Jamaica - Population Project

z2M-O -$A fi, RETURN TO FLE RESTRICTED REPORTS DESK COPY Report No. PP-Za WITHIN -ONE WEEK This report was prepared for use within the Bank and its affiliated organizations. They do not accept responsibility for its accuracy or completeness. The report may not be published nor may it be quoted as representing their views. INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT INTERNATIONAL DEVELOPMENT ASSOCIATION APPRAISAL OF A POPULATION PROJECT JAMAICA June 2, 1970 Population Projects Department  Currency Equivalents Currency Unit: = Jamaican Dollar (J$) Note: The currency unit was officially changed from the pound (L) to the dollar (J$) in September, 1969. At the change-over the Jamaican pound was officially valued at J$ 2.0 or US$ 2.40. The only currency units used in the report are the following. US 1.0 cent J 0.83 cents US$ 1.00 = J$ 0.833 US$ 1,000,000 = J$ 833,333 J 1.0 cent = US 1.2 cents J$ 1.00 = US$ 1.20 J$ 1,000,000 = US$ 1,200,000 Abbreviations EV - Encouragement Visitor FP - Family Planning JFPA - Jamaica Fanily Planning Association KSAC - Kingston - St. Andrew Corporation Area MCW - Ministry of Communications and Works NFPB - National Family Planning Board RMC - Rural Maternity Center USAID - United States Agency for International Development VJJH - Victoria Jubilee Hospital Fiscal Year April 1 to March 31 Population 2.0 million (1970) Rate of natural increase: about 2.7%  JAMAICA APPPAISAL OF A POPULATION PROJECT TABLE OF CONTENTS Page No. SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . i-i I. INTRODUCTION . . . . . . . . . . . . . . . . . . . 1 II. SOCTAL AND ECONOMIC BACKGROUND . . . . . . . . . . . 2 III. JAMAICA'S POPULATION PROBLEM . . . . . . . . . . . . 4 The Demographic Situation . . . . . . . . . . . . . . 4 IV. THE GOVERNMENT'S POPULATION CONTROL PROGRAM . . . . . 6 Organization of Family Planning Services . . . . . . 6 Program Activities and Accomplishments . . . . . . . 8 Present Maternity Facilities . . . . . . . . . . . . 11 Finances . . . . . . . . . . . . . . . . . . . 13 Prospects for a Successful Population Program . . . . 14 V. THE PROJECT . . .. * * o o a . * . . . . . . . 16 Summary Description . . . . . . . . . . . 16 Cost Estimates . . . . . . . . . . . . . . . . . . 17 Project Facilities . . . ............. 18 Project Technical Assistance . . . . . . . . . . . 21 Design, Tendering, and procurement . . . . . . . . 23 Coordination and SuDervision . . . . . . . . . . . . 23 Project Timetable . . . . . . . . . . . . . . . . . . 24 Financing and Disbursements . . . . . . . . . . 25 VI. SOCIO-ECONOMIC CONSIDERATIONS . . . . . . . . . . . . 28 VII. RECOMENDATIONS .................. . 30 This appraisal report is based on the findings of a mission which visited Jamaica from December 7 to 21, 1959. The report was prepared by Messrs. G. B. Baldwin, T. King, P. Oltmanns, and G. Zaidan. Mr. Baldwin re-visited Kingston from March 16 to 19, 1970.  1. Population, Births and No. of Deliveries in Public Hospitals and by District Midwives by Parishes, 196h-1968 2. Anticipated crude birth rate 1966 - 1980 3. Table 1 - Service Statistics, National Family Planning Program by Month for Period November 1968 through January 1970 Table 2 - Number of New Acceptors and Re-visits by Parish: Jan. - Dec. 1969 Table 3 - Parish Targets for New Acceptors: April 1969 - M4arch 1970 Table h - New Acceptors Classified by Number of Previous (a) Live Births and (b) Pregnancies Table 5 - Productivity of Clinics as Measured by New Acceptors Recorded (January, 1970) Table 6 - Number of New Acceptors by Method of Contraception Accepted Table 7 - New Acceptors Classified by Source of Referral (1969) 4. Cost. Estimates 5. Victoria Jubilee Hospital: Recurrent Estimates Before and After the Project 6. Table 1 - Budget of the National Family Planning Board for the Fiscal Year Ending March 31, 1970 Table 2 - Estimated Annual Recurrent Expenditure, National Family Planning Board, April 1, 1971 - March 31, 1976 7. Location Data for Rural Maternity Centers 8. Note on Rural Maternity Centres Table 1 - Rural Maternity Centres, Preliminary Cost Estimates 9. Tentative Project Timetable 10. Scheduling Study of Kingston Area Facilities (Draft Terms of Reference) 11. Proposed Terms of Reference for Study of Tasks Performed by Health Center Personnel in Jamaica National Family Planning Program 12. Proposed Terms of Reference for Training Adviser to NFPB 13. Illustrative Terms of Reference for the Annual External Review LAP  JAr4ICA APPRAISAL OF A POPULATION PROJECT SUMMARY AND CONCLUSIONS i. The Government of Jamaica (GOJ) has adopted a national policy of slowing down the growth of population. This policy is intended to reduce the burden of chronic unemployment, to relieve the economy of the costs of maintaining a high proportion of dependents, and to increase long-run possibilities for raising per capita incomes. In pursuit of these ends the Government has established a program