Malawi - Population and Family Planning Project

Document of The World Bank Report No: 17921-MAI PROJECT APPRAISAL DOCUMENT ONA PROPOSED LEARNING AND INNOVATION LENDING (CREDIT) IN THE AMOUNT OF SDR 3.8 MILLION (US$5 MILLION EQUIVALENT) TO THE GOVERNMENT OF MALAWI FOR A POPULATION AND FAMILY PLANNING PROJECT September 23, 1998 Human Development 1 Country Department 3 Africa Region  CURRENCY EQUIVALENTS (Exchange Rate Effective June 30, 1998) Currency Unit = M:alawi Kwacha (MK) US$1 -, M:K26.45 SDR1 US$1.3315 NB: On September 17, 1998 after this Project was negotiated the Exchange Rate moved to Mkl = US$0.0227 US$1 = Mk44.0000 MEASURES Metric Systenm FISCAL YEAR July 1 - June 3 0 (as of July 1998) Vice President: Callisto E. Madavo Country Director: Barbara Kafka Sector Manager: Ruth Kagia Task Team Leader: Norbert Mugwagwa  ABBREVIATIONS AND ACRONYMS AIDS Acquired Immunodeficiency Syndrome BLM Banja La Mtsogolo CAS Country Assistance Strategy CBD Community-Based Distribution CBDA Community-Based Distribution Agent CBDO Community-Based Distribution Officer CDLMIS Contraceptive Distribution Logistics Management Information System CHAM Christian Health Association of Malawi CNA Community Nexus Approach CPR Contraceptive Prevalence Rate DDLGA Department of District & Local Government Administration DFID Department for International Development (UK) DHMT District Health Management Team DHO District Health Office DHS Demographic and Health Survey EU European Union GOM Government of Malawi GTZ Deutsche Gesellschaft fur Technische Zusammenarbeit HIV Human Immunodeficiency Virus IDA International Development Association IEC Information, Education, and Communication IUCD Intra-uterine Contraceptive Device KAP Knowledge, Attitude and Practice LIL Learning and Innovation Loan MIS Management Information System MOHP Ministry of Health and Population NFPC National Family Planning Council of Malawi NGO Non-Governmental Organization PHN Population, Health & Nutrition PHRDU Population and Human Resource Development Unit PIP Project Implementation Plan PIU Project Implementation Unit PPT Project Preparation Team PSC Project Steering Committee PSI Population Services International RHU Reproductive Health Unit STD/STI Sexually Transmitted Diseases/Sexually Transmitted Infections TFR Total Fertility Rate UNFPA United Nations Population Fund UNICEF United Nations International Children's, Fund USAID United States Agency for International Development WHO World Health Organization  Malawi Population and Family Planning Project CONTENTS A: Project Development Objective ...................................................2 1. Project development objective and key performance indicators ...............................2 2. Key Performance Indicators ...................................................2 3. Justification for the use of a Learning and Innovation Loan .....................................2 B: Strategic Context ...................................................3 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project ...................................................3 2. Main sector issues and Government strategy ................................................... 3 3. Sector issues to be addressed by the project and strategic choices ............................4 C: Project Description Summary ...................................................5 1. Project components ...................................................6 2. Key policy and institutional reforms supported by the project ..................................7 3. Benefits and target population ...................................................7 4. Institutional and implementation arrangements ................................................... 7 D: Project Rationale .................................................. 12 1. Project alternatives considered and reasons for rejection ........................................ 12 2. Major related projects financed by the Bank and/or other development agencies .................................................. 12 3. Lessons learned and reflected in the project (lesign ................................................. 13 4. Indications of borrower commitment and ownership .............................................. 13 5. Value added of Bank support in this project .................................................. 14 E: Summary Project Analysis .................................................. 14 1. Economic .................................................. 14 2. Financial .................................................. 14 3. Technical .................................................. 14 4. Institutional .................................................. 15 5. Social: .................................................. 15 6. Environmental assessment ................................................... 15 7. Participatory approach .................................................. 15 F: Sustainability and Risks .................................................. 16 1. Sustainability .................................................. 16 2. Critical Risks .................................................. 17 3. Possible Controversial Aspects .................................................. 18 G: Main Credit Conditions .................................................. 18 1. Negotiations .................................................... 18 2. Effectiveness Conditions ................................................... 18 3. Main Credit Conditions ................................................... 18 4. Other ................................................... 18  H. Readiness for Implementation ......................... 20 I. Compliance with Bank Policies ......................... 20 Annex 1 Project Design Summary ......................... 21 Annex 2 Detailed Project Description ......................... 33 Annex 3 Estimated Project Costs ......................... 36 Annex 4 Procurement and Disbursement Arrangements ........................................ 37 Table A: Total Project Cost by Procurement Arrangements .................. 39 Table B: Threshold for Procurement Methods and Prior Review .......... 40 Table C: Allocation of IDA Credit Proceeds .......................................... 42 Annex 5 Project Processing Budget and Schedule ................................................. 44 Annex 6 Documents in the Project File .................................................... 45 Annex 7 Status of Bank Group Operations in Malawi IDA Credits in the Operations Portfolio ................................................... 46 Annex 8 Socio-Economic and Population Indicators ............................................. 47 Annex 9 Malawi at a Glance ................................................... 