected because program effectiveness will continue to worsen in the absence of changes. Despite increased spending on malaria control, the number of malaria cases and malaria-related deaths reported to NMP has risen over the last decade (see Figures 1 to 3). At present, the NMP focuses largely on indoor residual spraying and case detection and treatment. The declining effectiveness of these two approaches is a result of vector resistance, poor operational coverage and beneficiary compliance with indoor residual spraying, delays in laboratory diagnosis of malaria cases, resistance to drug treatment, lack of an organized system for treatment of severe or complicated cases, and ineffective distribution of malaria control drugs. Further declines in program effectiveness can be expected unless changes in spending patterns are made. A diversified approach makes sense because of diminishing returns from any one intervention. The cost of vector control activities, for example, will rise with expansion as a result of decreasing population and vector densities. The costs of active case detection and treatment will also rise as the frequency of cases falls. The second alternative, expanding the current program, was rejected because it would lead to an ineffective and unsustainable program. Intensification of current activities, which are dominated by indoor residual spraying, is an undesirable alternative because of the rising cost and declining effectiveness of insecticides, the limited sustainability of such an approach, and the detrimental environmental consequences. The NMP cites three factors limiting the effectiveness of indoor residual spraying: (a) poor operational coverage; (b) inability of states to increase the wages of spraying staff (resulting in reduced provider compliance and poor coverage); and (c) development of vector resistance. Effective insecticides are expensive and the operational costs of spraying are high. An intensification of indoor residual spraying under IDA financing would thus be difficult for GOI to sustain beyond the period of financing. Even if the NMP shifted towards newer, more environmentally neutral insecticides, widespread use would be costly. Moreover, widespread use could induce mass resistance to which there would be no adequate remedy. Finally, all insecticides affect non-target organisms to some extent, disturbing the ecosystem. It is thus desirable to use insecticides judiciously for vector control, and to limit unnecessary release into the environment.  Project Appraisal Document Page 9 Country: India Project Title: Malaria Control Figure 1. Average annual costs of NMP activities at present under the enhanced program if more of the same activities were carried out, and if current spending were restructured as envisioned under the enhanced program. 3,000 2% 5% 2% 2,500 6% 40/o 22% 2,0004-% 22% l Epidemic Response & X Intersectoral Collaboration 1,500 l- 4% l Medicated Mosquito Nets 2% 5% 2% 6 4% [QIEC |22% |7;0/o E 1,000 l5% | Institutional Strengthening 69% ~~~~220% % ;;4% E Integrated Early Detection & Treatment 500 i Larvicidal Activities I * Indoor Residual Spraying At Present Enhanced More of Restucture Program Same Current Spending Cost (millions of 1996 Rs.) The third alternative, maintaining the current level of spending, but shifting spending toward the mix of interventions proposed under the enhanced program, was rejected because political concerns and institutional inertia prevent significant restructuring of current spending. A gradual shift of current NMP spending toward a better mix of cost-effective interventions would help improve malaria control in India. However, political concerns and institutional inertia tend to prevent diversification from indoor residual spraying. Although decreasingly effective, indoor residual spraying is a highly visible GOI activity demanded by many politicians at all levels. In addition, many malaria officers were trained during the eradication era and believe that malaria control demands more insecticide and drug use. Despite growing dissatisfaction with household spraying, many Indians equate malaria control with annual visits from spray teams. Finally, concern over loss of jobs at Hindustan Insecticides, a GOI-owned enterprise and the sole domestic producer of DDT, contributes to GOI's  Project Appraisal Document Page 10 Country: India Project Title: Malaria Control 7 reluctance to decrease insecticide use. In the absence of the IDA Credit, it is unlikely that current spending would be restructured. The fourth alternative, confining the IDA Credit to geographic areas in which malaria is most endemic, was rejected because malaria is mobile. The enhanced set of interventions could be piloted in certain geographic regions and then expanded to the rest of the country. Although malaria is more endemic in certain geographic zones, outbreaks can occur in even the unlikeliest of areas. The incidence and location of malaria cases depends on many dynamic factors, and problem areas can vary from one malaria season to the next. The fifth alternative, decentralizing "horizontal" primary health care, was rejected because malaria requires a categorical program with functions and capacities at the national level. As an alternative to the enhanced program, the IDA Credit could be used to decentralize the management and delivery of malaria control, putting responsibility in the hands of primary health care staff. Experience from other countries warrants caution in decentralization, however. "Through decentralization, strong malaria control programs have, in many countries, lost their key distinguishing features: their unity of purpose, dedicated staff, commitment to getting results in the field, and ability to adapt to changing epidemiological conditions on the ground. The key is not to decentralize everything, as some national- level functions and capacities are essential. These functions include (but are not limited to) such important aspects as: (a) providing strategic direction; (b) policy-making and resource allocation at the national level; (c) providing oversight over decentralized and devolved functions; (d) setting standards, norms and indicators for monitoring operational activities; (e) providing technical back-stopping of operational levels; and (f) evaluating and validating program activities including operational research undertaken at or by the operational levels."g 9. Major related projects financed by the Bank, lessons learned and reflected in the project design: Global eradication of malaria will not be possible in the next few decades, but control through a better mix of effective malaria control interventions is possible. The World Bank has financed and completed two malaria control projects in Brazil and a smaller project in Indonesia and is financing on-going projects and in Cambodia, Laos, Senegal, Sri Lanka, Venezuela and Vietnam. Other agencies have financed projects in El Salvador and Mexico (see Table 3 in Annex 4). The Bank's first project in Brazil failed to reduce malaria because of strict reliance on DDT spraying and drug distribution, and inadequate planning for the large number of migrants into the project area. In contrast, the Bank's second project in Brazil reduced deaths from malaria by fifty percent and saved nearly nine million DALYs between 1988 and 1996. Conditions in Brazil before the second project began closely resemble conditions in India today. Projects in Indonesia and El Salvador reduced malaria burdens significantly. The enhanced program incorporates several key elements from these projects including: (a) the use of information-based planning of malaria control; (b) flexibility to respond to local conditions; (c) the use of complementary interventions, such as vector control, better treatment and medicated mosquito nets to minimize the risk of failure and diminishing returns associated with a single intervention; and (d) strengthening capacities of staff in planning and management, including administrative continuity. Lessons from other World Bank projects in India: The IDA Credit will make use of two lessons from the Bank's experience in the social sectors in India by: (a) building efforts for high borrower 7Hindustan Insecticides created in response to the NMP's demand for insecticides, employs more than 2,500 people. In 1992/93 the company earned Rs. 4 million; in 1993/94 profits were Rs. 20 million. 8 Operational Issues in Malaria Control: Report of a Working Meeting of the WHO and World Bank (1995).  Project Appraisal Document Page 11 Country: India Project Title: Malaria Control commitment and ownership of projects; and (b) using IDA financing to accelerate a shift of paradigms away from strict public sector-based activities and inefficient approaches. The Leprosy Elimination Project, for example, shifted control toward multiple-therapies and better access to care resulting in leprosy cases declining by two-thirds in four years. Indicators of readiness to implement the IDA Credit: The NMP shows evidence of technical and managerial readiness to implement the IDA Credit. Indicators of technical readiness include the fact that NMP has already: (a) created expert committees to revise insecticide guidelines, examine the implementation of medicated mosquito nets, and advise on new information systems; (b) created guidelines for district implementation plans; (c) held detailed planning workshops in four districts in four states; (d) registered several district malaria societies; (e) spent funds on medicated mosquito nets in several states; (f) started diversifying methods of vector control; (g) created detailed plans for training and for IEC; and (h) joined a research project in Gujarat that evaluates various interventions and will train NMP staff in epidemiology and management. Indicators of managerial readiness include the fact that NMP has already: (a) created tender documents for major first year purchases; (b) created detailed procurement plans, including requests for services of competent procurement specialists; (c) installed a management, budgeting and accounting system; and (d) identified staff for project management for the first two years of the enhanced program. In addition, the NMP's PIP outlines implementation barriers and uses realistic procurement schedules. 