of voluntary family planning (FP) services supported by a mass-media educational campaign and a system of personal recruitment intended to interest people in becoming acceptors of family planning. ii. Somewhat paradoxically, the project consists primarily of the con- struction of new maternity facilities. This is because the Jamaican FP program relies primarily on the recruitment of women immediately after childbirth: it therefore depends heavily on the provision of maternity centers to which can be attached medical and other personnel trained to offer women family planning information during their post-partum recovery period. iii. Some US$ 2.0 million of the project costs are for expansion and remodelling of the country's largest maternity hospital, the Victoria Jubilee Hospital (VJH) in Kingston. Over 20% of all births in the country occur in this overcrowded building. Today this hospital has a normal occupancy rate of over 100% despite the discharge of most patients less than 24 hours after admission. The second major component of the project consists of the construction of the ten Pural Maternity Centers (RMC's) at a total estimated cost of US$ 428,000. These are a new type of facility for Jamaica; they are intended to provide delivery facilities for rural women who traditionally deliver at home because they live too far from one of the island's 12 Parish Hospitals. In addition to its twro construc- tion components, the project would include four technical assistance activi- ties designed to improve the efficiency of the Government's overall program! (1) A study of the tasks now being performed by the medical and para-medical personnel engaged in family planning activities with a view to relieving highly-skilled groups of routine functions thus increasing the productivity of Jamaica's scarce doctors and nurses and reducing costs. (2) The provision of an experienced training adviser to help the National Family Planning Board (NFPB) increase the amount and effectiveness of training for personnel engaged in family planning activities;  - ii - (3) A study of how to make the best use of health clinics and of professional manpower offering family planning services in the Kingston metropolitan area. (4) The recruitment of a small team of outside experts to conduct an annual review of the national program during each of the next four years. The four technical assistance components are estimated to cost approxinately US$ 100,000. The results of these four activities should be of interest to other countries in the Caribbean and elsewhere. Total project costs are US$ 2.97 million including contingencies at 20%. iv. The Bank would finance the foreign exchange costs of the project (US$ 1.6 million) plus interest and commitment charges during construction of US$ 0.3 million. For loan purposes the total estimated foreign exchange re- quirements of US$ 1.9 million have been rounded to US$ 2.0 million. All other project costs would be financed by the Government of Jamaica, with the possible exception of a small grant (approximately US$ 25,000) from the United States Agency for International Development (USAID) to fund the two studies that form part of the technical assistance component. v. The Borrower would be the Government of Jamaica. The loan would not become effective until enactment by the Jamaican Parliament of a statute establishing the National Family Planning Board on a permanent basis and appointment by the Minister of Health of a Board and a Chief Executive (para. 4.05). vi. Construction would be divided into two separate international tenders, one consisting of the Victoria Jubilee Hospital, the other consisting of the 10 EMC's on which contractors would be invited to bid either singly or on a i'package"' basis. vii. The project would have important socio-economic benefits. These consist of improved maternal and child health, higher living standards for families practicing family planning and for the population generally, savings on the government budget, and an eventual contribution to reducing unemploy- ment by limiting the growth of the potential labor force. viii. The proposed project covered by this appraisal report would be the initial Bank/IDA operation for population control. although the Bank's money will be used primarily for "bricks and mortar," the main significance of the Bank's involvement is the catalytic role which the government hopes the Bank can play in institution-building. ix. The project is suitable for a Bank loan of US$ 2 million, carrying a 20-year term inclusive of a five-year grace period.  