48 Map: IBRD No. 29658  Malawi Population and Family Planning Project Project Appraisal I)ocument Africa Regional Olfice Human Development I Date: September 23, 1998 Task Team Leader: Norbert Mugwagwa, AFTHI Country Director: Barbara Kafka, AFCO3 Sector Manager: Ruth Kagia, AFTH I Project ID: MW-PE-36038 Sector: Human Resources Program Objective Category: Poverty Reduction Lending Instrument: LIL Program of Targeted Intervention: [X3 Yes [ No Project Financing Data [] Loan [X I Credit [] Guarantee [ Other [Specify] For Loans/Credits/Others: Amount (US$m/SDRm): US$5 million/SDR 3.8 million Proposed terms: [x ] Multicurrency [] Single currency, specify Grace period (years): 10 [3 Standard Variable [] Fixed [3 LIBOR-based Years to maturity: 40 Commitment fee: 5% (but at present, is waived) Service charge: 0.75% Financing plan (US$m): Source Local Foreign Total Govemment 0.5 0.5 Cofinanciers IBRD IDA 5.0 5.0 Other (specify) Total 5.5 Borrower: Govemment of Malawi Guarantor: N/A Responsible agency(ies): MOHP, NFPC Estimated disbursements (Bank FY/US$M): 1999 2000 2001 Annual 2.3 1.3 1.4 Cumulative 2.3 3.6 5.0 For Guarantees: [] Partial credit [ Partial risk Proposed coverage: N/A Project sponsor: N/A Nature of underlying financing: N/A Terms of financing: Principal amount (US$) N/A Final maturity N/A Amortization profile N/A Financing available without guarantee?: N/A [ ] Ves [] No If yes, estimated cost or maturity: N/A Estimated financing cost or maturity with guarantee: N/A Project implementation period: 3 years Expected effectiveness date: November 1, 1998 Expected closing date: June 30, 2002  Page 2 A: Project Development Objective 1. Project development objective and key performance indicators (see Annex 1): The objective of this project is to test the feasibility of a comprehensive and district-wide Community- Based Distribution (CBD) approach to Population/Family P'lanning services provision in three pilot districts through the public sector. This is expected to increase the contraceptive prevalence rate for modern methods through (a) increased knowledge of and improved attitude towards family planning, leading to increased demand for modem family planning (FP) services; and (b) increased access to such services among men, women, and adolescents living in rural and under-served areas of Malawi. 2. Key Performance Indicators The success of this project in the three pilot districts will be evaluated based on the following key indicators and targets: a) Double the Contraceptive Prevalence Rates (CPR) for rnodern family planning methods among target groups (outcome); b) Increase to 70 percent the proportion of men and women with positive attitude toward family planning (output); c) Train a total of about 100 Community-Based Distribution Agents (CBDAs) and retain at least 80 percent of them at the end of the project (input); d) Ensure that CBDAs achieve an average list of at least 2,00 clients by the end of the project (output); and e) Ensure that all static health/FP units have the equipment, supplies and trained staff needed to provide the full range of clinical contraceptive services appropriate for each type of facility to the clients referred by the CBDAs (input). Baseline values for indicators (a) and (b) will be determinecd through the project baseline survey, and the targets will be reviewed and confirrned or modified on that basis. In addition to providing powerful tools for assessing success of the approach being tested in this project, these indicators will be used to evaluate the effectiveness and cost-effectiveness of the project CBD program against both quantitative and qualitative success rates of existing family planning (FP) services and CBD programs in the public, CHAM and other NGO sectors. This evaluation will serve as the basis for future nation-wide expansion of the CBD program. 3. Justification for the use of a Learning and Innovation Loan The use of a Learning and Innovation Loan (LIL) for this project is appropriate for three reasons: First, a LIL provides the necessary flexibility needed to modify sonme of the elements in the design as they unfold (e.g. modifying the number of households to be covered by each CBDA). Second, a LIL provides the necessary experience and opportunities to MOHP, NFPC and other agencies to strengthen their management and planning capacities so that they can undertake a national CBD program. Third, a LIL will test the institutional feasibility and cost-effectiveness of expanding the contraceptive prevalence rate (CPR) for modern methods and decreasing fertility through an expansion of the Community-Based Distribution approach.  Page 3 B: Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project (see Annex 1): CAS document number: 18349-MAI. Date of latest CAS discussion: August 27, 1998. The main objectives of the Malawi CAS are to reduce poverty and increase economic growth through: (a) macroeconomic stabilization; (b) unleashing private initiatives (c) population control and human resource development; and (d) civil service reforms, capacity building and decentralization. This project would contribute to strategic objective (c) by testing a new approach to population and family planning activities at the community level in the rural/under-served areas of the project districts. This Community-Based Distribution approach would expand on the experience gained from small-scale activities of the National Family Planning Council (NFPC), MOHP, GTZ, Banja La Mtsogolo (BLM), and other NGOs. 2. Main sector issues and Government strategy: Malawi's rapid and unsustainable population growth, caused by high fertility, is undermining Government's efforts to reduce poverty. This high growth is increasing pressure on natural resources and social services. The average land per capita in many parts of the country is already insufficient for subsistence farming. Further growth in population will reduce land availability per capita, and increase still further the already high levels of malnutrition, poverty, and environmental degradation. Demand for social services such as education and health will increase, while the ability of the country to provide these services will decline. Malawi still has one of the highest total fertility rates (JFR) in sub-Saharan Africa, despite a slight recent decline in fertility. The TFR declined from 7.6 children per woman in 1984 to 6.7 in 1992 according to the 1992 Demographic and Health Survey. The 1992 DHS also found that the desired TFR was 5.7 and that the met and unmet demand' for contraception was 15 percent and 36 percent respectively. In 1994, the Government of Malawi (GOM) adopted the National Population Policy to improve the standard of living and quality of life through an improvement in key health indicators, such as declines in the TFR from 6.7 to 5.4 children per woman, in infant mortality from 134 to 100 per 1,000 live births, in child mortality from 234 to 150 per 1000, and in maternal mortality from 620 to 200-3 00 births per 100,000 live births by the year 2002. One strategy included in the Policy is to increase the contraceptive prevalence rate for modem methods from 7 percent to 28 percent by the year 2002. This will be achieved through an increase in the delivery points of contraceptives and an extensive information, education and communication (IEC) campaign to further stimulate demand. The Policy also includes strategies related to safe motherhood, prevention of STDslAIDS, education, gender, development, and employment2. Unmet demand was defined as: pregnant women whose pregnancy was mis-timed, amenorrheic women whose last birth was mis-timed, women who are neither pregnant nor amenorrheic and who were not using FP and said they wanted to wait two or more years for their next birth. Pregnant women whose pregnancy was unwanted, amenorrheic women whose last child was unwanted, and women who were neither pregnant nor amenorrheic and who were not using any method of FP and who wanted no more children. 2 A list of the demographic, family planning and health targets as well as the education, gender, employment and economic targets is given on page 18 of the National Population Policy. The targets are summarized in Annex III of the Policy.  