10. Indications of borrower commitment and ownership: Although political commitment to malaria control is high, political ownership of the enhanced program is weak. Major malaria outbreaks in Rajasthan and in some urban settings have created much concern in Parliament and in the MOHFW. Parliamentary committees have called on several MOHFW and NMP officials to appear before them, and both NGOs and the media have criticized GOI's malaria control efforts.9 Politicians' appeals for more indoor residual spraying have increased spending on the NMP (Figure 2), but the rising cost of insecticides has consumed most of this increase. In contrast to the low level of political support, the level of commitment to and ownership by the NMP is high, as shown by its technical and managerial readiness, and revised policies including phasing out of BHC. 11. Value added of Bank support: IDA investment in the enhanced program is justified on following grounds: (a) the enhanced program supports IDA's objectives of improving access of the poor to essential health services; (b) the IDA Credit will help convert the high level of political concern about malaria into support for an enhanced, cost- effective, and sustainable control program; (c) IDA financing would help shift the balance of interventions away from insecticide spraying; (d) IDA brings experiences from other countries, such as Brazil, to assist India in modernizing technical paradigms for malaria control; (e) IDA has provided substantial input to improve the community focus of the enhanced program, including sponsoring social participation workshops in pilot districts; and (e) no other donor has the capacity to assist in these areas on the scale needed to control malaria in India. Partially as a result of GOI-Bank dialogue, a harmful insecticide (BHC) was banned from use or production on April 1, 1997. On-going GOI-Bank dialogue should help reduce further spraying of most other insecticides. 9Makodi, K. "Political and Economic Roots of Disease: Malaria in Rajasthan." Economic and Political Weekly, pp. 42-47, January 27, 1995; Kaul, S. "New Malaria Action Plan: Panic Response", Economic and Political Weekly, pp. 2172-2173, September 2, 1995.  Project Appraisal Document Page 12 Country: India Project Title: Malaria Control BLOCK 3: SUMMARY PROJECT ASSESSMENTS (Detailed assessments are in the project file. See Annex 8) 12. Economic Assessment (see Annex 4). A projected rate of return for this project was not calculated, due both to a paucity of India specific cost- consequence data and to the fact that the cost per unit output of malaria interventions varies tremendously with time and location (even within a country), making it difficult to quantify the impact of control activities. The major economic gains from malaria control are likely to be substantial, however. Economic gains include the following: (a) Reductions in death and morbidity, which constitute the major cost of malaria. Most cases of malaria occur during the productive middle ages: over ninety percent of DALYs lost are among people aged forty-four years or less. (b) Increases in production and household earnings by reducing the incidence of malaria, particularly during peak agricultural seasons and among poor agricultural workers. Estimates suggest that the average episode of malaria causes seven days of lost work, and that families with malaria clear sixty percent less land than families without malaria. (c) Reductions in household and community expenditures on malaria drugs and treatment, especially among the poor. As noted in Section 3, out-of-pocket expenditures on malaria treatment represent a higher percentage of annual household income among poorer households. (d) Reduction in environmental pollution from spraying and improvement in India's ability to export agricultural goods, which are banned in some countries because traces of DDT have been reported in vegetables, fruits, and other agricultural products. Public sector involvement in malaria control is justified because: (a' -iblicly financed investment in the health of the poor can reduce poverty or alleviate its consequences; and (b) malaria control promotes many public goods and has broad positive externalities, implying that private markets would not produce them at all or would produce very little. The economic justification for the whole program and for particular interventions is based mostly on their cost-effectiveness. Partly due to great variability with focal conditions, cost-consequence data on malaria are limited. The IDA Credit is likely to be cost-effective, given that a similar Bank-financed malaria control project in Brazil cost about $250 per DALY saved, and the fact that India and Brazil are comparable in epidemiological and program features. Moreover, through diversification, the enhanced program avoids the diminishing cost-effectiveness of any one intervention, a trait of current NMP activities. The individual interventions in the enhanced program are highly cost-effective and would be included in any essential package of publicly financed preventive and curative services. Each component in the enhanced program provides potential economic gains. The early detection and prompt treatment component reduces death and morbidity. The selective vector control component reduces environmental pollution and the risk of resistance that would be expensive to control. The medicated mosquito nets should also decrease malaria cases and deaths. By preventing epidemics from spreading, the epidemic response and intersectoral collaboration component lowers the costs of malaria control and reduces losses to industry from ill construction workers. The institutional strengthening component provides indirect economic gains by supporting other components.  Project Appraisal Document Page 13 Country: India Project Title: Malaria Control 13. Financial Assessment (see Annex 5): Because it is largely a public good, malaria control will continue to require significant financial commitment by the GOI. Moreover, malaria control requirements will grow in the future because of population growth and likely increases in conditions that promote malaria, such as migration, climactic changes, and development projects. The NMP, which controls the bulk of spending on malaria control in India, is sponsored and led centrally, yet receives fifty percent financial contribution from the states. State contributions cover salaries of staff often assigned to tasks other than malaria control. Currently, the NMP procures almost all insecticides and drugs used nationally, while states provide the operational wages of staff and district-level seasonal spray workers. In wealthier states, such as Maharashtra, this system works well. In poorer states, such as Bihar, effective malaria control often relies upon cash transfers from NMP, usually to hire seasonal spray workers. States, however, do contribute more in times of epidemics. The NMP program is already large, but without the enhanced program its effectiveness is likely to decline. Under the GOI's Eighth Five Year Plan (1992 to 1997), about Rs. 5 billion (approximately eleven percent of all outlays by MOHFW) went to malaria control. Over this five-year period, inflation- adjusted annual expenditures by NMP increased from Rs. 1. I billion in 1996 prices to Rs. 1.4 billion (Figure 2). The planned expenditures in FY1996/97 represent eleven percent of MOHFW outlays. Figure 2. Annual Expenditures by the NMP Under the Eighth Five Year Plan -' 1,500 ~-1,000- 500j 92-93 93-94 94-95 95-96 96-97 Fiscal Year The increase in budget by the NMP under the enhanced program is comparable to increases in other Bank-assisted projects, such as Leprosy Elimination and Cataract Blindness Control. IDA will help finance the incremental salaries of malaria link functions and seasonal spray workers in areas in which malaria is endemic. The malaria link functions are not permanent posts, implying that local districts will be permitted to hire anyone, including existing workers to execute these core functions. States, village councils or community sources of financing will be required at the end of the project to sustain local malaria control efforts. The flow of funds will be as follows: (a) NMP will procure all major goods and equipment nationally and distribute them as resources in kind to districts, states and regional offices. (b) In most states, districts will establish a revolving fund, administered by a society or an empowered committee, to procure small purchases, pay for malaria link functions, and meet operational  Project Appraisal Document Page 14 Country: India Project Title: Malaria Control costs. The NMP will fund these and review their technical, managerial and financial performance. Districts will contract an accountant to monitor spending, and state