JAMAICA APPPAISPL OF A POPULATION PROJECT I. INTRODUCTION 1.01 A Bank economic mission visited Jamaica in May/June, 1968; it found that considerable improvement was needed if the country's newly- established family planning (FP) program was to become effective. The matter was discussed with the Minister of Finance during the Bank's Annual Meeting in September, 1968. In December, the Government requested the Bank to organize a mission that would review the family planning program and make suggestions for improving it. fi five-man Review Miission visited Jamaica from January 26 to February 22, 1969; it was led by Mr. S. M. Keeny of the Population Council and included Dr. K. Kanagaratnam (then Chairman of Singapore's National Family ;lanning Board), Dr. S. Khanna (Pan American Health Organization), and Messrs. S. Kuriyama and G. Zaidan of the Bank's staff. 1.02 The Review Mission's recommendations included the preliminary identification of a possible Bank project, comprising among other things, the expansion of the Victoria Jubilee Hospital (VJH), the country's largest maternity hospital, and the establishment of a new kind of h to 12 bed maternity home in the remote rural areas. Subsequent discussions with the Bank defined the project more precisely. The appraisal mission of December, 1969 resulted in additional modifications of the original pro- posals, mainly in the direction of eliminating a number of very small components and of adding certain technical assistance elements designed to increase the overall effectiveness of the Government's program. 1.03 The appraisal mission was headed by Mr. G. B. Baldwin (economist) and included lMessrs. T. King (economist), P. Oltmanns (architect), and M. Nilo, Jr. (consultant architect). The Director of the Population Projects Department, Mr. K. Kanagaratnam, visited Kingston briefly during the mission. Mr. A. J. Davar, the Loan Officer for Jamaica, was present for much of the mission's stay and participated in many of the meetings. Mr. Baldwin re- visited Kingston in March, 1970.  - 2 - 1I. SOCIAL AND ECONOMC BACKGROUND 2.01 Jamaica is a densely populated tropical island in the Caribbean with an area of 4,400 square miles and a population of 2.0 million. Economic growth in recent years has been rapid. In the last decade real GDP has grown at a rate of over 5% per annum, the main thrust being provided by the bauxite, manufacturing, and tourism sectors. Per capita income is just over US$ 500, higher than in most countries of Latin America and the Caribbear. Income distribution, however, is very unequal: there is high unemployment, estimated at 15-20% of the labor force, and a large proportion of the agri- cultural production is accounted for by poor smallholders. 2.02 Jamaica became an independent nation within the British Common- wealth in August, 1962. It has been politically stable with the two major political parties, the Jamaica Labor Party (JLP) and the People's National Party (PNP), contesting for power through orderly elections. The JLP has been in power since 1962; the next elections are due in 1972. 2.03 The population of Jamaica is predominantly of African descent but also has some Indian, Chinese and European components. Discovered by Columbus in 1494 and first settled by the Spanish, Jamaica came under British rule in 1655 and was developed as a major source of sugar and rum. The aboriginal Arawak Indians having proved unsuitable as plantation labor, large numbers of workers were Drought in from Africa. After the abolition of slavery in 1838, there was an exodus of workers from the sugar planta- tions to the hills of the interior. Their descendants constitute the over- whelming majority of agricultural smallholders, still the largest segment of the population. They live in the tradition of a maternally-oriented society, with the women often carrying the economic burden of child-rearing. This is partly the result of the parental relationships customary in the culture: most are common-law marriages or less pennanent "visiting relation- ships," with only a small proportion of legal marriages. About 70% of all children are born outside legal wedlock. 2.04 The rate of natural increase of population in Jamaica has been high in recent years, averaging over 3% per annum from 1960 through 1967. Although this has been tempered somewhat by emigration, the economic burden of this increase is high, particularly in the light of already substantial numbers of unemployed and the limited availability of arable land. The anticipated exhaustion within the next 40 to 50 years of bauxite reserves, the island's foremost foreign exchange earner, emphasizes the desirability of slowing down the rate of population growth. 2.05 Population pressure in the rural areas, together with the lack of rural employment opportunities, has intensified migration to the urban centers. By 1966 the metropolitan area of Kingston and St. Andrew, con- taining 4% of the land area, contained 30% of the country's population. The high rate of natural increase, and the young age structure, place a  - 3 - heavy strain on Government expenditures on education, health, and housing. Slowing population growth through emigration gives little or no relief to educational budgets, since most emigration occurs after the school-leaving age. On the other hand, reductions in fertility rates would release funds for improving the quality of education and upgrading the skills of the labor force. In the face of the country's limited endowment of natural resources and the heavy budgetary pressure of a young and rapidly growing population, the Government has made a reduction in the birth rate an explicit goal of national policy.  - 4 - III. JAMAICA'S POPUDLTION PROBLEM The Demographic Situation 3.01 The population picture is similar to that found in many developing countries, i.e. a pronounced rise in the rate of natural increase resulting from a fall in mortality rates without any significant fall in the birth rate until very recently. Conspicuous declines in mortality began in the 1920's and, as the table below shows, have continued since World War II. These declines have occurred more than twice as fast as they did, histori- cally, in many European countries. Present mortality rates in Jamaica are low by world standards and no further dramatic declines in the overall rate can be expected. Recent Population Trends 1943-68 (1) (2) (3) (4) (5) (6) Birth Death Rate of End of Growth rate rate natural Net emi- year pop- rate of (per (per increase gration ulation population C00) COO) ((l)-(2)) (in OOO's) (in COO's) (% per year) 1943 31.8 14.5 17.3 - 1,237 1954 34.7 10.9 23.8 - 1,531 2.0 1960 42.1 8.8 33.3 40.4 1,639 1961 40.0 8.6 31.h 38.5 1,652 0.8 1962 39.1 8.5 30.6 28.7 1,676 1.5 1963 39.0 8.9 30.1 7.3 1,720 2.6 196h 39.2 7.7 31.6 13.5 1,762 2.4 1965 39.0 7.9 31.1 6.5 15811 2.8 1966 38.85 7.8 31.05 8.9 1,859 2.7 1967 35.94 7.1 28.8 20.0 1,893 1.8 1968 34.2 7.6 26.6 20.0* 1,923 1.6 *Preliminary estimate. 3.02 A declining fertility trend appeared to set in about 1960. Taking the 1960-68 period as a whole, with a crude birth rate of 38 per 1,000 and a crude death rate of 8 per 1,000, the annual rate of natural increase was 3.0%; this ratio, if continued, would result in a doubling of the popula- tion within 24 years and a total population of nearly 5 million by the year 2000. This is the underlying arithmetic of the Government's decision to adopt a population policy. In actual fact, population growth has been kept under 3% by fairly substantial net emigration, most of it to Britain and the United ntates. Emigration, however, has been erratic, mainly because of changes in immigration policy in the main receiving countries.  The Government's Perspective Plan (1968-1988) assumes continuing net emigra- tion at 15,000 p.a.; but officials have felt that emigration alone could not be counted on to provide sufficient relief from the underlying demo- graphic situation. 3.03 The spread of family planning practices will be one of the key factors governing fertility and the rate of population growth in the future. Other factors are the number of women in the child-bearing ages (itself affected by ernigration patterns), shifts in family arrangements (increases in the proportion of marriages as compared with Visiting Relationships would tend to raise fertility), and family-size goals as influenced by economic and sociological forces. These underlying influences prevent one from assuming that there will be an immediate reduction in the birth rate as a result of introducing family planning; over a period of several years, however, the birth rate will almost certainly faUl. All one can say with certainty about short-nm effects is that an effective FP program will lead to a birth rate lower than it would otherwise have been. 3.04 The National Family Planning Board (MFPB), which is responsible for carrying out the Government's policy, hopes that by 1975 the birth rate can be reduced fron the rate of about 35/1,000 when the national program started in 1968 to around 25/1,000. This would almost repeat the experi- ence of another Caribbean country, Barbados, which has had an active Govern- ment-assisted FP program during the past decade. 3.05 Experience in Barbados suggests that if about one-third of the females in childbearing age use birth control, marked reductions in fertility can be achieved. The NFPB program aims at 20,000 new users each year. Over a five-year period this should result in at least one-fourth of all women of childbearing age adopting family planning; added to pre-existing acceptors, the total proportion would approach the one-third figure cited from Barbados. At the rate of acceptance assumed by the NFPB, a "saving" of 8,000 to 10,000 births may be attained over the first five years of the program. Such a development would bring the birth rate down to the low 30's by the early 1970's and, with increasing momentum, to the target figure of 25/1,000 by 1975.  - 6 - IV. THE GOVERNMENT'S POPULATION CONTROL PROGRAM Organization of Family Planning Services 4.ol The Government of Jamaica has been one of the first in the Western Hemisphere to adopt a policy of slowing down the growth of its population. The official Jamaican effort began in 1964 when the Government first offered family planning services at public hospitals. Private voluntary organiza- tions, however, had been active ever since 1939. In 1964, these groups had merged into a single organization, the Jamaica Family Planning Associa- tion (JFPA), still very active. The JFPA operated with private funds and served the private needs of clients within reach of its two clinics, one in Kingston, one on the north coast. In 1966, the Government established a Family Planning Unit in the Ministry of Health to coordinate planning efforts. In September, 1967 this Unit was replaced by the National Family Planning Board (NFPB), the present instrument for carrying out the Govern- ment's policy. 4.02 The NFPBl/ is a semi-autonomous body appointed by and broadly responsible to the Minister of Health. The Board was established by the Minister under interim legal arrangements intended to be followed by enact- ment of a permanent statute. The Bank originally expressed the view that the usual commercial reasons for establishing semi-autonomous bodies did not seem sufficiently strong to justify the use of this arrangement for a family planning program. Subsequently, the Bank accepted the Govern- ment's preferred arrangement, provided only that the powers and responsi- bilities of the agency, and its relation to the Ministry of Health and to the voluntary agencies, should be appropriate and clear. 4.03 In its first two years, the Board has operated much more as a detached department of the Ministry of Health than as an independent statutory body. Although the Director of the Board is identified with the opposition party, the relations between the NFPB and the Ministry have been satisfactory. A close working relationship between the Board and the Ministry is essential since the Board relies heavily on the use of Ministry buildings and staff to carry out its program. No significant change in the Board's relation to the Ministry is expected when its establishment is made permanent by enactment of a statute (see para. 4.05). 4.04 The first two years' experience with the Board arrangement has revealed problems of representation on the Board, of the Director's rela- tionship to the Board, and of the NFPB' s relationship to the private JFPA. The latter organization has made outstanding contributions to 1/ The NFPB refers both to the nine-member Board itself, a policy- making group of professional and business leaders who meet every 2-3 months to set policy and approve plans and budgets, and to the full- time administrative staff of over 60 employees who carry out the progra:n from the Board headquarters in Kingston.  - 7 - family planning education and clinical practice and includes among its leading members some of the most prominent names in the field. The com- mingling of JFPA and IFPB interests which has taken the form of excessive JFPA representation on the NFPB Board, has affected program planning and execution. The clarification of these relationships is essential to the strengthening of the NFPB's program. Two steps need to be taken immediately. One is to reduce the number of persons identified with the JFPA on the NFPB Board and to replace them with governmental representatives; the second is to transfer direct responsibility for the Encouragement Visitor program from the JFPA to the NFPB (see para. 4.16). 4.o5 The enactment of a statute giving the NFPB a permanent and clear legal foundation is essential to the future of the program. The key points at issue have been the membership of the Board and the concept of the NTPB's chief executive officer and his relationship to the Board. The Board it- self needs wider representation of government interests. At the administra- tive level, the NIFPB requires direction by an individual who is primarily an effective administrator (whether or not he is also a doctor) and who will be a member of the Board, perhaps serving as its chairman. Draft legis- lation satisfactory to the Bank covering these points was agreed during negotiations. Enactment of this legislation and appointment of the new Board and of a chief executive officer mutually acceptable to both the goverrmient and the Bank. 4.o6 In executing its program, the Board operates through the professional staff of the Hlinistry of Health and uses, on a part-time basis, the Ministry's extensive network of health centers, plus selected hospitals, spread over the island. The NFPB prepares its own long-range program, which need not be approved by the Tinister of Health, and its own annual budget; the latter is included in the Yinistry's overall submission to the Mlinistry of Finance. Except for minor iterms of office equipment and a few vehicles owned by the Board, the facilities and equipment it uses are owned by the Ministry of Health and are financed from the Ministry's capital budget. The Board employs its own headquarters staff directly; these are government employees but they are not considered employees of the Ministlr of Health. The Board maintains its own accounts separate from the Ministry's funds, may purchase its own equipment and supplies, is authorized to make its own disbursements, and is subject to annual financial audit by the government's Auditor General.  - 8- Program Activities and Accomplishments 4.07 WShen the Minister of Health established the NFPB in September 1967 he directed it to prepare a progran of objectives and operations for the next three to five years. The Board's three-year program (1968-1971) was published in June, 1968. Its five main objectives are (i) to organize an educational campaign to interest people in family planning, (ii) to increase clinical facilities sufficiently to make available FP services throughout the island, (iii) to train clinic staff in family planning operations, (iv) to organize as part of the program measures for the early detection and treatment of uterine cancer, and (v) to maintain close contact with world developments in the field of family planning. The Board was able to make its senior staff appointments and to mount a national program relatively quickly and without more than normal start-up difficulties. 4.08 The NFPB program has so far been aimed almost exclusively at women. It requires a combination of activities to educate, motivate, and to give technical advice and service to the island's female population. It is natural, therefore, that the FP program should be closely linked to the general structure of Maternal and Child Health (MCH) services, including the facilities and staffs engaged in antenatal, obstetrical, post-partum, and post-natal care. The close link between FP activities and these general health services associated with pregnancy, birth, and post-partum recovery underlies the Bank project. 4.09 In addition to its central rmaternity-focused program for motivating and recruiting new acceptors, the Board (1) has successfully arranged for greatly-expanded coverage of family planning material in the professional curriculum of all medical personnel, (2) has tried (so far without much success) to arrange for the preparation of family planning material by the Ministry of Education for use in the general school curriculum, (3) has launched a mass-media program based mainly on billboard and poster advertise- ments, and (4) has tried to develop a network of face-to-face recruitment workers ("Encouragement Visitors," or EV's), and (5) has developed a testing service for cervical cancer for all women who wish it. This test serves to attract women to FP clinics, to identify women for whom neither the pill nor the TUD should be recommended, and as a general health measure independent of FP considerations. 4.10 The ITFP3 program depends heavily, although not exclusively, on motivating and educating women during the post-partum period. This explains why the Bank is financing an expansion and modernization of the largest maternity hospital in the country, the Victoria Jubilee Hospital in Kingston, and the establishment of Rural Maternity Centers for women who live too far from a parish hospital. The task of motivating and educating women during their post-partuin recovery is shared by all redical and para-medical personnel employed at maternity facilities (i.e., doctors, nurses, and midwives) and by specially-trained Family Planning Education Officers (FPEO's). (This latter class of NFPB employee spend most of their time in general FP educa- tion activities outside maternity facilities; but they play an occasional role in post-partum education, especially at the VJH.) For these reasons  - 9 - it is important that all health personnel involved in maternity care have training that will give them a general understanding of family planning from the viewpoint of government and personal objectives, as well as techni- cal FP training appropriate to their specific functions. The NFPB is responsible for seeing that these two types of training are provided; the Bank project will assist it in this function. 4.il Much FP education, and nearly all service activities, are performed in the network of 143 health centers (or clinics) operated by the Ministry of Health throughout the island. These clinics are reserved exclusively for FP use by the NFPB on regular schedules of one, two, or four half-days a month. Each such half-day use is called a "session." The typical session is manned by a four-man team consisting of a doctor, a trained nurse, a midwife, and a records' clerk. The medical members of the team are normally but not necessarily I1inistry of Health employees (midwives are normally employed by the local parish councils). The NFPB pays sessional fees, constituting extra income to all staff serving on the family planning teams at health centers and hospitals; these fees are uniform throughout the country. 