India - Child Survival and Safe Motherhood Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 16353 IMPLEMENTATION COMPLETION REPORT INDIA CHILD SURVIVAL AND SAFE MOTHERHOOD PROJECT (CREDIT 2300-IN) March 3, 1997 Population and Human Resources Operations Division Country Department II South Asia Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS Name of currency = Indian Rupee (Rs.) IDA Fiscal Year Averages US$1.00 (FY90) = 17.0 US$1.00 (FY94) = 31.4 US$1.00 (FY91) = 18.7 US$1.00 (FY95) = 31.4 US$1.00 (FY92) = 25.8 US$1.00 (FY96) = 34.2 US$1.00 (FY93) = 27.8 GOVERNMENT FISCAL YEAR April 1- March 31 ABBREVIATIONS ANM Auxiliary Nurse Midwife ARI Acute Respiratory Infection AWW Anganwadi Worker BCG Bacillus Calmette-Guerin CHC Community Health Center CS Child Survival CSSM Child Survival and Safe Motherhood DDK Disposable Delivery Kit DPT Diphtheria Pertussis Tetanus Vaccine EOC Essential Obstetric Care FRU First Referral Unit GOI Government of India ICDS Integrated Child Development Services Program IEC Information, Education and Communications IPP India Population Project MCH Maternal and Child Health MICS Multi-Indicator Cluster Survey MIS Management Information System MOHFW Ministry of Health and Family Welfare MOPHC Medical Officers, Primary Health Center NFHS National Family Health Survey OPV Oral Polio Vaccine OR Operational Research PIU Project Implementation Unit PVO Private Voluntary Organization RITES Railway Institute for Telecommunication and Signalling SAR Staff Appraisal Report SM Safe Motherhood TBA Traditional Birth Attendant UIP Universal Immunization Program UNICEF United Nations Children's Fund Vice President Mieko Nishimizu Director Robert S. Drysdale Division Chief Richard Skolnik Staff Member Anthony Measham  FOR OFFICIAL USE ONLY IMPLEMENTATION COMPLETION REPORT INDIA CHILD SURVIVAL AND SAFE MOTHERHOOD PROJECT (CREDIT 2300-IN) CONTENTS Page PREFACE ............................................ i EVALUATION SUMMARY ............................................ ii PART I: PROJECT IMPLEMENTATION ASSESSMENT A. Project Objectives ............................................ 1 B. Achievement of Project Objectives . ............................................ 4 C. Major Factors Affecting Project Implementation .......................................: 9 D. Project Sustainability ...................................... 10 E. Bank Performance ...................................... 11 F. Borrower Performance ...................................... 11 G. Assessment of Outcome ...................................... 11 H. Lessons Learned ...................................... 12 PART II: STATISTICAL TABLES Table 1. Summary of Assessments .14 Table 2. Related Bank Loans/Credits .16 Table 3. Project Timetable .17 Table 4. Credit Disbursements: Cumulative, Estimated and Actual .18 Table 5. Key Indicators for Project Implementation .18 Table 6. Studies Included in the Project .19 Table 7A. Project Costs by Category of Expenditure .................... ......................... 19 Table 7B. Project Financing ............................................. 19 Table 8. Status of Legal Covenants ............................................. 20 Table 9. Compliance with Operational Manual Statements ............................................. 23 Table 10. Bank Resources: Staff Inputs ............................................. 23 Table 11. Bank Resources: Missions ............................................. 24 APPENDICES Appendix A. The ICR Mission's Aide-Memoire Appendix B. Borrower's Contribution to the ICR This document hag a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.   IMPLEMENTATION COMPLETION REPORT INDIA CHILD SURVIVAL AND SAFE MOTHERHOOD PROJECT (CREDIT 2300-IN) PREFACE This is the Implementation Completion Report (ICR) for the Child Survival and Safe Motherhood Project in India, for which Credit No. 2300-IN in the amount of SDR 160.9 (US$214.5 million equivalent) was approved on September 17, 1991 and made effective on March 5, 1992. The Credit closed on September 30, 1996 compared to the original closing date of September 30, 1995. It was fully disbursed, and the last disbursement took place on December 5, 1996. The ICR was prepared by Anthony Measham (Task Manager) and Lessel H. David (Consultant), with technical assistance from Ann Hammond, Mark Schlagel and R. Sethuraman. Nira Singh and Mark Schlagel provided office technology assistance. The ICR was reviewed by Richard Skolnik (Division Chief, SA2PH) and Kazuko Uchimura (Project Advisor, SA2DR). Preparation of this ICR began during the September/October 1996 supervision mission. It is based on material in the project files, field visits, and interviews/discussions with beneficiaries, project staff, Government officials and Bank staff. The Borrower contributed to the preparation of the ICR by hosting a workshop on September 30-October 1, 1996 and by preparing its own evaluation of the project's preparation and execution. Comments were received from the Borrower on drafts of the report and were taken into account in the final version. The cooperation and assistance of the Government of India (GOI) and the State Governments is gratefully acknowledged.   - ii - IMPLEMENTATION COMPLETION REPORT INDIA CHILD SURVIVAL AND SAFE MOTHERHOOD PROJECT (CREDIT 2300-IN) EVALUATION SUMMARY Introduction 1. IDA has supported India's family welfare program since 1972 through nine India Population Projects (IPPs) in various states. Four related projects, also limited to one or two states, supported child health and nutrition services. The Child Survival and Safe Motherhood (CSSM) project was the first project that operated country-wide. Project Objectives 2. The project's overall objectives were to: (a) shift India's family welfare program from its near-exclusive concern with fertility regulation to mother and child health (MCH); and (b) to provide a social safety net during the period of financial stringency and economic reforms. The project's specific objectives were to: (a) increase child survival; (b) promote safe motherhood, including establishing first referral units (FRUs) for secondary-level care of mothers and their newborn; and (c) strengthen the delivery of services by improving institutional capability. 3. Enhancing institutional capability was to be achieved through: training for field workers and program administrators; more effective information, education, and communications (IEC); improved management information systems (MIS); better materials management, including equipment maintenance; and extending coverage by involving other government departments, private medical practitioners, and private voluntary organizations (PVOs). 4. The activities planned for the project were well conceived and collectively comprise a comprehensive approach to improving the health of women and children. The expected coverage, however, was ambitious given the project's four-year duration and extensive geographic spread. Implementation Experience and Results 5. The project's overall objectives were met. The Department of Family Welfare has discontinued its practice of setting fertility reduction targets and has increased the em- phasis on MCH. Government of India (GOI) has also prepared a Reproductive and Child Health Project which is to be appraised by IDA in early 1997. The credit was fully dis-  - 111 - bursed. Not only were ongoing MCH activities sustained, but the range of services in- creased. 6. The specific objectives were met, though less substantially and not uniformly, as follows: 7. Child Survival. Surveys show that the percentage of children fully immunized increased by about 20 percentage points during the project. Among the more recently in- troduced services, the percentage of children receiving vitamin A prophylaxis increased from 20 to 62 percent. Efforts to extend the treatment of acute respiratory infection (ARI) -- an important cause of child mortality -- did not meet with much success. During field visits, it was encouraging to note that parents spontaneously brought children for immunization. 8. Safe Motherhood. The protection of pregnant women against tetanus and anemia increased, as did the proportion of institutional deliveries. However, the planned piloting activities for safe motherhood were less successful. Against the required 1,700 FRUs, about 600 are reported to be functioning. Even at the FRUs reported to be fully func- tional, some services and specialists are not available. 9. Institutional Capability Strengthening. Approximately three-quarters of the medical and paramedical staff have received the planned training. The effectiveness of IEC increased and was well planned. MIS has not served its intended purpose of either providing data for mid-course corrections or for planning activities at the field level. Equipment maintenance, particularly for the transport and storage of vaccines, improved dramatically. Coverage has been extended by involving the Integrated Child Development Services at the field level. Involvement of private practitioners, PVOs, and local community groups did not make any significant progress. 10. A special feature of the project was parallel co-financing from the United Nations Children's Fund (UNICEF). This led to a rewarding collaboration between GOI, UNICEF, and IDA. Key Lessons Learned 11. With the benefit of hindsight, the program strategy was not modified to the degree required by the addition of new services to the program, for example, by greater decentralization. Prior to CSSM, the major MCH activity was immunization through the Universal Immunization Program (UIP). CSSM added curative components (UIP-plus) as well as essential obstetric care (EOC), including secondary-level care at FRUs. UIP's strategy was characterized by a high degree of centralization and rigid programming. It served UIP well, but not CSSM. The UIP component carried over to CSSM did well; the more recently introduced components did not; recency alone cannot explain the shortfall.  - iv - 12. Large projects such as CSSM, especially those with varied components, need a well-functioning MIS, one that has been designed in consultation with users at all levels and therefore has a greater chance of being implemented. This need was not met. 13. When private sector involvement is necessary to fully achieve project objectives, it should be built into the project management and monitoring mechanisms. This requirement was not met in the case of CSSM. Further, the private sector is heterogeneous and different segments require different approaches. 14. Management training of health planners and administrators becomes more critical as boundaries and the size and shape of programs increase. Efforts to strengthen managerial skills deserves more attention then they received in the project. Project Outcome 15. The project outcome is rated "satisfactory". The project's contribution to broadening the scope of the family welfare program, especially with regard to child survival and safe motherhood, is noteworthy and certain to be sustained. Some of the more specific objectives fell short of expectations, but these did not affect significantly the overall project outcome.   IMPLEMENTATION COMPLETION REPORT INDIA CHILD SURVIVAL AND SAFE MOTHERHOOD PROJECT (CREDIT 2300-IN) PART I: PROJECT IMPLEMENTATION ASSESSMENT 1. IDA has assisted India's family planning - later, family welfare - program since 1972 through nine India Population Projects (IPPs). With two exceptions, IPPs supported multiple family welfare activities in selected districts and urban agglomerates; the exceptions being IPPs VI and VII which focused on training state-wide. Four related projects supported efforts to improve the nutrition and health of pre-school children in selected states. All thirteen projects were limited to a few states at a time; the Child Survival and Safe Motherhood (CSSM) project broke new ground in that it was country-wide. 2. In July 1991, the Government of India (GOI) announced its CSSM program to strengthen the maternal and child health (MCH) components of its National Family Welfare Program. Essentially, CSSM combined disparate MCH programs into a single package and initiated a wider range of maternal health measures. 3. GOI allocated Rs. 11,255.81 million (US$495.8 million) for CSSM. This amount was equivalent to the difference between MCH outlays for 1985-90 (Seventh Plan) and those proposed for the six years 1991-97 (Eighth Plan and inter-plan period). 4. The CSSM proposal was appraised by the Bank in April 1991, and the Staff Appraisal Report (SAR) recommended an IDA credit of US$214.5 million. UNICEF committed an additional US$67.8 million. The credit became effective in March 1992 and was to close on September 30, 1995, later extended to September 30, 1996. A. PROJECT OBJECTIVES 5. The project's strategic objective was to shift the family welfare program from its preoccupation with demographic goals and fertility reduction to more broad-based MCH concerns. Within MCH, child-centered interventions dominated. While supporting and extending services to under served areas and groups, the project sought to raise the concern for mothers - safe motherhood - not merely as it related to child survival but in its own right. Later, safe motherhood was to serve as an entry point for promoting reproductive health as a major objective of the family welfare program.  - 2 - 6. However, adverse economic conditions prevailing towards the end of the Seventh Plan (1985-89) period threatened social services. This jeopardized their operations and made their expansion infeasible. CSSM was, inter alia, an instrument to direct fiscal support to MCH; quick disbursement of funds to sustain its programs was an implicit, but important, objective. 7. The specific objectives of the project were in three clusters: child survival, safe motherhood, and the effectiveness of their services. 8. Child Survival (CS): Two ongoing programs formed the core of the CS strategy; the Universal Immunization Program (UIP) and a wider range of MCH interventions that came to be known collectively as UIP-plus. UIP immunized against six childhood diseases and protected pregnant women against tetanus. UIP-plus provided curative (diarrhea and acute respiratory infections - ARI), preventive (anemia and vitamin A deficiency), and promotive (breast feeding and birth spacing) services. 9. The UIP was already operating in all 466 districts of the country and was to be sustained by the project. UIP-plus components were limited to a few pilot districts, and the project sought to extend them to all districts, phased over five years (1991-92 to 1995-96). 10. Safe Motherhood (SM): in addition to the UIP and UIP-plus components which benefit mothers and the ante- and post-natal services already being provided, the project promoted essential obstetric care (EOC) by: (a) strengthening the training of traditional birth attendants (TBAs) and providing them and pregnant women with pre-sterilized disposable delivery kits (DDKs); (b) training TBAs and auxiliary nurse-midwives (ANMs) in early detection of high- risk pregnancies; and, (c) establishing first referral units (FRUs) for secondary-level obstetrical and neonatal care. 11. FRUs to deal with obstetrical and neonatal emergencies were a significant addition to the UIP and UIP-plus agendas. One FRU was to be established for every 500,000 (in some instances, every 300,000) population by strengthening selected community health centers (CHCs) or other sub-district facilities such as post-partum centers by: adding obstetrician- gynecologists, pediatricians, and anesthetists to their staff; upgrading equipment; and increasing mobility by providing an ambulance for each FRU. 12. While the GOI's CSSM proposal initially supported SM in 215 districts in six states, the program extended it to all states in 1995. IDA support, however, was limited to the six states originally proposed -- Assam, Bihar, Madhya Pradesh, Orissa, Rajasthan, and Uttar Pradesh -- which together contain about half the country's population and are particularly deficient in MCH care.  - 3 - 13. Effectiveness of service delivery was a major concern of the project. The project proposed to enhance it by: (a) strengthening institutional systems, specifically, training of field workers and program administrators in association with private voluntary organizations (PVOs); (b) expanding information, education, and communications (IEC) activities in cooperation with women's and other community groups; (c) strengthening state and district management information systems (MIS) for mid- course corrections and for field workers to plan their activities; (d) enhancing logistics and maintenance systems, including those of the cold chain; and, (e) extending the program's reach through partnership with other public sector programs such as the Integrated Child Development Services (ICDS) program, private medical practitioners, PVOs, and community action groups. 14. The SAR recommended: operational research (OR) studies in nine program areas; a baseline study to establish maternal mortality parameters; policy level reviews of UIP-plus components that had been recently introduced - diarrhea management, nutritional anemia and vitamin A deficiency; and a series of workshops to discuss, and if need be, recast, field workers' work routines. 15. Special aspects: Apart from the country-wide coverage of the project, three other aspects deserve special mention: (a) the project received parallel co-financing from UNICEF and built on activities assisted for several years by UNICEF; (b) project preparation was marked by intensive collaboration among the Ministry of Health and Family Welfare (MOHFW), UNICEF, and the Bank; and, (c) the project was implemented directly by the existing management structure, and not, as in most other projects of comparable size, through a separate project implementation unit (PIU), either at MOHFW or in the health directorates of the various states. 16. The project objectives were wide-ranging yet mutually supportive and, prima facie, manageable. Collectively they comprise a comprehensive approach to the health of children and women, particularly the former. The expected coverage - the number of beneficiaries was  - 4 - expected to double - appears unrealistic in hindsight given the project's four-year duration and phased country-wide implementation. B. ACHIEVEMENT OF PROJECT OBJECTIVES 17. The strategic objective of broadening the scope of the family welfare program was met substantially. MCH now receives more priority in district plans and field workers' activities and this emphasis can be expected to increase even further consequent to the family welfare program's recent discontinuation of its demographic, target-driven approach. In addition, GOI has prepared a project to enhance reproductive and child health and it will be appraised by IDA in early 1997. 18. The financial objective - quick disbursement of funds - was met. After an initial lag, disbursements picked up and the credit was fully utilized by the extended closing date. The UNICEF commitment has also been fully utilized. Table 1: Achievement of Key Child Survival Process Indicators CSSM, India, 1986,1991, and 1996 iNDICATOR 1986 1991 1996 Low birth-weight births identified NA NA NA Immunization, by type of antigen DPT 41% 91% 90% OPV 36% 91% 91% Measles 1% 85% 81% BCG 29% 103% 96% ARI cases treated NA NA NA Diarrhea cases treated NA NA NA Vitamin A prophylaxis NA 20% 62% NA: Not available Source: Immunization coverage: MOHFW Background Paper, ICR workshop; Other: MCH Division, MOHFW, October 1996. 19. The SAR specified service delivery objectives in terms of the absolute number of beneficiaries. However, MOHFW reports the coverage rates (Tables 1 and 3), derived from service statistics. Two other sources also report coverage rates, but derived directly from  surveys: the National Family Health Survey (NFHS), 1992-93, and UNICEF's Multi-Indicator Sample Survey (MICS) 1995-96 round. Both these surveys sampled from the same universe using nearly identical methodologies and, having been done three years apart, provide comparisons over time (Table 2). These surveys show lower coverage rates than those provided by MOHFW, but an increase over time. 20. Child Survival. The objectives related to child survival were mostly achieved. According to the data provided by the MOHFW, immunization coverage increased dramatically -- to near universal coverage -- between 1986 and 1991 (Table 1), before the inception of the project (1992). Subsequently, coverage increased marginally, or in some cases, declined. The NFHS and MICS surveys show lower immunization coverage than that derived from service statistics, but nonetheless, significant progress during the project (Table 2). Field visits confirmed that the supply of vaccines was adequate, the cold chain was well maintained, and parents increasingly brought their children for immunization at their own volition. This suggests that the immunization coverage will rise steadily. Table 2: Coverage of Selected MCH Services, India, 1992-93 and 1995-96 INDICATOR NFHS (1992-93) MICS (1995-96) Children fully immunized 35.6% 52.4% Received oral rehydration salts for 35.6% 34.5% diarrhea Last closed birth interval > 36 months 39.7% 35.4% Pregnant women fully immunized 54.8% 66.6% against tetanus Pregnant women received iron/folate 51.4% 68.8% Source: Extracted from MICS India 1995-96, Draft Summary Report, UNICEF, New Delhi, 16 August 1996, pp 2-5. 21. The UIP-plus components, being more recently introduced, have lagged considerably behind achievements in immunization. No service statistics data are available for UIP-plus components except for Vitamin A prophylaxis, which has registered a substantial increase (Table 1). Surveys show that coverage increased with respect to three out of five indicators (Table 2). According to the statistics provided by MOHFW, 66.3 percent of the children with ARI had been taken to health facility for treatment in 1992-93 and this slipped to 39.2 percent in 1995-96'. However, this is based on two different surveys and could be due to methodological differences between the two surveys. I Implementation Completion Report, India: Child Survival and Safe Motherhood Project, undated, p.13  - 6 - 22. Safe Motherhood. The objectives related to safe motherhood were met partially. In 1996, based on service statistics, an estimated 79 percent of pregnant women were immunized against tetanus and 57 percent received supplementary iron/folate for anemia prophylaxis (Table 3). Surveys show lower coverage for iron/folate, but nonetheless indicate progress (Table 2). Almost all ANMs met during field visits were well versed in identifying high-risk pregnancies - an observation confirmed by UNICEF. A program to train all TBAs was started in 1994 and was expected to be completed by March 1997. However, timely completion is unlikely, given the backlog - in one state at least (Orissa), traditional birth attendant training has not yet commenced - and the low priority accorded to TBA training. The supply of disposable delivery kits was erratic. Table 3: Achievement of Key Safe Motherhood Indicators CSSM, India, 1991 and 1996 INDICATOR 1991 Status 1996 Status Ante-natal registration by NA NA trimester Ante-natal care Tetanus immunization 53.8% 78.8% Anemia prophylaxis and 50.8% 57.0% treatment Examination and tests NA NA Institutional deliveries 25.5% 32.5% Deliveries assisted by trained 34.2% 53. 9% health personnel Low birth-weight births 30.0% NA Post Natal Care NA NA Contraceptive prevalence rate All methods 40.6% 45.8% By methods NA NA NA: Not available Source: Government of India, Implementation Completion Report, Child Survival and Safe Motherhood Project, December 1996. 23. No accurate data are available regarding the functioning of FRUs in the SM states. MOHFW estimated that 2,500 FRUs would be required country-wide. Of these, the location of 1,700 has been identified though only 600 are reported to have started functioning, albeit  - 7 - mostly without blood replacement facilities. No information is available as to the number of obstetrical and neonatal emergencies that have been dealt with at FRUs. 24. During field visits, evidence of a functioning referral system was lacking. ANMs, having identified pregnancies requiring secondary level care, leave to the family the option of where they should seek such care. Not one FRU visited had the full complement of specialists; anesthetists in particular, were lacking. Such specialists are in short supply and hesitant to accept assignments away from district headquarters. The anesthetist posts have not been sanctioned in some states for fear that they will add to the state's financial burden: the recurring costs of FRUs are borne by the states. To circumvent this, general duty doctors assigned to CHCs or sub-district hospitals where the FRU is located are being given short-term training in the required discipline. The provision of ambulances is uneven. 25. Effectiveness of service delivery. Objectives related to increasing the effectiveness of service delivery were met only partially. The training of medical officers of primary health centers (MOPHCs) and paramedical workers has fallen considerably behind schedule. UNICEF reported that, as of December 1995, 31 per cent of MOPHCs and 40 per cent of paramedical workers had yet to be trained, and this excludes those districts where CSSM was extended in Phase V (1996-97)2. Since training should be a continuous process rather than one-time, the backlog seems formidable. A national workshop on training was organized by UNICEF in February 1996, the proceedings of which suggest that PVOs have not so far been involved in the training to any significant extent3. At least three factors appear to have contributed to the lack of progress in training MOPHCs and paramedical workers: competing demands on trainees' time, shortage of trained trainers, and irregular supply of training materials. 26. No reports are available on the management training of program administrators. Discussions with several state and district administrators suggest that management training was given to a select few and not spread evenly across the trainee universe. 27. The IEC achieved considerable success: an awareness level of 95 percent was reported for UIP and UIP-plus components. An integrated multi-media approach was used, including television and radio spots supported by informative handouts distributed to paramedical staff and women. In the last year, most of the IEC was in support of Pulse Polio Immunization campaigns, to the possible neglect of other components. 