coordinators will be responsible for timely collection of financial information. (c) Parts of certain components, such as IEC activities, medicated mosquito net distribution, and social marketing, will be contracted to NGOs or private groups on a competitive basis. Disbursement on the basis of statements of expenditure will include: (a) incremental operating costs; (b) consultants' services under contracts not exceeding $200,000 equivalent in the case of firms and $50,000 equivalent in the case of individuals; (c) contracts for goods and works not exceeding $300,000 equivalent each; (d) contracts for medicated mosquito nets not exceeding $300,000 equivalent each; and (e) contracts for vehicles and insecticides not exceeding $100,000 equivalent each. Given the large size of the Credit and the disbursement period (66 months), a special account of US$8 million equivalent will be used. Retroactive financing: In order to facilitate a timely project start and to meet several costs associated with adoption of the enhanced program, retroactive financing up to US$5 million equivalent (or three percent of the credit) would be provided to cover eligible expenditures incurred after September 30, 1996. Expenditures would be for eligible insecticides, mosquito net program, malaria link functions, publicity, consultant services, training and workshops, and incremental operating costs. Financial sustainability: The project is likely to be sustainable for several reasons: (a) There is tremendous political support for controlling malaria, given much publicized outbreaks and the fact that malaria occurs nearly everywhere in India. (b) Even in the worst case scenario, the recurrent cost liability at the national level would be about $20 million per year, or about five percent of all MOHFW expenditures, or about 0.03 percent of total GOI expenditures; at the state level the recurrent cost liability would total about $6 million. A more favorable scenario is a recurrent cost liability at the national level of about $6.7 million in the final year of the IDA Credit, of which IDA will finance about a fifth. This liability represents about seventeen percent of the NMP's budget in 1996. However, future outlays to the NMP should increase. (c) Health expenditure by GOI is expected to be sustained. In the proposed Ninth Five-year Plan (1997 to 2002), health expenditure is expected to be slightly under three percent of GOI spending, comparable to the Eighth-Five year Plan. (d) The enhanced program will improve the efficiency of the NMP. Improved logistics and distribution will ensure that drugs and insecticides are not wasted, for example. Better information systems will help to reduce the use of insecticides. (e) The enhanced program favors interventions with lower recurrent costs: the ratio of recurrent costs to total costs is lower for early detection and prompt treatment, or medicated mosquito nets, than it is for indoor residual spraying (see Annex 4). Savings from the reduced insecticide purchases will be available for other interventions. 14. Technical Assessment: IDA made detailed technical assessments for each component and their potential economic gains (see project file). IDA shared these assessments with GOI who incorporated these into its National Policy Letter (Annex 2B). The enhanced program has already been recommended by the Expert Committee  Project Appraisal Document Page 15 Country: India Project Title: Malaria Control reporting to the Prime Minister (1995) and reflects the WHO Revised Malaria Control Strategy (1995). The WHO, the Malaria Consortium, and other agencies have reviewed the IDA Credit and agree that the enhanced program is well designed. Widespread malaria control in India, based largely on indoor residual spraying, began in the 1950s. The number of malaria cases fell dramatically from seventy-five million annually in the early 1950s to one hundred thousand in the mid-1960s, when a resurgence of the disease occurred. That resurgence, which peaked in 1976 with six and one-half million cases, was caused by multiple factors, including inadequate funding and management of the NMP, and insecticide and drug resistance. Since the early 1980s, continued reliance on indoor residual spraying, and inadequate use of other interventions have led to increasing cases, despite higher spending (Figure 3). India currently suffers from endemic malaria and occasional epidemics, especially of severe malaria. The percentage of severe cases of malaria has risen over time, partly reflecting resistance to DDT spraying and chloroquine drugs. Malaria shows great regional variation in India, with the ten states of Andhra Pradesh, Bihar, Gujarat, Madhya Pradesh, Maharashtra, Orissa, Rajasthan, Uttar Pradesh, Punjab and Assam accounting for eighty-five percent of malaria-related deaths and two-thirds of all malaria cases in India. Recognizing the local nature of malaria, the NMP in 1986 adopted an epidemiological risk stratification approach, which allows stratification of regional malaria burdens based on selected technical information. This stratification does not yet incorporate ecological and occupational factors or community-based factors. In the enhanced program, epidemiological stratification will be done at the village level. With further developments of information systems, including the geographic information system, more complex stratification may enable even more focal control activities. 15. Institutional Assessment: The enhanced program will build upon the strengths of NMP and address its weaknesses. The NMP strengths include: (a) more than forty years of malaria expertise in entomology, treatment, and monitoring; (b) strong leadership and a committed core staff of forty professionals with more than one thousand years of experience in malaria control; (c) considerable experience in two of the enhanced program's components, vector control and drug distribution; and (d) experience in procurement of insecticides, drugs, microscopes, and ether items. The enhanced program will build on NMP's strengths by: (a) using its existing administrative procedures to pay seasonal spray workers to distribute drugs; (b) enhancing its expertise in entomological and drug monitoring; (c) drawing upon procurement experience to purchase items such as insecticides, drugs and microscopes, using IDA guidelines; and (d) strengthening operational research links with the MRC and other groups. The NMP's weaknesses include: (a) the lack of appropriate skills mix among professional staff, most of whom are narrowly trained in entomology and few of whom have exposure to epidemiology, management, IEC, or social assessment; (b) limited experience working with community-based "ground- up" malaria control programs run by district societies, NGOs and village councils; (c) an inefficient information system, including heavy paperwork requirements for districts; and (d) limited financial skills among staff.  Project Appraisal Document Plage 16 Country: India Project Title: Malaria Control Figure 3. Epidemiological profile of malaria in India, 1961-1994 7 70 CASES 6 50 CD~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~l 3 ~~~~~~~~~~30~ (n w 1~~~~~~~~~~~~~1 61 6365 6769 71 737577 79 8183 8587 8991 94 Abbreviations: ABER = Annual blood exarnination rate per 100 population. Pt/o = The percentage of severe malaria (P. falciparum) to total malaria. SPR = slide positivity rate or number of positive slides per 100 examined. The enhanced program would systematically address these weaknesses in several ways: (a) NMP will add consultant staff in key areas such as epidemiology, financial management, IEC and social assessment. All staff working on the project will be integrated into NMP's overall management structure. Key skills will be institutionalized into NMP in the long term by creating a limited number of permanent positions. (b) NMP will encourage micro-planning by districts to build community-based malaria control by means of district implementation plans. Such efforts in four pilot districts during project preparation suggest that a better balance of malaria control interventions is achievable. In addition, during the early part of the enhanced program, the NMP will work carefully with the Cataract Blindness Program to learn lessons on effective and timely flow-of-funds to districts. (c) NMP will update and computerize its information system. NMP will continue to use a paper- based information system during the first year of implementation while it conducts a detailed evaluation of a computerized system. (d) National, state and district level staff will receive technical and management training. To ensure suitably qualified personnel are hired, NMP will use market rates for training allowances, and daily allowances and consultant services.  