Page 4 Under the Population Policy, the task of reducing population growth is seen as a shared responsibility of many actors including government, NGOs, donors, private sector, and local. Family Planning services are carried out by both public and private institutions, with MOHP being the main provider of services. Other providers include the Christian Health Association of Malawi (CHAM), the Department of District and Local Government Administration (DDLGA), the health units run by industrial establishments, agricultural estates, army/police, and the Agricultural and Marketing Corporation. The largest NGO provider is BLM and the largest social marketing program is run by Population Services International. There are serious reservations about whether the ambitious targets of the Population Policy can be achieved given the prevailing irregular supply of contraceptives, limited mix of services, and other logistic bottlenecks. Even if contraceptives are always available, the quantity and quality of FP services discourage their use, especially among adolescents. In addition, the attitudes of both providers and the community deter the use of FP services by the youth. Services are available only during certain hours on certain days due to a shortage of staff. The 1995 Population Sector Study indicated that only two-thirds of the trained staff in family planning are actually providing services. For these and other broader development-related reasons, it is clear that a comprehensive approach will be required at community and district level to ensure implementation of the National Population Policy and to be consistent with recommendations of the 1994 International Conference on Population and Development in Cairo. In response to the National Population Policy, very small-scale pilot projects have been implemented to test out the feasibility of Community-Based Distribution (CBD) of contraceptives in various places in Malawi. Such projects have increased in number from 5 in 1994 to 25 in 1997, well above the target (20) set in the National Family Planning strategy, 1994-1997. Although these small scale projects demonstrate that there is potential for the approach to increase CPR in Malawi, they are not sufficiently comprehensive and standardized in their approach to be replicated countrywide. Furthermore, the impact of these projects on the CPR is not known because they have not been systematically evaluated. Therefore, there is a need to test an integrated national CBD program-, delivered through the public sector, that borrows from these small scale experiences. 3. Sector issues to be addressed by the project and strategic choices: The impact of past and present programs on both demand for and supply of family planning services is an issue of considerable concern to Government and other stakeholders. Problems of access to family planning services in Malawi are substantial and well-known. With the exception of a few small projects using Community-Based Distribution Agents (CBDAs), most FP services are currently provided by static units. This is a major reason for unmet demand, since almost 70 percent of rural women must travel more than an hour to reach a health unit, and longer in the rainy season. Moreover, less than half of the health units currently offer family planning services on a daily basis, and even fewer in areas served solely by providers whose religious beliefs do not embrace the use of contraceptives. However, the 1995 Population Sector Study documents that better access to family planning services will not alone succeed in increasing the contraceptive coverage rate. Several other studies inclicate that, aside from access, low use of family planning services is due to persistent pronatalist attitudes, and cultural and/or religious barriers. To reach the defined CPR target, the demand for family planning will also need to be increased. The proposed project will test an integrated, comprehensive, community-based approach to increase contraceptive prevalence rates and subseq[uently reduce fertility in three districts, throughl interrelated and  Page 5 concurrent activities which address both supply-side and demand-side issues. CBDAs will have three main functions, all at the doorstep of clients: to promote and counsel on family planning; to supply pills, condoms and spermicides; and to refer to static health/FP for a range of clinical FP methods including injectables, IUDs, Norplant and sterilization, as follows: 3.1 Demand-side Activities The project will address demand-side issues in several ways. First, the project will train CBDAs in counseling (including youth counseling), in interpersonal skills and in bringing services to the doorstep of the clients. Second, CBDAs will promote population and family planning information and education by using radio-cassette players and cassettes with pre-recorded family planning messages for listening groups. Third, the project will develop, pretest and produce IEC messages and materials, and undertake related activities designed to increase knowledge and change attitude and behavior regarding family planning. IEC materials will be adapted to specific target groups, including opinion leaders, adolescents, and men and women in the project districts. Finally, the project will collaborate with other agencies (Ministries, donors, NGOs, CHAM, etc.) that are supporting demand-stimulating activities. 3.2 Supply-side Activities Two main activities address supply side issues. First, CBDAs will bring modern family planning methods to clients in their homes, including both progesterone-only and combined pills, condoms, and spermicides; they will promote, distribute and monitor these, using bicycles to increase their reach. Second, CBDAs will refer clients for back-up physical exarminations, clinical FP methods, and STD treatment to static health/FP facilities whose capacity has been strengthened by the project through provision of needed equipment, supplies and staff training. Health centers will provide injectables and IUDs, while the district hospital and FP clinic will additionally provide Norplant and sterilization services. C: Project Description Summary Three pilot districts will implement the project interventions, with three matching control districts where services will continue as they are at present. The most important selection criteria for the pilot districts will be: the presence of a committed District Health Management Team (DHMT), low CPR, high population density, low literacy and readiness to participate in the project. These criteria were chosen to ensure the best possible conditions for implementation within the DHMT, and a high level of need for FP services, hence potential for the CBD program to achieve early and substantial change. The three pilot districts are: Chitipa (Northern Region), Ntchisi (Central Region), and Chiradzulu (Southern Region). The control districts, which are adjacent to the respective pilot districts, are: Karonga (Northern Region), Dowa (Central Region), and Mulanje (Southern Region). The six districts have actively participated in the preparations for the pilot.  Page 6 1. Project components (see Annex 2for a detailed description and Annex 3for a detailed cost breakdown): Component Category Cost Incl. % of Bank- % of Contingencies Total financing Bank- _ (US$M) (US$M) financing Community Based Distribution - motor vehicles, 1.7 31 1.5 30 contraceptive distribution by recruited IEC materials, CBDAs; supervision by CBDA materials and Supervisors, health centers, family medical products planning coordinators and DHMT; and other goods; provision of incentive package for the TA and CBDAs, salaries and motorcycles for incremental CBDA Supervisors and motor vehicles operating costs for FP coordinators; and wide mix of contraceptive commodities. Information, Education and IEC materials, 0.6 11 0.5 10 Communication (IEC) - support the training, TA, development, pre-testing, production incremental and dissemination of IEC materials; operating costs distribution of materials in local language on advantages and safety of FP and dangers of STDs/AIDS; modification of attitudes towards youth reproductive needs and IEC training. Strengthening Back-up support - equipment, 2.5 45 2.3 46 improve capacity of health professionals vehicles, medical to support FP services provided by products and CBDAs through clinical training; other