28. The MIS was designed to span all CSSM components. Performance against key indicators is not available either at MOHFW or in the states. Differences between coverage levels as derived from service statistics and surveys have not been reconciled. There was no evidence of the MIS being used by field level operatives to plan their activities or by their 2 CSSM Donors' Report, April 1995-March 1996, UNICEF, New Delhi, June 1996, p. 23 3 Ibid, p. 24  - 8 - supervisors for monitoring. Beyond providing hardware, MIS operations seem to have received little attention. 29. Material management was satisfactory. The most difficult task of maintaining the cold chain has been successfully accomplished and the responsibility passed on from GOI to the states with equal success. This is due to MOHFW's long experience with, and commitment to, UIP, and UNICEF's continuous assistance. The procurement and supply of equipment to FRUs was stalled and rectified only when, at the Bank's urging, the responsibility was assigned to the Railway Institute for Telecommunication and Signalling (RITES) and UNICEF stepped in to procure equipment domestically and internationally. With few exceptions, the supply logistics for vaccines and other medical supplies worked well, and no shortage was reported. Vehicle supply and maintenance continues to be a problem, especially for FRUs. 30. Collaboration with GOI's Integrated Child Development Services was in evidence: ANMs regularly visit ICDS nutrition centers and Anganwadi Workers (AWWs) assist in immunization and seek the auxiliary nurse midwife's (ANM's) assistance to treat minor ailments of children under their charge. AWWs also stock DDKs. However, joint planning and training exercises were exceptions rather than routine. There was no evidence of private medical practitioners being involved at the field level. PVOs were called upon only to muster people for Pulse Polio Immunization. Women's health committees have been formed at some health sub-centers. Their members were selected by the ANM and assigned responsibilities such as bringing children for immunization. 31. Studies. The project objectives relating to studies were partially met. Much of the baseline data came from the NFHS survey. The Council for Social Development has been commissioned for an end-line survey and Mothercare undertook a review of SM in three states. Eight other studies were done through the Indian Council of Medical Research. Of these eight studies, none has been made available to the Bank. A workshop to identify further study areas was held in July 1996, and its report is awaited. A similar effort was made in February 1996 at UNICEF's initiative and seven OR projects identified; they are expected to be completed by mid-19974. A policy review of ARI was undertaken in 1994 and a similar exercise for Vitamin A prophylaxis and nutritional anemia is to be completed shortly. No workshops to review field worker routines were held. In general, OR studies and associated reviews were not done or considerably delayed. 32. UNICEF collaboration. The collaboration with UNICEF worked well, most notably in the procurement and distribution of cold chain and FRU equipment. Other areas include the design of training modules for MOPHCs and paramedical staff, and program monitoring through MICS. Staff at the UNICEF state offices also provided invaluable insights into field operations. Reciprocally, IDA's assistance helped UNICEF complete its unfinished UIP tasks and gave greater clout to the latter's advocacy role. Ibid, p. 25  - 9 - C. MAJOR FACTORS AFFECTING PROJECT IMPLEMENTATION 33. The CSSM project differed from its IDA-financed predecessors not only in that its scope was country-wide, but also in the range and complexity of its interventions. Project implementation was therefore dependent on a wider range of factors than usual. These fall in three clusters: (a) those largely, but not entirely, outside the implementing agency's control, such as the project's structure and scope, the financial condition of the various states, and the availability of specialists for FRUs; (b) those mainly within the implementing agency's control but determined at the time of project design, especially the choice of implementation strategy; and (c) those entirely within the implementing agency's control, e.g., planning for FRUs. 34. Two aspects of the project's scope severely taxed the managerial capabilities of MOHFW's MCH division: the country-wide coverage and the absence of a specially-created PIU - both unusual for IDA projects in India. This is not to argue that the project should have been limited to selected states: this would have been politically untenable, as evidenced by the GOI extension of SM to all states. Nor is it argued that PIUs would be of benefit in the long run. The point is that the large geographic spread combined with working through existing structures did impose a major implementation burden in the short run. MOHFW, its MCH Division in particular, lacked staff capacity, both in numbers and range of expertise, to handle this heavy and variegated burden. 35. The financial position of some states weakened in the 1990s, the safe motherhood ones in particular. The release of CSSM allocations for locally-incurred expenditures such as the training of TBAs, supply of DDKs and reimbursement of travel costs, was considerably delayed and funds were not utilized in time nor carried to the next fiscal year. Thus, TBAs were not trained and DDKs were not regularly available, to facilitate safer domiciliary deliveries. 36. Nearly all states found it difficult to position qualified specialists, especially anesthetists, at FRUs. Some sought to remedy this by short training programs for general duty medical officers. However, in quite a few states, the trainees were reluctant to accept responsibility when back at the FRU. The training, they said, was inadequate, no protection was offered from the Consumer Protection Act, and they were denied specialist rank and pay when they were doing the same work as the formally appointed specialists. The proposed Reproductive and Child Health project will address this problem in part by contracting specialists from the private sector. 37. From the strategic and managerial perspectives, CSSM had two kinds of programs: (a) the UIP which was concerned exclusively with immunization; and (b) UIP-plus and essential obstetric care (EOC) which had more varied components. The UIP lent itself to top-down  -10- planning, target setting, and a high degree of centralization. Further, it required only passive compliance from the beneficiary, i.e., parents had to bring their children to a predetennined place at a predetermined time to have them immunized. On the other hand, UIP-plus, its curative components in particular, and much of EOC could only be served by bottom-up planning, demand for services by the end user, and required the active participation by intended beneficiaries; to that extent they do not readily lend themselves to performance targets. The CSSM strategy was inherited from UIP5 and characterized by a high degree of centralization and "push" of supplies and services. In further evidence of the degree of centralization, training modules were centrally designed and the composition of drug kits supplied to ANMs was determined by MOHFW and uniform across the country. As could be expected, not only were the UIP achievements higher but its activities received more support from training, IEC, and MIS, to the neglect of much of UIP-plus and almost all of EOC. 38. FRUs were a major addition to the UIP and UIP-plus agendas and differed from them on at least four counts: (a) all other activities were field-based, while FRUs provided institutional care; (b) other interventions were top-down and discrete, while FRUs required patients to flow in the reverse direction and the referral system to function well; (c) FRUs would mainly be located in urban areas and run into competition with private sector facilities; and (d) while selected recurrent costs of UIP and UIP-plus were supported by the project, those of FRUs were not. None of these factors seems to have been taken into account in the training, IEC, or MIS. Access to transport for moving patients to or from FRUs was not provided to any significant extent. FRUs suffered, as a senior program administrator put it, "from faulty planning, both in space and time". D. PROJECT SUSTAINABILITY 39. The financial sustainability of the project appears likely. The SAR estimated the recurrent costs to be about Rs. 1,524 million or about 3.4 percent of projected MCH expenditures. However, this probability needs to be qualified. In the first place, the Ninth Plan is yet to be formulated. Though there is no reason to believe that it will curtail MCH expenditures, the level of finance for capital items is uncertain. Second, the recurrent cost of UIP and UIP-plus components are met by the GOI; those of FRUs are the responsibility of states, and they, the SM ones particularly, have less stable finances. 40. Programmatically, the UIP achievements are likely to be sustained. Both the supply and demand sides of immunization have been developed to the take-off point and it is reasonable to expect that immunization coverage will increase with minimal additional inputs. The UIP-plus components impose no heavy financial burden and are likely to be sustained. 41. The FRUs are not yet fully functional as referral centers (see paras. 22 and 23, above). Their sustainability in terms of added functions is, therefore, unclear. Child Survival and Safe Motherhood - India, Ministry of Health and Family Welfare, July 1991, p. 11 et seq  - 11 - E. BANK PERFORMANCE 42. The Bank's performance was satisfactory with respect to project identification, preparation assistance, and appraisal. The Bank assisted GOI in developing the long-term vision needed for MCH activities. 43. The Bank's supervision was focused mainly on resolving critical finance procurement, and implementation hurdles, and did so satisfactorily. Technical supervision was greatly aided by the assistance provided by UNICEF, including its regional offices. In addition, UNICEF provided valuable assistance in facilitating the procurement of equipment for the project. 44. Task management was transferred to the New Delhi resident staff in February 1994. From then on, supervision missions were carried out one state at a time, and supervision reports submitted after several state visits. Delhi-based supervision facilitated the resolution of pro- curement and disbursement problems, by making continuous follow-up easier. F. BORROWER PERFORMANCE 45. The borrower's performance was satisfactory with respect to project preparation, which was worked out in adequate detail. The project's strategy, in hindsight, appears limited (para. 36). In particular, it was deficient in planning for FRUs (para. 37). 46. Implementation was satisfactory with respect to utilization of the credit and the phasing of districts. Drugs and medical supplies were provided to far-flung service delivery points. IEC was well developed and effective for the UIP components. However, performance was deficient in five areas: training, MIS, OR studies, the involvement of private medical practitioners, PVOs and community groups, and reporting. 47. Compliance with several covenants was delayed (see Table 8). MOHFW did not provide the Bank with Annual Plans and Monitoring Reports on time. Nor were reviews of MIS, OR studies, nutritional anemia, vitamin A prophylaxis, and field worker routines undertaken in a timely way. Finally, several planned studies were not undertaken and others were delayed. G. ASSESSMENT OF OUTCOME 48. The overall outcome is satisfactory: the project achieved its major objective in broadening MOHFW's family welfare strategy. The main service objectives other than EOC were met. Critical institutional objectives such as MIS strengthening, OR studies, and private sector involvement were not, but this did not prevent the project from achieving its development objectives. When the project began, budgetary cutbacks threatened health programs generally. The project was instrumental in not only sustaining MCH but expanding it. One of the more noteworthy outcomes is that the concern for women - safe motherhood - has been brought closer to center stage. Though achievements in safe motherhood have fallen short  - 12 - of expectations, the means have been clarified and widely accepted. The MOHFW is now initiating further support for women's health and will integrate these efforts with programs for adolescent girls. 49. The MOHFW is aware of the shortfalls of its CSSM program. These were discussed at the workshop held during the Implementation Completion Mission and elaborated in the Aide- Memoire of October 25, 1996 (Appendix A). Some of the remedial action, such as OR studies and policy reviews, can be undertaken by March 1997. Most others will require more time. H. LESSONS LEARNED 50. The CSSM project differed from its predecessor family welfare projects on at least three counts: it was country-wide, it was reform-oriented, and several of its interventions such as the treatment of ARI, diarrhea, and EOC required clients to take the initiative. Assuming that successor projects will be similar in these respects, the lessons leamed from the project are of great relevance. 51. First, the expanded scope of activities undertaken in CSSM required greater modifications in program strategy than were adopted. CSSM added UIP-plus and EOC to UIP but did not either decentralize operations sufficiently, or put in place an enhanced program management capacity. 