Project Appraisal Document Page 17 Country: India Project Title: Malaria Control 16. Social Assessment: The prevalence of malaria is affected by numerous social factors, including population shifts and changes in social conditions. Malaria disproportionately causes suffering and economic loss among the most vulnerable groups of society, namely, children, pregnant women, migrant laborers, and scheduled castes and tribes. An integral part of the enhanced program is inclusion of social factors in the planning of malaria control through institutionalizing social assessment, participatory workshops and stakeholder analysis (see section 18). Tribal strategy. The GOI conducted a beneficiary assessment (BA) to: (a) ensure that scheduled castes and tribal peoples benefit from the proposed project; (b) avoid or mitigate potential adverse effects on scheduled castes and tribal peoples; (c) identify their perceptions of the problem and of the proposed interventions; and (d) enhance beneficiary ownership of local malaria control. The BA found that knowledge of the cause and spread of malaria was low in tribal communities, even among health workers, and that past efforts by NMP to deliver early detection and prompt treatment had not been successful in the districts studied because of poor coverage, inadequate inputs, and a lack of community awareness and involvement. The BA supported the need to build capacity at the state and national levels to provide linkages between the community and NMP in order to improve the district implementation plans and their impact. The enhanced program will include appropriate measures to ensure that the social and economic benefits reaped by such groups are in harmony with their cultural practices. These measures are consistent with the World Bank's Operational Directive (OD) 4.20 on Indigenous Peoples and OD 4.30 on Involuntary Resettlement and include the following: (a) use of local IEC and mass awareness programs for malaria control at weekly markets and other venues in tribal areas and increased interaction between health workers and tribal populations; (b) provision of on-going training for front-line health staff in the diagnosis, treatment, and prevention of malaria; (c) selection of local NGOs and grassroots organizations in the production and distribution of medicated mosquito nets; and (d) establishment of early detection and prompt treatment facilities after appropriate measures are taken to involve the community in their selection. The location of the drug distribution centers and fever treatment depots will be publicized, and community leaders, traditional healers, teachers, village councils members, educated youth and forest guards will be trained to support these centers or depots. Building capacity for on-going social assessment. The enhanced program will build capacity for social and anthropological skills to incorporate social, occupational and anthropological factors into planning malaria control and to improve assessment of the needs of less advantaged groups. An anthropologist will be appointed to NMP to coordinate social assessment activities and to provide training to state and district level officers. Operational research that has a strong social assessment component will be conducted with the help of village-level and district-level health functionaries, grassroots NGOs and independent research organizations. Social assessment procedures will also be incorporated into the revised operational guidelines. 17. Environmental Assessment: IDA gave the proposed credit a "B" rating for environmental assessment because of its concern about the potentially high level of indoor residual spraying. Insecticide spraying is part of malaria control  Project Appraisal Document Page 18 Country: India Project Title: Malaria Control strategies worldwide and will continue to be part of the strategy in India and elsewhere. There is much precedent for the Bank financing insecticides as part of malaria control programs: insecticides constituted thirteen, six and three percent of spending in the Brazil, Sri Lanka, and Cambodia projects, respectively. These projects, like the enhanced project, follow WHO guidelines for insecticide use in public health programs. None of these previous projects conducted an environmental assessment. GOI contracted the National Environmental Engineering Research Institute to conduct a detailed environmental assessment, in consultation with NMP, the MRC, the Ministry of Environment and Forestry, and the WHO. Given the national scope of the credit, the environmental assessment adopted a "sectoral" approach that involves sector-wide environmental analysis and supports integration of environmental issues into long-term planning. The sectoral approach obviates the need for an environmental assessment in any district in which the IDA Credit would spend resources, and creates guidelines that are incorporated into normal procedures. The environmental assessment fulfills OD 4.00 on Environmental Assessment and Operational Procedure 4.09 on Pest Management. Key results from the environmental assessment include the following: (a) All insecticides harm the environment to some extent. However, the risk of increased death and morbidity from not using insecticides exceeds their negative environmental impact, especially among the rural poor. (b) The environmental risks from insecticides use in agriculture far outweigh those of spraying for malaria control. (c) The proposed insecticide choices should be based upon efficacy, cost and safety. Synthetic pyrethroids are the most effective and safe but cost substantially more than DDT. Other older insecticides, such as BHC, are much more toxic and should be eliminated as quickly as possible. (d) In addition to cutting back on routine spraying, improved training and logistics, better environmental management, and diversifying to other biological agents may minimize environmental damage. The environmental assessment included guidelines on better environmental management. As a result of the environmental assessment, the project design was modified in the following ways: (a) The project will help catalyze the phasing out of some insecticides commonly used in India, such as DDT on both demand and supply sides. Demand for these insecticides will drop because of the Revised Insecticide Guidelines and the revised operational guidelines, better IEC, and alternative interventions. To address the supply side, the enhanced program will include feasibility studies for privatizing and diversifying the manufacture of some insecticides. (b) The project will finance another environmental assessment around the third year of implementation. The enhanced program will also finance the costs of an on-going operational committee comprising NMP, MRC and other staff to discuss environmental issues. The results of these meetings will be reported to the annual program development review. (c) Key parts of the environmental assessment will become part of the revised operational guidelines. The revised operational guidelines will include efforts to improve the quality of spraying, ensure the safety of spray workers, and reduce spillage and theft. (d) The project will finance operational research studies, including studies related to environmental impact.  Project Appraisal Document Page 19 Country: India Project Title: Malaria Control 18. Participatory Approach: Stakeholder participation. The overall objective of the stakeholder analysis has been to consult and seek the active collaboration and participation of various beneficiaries in the enhanced program (Tables 3 and 4). In addition to the BA, seven distinct sets of participation consultations have been conducted with stakeholders, all with IDA involvement: (a) GOI held a series of regional workshops with community participation before the identification mission; (b) GOI and IDA held a joint review of GOI's proposal for malaria control with various stakeholders and community groups during the identification mission (November 1995); (c) representatives from village councils held a planning workshop with GOI and IDA during the pre-appraisal mission (March 1996); (d) NMP held two social participation and planning workshops in each of the four districts identified to develop the guidelines for district implementation plans (May to July 1996); (e) GOI and IDA held state-level consultations with the Departments of Tribal Welfare and Rural Development; (f) GOI and IDA held a joint intersectoral workshop with various line ministries (March 1996); and (g) an NGO consultation on insecticide policy was held in February 1997. These meetings have contributed to the stakeholder analysis at the secondary and primary levels. Participatory efforts in the preparation of the IDA Credit have already had three impacts: (a) they helped expand the scope of the project to involve the entire malaria control program rather than choosing a particular geographic area; (b) they sharpened the focus on community-based interventions and intersectoral collaboration; and (c) they increased the extent of district-level planning. Table 3. Stakeholder analysis of the enhanced program Participant Mechanism Output or Impact Government health service providers Workshops, planning briefs from Project design that is developed both national and state programs from above and below Government non-health sector service Intersectoral board Increased awareness of malaria and use providers (e.g., other ministries) of methods to lower malaria sources NGOs and private sector Workshops and competitive Enhanced NGO and private provider contracts activity in IEC campaigns, awareness, and medicated mosquito net provision Village councils, local community Social participation workshop; Enhanced awareness of malaria, leaders, and women's groups personal interview, focus groups, support of local IEC efforts, and BA and district societies medicated mosquito net distribution Local households, including Focus groups and personal Increased use of MMN program scheduled caste and tribal peoples interviews in the BA, IEC efforts, measures, heightened awareness of community mobilization via and malaria and greater access to early district societies detection and treatment. Table 4. Level of participation in the enhanced program by various groups Group Identification/Preparation Implementation