goods; provide clinical supervision to CBDAs; training, TA, and support the FP coordinator and manage incremental the contraceptive logistics system operating costs, (CDLMIS). Training - develop standard training vehicles,, 0.7 13 0.7 14 protocols for service skills, counseling, materials, supervision and performance medical products assessments for CBDAs and their and other goods; supervisors; train service providers and training, TA, and their supervisors in counseling, incremental commodity distribution and re-supply, operating costs dissemination of educational messages on STD prevention and protection; provide in-service training for FP providers; and train FP providers at HCs and district hospitals to provide full range of FP methods. Total 5.5 100 5.0 100  Page 7 2. Key policy and institutional reforms supported by thie project: The project is supporting the introduction of a pilot comprehensive, district-wide community based distribution program for contraceptives with strong community level involvement in the selection and supervision of the CBDAs. In addition, it is institutionalizing the role of a non-medical supervisor to oversee the CBDA. The program introduces distribution of pills as non prescriptive drugs in a country known for strict prescription rules. By proposing to address - with the help of the Ministry of Women, Youth and Community Services (MOWYCS) - the reproductive health problems of the youth, the pilot is taking on a traditional and cultural conservatism among the communities and service providers, and working with them to find lasting solutions to a serious problem. Luckily the findings of the Systematic Client Consultation (SCC) carried out in 1994 do confirm that parents and social leaders are amenable to adoption of program activities that help the youth deal with adolescent sexuality. The setting-up of the management unit as a separate entity is also innovative in that it de-bureaucratizes the service provision and provides the leeway for the unit to confer with all the stakeholders in the Population/FP field. Freedom to freely liaise with agencies such as the NFPC as well as the MOHP's RHU and PHRDU will also ensure that existing policies and practices are taken into account during the pilot and that there is complementarity with existing programs. 3. Benefits and target population: The target audience for this project would be the Ministry of Health and Population, the National Family Planning Council, NGOs, academic institutions, and other stakeholders. They would benefit from the project through the basis it would provide for implementing a successful nationwide CBD program. The ultimate beneficiaries of both the pilot and a subsequent nationwide CBD program would be men and women in the reproductive age groups and adolescents living in rural and under-served areas of Malawi. Immediate benefits in the three pilot districts will include spacing of pregnancies with subsequent improved nutritional status of mothers and children; decreased number of births with subsequent higher availability of resources per household member; decreased maternal mortality and delivery complication due to less number of pregnancies; and a decrease in the number of pregnancies and STD incidence among the unmarried adolescent population. Long-term benefits to the same groups nationwide will be similar. For Malawi as a whole, the long-term benefits of a successful pilot followed by a successful nationwide CBD program will include reduced fertility, which will in turn, reduce population growth and have a positive impact on other sectors such as education and environment. Reduced frequency of child bearing and rearing will also free women's time for productive use and empower them to be active members of communities with an overall positive impact on society. Adolescent youth will likewise be enabled to exploit their full potential in society. 4. Institutional and implementation arrangements: 4.1 Project Management and Implementation Structure: The institutional and implementation arrangements for the project are summarized in the accompanying organigram, (see Figure 1) and are as follows: 4.1.1 Policy Guidance: A multi-agency Project Steering Committee (PSC), chaired by the PS MOHP, will be established to provide guidance in the interpretation of Government population, FP and reproductive health policies. The PSC's membership will i;nclude senior representatives of relevant ministries, the NFPC, RHU, PHRDU, DHOs from the project and control districts and NGOs. The PSC will meet twice a year to review the quarterly project reports and ensure that the project is being implemented in line with its objectives. The PSC will review and approve the plan of action for the  Page 8 following year. The PHRDU will, in addition to its own routine functions, act as the Secretariat to the PSC. It will review and distribute quarterly project progress reports prepared by the CBD Management Unit to the PSC. 4.1.2 Project Management at Central Level: Whereas the P'roject Preparation Team has done a great job of preparing this pilot project with the support of the PS, Ministry of Health and Population, NFPC, PHRDU, RHU and DHMTs, Government does not have a pool of experience with commtnity-based population/family planning projects. However, the establishment of a separate implementing unit for the pilot would allow the project to tap into existing experience in different agencies. The project will be managed by a CBD Project Coordinator (CBDPC), located in a separate Unit in the Regional Office, Lilongwe, who will also technically supervise component (a) (see Figure 1 - Organigram). The CBD Project Coordinator's responsibilites will include: a) overall management of project activities at central and district level; b) preparation and submission of quarterly progress reports, annual workplans and budgets to IDA, the PSC and the DHMT; c) supervision of the CBD supervisors; d) procurement, disbursement of funds, accounting, financial reporting and internal auditing arrangements carried out by the PIU (see Annex 4); and e) ensuring that financial reporting and auditing arrangements are submitted to IDA on tiime. The CBDPC will be supported by four technical specialists responsible for IEC, training, back-up clinical support and overall monitoring and evaluation. These four specialists will oversee their respective project activities with the support of the NFPC and the RHU and will be hired on a contractual basis by the project. They will be located in a separate Unit at the Regional Health Office, Lilongwe, and will liaise with the relevant Units in the MOHP and NFPC, but will work full time on the project. The CBDPC's office will have a full complement of project support staff, i.e. secretarial support, drivers and a general hand. The MOHP will enter into a Memorandum of Understanding with the NFPC for the delivery of activities covered under the NFPC's mandate as highlighted in the Project Implementation Plan (PIP). (f) Utilization of the services of the PIU (see Annex 4) during the first six months to: (i) establish and maintain project accounts; (ii) disburse funds; (iii) keep financial records and document all project expenditures in accordance with sound accounting practices; (iv) make available project accounts for internal auditors and project coordinator; (v) prepare and submit budgets and financial records to the project coordinator, and (vi) carry out procurement. The PIU will be strengthened by the addition of an Assistant Accountant to be employed by the Project.  