52. Second, a country-wide project needs a well-functioning MIS for monitoring and mid- course corrections which CSSM lacked. A project with varied, often competitive, activities and a "life cycle" approach needs an MIS tailored to field operatives' requirements for planning. CSSM's MIS was found wanting on both counts (para. 27, above). The experiences of other health and family welfare projects, including IDA-assisted ones, have been similar. What is required is an MIS design keeping implementation and the needs and limitations of field workers in mind. This approach is being followed in the proposed Reproductive and Child Health Project. 53. Third, if involvement of the private sector is imperative to meet project objectives, mechanisms to ensure such involvement and monitor progress must be built in, such as in performance reporting. Further, the ways of involving the private sector need to be tailored to its varied segments. The private sector is not homogeneous; for example, the treatment of ARI and EOC differ. Curative services, such as for ARI, are overwhelmingly provided by private medical practitioners, most of whom in the rural areas are not members of the Indian Medical Association and can only be approached at district or lower levels. Conversely, EOC requires women to be mobilized to demand services. This requires local women's groups to be activated but such groups can only gather strength if networked with larger and more established ones, and the latter will not accept secondary roles which are handed down. They need to be involved at the design stage. Active and purposeful partnership with PVOs is as difficult as it is necessary.  - 13 - 54. Fourth, systematic management training must be a major concern for large and complex projects. CSSM's mandate was larger and more complex than say, UIP, or any other single- purpose program and its management more taxing. Future projects could profit by paying greater attention to broad-based, not project-specific, management training at district and higher levels. This should be a continuous process, spread evenly across the trainee universe, and based on a rigorous management needs assessment. One option would be to liaise with established management institutions, particularly those with experience of mid-career training, and entrust management development for one or two states to each of them on a long-term basis.   - 14- PART II: STATISTICAL TABLES Table 1: Summary of Assessments A. Achievement of Objectives Substantial Partial Negligible Not Applicable Macro policies Wx Sector Policies W xII Financial objectives [] E Institutional development W [I L Physical objectives I ] x I Poverty reduction K xKK Gender issues K K] Other social objectives ] K] K Environmental objectives K K K E Public sector management K K K] Private sector management K K ]  - 15 - Table 1: Summary of Assessments (continued) B. Project sustainability Likely Unlikely Uncertain E I C. Bank performance Highly Satisfactory Deficient Satisfactory Assessment W 7 Preparation assistance W EL Appraisal lI lE Supervision lT Ll D. Borrower performance Highly Satisfactory Deficient Satisfactory Preparation L LI Implementation L LI Covenant Compliance I L L Operation (if applicable) L L L E. Assessment of outcome Highly Satisfactory Unsatisfactory Highly Satisfactory Unsatisfactory LI LI LI LI  - 16- Table 2: Related Bank Loans/Credits Credit Title Purpose Year of Status Approval First Population Project To support the family welfare program in five 1972 Credit closed CR 312-IN districts of Mysore (now Karnataka) and six dis- June 30, tricts of Uttar Pradesh. 1980 Project Completion Report (PCR) 6/81; PPAR 1/82 Second Population To support the family welfare program in six 1980 Credit closed Project districts of Uttar Pradesh and three districts of March 31, CR 981-IN Andhra Pradesh. 1988 PCR 1/90; PPAR 8/90 Tamil Nadu Integrated To improve the nutritional and health status of 1980 Credit closed Nutrition Project I preschool children and pregnant and nursing March 31, (TINP I) women. 1989 CR 1003-IN PCR 1/91; Impact Evaluation Report 12/94 Third Population Project To support the family welfare program in six 1984 Credit closed CR 1426-IN districts of Karnataka and four districts of Ker- March 31, ala. 1992 PCR 8/93 Fourth Population To support the family welfare program in four 1985 Credit closed Project districts of West Bengal. March 31, CR 1623-IN 1994 PCR 12/94 Fifth (Bombay and To reduce infant, child and maternal morbidity 1988 Credit closed Madras) Population Project and mortality and to moderate fertility in the cit- March 31, CR 1931-IN ies of Bombay, Madras and other urban areas of 1996 Tamil Nadu, and to assist the Municipal Authorities in designing and implementing im- ICR 10/96 proved health and family welfare programs. Sixth (First National Family To support the family welfare program in the 1989 Credit Welfare Training and states of Uttar Pradesh, Andhra Pradesh and scheduled to Systems Development) Madhya Pradesh. close March Population Project 31, 1997 CR 2057-IN Tamil Nadu Integrated To extend the successful TINP program to all of 1990 Credit Nutrition Project 11 Tamil Nadu's 20,000 villages. scheduled to (TINP 11) close CR 2158-IN December 31, 1997  - 17 - Table 2: Related Bank Loans/Credits (continued) Credit Title Purpose Year of Status Approval Integrated Child To improve the nutrition and health standards of 1990 Credit Development Services pre-school children and mothers in tribal, scheduled to Project I (ICDS I) drought-prone and otherwise disadvantaged ar- close CR 2173 -IN eas of Andhra Pradesh and Orissa. December 31, 1997 Seventh (Training) To support lower-income women in the rural ar- 1990 Credit Population Project eas of Bihar, Gujarat, Haryana, Jannu, Kashmir scheduled to CR 2133-IN and Punjab, through the training of new and ex- close June isting health workers and non-Health Department 30, 1998 personnel. Eighth (Family Welfare To help the Government of India increase the 1991 Credit Urban Slums) Population supply of family welfare services in the slum scheduled to Project populations of Andhra Pradesh, Karnataka, West close June CR 2394-IN Bengal and Delhi. 30, 2001 Integrated Child To improve the nutrition and health status of pre- 1993 Credit Development Services school children and their mothers by strengthen- scheduled to Project II (ICDS 11) ing and increasing the outreach of the ICDS pro- close CR 2470-IN gram in Bihar and Madhya Pradesh. September 30, 2000 Ninth (Family Welfare To support the family welfare program in the 1994 Credit Assam, Rajasthan and states of Assam, Rajasthan and Karnataka. scheduled to Karnataka) Population close Project December CR 2630-IN 31, 2001 Table 3: Project Timetable Steps in Project Cycle Date Depart Preparation Mission November 27, 1990 Depart Appraisal Mission April 17, 1991 Start Credit Negotiations August 14, 1991 Board Approval September 17, 1991 Credit Signing February 20, 1992 Credit Effectiveness March 05, 1992 Original Closing Date September 30, 1995 Revised Closing Date September 30, 1996  - 18- Table 4: Credit Disbursements: Cumulative, Estimated and Actual (US$ millions) FY92 FY93 FY94 FY95 FY96 FY97 / I SAR Appraisal Estimate 46.20 93.60 151.40 207.40 214.50 214.50 Actual 29.40 46.79 83.97 153.46 209.02 234.54 Actual as Percentage of 64 50 55 74 97 109 Estimate /I The Credit was fully disbursed (100 percent in SDR terms) on December 5, 1996. Table 5: Key Indicators for Project Implementation Key Implementation Indicators in the Estimated Actual SAR/MOP 1990 Status 1996 Status 1. Child Survival a. Low birth-weight births 30% Not available b. Immunization coverage by type and dose DPT/OPV 70% (1991) 90% OPV 76% (1989) 91% Measles 69% (1992) 81% Tetanus Toxoid 65% 79% c. ARI cases treated Not available Not available d. Diarrhoeal disease cases treated Not available Not available e. Vitamin A prophylaxis 20% 62% 2. Safe Motherhood a. Antenatal registration by trimester Not available Not available b. Antenatal care including: tetanus toxoid 65% 79% anemia prophylaxis (I&F) and treatment 60% 57% examination and tests c. Attendance at delivery by type Not available Not available Deliveries by Deliveries by trained TBAs trained TBAs d. High-risk referrals by type 40% (1991) 48.8% (1993) e. Post-natal care Not available Not available f. Contraceptive prevalence Not available Not available 42% (1989) 46.5%  - 19 - Table 6: Studies Included in the Project Title Status Impact 1 Program Management Not done 2 District Planning Not done 3 Persistent Diarrhea Completed Used in training 4 Acute Respiratory Infection Completed Used for planning 5 LBW Babies Not done 6 Anemia Prophylaxis Completed Guided modifications 7 SM Referral Not done 8 Field-level Communication Completed Guided strategy 9 Social Marketing of ORS Not done Table 7A: Project Costs by Category of Expenditure Original Estimate (US$m) Actual Disbursement (US$m) i 1 Source Local Foreign Total Local Foreign Total Civil Works 20.91 2.57 23.48 l Equipment, Vehicles, Medicines, Vaccines, 171.79 34.57 206.36 Vitamins, IEC Materials, and MCH Medical Supplies Consultants' Services and 53.56 1.14 54.70 Training Operating Costs 48.52 1.20 49.72 Special Account l Physical Contingency 23.85 3.76 27.61 Price Contingency -35.58 3.29 -32.29 TOTAL 283.05 46.53 329.58 /1 Data not available from GOI. Table 7B: Project Financing Original Estimate (US$m) Actual/Latest Estimate (US$m) Source Local Foreign Total Local Foreign Total IDA 179.20 35.30 214.50 n.a. n.a. 234.54 GOI /I 47.30 - 47.30 n.a. n.a. 126.12 UNICEF 56.60 11.20 67.80 56.6 11.2 67.80 Total Project Costs 283.10 46.50 329.60 n.a. n.a. 428.46 /1 GOI maintains records only in Rupees; a blended rate of 32.96 was used to convert actual GOI financing into US dollars.  - 20 - Table 8: Status of Legal Covenants Agreement Section Covenant Original Revised Status Comments Description Class(es) Fufill- Fulfill- ment ment Date Date CREDIT Sch. 5 1/31/94 CD The Borrower shall by January 31 4-1. each year, in consultation with the Association and in accordance with a phased implementation schedule agreed to by the Association, prepare a draft Safe Motherhood Plan. The Plan shall be implemented in a timely manner and based on the Safe Motherhood Model Plan pre- pared by MOHFW and acceptable to the Association. CREDIT Sch. 5. 9, 10 1/31/94 CD The Borrower shall, by January 31 4-2. of each year, prepare and submit to the Association for its review: (a) an Annual Plan regarding implementa- tion of UIP, (b) an annual plan re- garding implementation of UIP Plus, and (c) an Annual Plan regard- ing implementation of the Safe I_______ ____________________________ M other hood Program . CREDIT Sch. 5 C The Borrower shall cause the Project 4-3 Entities (states) to institute district (a). planning, including community par- ticipation and civil works programs, based on MOHFW guidelines ac- ceptable to the Association. Sch. 5 C District UIP plus plans have The Borrower shall ensure that no CREDIT 4-3 been prepared by all project district is included in the Project (b). districts. unless it has completed a district UIP Plus Plan, based on MOHFW guide- lines acceptable to the Association. CREDIT Sch. 9, 10 4/1/92 C A national mortality review The Borrower shall, in consultation 4-4. committee has been established. with the Association establish Na- Plans for maternal mortality data tional and Regional Mortality Re- collection are proceeding. De- view Committees to monitor, evalu- centralization to state level has ate and assist MOHFW in the im- been decided upon, instead of plementation of the Safe Mother- regional committees. hood Program. CREDIT Sch. 5 1/1/92 C Distribution of tasks and work The Borrower shall institute on a 4-5. routine changes for health work- national basis, distribution of tasks ers have been prepared and form and work routine changes for health part of training. These are being workers satisfactory to the Associa- instituted on a national basis. A tion. government order has been is- sued and implemented. CREDIT Sch. 5 4/1/93 C Transfer completed. The Borrower shall transfer mainte- 4-6. nance of the cold chain system to the Project Entities (States). CREDIT Sch. 5. to C The process of redeploying staff, The Borrower shall appoint or cause 4-7. creating new posts, and surren- the Project Entities (States) to ap- dering other positions is pro- point, key additional staff: according ceeding. to a schedule satisfactory to the As- sociation.  - 21 - Table 8: Status of Legal Covenants (continued) Agreement Section Covenant Original Revised Status Comments Description Class(es) Fufill- Fulfill- ment ment Date Date CREDIT Sch. 9, 10 C The Borrower shall: (i) utilize key 4-8 performance indicators satisfactorv to (i). the Association for evaluating prog- (i).