Operation Beneficiaries/community groups Close collaboration Close collaboration Close collaboration Village councils (district, block Close collaboration Close collaboration Close collaboration and community level) and NGOs Other donors (WHO and ODA) Collaboration Collaboration Collaboration Medical associations Consultation Collaboration Collaboration  Project Appraisal Document Page 20 Country: India Project Title: Malaria Control 19. Sustainability: In addition to financial sustainability (Section 13), the technical and managerial sustainability of the enhanced program has been analyzed. Technical sustainability is high because we expect: (a) The NMP would continue to be the effective leader of malaria control activities well into the future and would continue to promote the better mix of effective malaria control interventions throughout the country after the IDA Credit closes. (b) The revised operational guidelines would help institutionalize successful interventions and approaches such as social and environiental assessments. (c) Investments in training, acquisition of new expertise, better information systems, and ongoing review would all help NMP to implement the enhanced program. (d) Improved capacity at the district level, including the training of district malaria officers and engagement of local societies, would help maintain community-based ownership. (e) The GOI's efforts to increase autonomy of village councils would help ensure that local demand for malaria control will continue into the future. (f) Efforts at intersectoral collaboration would help heighten awareness by industries and development projects of simple environmental management and low-cost treatment options. Managerial sustainability is high because we expect: (a) NMP staff would receive considerable management training and district-level staff would acquire micro-planning skills through the guidelines for district implementation plans and other approaches. Use of market rates for training will ensure participation in training. (b) A better information system and a focus on monitoring and evaluation would help manage interventions more effectively at all levels. (c) Skills in accounting, financial review, procurement, management planning and information will be integrated into NMP's overall management structure. (d) Creation of district-based implementation plans would increase transparency and accountability of local malaria control activities. 20. Critical Risks (see fourth column of Annex I and Table 5): The overall risk of the project failing to meet its developmental objectives is rated as medium. Key risks and their safeguards include: (a) Unforeseen major epidemics or insecticide and drug resistance could push the entire program toward short-term responses. The enhanced program will strengthen epidemic planning and response by establishing regional response teams and a geographic information system. (b) Political pressure may lead to adoption of a malaria control that is dominated by insecticide spraying. The enhanced program relies upon both supply and demand-side reduction to prevent this potential problem. The IDA Credit will closely monitor adherence to the National Policy Letter and  Project Appraisal Document Page 21 Country: India Project Title: Malaria Control Revised Insecticide Guidelines, including examination of any widespread spraying that may threaten the investment. (c) Information may be inadequate to control malaria locally. To improve the quality and quantity of information available, the enhanced program will contain considerable efforts in training and information systems. (d) Correction of ineffective activities may take place too slowly. Annual program development reviews will help to ensure that the progress continues. 21. Possible Controversial Aspects: The enhanced program includes several potentially controversial elements: (a) Epidemics will attract media and public attention. Criticisms may be directed at IDA, despite the enhanced program, and demand for short-term responses may rise. Such controversy is unavoidable, but better planning will help the NMP respond to epidemics, and better IEC will inform the public about options for malaria control. (b) Insecticide use may disturb environmentalists. The enhanced program will promote better operational quality, reduce insecticide demand (and possibly supply) and periodically review environmental issues. (c) NGOs have not yet been very active in malaria control but have been critical of poor response by the GOI to epidemics. Several NGOs were consulted at identification and in social participation workshops to solicit inputs. Several other NGOs met in February 1997 to review insecticide issues. Finally, other NGOs will help deliver IEC and the medicated mosquito net program. (d) Politicians may object to removing eradication from the NMP's full title. However this name change is necessary to provide the public with a more realistic appreciation of malaria control. BLOCK 4: MAIN CREDIT CONDITIONS 22. Effectiveness Conditions: None 23. Other. During negotiations, IDA obtained the following assurances from GOI representatives: (a) GOI shall implement the IDA Credit in accordance with the National Policy Letter, the Revised Insecticide Guidelines, and the PIP agreed with IDA. (b) GOI shall ensure that an independent review of the technical, administrative and operational aspects of the enhanced program is completed by December 15, 2000. (c) GOI shall make provision for three dedicated positions within the NMP for staff with skills in finance and administration, social assessment and IEC, and shall appoint staff to fill such positions by April 1, 2000. By April 1, 1998, GOI shall change the name of the NMP Directorate to "Directorate of National Malaria Action Program" or such other name reflective of the policies and objectives of the enhanced program and not reflecting eradication.  Project Appraisal Document Page 22 Country: India Project Title: Malaria Control Table 5: Summary of Risks, Ratings and Minimization Measures Risk Risk Risk Minimization Measure - - - ~iTi7nT&o7r~s Rating Over reliance on indoor residual High National Policy Letter, Revised Insecticide Guidelines, on- spraying, especially for political going review and limited IDA financing of insecticides will reasons, may continue. discourage inappropriate use. Reviews will carefully monitor spending, coverage, and quality of indoor residual spraying. The NMP will inform Parliament about effective control. IEC activities will help inform public opinion about spraying and alternative methods. Entrenched NMP staff may not Low The NMP helped to design the IDA Credit, including the PIP, accept and own the enhanced guidelines for district implementation plans, and program. insecticide policies. The IDA will share lessons from successful control programs elsewhere in the world. The enhanced program will emphasize management, training and capacity building. Major epidemics or increasing High NMP will strengthen regional epidemic offices and will resistance will alter NMP focus to carefully monitor resistance. The annual program development short-term responses, including review will help guide major program changes and ensure that mass indoor residual spraying. short-term responses are consistent with longer-term objectives. Medicated mosquito nets will fail High The focus of first-year activities will be careful studies, limited due to poor social marketing, or distribution, evaluation, and engagement of NGOs and social poor acceptance. marketing agencies to promote public, private, and voluntary distribution. The annual program development review will evaluate medicated mosquito nets. Involvement of the household and Medium The enhanced program will use the guidelines for district the community may vary among implementation plans. The NMP will evaluate lessons from states and communities. districts piloting the guidelines for district implementation plans. District societies will facilitate local spending and community participation. The NMP will have flexibility to respond to local conditions and implementation abilities. Delays, driven largely by Medium The design of project includes up-front discussion and MOHFW, in procurement or clearances requested on major items, and no geographic clearances will hinder effective restriction in responding to emergencies (except for meeting malaria response financial, accounting, and audit requirements). IDA procedures and guidelines are familiar to NMP staff and procurement arrangements are well advanced. Some states or districts will have High The NMP will have the flexibility to spend funds based upon poor start-up to malaria control, demonstrable need. State officers will help focus on and delays in filling posts management and resolution of obstacles. Flow of cash or goods from the Medium The enhanced program will adopt a flow of funds procedure NMP to districts will not be timely similar to that used in the Cataract Blindness Project. State and adequate malaria coordinators will help collect financial data. Districts will contract accounting and management expertise.  