Page 9 Figure 1: Institutional Structure for Main Actors at Central, District and Community Levels PS Project Steering Committee (PSC) Policy Development & Guidance Project Direction and Oversight PHRDU Project Coordlinator PSC secretariat (located in M[oHP) PIU (Assistant accountant, located in MoHP) Accounting,financial Reporting, Procurement, Disbursement,Internal Audit IEC ra ng BackUp M & E (MOHP) (MOHP) Support (NFPC) (MICHP) DHMT [ HEO | | CBDA |.. Supervisor | t |.............. C A---- H |District Hospital Health Centre Km Community Mobilation  Page 10 4.1.3 Project Implementation at District Level: The project will be implemented at the district level by the District Health Management Team, which comprises the DHO, District Nursing Officer, Administrator, Accountant, District Environmental Health Officer (DEHO) and Clinical Officer. Two CBDA Supervisors hired by the project and the existing district Family Planning Coordinator will be incorporated into each DHMT for the purposes of project implementation. The DHMT vvill be responsible for: a) providing back-up support for referrals on injectables, IUCDs, sterilization, and Norpllant, and STD case management (see below); b) distribution of contraceptives to the health units and the CBDAs; c) provision to CBDAs of contraceptive kits; d) supervising CBDAs; e) preparing quarterly progress reports; f) distributing CBDA incentive packages; and g) vehicle maintenance. 4.1.4. Logistics Arrangements: The Regional Medical Stores will supply contraceptives to project districts. Project districts will be given an annual budget to pay handling charges when they collect contraceptive supplies. Using a vehicle, the FP coordinator will move the contraceptive supplies from the RMS depots to the pilot districts (see Figure 1). 4.2 Monitoring and Evaluation: Monitoring and evaluation systems (see Figure 2) are built into the project in order to ensure that the objectives of the project are met. They will track inputs, outputs and outcome indicators (see the LogFrame). Data collected in the field will flow to the district FP coordinator, who will consolidate and then forward them to the M&E specialist. The M&E specialist will, with the support of the NFPC and the contraceptive logistics officer in the RHU, be responsible for: (a) supervising data collection, and analyzing and interpreting data, for input, output and outcome indicators, (b) consolidating and maintaining all service statistics from the DHMT in a project data bank, (c) providing regular reports and feedback on progress of project activities, and (d) consolidating existing data collection instruments and commissioning new service statistics as needed. Evaluation will be centered on a population-based baseline and repeat evaluation sample survey, which together will assess the achievement of the pilot CBD program in improving demand for, access to, and use of modern family planning through comparative analysis of trends in pilot and control districts. At about the mid-point of the project, an in-depth field study of the CBD program will also be carried out, in order to assess on-the-ground achievements, issues and problems and identify any system modifications that need to be made. The M&E specialist will be responsible for supervising these evaluation activities.  Page I 1 Figure 2 The Contraceptive Logistics Management System RHU M & E Specialist Reional Medical Store l K FP coordinator (DHMP) D H I b 2 3 c Health CentexiI CBDA Supervisor a CBDAs Contraceptive users flow of information ...............> flow of supply Ia certain amount of CBDA supply through supervisor 2 the rest of CBDA supply through Health Center 3supply of Health Center for its own needs 2 & 3 to be packed in separate boxes a CBDA supervisor compiles information from CBDAs and transmits it to DHMT bfeed-back of information concerning supply of CBDA by Health Center c information on own needs of Health Center  Page 12 D: Project Rationale 1. Project alternatives considered and reasons for rejection: a) Consistent with Malawi's recent priorities and the Bank's emphasis on poverty alleviation, the project will fund a pilot approach to CBD programs in the rural and under-served areas of the country. The Community-Based Distribution approach was adopted by the government in consultation with communities, non-governmental organizations, and special interest groups including the donor community. b) An expansion of the network of static health/FP facilities was considered as an alternative. However, this was rejected because it is believed to be less cost-effective than the CBD approach and would require considerable resources to meet the infrastructure and staffing requirements. Donors are already providing additional financial support through static units but there is need to augment support to community-based FP activities. c) Use of outreach from MOHP and CHAM health units was also rejected as an alternative to a CBD system. This was again due to the high costs entailed in implementing such a system, including transportation and subsistence allowance for the staff, as well as the lesser degree of comrnunity participation. 2. Major related projects financed by the Bank and/or other development agencies (completed, ongoing and planned): Sector issue Project Latest Supervision (Form 590) Ratings (Bank-financed projects only) Implementation Development Progress (IP) Objective (DO) Bank-financed Health, Nutrition and Population PHN Sector Credit S S Poverty Reduction Social Action Fund HS S Education Education Sector II S S Primary Education Project S S Secondary Education Project P P Environment Environment Management S S Other development agencies (See tables l & 2 Below) IP/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsaitisfactory), P (Planned) The 1995 Population Sector Study3 estimated that annual expenditures on population activities in Malawi were about US$ Il million, of which about 7 percent was contributed by GOM, 6 percent by NGOs and 87 percent by the donors. As indicated in Tables 1 and 2, the largest contributor among the donors was USAID, followed by DFID, UNFPA, EU, GTZ, UNICEF and IDA. UNFPA was the largest contributor Source: 1995 Population Sector Study  Page 13 to DDLGA, CHAM and estate and private for profit organizations; DFID was the only contributor to Banja La Mtsogolo, and IDA was the largest contributor to NFPC. The highest share of donors' resources (see Table 2) goes to FP services in static units, followed by STD/AIDS prevention activities, institutional support, IEC activities, contraceptive supplies, training, social marketing, and CBD. The largest contribution to clinic-based FP services and IEC comes from UNFPA; to training, supplies, CBD, Social Marketing (SM) and STD/AIDS from USAID; and to institutional support from DFID. Table 1: Source of Funding in Population/Family Planning in Malawi (in percent) Source of MOHP DDLGA NFPC NGOs CHAM BLM Estates Other TOTAL funding private GOM 8.8 64.9 25.5 11.5 7.4 NGOs 9.8 25.5 5.9 Donors 91.2 35.1 74.5 100 90.2 74.5 100 88.5 86.7 Total 100 100 100 100 100 100 100 100 100 Source: WB 1995, Population Sector Study. Table 2: Distribution of Resources by Services (in US$ '000) Source Clinic I rain- Contra- IlJ CBL/ "Social S I D/ Institutional I O I AL of based ing ceptive TBA Marketin AIDS support funding FP supplies g UiOM 215 132 5(: S 366 139 902U NGOs 642 5 647 Donors 2,129 471 918 1530 201 550 2,259 1,725 9,783 TOTAL 2,986 603 923 1580 201 550 2625 1864 11,332 Row % 26% 5% 8% 14% 2% 5% 23% 16% 100% 3. Lessons learned and reflected in the project design: Until the early 1990s, FP in Malawi was only acceptable as child spacing and was integrated into other services such as maternal and child health. Therefore, the experience with community-based FP activities in Malawi is relatively recent. Even though the PHN Sector Credit financed the construction of FP Units, completion and-utilization of the units has been sllow, a reflection of broader sectoral weaknesses. In view of these weaknesses, MOHP needs to find alternatives for implementation of family planning interventions, such as use of the NFPC under clearly specified and detailed operating policies and procedures. Another lesson learned from the past is that audit, procurement, and disbursement mechanisms have to be in place before the project becomes effective. 