______ ress of the Project. CREDIT Sch. 9, 10 C The Borrower shall furnish to the 4-8 Association, annual monitoring re- (ii). ports. CREDIT Sch. 9, 10 6/30/96 NYD Summative evaluation report The Borrower shall furnish to the 4-8 will now be undertaken. Association, an end-of-project sum- (iii). mative evaluation report focusing on _________ ________ ~~~~~~~~~~~~~~~~~~the impact of the Project. CREDIT Sch. 9,10 CD Project management taking The Borrower shall take necessary 4-8 action to accelerate the safe corrective actions as may be required (iv). motherhood component, which in implementation of the integrated is lagging. package of services of UIP Plus and Safe Motherhood Programs to achieve project objectives. CREDIT Sch. 5 4/1/92 C Modifications have been agreed The Borrower shall: (i) review the 4-9. and carried out. management information systems currently used in its health and fam- ily welfare programs in order to as- sess their conformity with functional guidelines agreed with the Associa- tion, (ii) indicate to the Association, the modifications it will make to its system to bring these into conformity with such guidelines. CREDIT Sch. 3, 5 1/11/92 C Planned budgetary allocations The Borrower shall: (i) maintain the 4-10 were maintained for FY92, levels of planned budgetary alloca- (a). FY93, FY94 and FY95. tions for the National Maternal and Child Health Program as agreed with the Association. For Fiscal Years 1991-1995; (ii) consult with the As- sociation before proposing any major change to such allocations: (iii) commencing in 1992, furnish to the Association for its review the annual plan budget allocation for such pro- gram for the Fiscal Year. CREDIT Sch. 2, 3 C All the states have signed their The Borrower shall cause the Project 4-10 respective letters of undertaking Entities to provide the required (b). (LOU), under which they will budgetary support for undertaking provide budgets for civil works. civil works under the Project. CREDIT Sch. 5 1/1/92 C The national advisory commit- The Borrower shall maintain its Ma- 4-11. tee on MCH has been main- ternal and Child Health Care Advi- tained. MOHFW and MOHRD sory Committee and institute reviewed existing MCH/ICDS mechanisms satisfactory to the As- mechanisms and found them sociation, for coordinating the activi- adequate if enforced. A letter ties of the MCH Program and ICDS was issued to the states instruct- Programs under the Project. ing them to enforce and monitor them.  - 22 - Table 8: Status of Legal Covenants (continued) Agreement Section Covenant Original Revised Status Comments Description Class(es) Fufill- Fulfill- ment ment Date Date CREDIT Sch. 9, 10 5/1/92 CD A number of studies, including The Borrower shall furnish to the 4-12. coverage evaluation surveys, Association for review, a phased have been conducted and re- program of operational research and ported, and others are planned. studies, including proposed imple- mentation arrangements for the studies. CREDIT Sch. 5 5/31/91 CD UNICEF assisting with pro- The Borrower shall enter into an 4-13. curement of equipment. agreement with UNICEF for assis- tance in the procurement of selected equipment and vehicles, and institu- tion and development of a program to improve the capacity of MOHFW and DOHFW regarding procurement and logistics for other equipment and materials. Status: C - Complied with CD - Compliance after Delay NC - Not Complied with SOON - Compliance Expected in Reasonably Short Time CP - Complied with Partially NYD - Not Yet Due Covenant Class: I Accounts/audit 2 Financial performance/generate revenue from beneficiaries 3 Flow and utilization of project funds 4 Counterpart funding 5 Management aspects of the project or of its executing agency 6 Environmental covenants 7 Involuntary resettlement 8 Indigenous people 9 Monitoring, review and reporting 10 Implementation 11 Sectoral or cross-sectoral budgetary or other resource allocation 12 Sectoral or cross-sectoral regulatory/institutional action 13 Other  - 23 - Table 9: Compliance with Operational Manual Statements The ICR did not identify any deviation of substance from the relevant OMS. Table 10: Bank Resources: Staff Inputs Stage of Project Cycle Planned /1 Revised /1 Actual Weeks 1000US$ Weeks 1 000US$ Weeks 1 000US$ Preparation to Appraisal 67.5 127.6 Appraisal 98.5 185.8 Negotiations through Board Approval 6.5 12.0 Supervision 191.4 360.8 Completion 8.0 2.2 TOTAL 371.9 688.4 /I Not available  - 24 - Table 11: Bank Resources: Missions Stage of Month/Year Number Days in Specialization Performance Rating 13 Problems /4 Project Cycle of Field Represented /Z Persons Imple- mentation Dev. Object. Preparation November- 5 18 A, EC, FMP, December PH, PHY _______ ______ 1990 _ _ _ _ _ _ _ Appraisal April-May 13 23 A, CPS, EC, 1991 ME, PH, PHY Supervision I March 1992 7 5 A, CPS, DEM, I EC, ME, PHY, Supervision 2 April 7 2 A, DEM, 2 2 AF, CL, FP, 1993 IEC/NGO, M, M, PR, S, TA, MIS, PHY, TS WID Supervision 3 /1 February - 4 21 FMP, PH, WID S S AF, CL, FP, M, June, 1994 PR, TA, S, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ W ID Supervision 4 /1 July 1994 - 4 42 FM, ML, PH HS S M, S, TA, WID June 1995 , , _ Implementation September- 3 12 FP, PH, TM S S M Completion October 1996 Mission /I Forms 590 were prepared periodically based on multiple state visits carried out over several months. Supervision 3 represents five separate state review visits that occurred from February to June 1994. These included Bihar (June 13-16 1994), Orissa (March 15-18 1994), Rajasthan and Madhya Pradesh. These missions were consolidated into a single supervision and Form 590, which was produced in June 1994. Supervision 4 represents 10 state reviews which took place from July 1994 to June 1995. States visited included Gujarat, Assam, Uttar Pradesh, Madhya Pradesh, Orissa, Maharashtra, Rajasthan, Haryana, Punjab and Andhra Pradesh. A single supervision report and accompanying Form 590 was produced in September 1995. /2 A = Architect, CPS = Community Participation Specialist, DEM = Demographer, EC = Economist, FM = Finance/Management Specialist, FMP = Finance/Management/Procurement, FP = Finance/Procurement, IEC/NGO = Information, Education, Communication /Non-governmental Organization Specialist, M = Management, ME = Medical Educator, MIS = Management Information Systems Specialist, ML = Mission Leader, PH = Public Health Specialist, PHY = Physician, SMS = Safe Motherhood Specialist, TS = Training Specialist, TM = Task Manager, WID = Women in Development Specialist. /3 I = No Significant Problems, 2 Moderate Problems (i.e., there are significant, but not critical problems from appraisal expecta- tions). HS = Highly Satisfactory, S Satisfactory. Please note that the HS/S ranking codes were first utilized with supervision 3. /A AF = Availability of Funds, CL = Compliance with Legal Covenant, FP = Financial Performance, M = Project Management Per- formance, PR = Procurement Progress, S = Studies Progress, TA = Technical Assistance Progress, WID = Women in Development Im- pact. Problem areas indicated are based on a rating of 2 from the respective Form 590s; none of these areas rated 3 during the life of the project.   Appendix A Page 1 of 13 INDIA CHILD SURVIVAL AND SAFE MOTHERHOOD PROJECT (CREDIT 2300-IN) WORLD BANK IMPLEMENTATION COMPLETION MISSION SEPTEMBER 30-OCTOBER 11, 1996 Aide-Memoire 1. A World Bank implementation completion mission was undertaken from September 30- October 11, 1996. The mission consisted of Dr. Anthony Measham (PHN Adviser and task manager), Mr. R. Sethuraman (Finance Specialist) and Dr. Lessel David (Consultant Public Health Specialist contracted to draft the ICR). The Ministry of Health and Family Welfare (MOHFW) hosted a national workshop from September 30-October 1, 1996 to review the les- sons learned from the CSSM project. In addition, MOHFW requested Mothercare, financed by USAID, to send a team to India for one month to undertake an independent review of the CSSM project. Dr. David accompanied the Mothercare team to the states of Madhya Pradesh and Orissa. His report, which summarizes the main findings of the ICR mission, is attached as An- nex 1 to this Aide-Memoire. 2. The mission would like to express its appreciation to the Department of Family Welfare for their cooperation, and for the excellent arrangements made for the successful workshop. The mission would also like to extend its thanks to the Governments of Madhya Pradesh and Orissa for receiving the mission, and to UNICEF, Mothercare and USAID for the valuable assistance in reviewing the lessons learned from the project. Mission Objectives and Overall Progress 3. The objectives of the mission were: (a) to review project progress in the final months leading up to the closing date of September 30,1996; (b) to discuss the views of the Borrower, the Bank, and other interested parties on the main lessons learned from the project, especially as they relate to the Government's Reproductive and Child Health Program; and (c) provide support to the Borrower in the preparation of its contribution to the ICR. 4. Progress on the Child Survival activities has continued to be good since the Rajasthan mission in May 1996. Details are given on progress in Madhya Pradesh (M.P.) and Orissa in Annex 1. The Safe Motherhood activities, especially the operationalization of the first-referral units (FRUs) has continued to lag, although it is not clear exactly how many are now operational. Annex I provides information on the slow progress evident in M.P. and Orissa. Good progress has continued on procurement and on disbursement: the credit is over 95% disbursed and it seems likely that the credit will be fully disbursed before January 31, 1997, the last date for dis- bursements. With the adoption by Government of India of the Reproductive and Child Health (RCH) approach, and the likely appraisal of a large, IDA-financed RCH project early in 1997, the prospects for CSSM project activities being sustained look good.  AppendixA Page 2 of 13 5. Financial Performance. The credit became effective in March 1992, six months after Board approval. Implementation began slowly, and the allocations for the first three years of the project fell short of the amounts specified in the project approved by the Expenditure Finance Committee (EFC). GOI increased the allocations for FY1994-95 and FY1995-96, thereby fully meeting the agreed commitments. Disbursements picked up correspondingly, particularly after procurement delays were resolved (see below). Nevertheless, the slow start and four-year proj- ect period combined to make it impossible to fully implement the project before the closing date, and the project was extended for a one-year period up to September 30, 1996. The UNICEF parallel co-financing of $67.8 million has been fully disbursed. 6. Procurement. Progress on procurement, which accounts for the major share of the proj- ect, began very slowly. Accordingly, the Bank recommended in late 1993 that responsibility for procurement be shifted from DGS&D to RITES, and that UNICEF be requested to assist with some of the procurement. These changes were instituted in August 1994 and dramatically im- proved the procurement performance. UNICEF contributed in two major ways. First, a major review was undertaken of the capacity of Indian suppliers to make available equipment and supplies in sufficient quantity and of acceptable quality. Second, when indigenous suppliers could not provide all the equipment needed for the project, UNICEF undertook offshore pro- curement, and arranged for shipment after consolidating the purchases in its Copenhagen ware- house. District-level delivery was then arranged after receipt of the goods in India. UNICEF thus made a major contribution to the implementation of the project, in assuring that the FRUs were equipped with the necessary items. Without this assistance, it is highly unlikely that the disbursements would have reached the high level achieved, and a major objective of the project would have been only partially achieved, i.e., equipping the FRUs. 7. Annex I provides a brief summary of the mission's findings on service delivery, based on field visits to M.P. and Orissa. Annex 2 outlines the approach to be taken in drafting the ICR. Project Issues 8. There are no outstanding project issues, except that the covenant annex has not yet been revised, since the last supervision report. The updated covenant annex will form part of the im- plementation completion report which is under preparation. 9. The rest of the Aide-Memoire is devoted to the ICR process, the CSSM Review work- shop and the preliminary findings to be elaborated in the ICR. Implementation Completion Report 10. In July 1996, the task team met with the project authorities and subsequently wrote to the Government of India requesting that MOHFW prepare its contribution to the ICR, make avail- able data required for that report, and organize the review workshop. The Department of Family Welfare invited 12 states, bilateral and multilateral donors, 10 NGOs and 15 professional asso- ciations and national experts to participate in the workshop. The workshop was well attended by about 50 participants, including the four-person Mothercare team. The presentations and dis- cussions were of a generally high standard.  