Project Appraisal Document Page 23 Country: India Project Title: Malaria Control (d) GOI shall cause the enhanced program to be adequately staffed and funded, and shall maintain such staff and funding for the duration of the IDA Credit. By April 15, 1998, GOI shall provide to IDA a list of the enhanced program staff, such list to summarize the job descriptions of each staff member. GOI shall take appropriate measures to maintain continuity of key staff of the enhanced program. (e) Proceeds of the Credit and goods and services purchased under the IDA Credit shall be provided to non-core participating states upon the NMP Directorate's determination of demonstrable need, such determination to be based on: (i) appropriate public health practices; (ii) accordance with the objectives of the IDA Credit; and (iii) adherence to the procurement, audit and all other applicable provisions stipulated in the Credit Agreement. (f) GOI shall, and shall cause the states to use insecticides for malaria control in accordance with the Revised Insecticide Guidelines, which Guidelines may be revised from time to time with the mutual agreement of GOI and IDA. (g) GOI shall carry out annual program development reviews (APDRs) conducted in accordance with Terms of Reference agreed with IDA. The APDR Committee shall meet not less than annually, and no later than October 31 of each year. (h) GOI shall select, and shall cause states to select, non-governmental organizations, social marketing agencies, and specialized agencies and institutes of the GOI to produce, market and distribute medicated mosquito nets in accordance with the procedures specified in the PIP. In accordance with the PIP, the GOI shall pursue, where appropriate, recovery of the costs of the medicated mosquito nets distributed under the enhanced program. (i) The NMP shall take all necessary measures to cause district implementation plans developed in accordance with the guidelines for district implementation plans noted in the PIP to be adopted and implemented in all districts in the core participating states in accordance with the following schedule: 15 percent of the total number of district implementation plans shall be completed and approved by the NMP by December 15, 1997; 50 percent by June 30, 1998 and 100 percent by June 30, 1999. (j) The NMP shall liaise with concerned authorities in respect of major development projects which may have a propensity to create malariogenic conditions, with a view to contain their health hazards. (k) GOI shall ensure that state Malaria Coordinators for the core participating states are appointed by December 15, 1997. GOI shall take appropriate measures to promote continuity of key staff at the state and district levels, including malaria officers trained under the enhanced program. (I) Operational research under the enhanced program shall be carried out in accordance with the procedures specified in the PIP. The identification of research topics and the implementation agencies to carry out such research shall be accomplished through a peer-review process. Selection of implementation agencies to carry out such research shall follow principles of transparency and competition. Relevant malaria research which receives international peer-reviewed funding shall be eligible for additional funding from GOI. (m) GOI shall use its best efforts to encourage all states to adopt the model by-law for urban malaria control contained in the PIP, with the goal of adoption by at least 15 states by April 30, 2000.  Project Appraisal Document Page 24 Country: India Project Title: Malaria Control (n) By July 31, 1999, the NMP shall review and update its existing Operational Guidelines to reflect the strategies and norns of the enhanced program. (o) By June 30 of each year, GOI shall provide to IDA summary results of the previous annual meeting of its existing inter-ministerial Working Group on DDT Use in Public Health. In addition, the NMP shall supply program expenditure data on insecticides, biolarvicides and larvivorous fishes, and the annual budgets and expenditures of the NMP. (p) GOI shall ensure that by April 30, 1998, at least two representatives from industry are members of its interministerial National Task Force on Intersectoral Issues in Malaria, and shall further ensure that such Task Force meets at least once a year. (q) GOI shall, and shall cause each state to, implement the enhanced program in any tribal area in accordance with the Tribal Strategy noted in the PIP, which Strategy was developed with the participation of the beneficiaries. (r) GOI shall: (i) maintain policies and procedures adequate to enable it to monitor and evaluate on an ongoing basis, in accordance with indicators satisfactory to IDA; (ii) prepare, under terms of reference satisfactory to IDA, and furnish to IDA, on or about November 30 of each year, a report integrating the results of the monitoring and evaluation activities; and (iii) review with IDA, by December 15 of each year, and take all measures required to ensure the efficient completion of the IDA Credit and the achievement of the objectives thereof, based on the conclusions and recommendations of the said report and IDA's views on the matter. Condition of Disbursement (s) Except as IDA shall otherwise agree, a Letter of Undertaking shall be required from each of the core participating States of (Andhra Pradesh, Bihar, Gujarat, Madhya Pradesh, Maharashtra, Orissa, and Rajasthan) in a format agreeable to IDA. BLOCK 5: COMPLIANCE WITH BANK POLICIES This IDA Credit complies with all applicable Bank policies. Task Manager: P rabh Country Manager: Robert S. brysdal ,   Annex I Page I of 5 Project Design Summary (Baseline and target values are given below. Qualitative indicators are indicated by an asterisk) Narrative summary Key performance Monitoring and supervision Critical assumptions indicators and risks I. CAS objective Improve national . Decline in malaria cases . Annual review of national . Malaria is a health (by year 5) health statistics significant cause of . Stabilization of "fatal illness and death and malaria" (i.e., P. inhibits socio- Falciparum) as a economic percentage of total malaria cases. II. Project development objectives U Use of the better mix . Percentage of total NMP . Biannual budget reports of . Political pressure of effective anti- budget (i.e., IDA + regular the IDA Credit may be exerted to malarial interventions budget) spent on non-IRS . Annual program use indoor residual activities over the development review spraying previous two fiscal years . NMP to provide details on , Target population covered full range of activities every by appropriate IEC six months messages . IEC surveys D Degree of adherence to National Policy Letter and Revised Insecticide Guidelines * D Strengthened and . Number of districts action . Reports provided by district . NMP staff may resist reoriented NMP plans that have been malaria officers/district the enhanced completed and have societies program resulted in more than two . Records kept at NMP . Households and community meetings and . External evaluation of communities will the spending of more than management skills in second take ownership of at least 60% of allocated or third year the enhanced funds program . Reduced morbidity and . Decline in malaria cases . Routine information . Reported cases of mortality due to (by year 5) collected by NMP malaria may rise or malaria. . Stabilization of "fatal remain unchanged in malaria" (i.e., P. the medium term Falciparum) as a . Drug and/or percentage of total malaria insecticide resistance cases. may increase  Annex I Page 2 of 5 Narrative summary Key performance Monitoring and supervision Critical assumptions indicators and risks III. Project Outputs by Component Integrated Early Detection and Prompt Treatment Improved accessibility, . Average time gap between . Routine data recorded at . Delays in procurement speed, and accuracy of collection of blood slide primary health centers . Failure to link training diagnosis of malaria and recording of diagnosis of personnel to cases at malaria lab provision of laboratory .Stabilization of "fatal equipment malaria" (i.e., P. . Drug and/or insecticide Falciparum) as a resistance may increase percentage of total malaria cases. Selective Vector Control and Diversification . Targeted spraying of . Availability of village-level . Routine reporting by district . Flow of cash or goods insecticides epidemiological malaria officers/district from NMP not timely information * societies or adequate .Degree of adherence to . Political pressure to use National Policy Letter and indoor residual Revised Insecticide spraying regardless of Guidelines * monitored conditions . Increased use of non- . Percentage of total NMP . Accounting records at NMP . Political pressure to use insecticide vector budget (i.e. IDA + regular indoor residual control methods budget) spent on non-IRS spraying activities over the previous two fiscal years Medicated Mosquito Net Program . Increased use of . Number of medicated . Accounting records at NMP . Poor distribution and medicated mosquito mosquito nets distributed . Special studies of marketing of medicated nets through public/voluntary effectiveness of medicated mosquito nets social marketing mosquito nets . Political pressure to use approaches indoor residual . Acceptability of medicated spraying mosquito nets *  Annex I Page 3 of 5 Narrative summary Key performance Monitoring and supervision Critical assumptions indicators and risks Epidemic Response and Intersectoral Collaboration .Strengthening of . Extend of functioning of . Reports filed by offices . Delays in procurement regional offices regional offices * .Intersectoral . Number of municipal . NMP data routinely . Poor cooperation by collaboration with corporations that have collected, reports from states and by other urban centers and adopted model anti- Ministry of Environment Ministries development projects malaria bylaws and Forestry .Number of