4. Indications of borrower commitment and ownership: The new Government of Malawi has taken several steps that indicate its commitment towards Population/FP. These steps include: establishment of the NFPC to supervise, coordinate and fill gaps in family planning services; the approval and adoption of a population policy; participation in the 1995  Page 14 Population Sector Study; requesting of a Population and Human Resources Developmenl (PHRD) Grant to fund preparation of the project; close collaboration with the consulting firm selected to conduct preparatory studies; and preparation of a Project Implementation Plan by a Project Preparation Team (PPT) chaired by the head of the PHRDU and with members from the MOHP, NFPC, and Ministry of Information, Broadcasting, Posts and Telecommunications. 5. Value added of Bank support in this project: The Bank's involvement in the health sector in Malawi dates back to 1980. Since the beginning of this involvement, it has played a significant role in the populationlFP sector in Malawi, including contributing to the development of the Population Policy and family planning services, financing the establishment of the NFPC, and conducting analytical work such as the 1995 Population Sector Study which highlighted the need for a CBD system. This work has provided leadership in developing population policy, planning FP service development and creating local ownership. The Bank; is thus uniquely well placed ito support the development of a CBD system as the next step in population policy and FP program development. E: Summary Project Analysis (Detailed assessments are in theprojectfile, seeAnnex 6) 1. Economic (supported by Annex 4): []Cost-Benefit Analysis: NPV=US$ million; ERR= %Yo []Cost Effectiveness Analysis: [] Other (Specify) The PHRD funded studies carried out a preparatory economic analysis of different FP outreach approaches, including cost-effectiveness analyses. Their results indicate that investments in CBD activities are likely to produce substantial fertility reductions. The project will support technical assistance to design and carry out a full economic analysis of the approach chosen for financing under the project. 2. Financial (see Annex 5): NPV=US$ million; FRR= % Financial gains accruing to men, women and adolescents benefiting by the project will be estimated in a beneficiary assessment. Data collected during implementation will generate estimates of per capita and recurrent costs required to implement a CBD program (including the cost to communities and the back- up support system) on a district and national basis. The data will also be used to estimate how recurrent costs of the CBD program are offset by cost savings arising from reduced social services expenditure due to reduced fertility. 3. Technical: Based on experience elsewhere and in Malawi itself on a small scale, the design of the CBD program to be piloted by the project is technically sound and can be supported by current technical resources in the health system. The technical capacity of the MOHP to carry out the proposed project on a national scale will be evaluated during the project.  Page 15 health system. The technical capacity of the MOHP to carry out the proposed project on a national scale will be evaluated during the project. 4. Institutional: a. Executing agencies: Based on the PHRD funded studies, the proposed institutional arrangements for project implementation are expected to be sound. These studies identified: the PHRDU as the source of policy guidance and coordination; the CBD Unit in the NFPC as the best agency to coordinate, manage, monitor and evaluate the CBD approach; the RHU as the appropriate source of support for back-up services; and the DHMTs as the critical level for field implementation and support to CBDAs. The proposed project implementation structure will be a separate entity working closely with the RHU and the NFPC. The Unit will make full use of the strengths of all agencies involved in the family planning sector and promote partnership with the districts. b. Project management: The use of the already existing MOHP PIU to support the CBD Project Coordinator is justified and cost- effective as the staff are in place and experienced in IDA procedures. The project will last only three years and hence needs to be implemented quickly and smoothly; yet a new Implementation Unit would take a long time to staff and to build similar expertise in procurement, disbursement and accounting. 5. Social: The project will conduct social assessments at the community level to explore the potential for social mobilization and development of community level monitoring of the CBDA performance in providing family planning and other social services. 6. Environmental assessment: Environmental Category [fA JIB [xl C This is a category C project. The activities envisaged are expected to contribute to the reduction of population growth in Malawi, and hence decrease environmental pressures and degradation. 7. Participatory approach [key stakeholders, how involved, and what they have influenced; if participatory approach not used, describe why not applicablel: Primary beneficiaries and other affected groups: Project preparation was preceded by a Beneficiary Assessment (1994) on community attitudes to family planning. This participatory approach adopted by Government was continued throughout project preparation. At the project identification stage, in July 1997, a national workshop of all potential stakeholders was held by the project preparation team in collaboration with the World Bank Mission, at which the project concept was presented, including scope, olbjectives, rationale, and components. As part of the PHRD funded studies, a consultative workshop of stakeholders was organized in December 1997. After the Studies were completed, the PPT followed up with a workshop to disseminate the results and feed them into the project preparation activities. The active involvement of the DHMTs from the six districts (3 pilot and 3 control) during project appraisal was also critical to establishing local ownership. In addition, the project will actively involve beneficiaries in modifying CBD program design and in Monitoring & Evaluation activities.  Page 16 Table 3. Entities Informed, Consulted/Invited to Participate Agencies Identification/ Impleimentation Operation Preparation Beneficiaries CONS, COL CONS, COL CONS, COL NGOs IS, CONS, COL IS, CONS, COL CONS, COL Academic institutions IS, CONS COL COL Government IS, CONS, COL IS, CONS, COL IS, CONS, COL Other donors CONS, COL CONS, COL CONS, COL Note: IS = Information Sharing, CONS = Consultation, COL = Collaboration. F: Sustainability and Risks 1. Sustainability: The issue of long-term financial and institutional sustainability of family planning services in Malawi remains unresolved. The project will finance the pilot phase of what could be expanded to a nationwide CBD approach and is expected to provide a rationale for continuing budget support from MOHP after the project. While a CBD program will initially consume resources, its costs are projected to be more than matched by savings in government expenditure on social services resulting from reduced fertility. More detailed analysis will be carried out on the data collected during the project.  