Appendix A Page 3 of 13 11. Progress with the CSSM project was assessed against the original objectives, which were as follows: * assist GOI to move the family welfare program to broader MCH concerns, espe- cially improving the capacity of the maternity care system; * assist GOI to maintain the social safety net, expand services to underserved areas and beneficiaries, and implement the integrated and cost-effective interventions proposed for 1991-1995; * put more emphasis on targeting resources to most needy, more participation of communities, PVOs, the private sector, and district-level planning and management; and * promote a holistic approach to the delivery of MCH services 12. The major achievements of the project are believed to be the following: * CSSM provided a bridge to the Reproductive and Child Health Approach * CSSM catalyzed district and state-level support for the family welfare program * CSSM revitalized the sub-center and enhanced the credibility of the ANM * CSSM strengthened the training of ANMs and other health and family welfare workers C GSSM strengthened child survival efforts, especially through immunization 13. Subject to confirmation in the ICR process, the following aspects of the project were judged by the mission to be less successful: * operationalizing the FRUs - specialists lacking * establishment of the referral system * involvement of communities in Safe Motherhood efforts * provision of transport for obstetric emergencies 14. Finally, key areas where further information is required to assess the success or lack thereof in the project are the following: * what services have been provided? * how many FRUs are operational? * what are the research findings?  Appendix A Page 4 of 13 15. The Borrower, the Bank, UJNICEF and other interested parties appear to be in general agreement with the main achievements of the project and those which did not succeed to the same extent. The ICR will attempt to articulate these further and substantiate its findings on the basis of data to be collected in the field, provided by GOI, and contributed by the Mothercare review. In addition, the ICR will endeavor to explain the reasons for the relative success of dif- ferent elements of the project. It is already clear that the CSSM project and program played a strategic role in the shift of the GOI Family Welfare Program from a top-down, demographi- cally-driven approach, to the broad-based reproductive and child health approach of 1996, which emphasizes serving individual client needs and enhancing the quality of services. Next Steps 16. The MOHFW is requested to provide its contribution to the ICR by November 30, 1996 and to furnish the data requested in our letter of July 30, 1996. 17. A first draft of the Bank's contribution to the ICR will be completed by November 30, 1996 and comments will be solicited from GOI and UNICEF. The draft ICR, including the GOI contribution, will be submitted to the Bank's headquarters by December 31, 1996. It is due to be sent to the Board by March 31, 1997.  Appendix A Page 5 of 13 Annex I REPORT ON CSSM MISSION TO MADHYA PRADESH AND ORISSA MADHYA PRADESH October 7 - 9, 1996 Persons met: Mr. P Mehrotra, Principal Secretary to Govt, Health Dr. P K Bajaj, Director, Health and Family Welfare Dr. Ms Sahu, Joint Director, MCH CMO and staff, Raisen District BMO and staff, Sanchi FRU Dr. Manu Kulkami, State Representative, UNICEF Dr. Yogendar Mathur, Project Officer, UNICEF Dr. T P Sharma, Technical Adviser, Danida Assisted H & FW Project Dr. B L Sharma, Coordinator, Danida assisted leprosy project. Child Survival The reported incidence of neonatal tetanus, polio, measles and diarrhea declined during 1995 - 96. However, immunization coverage seems to be slipping (Table 1). Though program administrators were aware of this, there was no evidence of any remedial steps taken by them apart from stepping up Pulse Polio Immunization. Table 1: Percent of Children Fully Immunized, by Antigen and Year, Madhya Pradesh Year DPT OPV BCG Measles 1992 - 93 79.0 84.5 81.5 67.3 1993 - 94 88.6 88.9 93.0 99.6 1994 - 95 96.7 96.9 104.2 99.6 1995 - 96 86.2 86.7 88.5 74.2 Source: Directorate of Public Health and Family Welfare, Madhya Pradesh, Status Paper on CSSM, August 1992 to September 1996, p 14 The state has assumed responsibility to maintain the cold chain and was doing it well. Equipment breakdown less than one per cent and trained mechanics available in nearly all districts. Safe Motherhood About 85 per cent of the deliveries are domiciliary. Any attempt to decrease their number must reckon with the poor physical infrastructure; two out of every three sub health centers function from rented buildings and a similar proportion of CHCs do not have adequate buildings. The supply  Appendix A Page 6 of 13 of DDKs, critical to domiciliary deliveries, is erratic. The training of Traditional Birth Attendants (TBAs) was stalled up to 1994 and is reported to have picked up since then though the number trained was not available. First Referral Units (FRU) Of the 228 institutions identified for upgrading to FRUs, 160 of them are reportedly equipped - with hydraulic operation tables, shadowless lamps and wall clocks! The remaining are expected to be equipped by the end of this year. One of the FRUs visited was less than 10 kms from a headquarters hospital of an adjoining district and, inevitably served for walk-in deliveries and not as a referral center. UNICEF felt about 15 to 20 per cent of the FRUs in the state were similarly sited. Of institutions where FRUs are, or will be located, 40 per cent have less than 20 beds and 20 per cent six or less. Training About a quarter of the field personnel have yet to be trained. The training of medical officers for specialist functions at FRUs was started in June 1996 and 100 are reported to have been trained. A breakdown by discipline was not available. ORISSA October 10 - 12, 1996 Persons met: Ms. M Gupta, Secretary to Govt and Commissioner, Health and FW Dr. Kanaklata Joshi, Director, Family Welfare Dr. S P Misra, Joint Director, MCH Dr. I C Mohanty, Joint Director, FW Dr. Dipti Mukerji, Deputy Director, MCH Mr. Vinod Alkari, State Representative, UNICEF Dr. V Pillai, Health Adviser, Orissa Health and FW project, Orissa Dr. N Sathpathy, Coordinator, Danida leprosy project Ms. Shanta Ray, Health Ed. adviser, Danida leprosy project. Child Survival The percentage of infants immunized range from 83 per cent (measles) to 101 per cent (BCG). Those receiving routine micronutrient range from 83.8 (anti anemic) to 143.0 (vitamin A). However, the immunization coverage evaluation survey (1992 - 93) by UNICEF in seven major districts shows significant gaps between coverage levels as estimated from service statistics and from surveys (Table 2). No attempt has been made to reconcile these two sets of figures.  Appendi2 A Page 7 of 13 Table 2: Immunization Coverage, as Estimated from Service Statistics and Survey Seven District Averages, by Antigen, Orissa, March 1993 Antigen Per cent coverage as estimated from Service Statistics Survey Oral Polio 80.1 51.3 Measles 85.8 52.4 BCG 100.8 55.6 DPT 92.6 63.4 Source: Coverage Evaluation Survey in Orissa, April 1992 - March 1993, UNICEF The cold chain equipment breakdown is of the order of eight per cent. Safe Motherhood The training of TBAs is expected to start shortly; as of the present, only trainers have been trained. As of March 1996, Rs 13,16,500 has been received for the purchase of DDKs. None of this has been utilized due to 'non finalization of tender.' First Referral Units (FRU) Sixty three FRU sites have been identified for Phase I to IV districts. Funds have been requested from ODA (UK) to renovate the buildings. The status of these FRUs in terms of equipment, staffing and functioning was not available. Training The CSSM training of MOPHCs and paramedical staff for phase I - III districts have been completed. UNICEF feels that the training has made a difference; field workers are better informed and skilled; for example, they can identify high-risk pregnancies with greater acuity. Skill training of FRU staff has been completed for three districts and GOI funds awaited for the remaining. COMMENTS In both states child-centered activities have been much better implemented than those of direct concem to women or mothers. This is in some measure due to CSSM inheriting not only the strategy but also the priorities of UIP; witness, UIP's higher immunization coverage of children than that of pregnant women. CSSM's generous funding for safe motherhood has not been able to alter this bias; it would be too much to expect that it would. To what extent maternal morbidity and mortality can be lowered by CSSM's prescriptions alone or needs to cross sectoral boundaries more aggressively needs to be debated.  Appendix A Page 8 of 13 Reverting to child survival or child-centered activities, the immunization coverage seems to be slipping. The impression is that health system managers are not aware of this, or if they are, have not sought the reasons and explored possible solutions. If this is indeed so, then the MIS is not serving its basic purpose. It does not require unusual foresight to anticipate that levels of service provision would decline as the delivery system was burdened. The SAR saw this and advised policy reviews such as that of IFA distribution and of FFMPW work loads. This was not done, and the result is distressingly evident. In both states, there is no significant progress towards safe motherhood. Any shift towards institutional deliveries is constrained by the condition of the SHCs, PHCs and CHCs. In Orissa, some relief may be forthcoming during the third phase of UK ODA assistance. In Madhya Pradesh less optimism is warranted as the third phase of Danida's assistance towards physical infrastructure will be limited to two of the state's six divisions which have already benefited from earlier Danida support. At the same time, what could have been done for safer domiciliary deliveries such as better trained TBAs and regular supply of DDKs has been neglected. As for FRUs, as a senior administrator put it, 'suffer from faulty planning in terms of space and time.' Perhaps their expansion should be frozen till a more coherent plan is developed. All is not gloom, however. The cold chain functions most satisfactorily and its maintenance intemalized. Further, CSSM has done well to combine all MCH related programs and in integrating support systems, particularly for training and MIS. This needs to be built upon and attention paid to their quality and relevance. If key result areas need to be identified, two surface immediately. One, to raise planning and coordination skills of CSSM apex and middle echelons. And two, sponsor multi-centric studies, mainly in the social science areas so as to strengthen the quality of training and fine tune implementation.  Appendix A Page 9 of 13 Annex 2 CSSM IMPLEMENTATION COMPLETION REPORT: DEFINING AN APPROACH 1. The Program 1.1 The CSSM program's overall objective is similar to that of the Universal Immunization Program (LJIP). This program was reckoned to have achieved a fair measure of success in 6 immunizing mothers and children . Circa 1990, UIP"s scope was expanded to a wider range of MCH services; a package that came to be known as UIP plus7. CSSM adds institutional deliveries, 8 systems development and self sufficiency in all essential supplies to UIP plus' agenda . 1.2 To increase the number of institutional deliveries, CSSM strengthened subsidiary, primary and community health centers to provide Essential Obstetric Care (EOC). Further, it sought to make emergency EOC available. So far such care had been available only at district and a few sub-district hospitals. CSSM planned to increase access by establishing one facility - first referral units (FRU) - for every 30,000 - 50,000 population9. FRUs are expected to deal with neonatal emergencies in addition to EOC. 1.3 FRUs were established by upgrading selected subdistrict hospitals and community health centers (CHC). These were to be equipped, staffed and operated according to MOHFW guidelines. 1.4 For planning coverage and allocating resources to states, CSSM differentiates between child survival (CS) and safe motherhood (SM). While CS would be supported in all the 466 districtsl' in the country, 215 districts in six states'1 would for SM along with ,'for demonstration 12 purposes', one in four other states 6 MOHFW, Child Survival and Safe Motherhood Program - India, July 1991, p 4 7 UIP plus consists of vaccination against tetanus, diphtheria, pertussis, tuberculosis, measles and polio; provision of iron with folic acid, vitamin A; the treatment of respiratory infections and diarrhea, promotion of breast feeding and contraceptive use. 8 MOHFW, 1991, p 13 9 lbid p45 10 Since then some the number of districts have increased by bifurcating existing ones. 1l Assam, Bihar, MP, Orissa, Rajasthan and UP 12 There is some confusion as to which four; at one place AP, Kamataka, Maharashtra and West Bengal are mentioned, at another Tamnil Nadu replaces Maharashtra.  Appendix A Page 10 of 13 1.5 CSSM's outlay is Rs 11,255.81 million over seven years(1991/92 to 1997/98). The actual flow of funds delayed till August 199213. In effect, CSSM was operational from 1992/93. By April 1995, just over half (54.7 per cent) of the districts have been brought in for CS and less than half (47.5 per cent) for SM14; the remaining are to be covered by March 1997. 1.6 No additional posts at state or district level were considered necessary; ORT and UPI administrative and clerical staff were assigned to CSSM. The salaries of specialist staff (Ob/Gyn, anesthetist and pediatrician) are borne by state governments. 1.7 In practice, CSSM's implementation follows that of UIP: to 'push' products and services to the periphery; specific targets and time frames and using field workers to create demand. Though CSSM mentions community participation, involvement of the private sector, IEC and such, these are not reflected in either the planning process or reporting formats. It does emphasize training, but 1 5 again, mainly in service delivery protocols 2. The CSSM Project Financed By IDA 2.1 The Staff Appraisal report (SAR) recommended a credit of US$214.5 million to be utilized by FY 1995, later extended to September 1996. Three clusters of activities were identified and provided for separately: Child Survival, Safe Motherhood and Institutional Development. 