malaria health- risk assessment studies launched by NMP Institutional Strengthening . Improved management . Percentage of key targeted . NMP training records . Resistance of and planning skills at staff at states/districts that management staff to NMP, state and district have acquired changed roles levels epidemiological and management skills . New skills at NMP . Number of multi- . NMP data (e.g., anthropology) disciplinary (non- entomological) staff hired at NMP . Creation and . Target population covered . Reports from state, regional . Failure to produce dissemination of IEC by appropriate IEC and district malaria officers, culturally appropriate program messages and village councils/ NGOs IEC messages .Degree of involvement of . IEC studies village councils/NGOs * . Increased operational . Quality of research . Working committee records . Resistance to research projects advertised, . Minutes of APDR meetings operational research or funded, initiated and to expert criticism completed * Utility of APDR recommendations * Baseline and target values for quantitative indicators 1. Number of malaria cases reported to NMP. Baseline: 2.85 million per annum Year 3: 5% increase over baseline (i.e., expected to rise due to publicity and better detection) Year 5: 10% decrease from year 3 2. "Fatal malaria" (i.e., P. Falciparum) as a percentage of total malaria cases. Baseline: approximately 40% (this value is rising; the enhanced program will minimize the increase) Year 3: less than 50% Year 5: stabilized at less than 50%  Annex 1 Page 4 of 5 3. Percentage of total NMP budget (i.e., IDA Credit plus regular budget) spent on non-indoor residual spray activities over the previous two fiscal years. Baseline: 25% Year 3: 30% Year 5: 40% 4. Target population covered by appropriate IEC messages. Baseline: 1% Year 3: 20% Year 5: 50% 5. Number of districts action plans that have been completed and have resulted in more than two community meetings and the spending of more than at least 60 percent of allocated funds. Baseline: 0 Year 3: 30 Year 5: 70 6. Average time gap between collection of blood slide and recording of diagnosis at malaria laboratory. Baseline: more than 14 days Year 3: 7 to 14 days Year 5: less than 7 days 7. Number of MMNs distributed through public/voluntary social marketing approaches. Baseline: 100,000 Year 3: 150,000 Year 5: 300,000 8. Number of municipal corporations that have adopted model anti-malaria bylaws in their state legislature. Baseline: 3 Year 3: 5 Year 5: 10 9. Number of malaria health-risk assessment studies launched by NMP. Baseline: 0% Year 3: 10% Year 5: 50% 10. Percentage of key targeted staff at states/districts that have acquired epidemiological and management skills. Baseline: 5% Year 3: 40% Year 5: 100% I 1. Number of multi-disciplinary staff hired at NMP Baseline: I Year 3: 3 Year 4: 5 ANNUAL PROGRAM DEVELOPMENT REVIEWS NEED AND TERMS OF REFERENCE FOR ANNUAL PROGRAM DEVELOPMENT REVIEW Need: The enhanced program envisages using a more diverse set of malaria control interventions. Annual review of the implementation process was considered necessary so that modifications could be incorporated as and when  Annex 1 Page 5 of 5 required. Such reviews will give the Directorate of the National Malaria Eradication Program (NMP) flexibility in assigning appropriate resources and will allow the program to benefit from the global expertise on malaria. Terms of Reference would be to: (a) review implementation of malaria control strategies in relation to annual national, state and district levels plans with a focus on project areas; (b) review epidemiological, operational, social, economic, entomological, and drug sensitivity data collected during the year; (c) assess the effectiveness of the enhanced program on the basis of (a) and (b); (d) identify gaps in information required to assess the effectiveness of surveillance and recommend ways of filling these gaps; (e) review summary results of operational research and recommend their adoption, where relevant; (f) monitor costs and trends, quality, and coverage of indoor residual spraying and insecticide activities, ensuring that the overall project strategy adheres to the Revised Insecticide Guidelines; (h) suggest long term strategies for strengthening and capacity building in malaria control; and (i) advise the GOI and IDA if certain performance and monitoring indicators should be improved, added, or dropped. Composition of Annual Program Development Review Committee: The committee will comprise six members plus a Chairperson, including one member each from the MRC, the National Institute for Communicable Diseases and NMP, one member drawn from the community, and two experts from outside India. All members will be experts in malaria control and community-based disease control. The Chairperson will be Director NMP. External members will be selected by GOI, in consultation with IDA. The Committee would ordinarily function for a minimum of two years and the term may be extended by mutual agreement between GOI and IDA. External members would be financed by IDA or other agencies. Non-governmental members will be paid travel and daily allowances as per the Central Government rates and a suitable honorarium commensurate with the volume of work. With input from NMP, WHO, and others, the GOI will nominate the six members plus the chairperson of the annual program development review by an agreed date. Meetings: Reviews will be annual after project effectiveness, held at time mutually agreed upon by the Government of India (GOI) and IDA. Dates for future meetings will be fixed after the first meeting. Each review will be of five to ten days duration and will include briefing at NMP, necessary field visits, and review of budgets and implementation plans for the next year. At least three weeks before each meeting the annual program development review cell will compile a report for the review on key issues, including budget spending, etc. Support Unit for Annual Program Development Review: A support unit responsible for preparing the material required for the reviews will be integrated into the enhanced program. This unit will be responsible for preparing the material required for the reviews. This team will report to the annual program development review committee directly, but will work on a day-to-day basis with the staff of the enhanced program. The staff will consist of an epidemiologist or health specialist and a typist or stenographer. Resources for computing, document processing, and other services will be provided under the Project. The support unit will collect the data and prepare the material in time for the annual reviews. The Project contribution will include costs for support unit staff and all costs for the annual program development review process, with suitable counterpart funding from GOI (via the NMP budget). Relation to the GOI and World Bank: The annual program development review will have no authority to bypass any of the rules, regulations, accounting requirements, or procurement and disbursement guidelines of either the GOI or the World Bank.   Annex 2A Page I of 3 Detailed Project Description The activities to be carried out under the enhanced program, and the total cost of each activity cluster or component, are as follows: I. Integrated Early Detection and Prompt Treatment - US$44.7 million 1. Improve the quality and accessibility of selected first level health units through: ensuring that existing fever treatment depots (FTDs) and drug distribution centers (DDCs) are stocked with glass slides, guidelines for the diagnosis and treatment of malaria, and malaria medications; establishing at least one FTD or DDC in villages where they do not already exist; establishing a system of malaria link functions (MLFs) who will transfer supplies and information between primary health care facilities (PHCFs) and FTDs and DDCs. provide FTD and DDC workers, multipurpose workers (MPWs) and MLFs with training for the diagnosis, treatment and referral of malaria cases. 2. Improve the speed and accuracy with which malaria cases are diagnosed through: providing all PHCFs and district hospitals with a microscope, a trained laboratory technician and laboratory supplies necessary for the microscopic diagnosis of malaria; providing selected PHCFs and district hospitals with Dipstick diagnostic materials for use in emergencies; making dipstick tests available on the market for use in private clinics based on cost-recovery; providing training on blood slide collection for FTD and DDC workers, MPWs and MLFs. 3. Improve the treatment of severe and complicated malaria cases through: equipping selected PHCFs and district hospitals to deal with severe and complicated malaria cases; providing private clinics with guidelines on the management of severe and complicated malaria cases and the supplies necessary to treat these cases based on cost-recovery; training medical officers and their technical assistants at primary levels on the treatment of severe and complicated malaria. 4. Improve the system for collecting and relaying data on malaria cases diagnosed and treated. II. Selective Vector Control - US$81.2 million 1. Reduce the area in which household insecticide spraying is in use and improve the cost- effectiveness and acceptability of insecticide spraying through: using epidemiological methods to select high incidence villages for spraying; improving the epidemiological record-keeping selecting the least expensive, effective insecticide for each village to be sprayed. 