Page 17 2. Critical Risks (reflecting assumptions in the fourth column of Annex 1): Risk Risk Ratirg Risk Minimization Measure Annex 1, cell "from Outputs to Objective" Religious groups support or are neutral to the project Low and DHMTs are committed to the project District teams have capacity to provide quality Medium Training coordinator at the project Unit will training identify trainers and discussions with DHMTs indicated that they can mobilize trainers from within the districts. Logistic bottlenecks continue to hamper the Medium FP Coordinator's main function in the DHMT distribution of contraceptives. is to ensure commodity availability from the regional stores. Logistics officer in the RHU will support pilot. Adequate coverage of quality IEC messages by the Medium Orientation of media people will be done and media message development is a critical early project activity. DHMT remains committed and CBD drop-out Low DHMT has shown commitment and CBDAs remains minimal incentive package will prevent high drop out rates. Community-Based Distribution Agents (CBDAs) Low DHMT will explain the incentive package and may not be able to fulfill their tasks because the monitor the response incentives are not sufficient Staff in RHU and NFPC to be committed and High Staff will need to be motivated and PIU will MOHP allows the PIU to support the project; NFPC provide systems support, induct and work with direct subvention withdrawn, Council funds likely to the appointed assistant accountant to work on be inadequate. pilot; MOHP has undertaken to fund the NFPC NFPC remains viable and continues to work with Medium Demand for NFPC services is high, the M&E RHU and CDLMIS - staff in the units are committed staff and the CDLMIS officer are very motivated Annex 1, cell "from Components to Outputs" DHMT mobilizes key people at the district level, Low DHMT and communities will be reached as communities are willing to participate, and part of the start-up activities candidates with minimum qualifications are identified at the village level Existing IEC materials for service providers and Medium NFPC and the health education unit have been CBDAs are in usable form preparing some materials Technically competent people are available to do the Low Training coordinator will carry out a skill review in time for the training to start search Community and service providers attitudes are Low IEC campaign will address this as a priority amenable to chaage Support is forthcoming from the Health Education Low IEC specialist will brief the unit and bring it on Unit; board Transport procurement is expedited, equipment, Low Documents used by the PIU are already drugs and commodities are delivered to district approved by IDA hospital Training specialist is in post in time and the M&E is Low Recruitment and M&E are priority activities active within each component Overall Risk Rating Low Both the President and the Minister of Health and Population consider the project a priority Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N (Negligible or Low Risk)  Page 18 3. Possible Controversial Aspects None. G: Main Credit Conditions 1. Negotiations As conditions for Negotiations: establish the project implementation structure, inc]luding the PSC, the CBD-Project Coordinator's office and the PIU, together with all positions in the structure (Section C, para 4) 2. Effectiveness Conditions: As conditions for effectiveness, GOM will: a) select the CBD Project Coordinator and the Assistant Accountant to be employed on contract at project start-up, whose qualifications are satisfactory to IDA (para 4.1.2); b) execute a MOU with NFPC; c) install a financial management and reporting system satisfactory to IDA. 3. Main Credit Conditions As conditions in the Development Credit Agreement, GOM will: a) complete the fieldwork for the project baseline survey in the pilot districts by June 30, 1999; carry out a mid-point field study of the CBD program by September 30, 2000; and carry out a repeat final evaluation survey by September 30, 2001; (Section C, para 4.2); b) recruit and sign contracts with the M&E, training, back-up- support and IEC specialists, 100 CBDAs and six CBDA Supervisors; c) carry out the project training program in a timely manner; d) use the indicators listed in the DCA (Schedule 6) to evaluate the success and impact of the project. 4. Other: Submit an inventory of the status of existing equipment, supplies and staff training needed to deliver appropriate clinical family planning methods in existing static facilities in each pilot and control district to IDA;  Page 1 9 Financial a) (i) The Borrower shall maintain or cause to be maintained records and accounts adequate to reflect in accordance with sound accounting practices the operations, resources and expenditures in respect of the Project; (ii) have the records and accounts referred to in paragraph (i) of this Section including those for the Special Account for each fiscal year audited, in accordance with appropriate auditing principles consistently applied by the Auditor General and acceptable to the Association; (iii) furnish to the Association as soon as available, but in any case not later than six months after the end of each such year, the report of such audit by said auditors, of such scope and in such detail as the Association shall have reasonably requested; (iv) furnish to the Association such other information concerning said records and accounts and the audit thereof as the Association shall from time to time reasonably request; b) For all expenditures with respect to which withdrawals from the Credit Account were made on the basis of statements of expenditure, the Borrower shall: (i) maintain or cause to be maintained, in accordance with paragraph (a) of this Section, records and accounts reflecting such expenditures; (ii) retain, until at least one year after the Association has received the audit report for the fiscal year in which the last withdrawal from the Credit Account was made all records (contracts, orders, invoices, bills, receipts and other documents) evidencing such expenditures; (iii) enable the Association's representatives to examine such records; and (iv) ensure that such records and accounts are included in the annual audit referred to in paragraph (a) of this Section and that the report of such audit contains a separate opinion by said auditors as to whether the statements of expenditure submitted during such fiscal year, together with the procedures and internal controls involved in their preparation, can be relied upon to support the related withdrawals; c) GOM will make available on a quarterly basis, the Government's counterpart funding; Other d) Maintain policies and procedures adequate to enable it to monitor and evaluate on an ongoing basis in accordance with indicators, the carrying out of the Project and the achievement of the objectives thereof; e) Prepare, under terms of reference satisfactory to the Association, and furnish to the Association, on or about September 30, 2001, a report integrating the results of the monitoring and evaluation activities performed pursuant to paragraph (d) of this Section, on the progress achieved in the carrying out of the Project including an in-depth field study of the CBD program, during the period preceding the date of said report and setting out the measures recommende(d to ensure the efficient carrying out of the Project and the achievement of the objectives thereof during the period following such date; f) Review with the Association, by September 30, 2001, or such later date as the Association shall request, the report referred to in subparagraph (e) of this para,graph, and, thereafter, take all measures required to ensure the efficient completion of the Project and the achievement of the objectives thereof, based on the conclusions and recommendations of the said report and the Association views on the matter; g) The Borrower shall by: (a) June 30, 1999, complete the fieldwork baseline survey in the Project and Control Districts; and (b) September 30, 2001, carry out a final evaluation survey in the same Districts.  