2.2 Child Survival: to sustain and extend UIP and UIP plus by financing equipment, training, consumables, incremental staff salaries and vehicle purchase and operations. MOHFW was required to submit annual plans to IDA and ensure that no district was included unless it had 1 6 prepared UIP plus plans according to the IDA guidelines 2.3 Safe Motherhood: was to be supported for equipment, consumables, expert services and training. Further, incremental staff salaries, equipment maintenance, vehicle operations and fees to TBAs would be supported on a declining scale. MOHFW had agreed to establish by April 1992 Maternal Mortality Review Committees (MMRC) at national and regional levels to monitor, 1 7 evaluate and assist MOHFW in implementing SM 2.4 Institutional Systems Development was a major thrust of the project. The following interventions were identified: 13 MOHFW letter M-14015/7/91-UIP dated March 25, 1992 to Health Secretaries of all states and UTs 14 MOHFW, CSSM Annual Report for 1994 - 95, p 7 15 MOHFW, National CSSM program, Program Interventions, June 1994 16 SAR, p 25, para 3.15 17 bTid, para 3.26  Appendix A Page 1 1 of 13 (a) Training, including changes in personnel policies; (b) Work routines of field staff, to be discussed at a series of workshops and recast by January 1992; (c) IEC to generate demand by improving field workers' interpersonal communications skills, using local groups and mass media; (d) Material and supply management, including improved prescribing habits; (e) Community participation; and, (f) Positioning key additional staff' 2.5 An indicative list of Operational Research studies lists nine areas and a baseline survey for SM19. In addition, policies for diarrhea management, nutritional anemia and vitamin A deficiency would be reviewed 21 2.6 SAR identified as many as 42 interventions and 27 expected outcomes . During negotiations, agreements were reached on 15 points, including that MOHFW would submit annual plans by January 1 5th each year 2.7 Key indicators identified were: A. Child Survival (a) Low birth weight (LBW) births identified; (b) Immunization coverage by type and doses completed; (c) Acute Respiratory Infections (ARI) cases treated; (d) Diarrhea cases treated; and, (e) Prophylactic doses of Vitamin A administered. 18 Ibid pp 29 - 34 19 SAR, Annex 30 20 SAR, p 18 21SAR, pp 18 - 20 22 SAR, p 45  Appendix A Page 12 of 13 B. Safe Motherhood (a) Ante-natal cases (ANC) registrations, by trimester; (b) ANC services including tetanus toxoid, anemia prophylaxis and treatrnent, examinations and tests; (c) Attendance at deliveries, including LBW identified; (d) High risk referrals, by type; (e) Post Natal Care; and 23 (f) Contraceptive usage, by type 24 2.8 The number of beneficiaries was expected to virtually double between 1990 and 1995 2.9 Among the special features of the project, SAR mentions increased support to the private sector and the collaboration with UNICEF25. As far as is known, there was nor private sector involvement in UIP or UIP plus. 3. Issues 3.1 Assessing performance: It will not be possible to assess impact in terms of lowering maternal or child mortality. The National Family Health Survey (NFHS) estimated the Maternal Mortality Rate of 4206, but this is a one-time estimate. More data are available on the Infant Mortality Rate and several sources confirm that it has fallen; however, it is difficult to relate the decline to any specific intervention. It would be more practical to limit assessment to the key indicators as in para 2.6 above. These date are reported in the Annual Report and will have to be specially asked for. 3.2 Assessing implementation will be easier. During Supervisory Missions more data were available at state level than finds its way into the Annual Report. If the needed data are identified by end August, it should not be very difficult for MOHFW to get most of it by end September. 3.3 What would be lacking are the insights gained during field visits. To supplement the somewhat limited observations, it would be advisable to ferret out as many reports from other 23 SAR, Annex 29 24 SAR, Annex 1, p 2. However, SAR seems to have mistaken the quantum of services rendered for the number of beneficiaries 25 SAR, para 1.01 26 National Family Health Survey, 1992 - 93, India Introductory Report, p 88  Appendix A Page 13 of 13 agencies and donors. The evaluation by Mothercare, if available even in draft by end October will be most useful. 3.4 First Referral Units (FRU): The establishment of FRUs was a significant addition to UIP plus' agenda and is different on at least four counts. One, all other activities are field based, FRUs provide institution based services. Two, other interventions are top-down; FRUs require patients to flow in the reverse direction and a functioning referral system. Three, in some states the administrative location of FRUs is different from that of the field based activities. Finally, it is inevitable that FRUs would be located in urban areas and run into much more competition from private sector facilities than any other CSSM activity. None of these seem to have been taken into account in designing CSSM's administrative structure or training, for example there has been no training in facility management or management of referral systems. 3.5 During Supervision Missions it appeared that FRUs functioned, where ever they did, as walk-in facilities and not as units on a referral chain. It will be difficult to comment on their performance as referral centers as, quite inexplicably, the monthly reporting forms do not ask for the number and source of incoming referrals2 . As a proxy for referrals, UNICEF uses, somewhat 28 disputably, the number of Caesarian Sections 3.6 Incorporating FRUs into CSSM could have implications that go beyond providing better maternal and child care: to knit field based services with static units. An analysis of the experience with FRUs would be a significant contribution to India's health care policies and practices. 4. ICR Components 4.1 Project Objectives will summarize paras 2.2 - 2.4 above. A priori, they appear somewhat ambitious given that the project's effective duration was three, later extended to four, years. 4.2 Achievement of project objectives will be in two major parts; (a) the immediate objectives as in paras 2.5 to 2.7, and (b), the long tern, mostly to do with policy shifts, institutional development and the successive Reproductive and Child Health (RCH) Project. 4.3 Implementation record and major factors affecting the project will be against SAR requirements as in para 2.5. 4.4 Future operations: the project comes to an end one year before the program does. Beyond that, MOIFW plans, including RCH, will be commented on. 27 MOHFW, letter M-14015/7/91-UIP dated March 25, 1996, p 14 28 UNICEF, CSSM Donors Report, April 1995 to March 1996, June 1996, p 14   AmppndixB Page 1 of 11 IMPLEMENTATION COMPLETION REPORT INDIA CHILD SURVIVAL AND SAFE MOTHERHOOD PROJECT (CR 2300-IN) Borrower's Contribution Department of Family Welfare, Ministry of Health and Family Welfare, Government of India Contents Preface Introduction Present Status of Goals Immunization Control of Diarrhoeal Diseases Control of Acute Respiratory Infections Essential Newborn Care Vitamnin A Prophylaxis Nutritional Issues Statistical Information Achievement Against Goals Incidence of Vaccine Preventable Diseases Infrastructure at Sub-centre and Village-level for CSSM  Appendix B Page 2 of 11 Preface The implementation completion report (ICR) in the Child Survival and Safe Motherhood Project is the outcome of various studies conducted by different institutions, information provided by the Monitoring and Evaluation Cell of the Ministry, field visits, discussions and presentations. This report is the outcome of joint task of MCH Division officers working under the auspices of Joint Secretary, Mrs. Adarsh Misra, under whose challenging leadership the programme has achieved its present status.  Appendix B Page 3 of 11 Introduction I. Several maternal and child health interventions have been implemented in the country for reducing infant, child and maternal mortality, coverage levels were less than optimal due to inadequate training, insufficient and irregular supplies and less effective use of available resources. The Universal Immunization Programme (UIP) taken up as a technology mission in 1986 has succeeded in establishing a logistics network and a system of regular contact between the beneficiaries and paramedical workers, i.e., the mothers, children and ANMs. The National Development Council while reviewing the strategy for the Eighth Five Year Plan, emphasized the importance of the interventions directed towards reduction of infant and child mortality rates in the larger context of family welfare and recommended implementation of an integrated package for bringing about qualitative improvement in the availability of services for improving maternal and child health. Accordingly, the Government of India launched the Child Survival and Safe Motherhood (CSSM) Programme in August 1992 by integrating all the basic MCH interventions like ante-natal care, prophylaxis for mothers and children against nutritional anaemia and Vitamin "A" deficiency, ORT Programme, ARI Control Programme and Dais' Training Programme, with the Universal Immunization Programme. The basic strategy of the CSSM Programme was to use the opportunity created by the UIP in terms of the regular contacts between the paramedical workers located at the sub-centres and the mothers and children so that all Maternal and Child Health Services could be provfded in an integrated manner and the national goals of the Health Policy are achieved. The National Health Policy goals incorporate the global objective of "Health for All by 2000 AD", as well as the goals agreed upon at the World Summit for Children in 1990. CSSM Programme Objectives 2. The objectives for the CSSM programme broadly define the strategies which were to be put into action to achieve the specific impact and coverage goals. These are: (a) to expand and improve the quality of care and universalize a package of child survival and maternal health interventions; (b) to develop and initiate implementation of a safe motherhood programme; (c) to provide support to existing institutional systems to enable them to deliver more effectively child survival and safe motherhood services; and (d) to achieve self-sufficiency in the production of all essential supplies required for the interventions for child survival and safe motherhood, and the manufacture of essential equipment for the programme.  Appendix B Page 4 of I1 Programme Components 3. Child Surjvial. Among the measures taken in CSSM to improve Child Survival and to reduce morbidity in the under-five age group, two stand out for particular attention in the extension of CSSM activities: standard case management of Acute Respiratory Infections (ARI), and neonatal care. Other measures like ORT and immunizations are also the core of the Child Survival component: (a) sustaining the Immunization Programme in all the districts with particular emphasis on increasing the coverage levels in identified pockets of low coverage; (b) sustaining the Oral Rehydration Therapy (ORT) programme in all the districts with emphasis on the appropriate management of diarrhoea in the district and medical college hospitals and increasing the availability of ORS packets in the rural areas; (c) expanding the ARI programme in the districts under CSSM by training the peripheral health staff and supply of medicines; (d) intensifying Vitamin A coverage in children under three years of age in all the districts; and (e) improving newborn care practice in the districts under CSSM by training medical and health personnel. 4. Safe Motherhood. The strategy adopted by the CSSM programme on safe motherhood is comprehensive and covers most of the critical interventions required for the reduction of maternal mortality: (a) intensifying coverage with IFA tablets in pregnant women to prevent maternal and perinatal deaths due to anaemia; (b) increasing the proportion of institutional deliveries and deliveries by trained personnel; (c) improving ante-natal care for identification and treatment of maternal complications; and (d) improving accessibility to emergency care for obstetric complications by setting up First Referral Units (FRUs) in sub-district level hospitals. Present Status of Goals 5. Immumizatio. The progress made under the Universal Immunization Programme has been sustained under the Child Survival and Safe Motherhood Programme. Nearly 80 per cent of the 27 million pregnant women and over 85 per cent of the 25 million infants received the full course of vaccines annually since the inception of the Programme. Immunization coverage  Appendix]B Page 5 of 11 levels have more than doubled since 1985-86. Drop-out rates have reduced and children are being increasingly brought to the immunization sessions at the right age. Awareness about the immunization programme and demand for services are high. 6. Monitoring of Adverse Events. A well established system of monitoring of adverse events has come into being in the last few years. Reporting of adverse events is a mandatory component of the monthly CSSM monitoring report. In addition, each state and union territory has set up a Committee of Experts to enquire into each reported adverse event and take immediate corrective measures to prevent recurrence. 