2. Strengthen non-insecticide vector control activities through: building larvivorous fish hatcheries and improving the system for distributing and monitoring these fish; selective use of biolarvicides, especially in urban areas; promoting legislative measures that prevent the creation of mosquito breeding sites. 3. Provide technical assistance services, training, equipment and supplies to support the above activities. III. Medicated Mosquito Net Program - US$23.4 million 1. In selected communities, assess the acceptability, sustainability, efficacy and cost- effectiveness of medicated mosquito nets for the prevention of malaria. Selected NGOs will be awarded consultant contracts to aid in distribution and testing.  Annex 2A Page 2 of 3 2. In areas where medicated mosquito nets are found to be effective, they will be distributed using social marketing techniques. Public, private and voluntary community organizations will be involved in the distribution and re-treatment of these nets. Local cooperatives and grassroots groups will be given small grants for pursuing medicated mosquito net manufacture and distribution. Widespread public distribution will be avoided prior to review of the mosquito net program. IV. lEpidemic Response and Intersectoral Collaboration - US$19.5 million 1. Strengthening Regional Malaria Epidemic Offices to coordinate control efforts in the case of an epidemic and assist states in carrying out suitable prevention activities. 2. Create, test and implement a Geographic Information System (GIS) at NMP including research on ecologic, climatic and socioeconomic risk factors for malaria. 3. Implement district-level committees to mobilize resources in the case of an epidemic. 4. Develop and distribute guidelines for reporting and responding to early indicators of an epidemic. 5. Provide Guidelines to industries and development projects on preventing malaria, and treatment of malaria cases. 6. Legislation efforts at municipal and state levels to ensure development projects do not cause malaria and treat it when it occurs., including introduction of model-by laws into state legislatures. 7. Work with Ministry of Environment and Forestry and other agencies to ensure that major developmental projects have a review of vector-borne diseases approved by NMP. V. Institutional Strengthening - US$35.] million 1. Produce, distribute and disseminate an integrated IEC program, including training videos and audiocassettes for promoting prevention and early detection and treatment of malaria. This will be targeted towards community leaders, local health-care workers and non-health personnel from private and voluntary sectors. 2. Provide in-service training for all those who are involved in the implementation of revised malaria control activities. Local and district-level training will be sufficiently flexible as to allow for locally relevant education. Training allowances and daily allowances will be near to market rates, so as to ensure participation of staff. Selected training will involve domestic and foreign study tours. 3. Develop, pilot and expand a Management Information System. This computer-based system will facilitate the collection and analysis of data at the local level and will allow for easy transfer of information between local, district, state and central personnel. 4. Strengthen central-level administration by providing new NMP headquarters. 5. Strengthen the monitoring of malaria control activities by conducting annual program development reviews and review of enhanced program activities. 6. Improve relevant applied research by providing a new MRC research facility.  Annex 2A Page 3 of 3 7. Identify a set of priority items for Operational Research, define their terms of reference and select competent research agencies to execute these projects. 8. Institutionalizing a mechanism for periodic reviews of environmental issues. 9. Health-risk assessment studies, and preparation of future projects. 10. Selected consultant studies including review of management functions at NMP. 11. Create advocacy package for parliament and state politicians about malaria control. 12. Strengthen the capabilities of the NMP for supervising the implementation of the enhanced program, including the provision of technical assistance, training in logistics management and information systems, and necessary equipment and supplies. Consultant salaries will be near market rates, so as to ensure suitably qualified personnel join the enhanced program. 13. Support a sub-unit which will be responsible for gathering and processing data for the annual program development review.  I  Annex 2B Page I of 7 91 rt 1 - 10ooi1 GOVERNMENT OF INDIA MINISTRY OF HEALTH & FAMILY WELFARE ;;'A44G11TA NEW DELHI - 110011 SHAILAJA CHANDRA Additional Secretary Tele 301-7451 April 24, 1997 Dear Mr. Drysdale This is in connection with the assurance for implementation of the enhanced Malaria Control Programme in India in accordance with the agreed policies, updated guidelines and mix of interventions. Based upon the Expert Committee on Malaria (1995), and on-going inter-agency and inter-ministerial policy development, the Government of India has proposed to the International Development Association (IDA) a project for the enhancement of the National Malaria Eradication Programme (NMEP) to cover all regions of the country, with a special focus on the highly endemic malaria control areas. The Government of India undertakes that the enhanced program will be implemented with a better mix of interventions, with the twin objectives of being more responsive to local needs, and strengthening the NMEP. The list of proposed activities is outlined as per the attached policy matrix. With regards, Yours sincerely, (SHAILAJ CANDRA) Mr. Robert Drvsdale, Director South Asia Country Department WORLD BANK 1818 H Street NW Washington. DC 20433  Annex 2B Page 2 of 7 Policy Matrix: The Current NMP and Proposed Changes with the Enhanced Program Component Current NMP Enhanced Program Selective vector Adulticidal activities Gradual reduction in spraying of adulticides through control Relies on indoor residual spraying with selected judicious, highly selective indoor residual spraying insecticides of variable efficacy. Village will become unit for spray operations Subcenter is unit for spray operations Use of newer insecticides (e.g., synthetic pyrethroids), especially in areas of triple resistance and drug resistance Larvicidal Activities Selective use of biolarvicides, based upon efficacy and Mostly uses chemical larvicides operational research and selected distribution of larvivorous fish Increased focus on environmental management through intersectoral collaboration Early detection Laboratory diagnosis is by microscopy, with Goal of one microscopy laboratory per 30,000 and treatment approximately one laboratory per 100,000 population population Dipstick tests for diagnosis in emergency situations Involves private physicians and traditional healers with cost recovery Increases number of drug distribution centers and fever Limited front-line detection and treatment by multi- treatment depots purpose workers, drug distribution centers, and fever Establishes malaria link function and makes adequate treatment depots drug supplies and artemesinine injectibles available at various selected levels for treatment Medicated Limited studies and use Larger studies of MMN and carefully evaluated mosquito nets distribution through grassroots organizations, social (MMN) marketing agencies, and public agencies, while avoiding widespread distribution prior to evaluation Epidemic Preventive activities are planned based on Improved epidemiological monitoring and planning and epidemiological data collected the previous year identification of risk factors for epidemics, including rapid response geographic information systems (GIS) Strengthening regional offices to address epidemics Intersectoral Limited engagement of industries and development Involves National Malaria Task Force collaboration projects Improved use of IEC; treatment guidelines, and model- by laws Information, Limited communication materials are disseminated Mass media, plus local information, education and education and to the state, district, and block level communication planning and implementation, with an communication emphasis on locally appropriate messages Institutional strengthening * Training and Routine training of all levels of staff Enhanced training material, training institutions, and management trainers at all levels, adds management and epidemiological skills * Management information Paper-based information system, with many Selects most important indicators and develops system (MIS) standard pro-formae computer-based MIS and GIS * Level of Central planning, target based Enhanced district implementation plans, and regional planning and state planning  Annex 2B Page 3 of 7 *4 It V; .41 1' I - I Cw1 q ftE -- 110011 GOVERNMENT OF INDIA MINISTRY OF HEALTH & FAMILY WELFARE SHAILAJA CHANDRA NEW'DELHI 110011 Additional Secretary Tele 301-7451 D.O. No.!vt. vO1'9!96-%[AL. 27th M,ar,:ch. t997. -- r IA~~ - Kindlv rere: co rry lecters dared 8kh Jan. '97 and Itch Feb.'97 and the outcome of [he visiE of the recent Appraisal Mlission f'or ;he Mvlalaria Conroui Project. The revised pojic le-cer for insecricide us-,e for the enharnced malaria control prograrrmme icti Wor.d Bank suopor: is en.clse' n Wich rezards. Yours sinc-erelv, (SHAILLAJA CHAYIDRA) Mr. R.chard Skolni:. Chiet;. Population & Humar. R-scu-7e Division. South Asia Councr-.- De-a.-ent 11 WORLD BANK. iSIS. F. Stree-t N.;. %% -SHI!NGTON DC 2