Page 20 H. Readiness for Implementation [ ] The engineering design documents for the first year's activities are complete and ready for the start of project implementation. [x ] Not applicable. [ x] The procurement documents for the first year's activities are complete and ready for the start of project implementation. [x ] The Project Implementation Plan has been appraised and found to be realistic and of satisfactory quality. [ ] The following items are lacking and are discussed under loan conditions (Section G): Staff, training program, computerized financial management system and survey of existing equipment in health facilities. The Project Implementation Plan has been completed. Job clescriptions for the project implementation structure have been prepared. Counterpart funding for the first year of the project has been included in the budget for Government's 1998/99 fiscal year. Standard bidding documents for the health/FP sector already exist and are in use. The Project Implementation Unit to be used by the project already exists and is functioning, and can begin work on the project as soon as needed. I. Compliance with Bank Policies [X] This project complies with all applicable Bank policies. [ ] [The following exceptions to Bank policies are recomimended for approval: Task Team Leader: Norbert Mugwagwa Sector Manager: Rt Pia Country Director: Barbara Kafca  Page 21 Annex 1 Project Design Summary Malawi: Population and Family Planning Project Narrative Summary Key Performance Means of Important Assumptions Indicators Verification CAS Objective: Decrease in the total National Sustained government An empowered rural fertility rate from 6.7 to 5.4 Statistics commitment population contributing to the by 2002 reduction of population Macro economic stability growth Program Development (From Program Objective: Development Objective to Goal) Increase the use of modem Increase in contraceptive Survey and Religious groups support or contraceptives nationwide prevalence rates from 7 to progress are neutral to the program . 28 percent reports Population do not perceive the program as antagonistic _____________________________ ___________________________ with their beliefs CBD approach of interrelated CBDAs achieve average Survey and Population is sensitized and elements of demand and client lists of 200. progress receptive to the program supply-sides of Population/FP reports successfully tested in 3 GOM and communities districts interested in investing resources nationwide for FP District Health Management Teams are .______________ _ _committed to the project Outputs: Key Performance Means of Important Assumptions Indicators Verification (from outputs to DO) All static health/FP facilities All gaps in equipment, Focus group Religious groups support or in the 3 pilot districts are able supplies and staff training reports, are neutral to the project to deliver an appropriate needed for appropriate Initial and range of clinical FP methods range of clinical FP repeat final District Health methods have been filled by survey of Management Teams are the end of the project facilities in committed to the project pilot districts  Page 22 IEC messages reach targeted Radio campaign established Pre- and post- District teams have capacity segments of men and women and operational by the end survey to provide quality training of first year Logistic system works 100 radios distributed to CBDAs to form targeted listening groups Adequate coverage of All planned educational quality ][EC messages by the materials produced and media distributed to targeted communities by third year Improved access to FP At least 50 percent of target Survey DHMT remains committed services to rural and population with access to and CBDAs drop-out is underserved groups in project FP services minimal areas NFPC and RHU capacity Timely submission of Monthly Staff in the two units are strengthened and PIU support monitoring and complete monitoring committed and MOHP provided financial reports reports allows tlhe PIU to support Annual the Pilot; financial and NFPC has adequate funds management from MOHP and other audits sources M& E system established and A Monitoring & Evaluation Baseline and NFPC remains viable and operational FP- System established and final continues to work closely operational by the third evaluation with the RHU CDLMIS month of the project studies including .___ ____ ____ ____ ____ _____ __ above surveys  Page 23 Inputs: (budget Project Components/Sub-components: for each (Components to (see Annex 2 for project description) component) Outputs) 1: Community-Based Distribution (CBD) of 1. US$ 1.7 * Quarterly * DHMT mobilizes Contraceptives: million Progress and key people at the monitoring district level, * contraceptive distribution by recruited Reports. communities are CBDAs; willing to participate, * supervision by CBDA Supervisors, * Disbursement and candidates with health centers, family planning reports. minimum coordinators and DHMT; qualifications are * provision of incentive package for the identified at the CBDAs, salaries and motorcycles for village level. CBDA Supervisors and motor vehicles for FP coordinators; and * provision of wide contraceptive method mix. 2. Information, Education and Communication (IEC): 2. US$ 0.6 * Existing IEC million materials for service * support the development, pre-testing, providers and production and dissemination of IEC CBDAs are in usable materials; form; * distribution of materials in local * Technically language on advantages and safety of FP competent people are and dangers of STDs/AIDS; available to do the * modification of attitudes towards youth review in time for the reproductive needs and IEC training; and training to start; * produce a strategy to strengthen IEC * Community and capacity. service providers attitudes are amenable to change; Support is forthcoming from the Health Education Unit. 3. Strengthening of the Back-up Support 3. US$ 2.5 * RHU support the System million project and health units staff are willing * improve capacity of health professionals to do more FP work; to support FP services provided by * Transport CBDAs through clinical training and procurement is  Page 24 provision of FP and STD equipment, expedited; drugs and supplies; * equipment, drugs and * provide clinical supervision to CBDAs; commodities are * support the FP coordinator and manage clelivered to district the contraceptive logistics management hospital. information system (CDLMIS). 4. Training 4. US$ 0.7 * Training specialist is million in post in time; * develop standard training protocols for * M&E is active within service skills, counseling, supervision each component. and performance assessments for CBDAs and their supervisors; * train service providers and their supervisors in counseling, commodity distribution and re-supply, dissemination of educational messages on STD prevention and protection; * provide in-service training for FP providers; and train FP providers at HCs and district hospitals to provide FP services and STD case management. Monitoring and evaluation is built into each of the above component.  Page 25 PX... .... ............................................ ....... .. ....:............................... ......................................... t C-N V 8 ............................ ............................. ....................................................................... V C g ].... ... ... .............................................. ............................ .................... ......... ............................ ........-............... "a - I 1 C Eu11XX11% X0t1 a - -- ----X- _ U- $||