7. Pulse Polio Immunization. The success achieved under immunization prompted the launching of the initiative for eradication of poliomyelitis in 1995-96. In the first year of the programme, every child under the age of three years was administered two doses of Oral Polio Vaccine on December 9, 1995 and January 20, 1996. During this campaign over 80 million children were immunized on each day. In the current year, children under five years have been targeted. Over 120 million children are expected to be immunized. The first dose of this round was given on December 7, 1996 and the second is scheduled for January 18, 1997. 8. Quality of Cold Chain. A system for the testing of Oral Polio Vaccine Samples lifted from various tiers of the health care delivery system has b5een established. Over 16,000 samples were tested annually during the currency of the programme. Over 90 per cent of these tested samples were found to be satisfactory indicating a satisfactory performance of the wide network of cold chain system established in the country. 9. Control of Diarrhoeal Diseases. The supply of ORS packets was taken up as central supplies. 150 packets of ORS are supplied in the Drug Kit A every six months at the sub-centers. The ORS packet has been standardized with a logo and uniform instructions for use on each of the packets. This has meant 100 per cent access to ORS packets at sub-center level. Efforts were made to supply ORS packets through Public Distribution System and an initial one time supply to initiate this was made to some states who have taken up the sale and distribution of ORS through the Public Distribution System. Population Services International have taken up social marketing for ORS in Uttar Pradesh, Orissa and some other states with assistance from USAID. 10. An algorithm for treatment of persistent diarrhoea in the health facilities was developed with the help of experts from All India Institute of Medical Sciences and IAP and forms a part of the clinical skills training for medical officers. 11. In order to seek commitment of States, academicians, researchers, NGOs and professional organizations and associations, a National Symposium on ORT was held in New Delhi in January 1995. International and donor agencies also participated in this symposium. The underlying objective for all efforts has been to improve the utilization of ORS in the community, educate mothers on home management and to reduce the deaths caused not only by diarrhoeal dehydration but also those caused by associated malnutrition.  Appendix B Page 6 of 11 12. Control of Acute Respiratory Infections. The ARI Control Programme was taken up as a pilot project in 14 districts of the country in 1990. Ten more districts were added in 1991. Since 1992-93, the programme is being implemented as a part of the CSSM programme. The diagnostic criteria and treatment schedules have been incorporated in the training material for the medical officers and paramedical workers. Peripheral health workers are expected to diagnose the cases of pneumonia and initiate treatment of uncomplicated cases. For this the anti-bacterial cotrimoxazole was supplied to all health workers as a part of the drug kit A. 13. Feedback from the field suggests that while the workers are now quite aware of the diagnostic and management protocol, they are diffident in initiating therapy. A doubt as regards the quality/management of cases is not of optimal quality. This may be a reflection on the training which was imparted under the programme. The training lacked hands-on clinical experience which may account for the fact that health workers are diffident in managing cases of pneumonia in the field. Another reason could be the inaccessibility to our health workers at odd hours of the day and on holidays. To cater to this scenario, discussions have been initiated with the Department of Women and Child Development to enable the anganwadi workers, who are present in the community throughout the day, to diagnose and initiate treatment of cases of pneumonia. 14. Essential Newborn Care. Essential care of the newborn was introduced as an intervention under the CSSM Programme. Resuscitation of neonates, prevention of infection and hypothermia and introduction of principles of exclusive breastfeeding were identified as prime intervention for reduction for perinatal and neonatal mortality. Training modules for medical officers and para-medical workers incorporate these issues. Since June 1993, an integrated clinical skills course on newborn care and the management of acute respiratory infections and diarrhoea has been started under the CSSM Programme for physicians working at district and sub-district level hospitals. The training includes care of the sick newborn. Practical sessions on resuscitation are held with the use of mannequins. 15. A project with the collaboration of the National Neonatology Forum was undertaken in 1994 wherein simple equipment which was produced indigenously was supplied to sub-centres, primary health centres and First Referral Units in 26 districts was initiated. Specialists from National Neonatology Forum were involved in training staff and operationalizing the equipment. Initial feedback from the districts shows that equipment supplied is being utilized and the resuscitation rates of asphyxiated babies, and over all practices for the care of the newborn have been institutionalized. 16. Vitamin A Prophylaxis. The Vitamin A Prophylaxis Programme was continued as an intervention under the CSSM programme. The objective of the intervention was to prevent the Vitamin A deficiency associated with blindness under five years of age. Recognizing the importance of Vitamin A in preventing morbidity and mortality in children, the scope of the intervention has been enlarged to encompass the wider issues.  Appcndix B Page 7 of 11 17. Nutritional Issues. While the specific intervention under the programme focused only on Vitamin A Prophylaxis, the wider issue of improving the nutritional status of infants and children received due importance in the programme. 18. Promotion of exclusive breastfeeding and appropriate weaning practices was introduced although it was not envisaged earlier as an input under the programme. The Baby Friendly Hospital Initiative has been firmly established in the country and till date over 900 hospitals have become "Baby Friendly". A single sheeter on exclusive breastfeeding was published and disseminated all over the country right down to the sub-entre level. An issue of the CSSM Review Newsletter was devoted to exclusive breastfeeding and weaning practices. The revised version of training materials have incorporated technical details of nutritional issues in detail. 19. Considerable achievement has been recorded in the field of reduction of infant and child (0-4) mortality. While the Infant Mortality Rate has been brought down to 74/1000 live births in 1'95, the Child Mortality Rate in 1993 was 23.7/1000. The comparative figures for IMR and CMR for 1991 were 80 and 28.7 respectively. This drop in mortality rate implies that interventions in 1993 were able to prevent the lives of over 3,15,000 children under five years of age.  Appendix B Page 8 of 11 CHILD SURVIVAL AND SAFE MOTHERHOOD PROJECT (CR.2300-IN) Achievements against Goals Year Goal for Indicators 1992-93 1994-95 1995-96 2000 AD I. SAFE MOTHERHOOD A. Mothers receiving Ante-natal care 49.1% 73.4% 75.8% 100% (NFHS) (MOHFW) B. Mothers receiving TT2 79.2% 83.4% 78.9% 100% C. Births delivered in health facility 25.5% 34.4% 32.5% 100% (MOHFW) (MICS) D. Deliveries assisted by health 46.2% 48.8% 53.9% 100% personnel (1991-SRS) (1993-SRS) (MICS) E. Pregnant women receiving IFA 61.0% 78.2% 70.0% 100% F. High risk pregnant women identified NA NA 27.7% 100% for referral obstetric care (CSD) G. Couple protection rate 43.5% 45.4% 46.5% 60% H. Total fertility rate 3.5 - - 2.2 (1993-SRS) I. Net reproduction rate 1.17% - 1.0 (1990) II. CHILD SURVIVAL A. LBW (2500g) babies born 30.0% 10% B. Exclusive breast feeding to new born 51.0% 100% (0-3 months) (NFHS) C. Immunization Coverage 3. BCG 96.5% 99.6% 96.2% 4. DPT 90.5% 94.2% 89.8% 5. OPV4 91.0% 94.9% 91.1% 6. Measles 85.8% 86.8% 81.0% 100% 7. DT 77.8% 64.5% 56.1% 8. TITO 69.4% 55.0% 50.8% 9. TT16 53.4% 48.0% 44.4% D. Children completely immunized by 35.4% NA 52.4% 100% first year (NFHS) (MICS) E. Prophylactic Vitamin A coverage 64.1% 84.3% 62.0% 100% F. IFA prophylactic coverage 58.3% 74.8% G. ORS for child diarrhoea treatment 1. Advised - - 51.2% 100% 2. Received 30.6% - 34.5% (NFHS) (MICS) H. Children with ARI taken to health 66.3% NA 39.2% 100% facility treatment (NFHS) (CSD)  A=ndix B Page 9 of II Year Goal for Indicators 1992-93 1994-95 1995-96 2000 AD III. MATERNAL AND CHILD MORTALITY A. Maternal mortality rate 4.37% NA NA 2% B. Infant mortality rate 79.0/o 74.0% 74.0% 60% (SRS-1992) (SRS- (SRS- 1994) 1995) C. Neonatal mortality rate 51.1% 47.2% (NFHS) (SRS- 1993) D. Child (U5) mortality rate 109.3 NA NA 70 (NFHS) 1. Source of information: 1992-93 - Safe Motherhood - NVFHS MOH&FW - State Govt. Reports where not specified 2. The cold-chain break down rate varied between 0.20 to 0. 70% (NIDC, 1994-95) NFHS - National Family Health Survey (1992-93) CSD - Councilfor Social Development MICS - Multi Indicator Cluster Survey SRS - Sample Registration System (RGI)  Appendix B Page 10 of 11 Incidence Of Vaccine Preventable Diseases S.No. VPD CASES DURING THE YEAR 1992-93 1994-95 1995-96 1. Diphtheria 6810 3987 2128 2. Pertussis 61648 38704 21649 3. Tetanus (NNT) 18710(6687) 35831 (4688) 7220 (2222) 4. Tuberculosis 942254 1039131 647850 5. Poliomyelitis 9390 7028 8675 6. Measles 92297 . 61381 31906 The Crude Birth Rate declined from 29.5/1000 population (1991) to 28.7 (1993) and is required to be further reduced to 21 by 2000 AD. Likewise the Crude Death Rate has shown a decline from 9.8/1000 (1991) to 9.3 (1993) and should drop down to 9 by 2000 AD. Similarly, the life expectancy (at birth) of 58.1 year for females and 57.7 years for males during 1992-93 has enhanced during 1995-96 to 61 years for females and 60 years for males as a result of CSSM Programme implementation in the country. Infrastructure at Sub-Centre and Village Level for CSSM In India 588651 villages are served for health care through 132285 Sub-centres of 21802 Primary Health Centres and 2401 Community Health Centres, besides the district level referral facilities. As on 31st December, 1995, the availability of ANM/MPW(F) , at sub-centres, is shown in table below: ANMIMPW (F) Average LHV / HAF Sanctioned in Position Population served Sanctioned in Position by ANM 140724 133452 (95%) 4710 21665 19019 (88%) The CSSM programnme prioritized the organization and training of Traditional Birth Attendance (TBAs) for their better skills towards maternal and child health at the village level. They are equipped with disposable delivery kits and a system of their convergence with ANM, anganwadi workers as well as community has been planned and is being operationalized in the country. The following is the position of TBAs up till December 1995 in the country. TBAs trained Average rural population Average village covered per served/trained TBA trained TBA 639435 983 0.92  Appendix B Page 11 of 11 BIBLIOGRAPHY Centre for Research, Planning & Action. Study of [FA and Vitamin A; New Born Care, ANC, Immunization, Natal, PNC. Council for Social Development. Coverage evaluation of the CSSM Program in India. New Delhi. Foundation for Research and Social Development. Study on community perception of the right age of marriage; Community perception about safe abortion; Birth spacing and delayed cohabitation; Emerging vis-a-vis essential obstetrics care rendered in the last 3 years; ARI and Diarrhoea and Analysis of secondary data on motherhood. IIPS. National Family Health Survey. Bombay MotherCare. CSSMEvaluation Report: Study of 31 facilities in Maharashtra Orissa and U.P. Population Research Council. Study on Utilization of Drug Kits. Bhopal. Population Research Council. Study on Child Health (Micronutrients). Shimia. Short Studies conducted by Indian Council of Medical Research Chakravarty, Indira. Study to correlate the role of diarrhoeal diseases on incidence of malnutrition. AIIHPS, Calcutta. Study to assess the dietary habits and nutritional profile of mundas in West Bengal.. AIIHPS, Calcutta. Ganapathy, Saraswathy. Exploration of Socio-culture Determinants of Obstetric Care and Maternity Outcome in Kanakapura Villages. Bangalore. Kumar, Rajesh. Development and Delivery of Reproductive Health Care in Primary Care Setting. PGIMER, Chandigarh. Ram, M. Mohan. Public Health Communication Strategy for Maternal and Child Health. NIN, Hyderabad. Rao, P.S.S. Sundar and Richard, J. Studies on Growth, Development and Health of Young Adults. Christian Medical College, Vellore. Reddy, Vinodini. Effect of preparation and preservation techniques on carotene content and Vitamin A value of Indian foods. NIN, Hyderabad. Srinivasa, D.K. Social Dimensions, Perceptions and Behaviour about Menarche and Menstruation among Adolescent Girls in Pondicherry. JIPMER, Pondicherry.    IMAGING Report No.: 16353 Type: ICR