4.12 Thuring the Drogram's first four years, the Ministry and later the Board have been successful in rapidly expanding the number of clinics offering FP services. starting with 25 clinics in 1966 the number doubled in 1967, nearly doubled again in 1968, and by December 1969 there were 135 clinics in operation. This rapid build-up of facilities has been achieved partly through the Ministry's construction of new health centers and partly through the renting of space wherever it could be found. The Board's 1958 target was to reach 150 clinics by 1971; this goal is now expected to be reached a year earlier. The following table shows the number of clinics in the metropolitan Kingston area and in the remainder of the island, plus the fre- quency of clinic sessions (at December, 1969): Number of clinics (graded by frequency of sessions) Grade I Grade II Grade III 1 per wk. 2 per mo. 1 per mo. Total Kingston-St. Andrew 25* 8 1 34 Rural parishes 22 52 27 101 Total 47 60 28 135 * are open every day The main problem in covering the island with a network of services has not been a shortage of physical quarters, equipment, or funds; the main problem has been staff, reflecting the national shortage of doctors and trained nurses.  - 10 - 4.13 In the 15 months from November, 1968 through January, 1970 the Board has averaged slightly more than 2,000 new acceptors each month (Annex 3, Table 1). The gross figure of 35,000 new acceptors (i.e., without allowing for dropouts) represents about 10 of all women in the child-bearing ages, estimated for Jamaica at about 1/6th of total population. The Board set new-acceptor targets for each parish for its fiscal year of April 1, 1969 to March 31, 1970: by December 31 two parishes had already exceeded their annual targets and it appears likely that almost all others would have reacheci theirs before the year-end (Annex 3, Table 3). Targets that are uniformly exceeded are doubtless too low, and the Board's single year of statistics does ntpxvvide sufficient experience for setting targets with much confi- dence. There was a slight decline in the monthly recruitment of new acceptors as 1969 progressed; this may well reflect the forced suspension of the EV program by the JFPA in mid-year as a result of misunderstandings and dis- agreements between the I4inistry of Health and the JFPA on the conduct of the EV program. There have been some attempts to evaluate the relative effectiveness of different sources of referral of new acceptors (see Annex 3, Table 7), but it is still too early in the Board's experience to draw firm conclusions. 4.14 The number of new acceptors added each month cannot be summed to arrive at a figure for the number of women practicing contraception. The dropout rate in all family planning programs is large; Asian figures suggest that only 50% of new post-partum acceptors continue as practitioners by the end of their first year following the -period of post-partum infertility and that this figure declines to 30%, 20% and 10$ by the end of the 2nd, 3rd, and 4th years. This experience means that any program must give major attention to keeping in touch with new acceptors in the hope of minimizing dropouts by keeping them motivated and supplied and of re-recruiting those who have discontinued. Despite the dropout rate, many births are prevented before discontinuation occurs so that the "new acceptor" figure is a key one in judging the effectiveness of the program. The figures on "re-visits and "missed visits" (Annex 3, Table 1) provide a rough indication of how successfully the program is retaining participation by past acceptors. 4.15 There appears to be a wide range in the effectiveness of different clinics. No annual figures are available but Annex 3, Table 5 groups clinics by the number of new acceptors registered during the month of January, 1970. Five clinics generated one-third of all new acceptors in the country and 11 clinics generated half the total. At the other end of the scale, 52 clinics (nearly hu0 of the total) were able to recruit only 9 acceptors or fewer; 26 of these signed up 4 or fewer. The tXFPB must soon begin to examine the cost-effectiveness of individual clinics and of alternative means of providing service to target populations now being covered at high cost. The Board is currently establlishing individual cost accounts for each clinic. The Kingston clinic scheduling study and the provision for an annual External Review are intended to help the Board become con- structively self-critical (see paras. 5.21 and 5.24).  4.16 One major factor that has proven essential to the effectiveness of FP in many countries is a system of personal recruitment and follow-up. In Jamaica the staff performing these functions are called Encouragement Visitors (EV's). During its first two years the NFPB contracted out to the JFPA the task of recruiting, training, deploying, and supervising a staff of 120 EV's. The Minister of Health, the Bank, and others have felt that this arrange- ment was unsatisfactory. There has been doubt about the qualifications of many of the EV's, lack of coordination between their deployment and the operation of NFPB clinics, and insufficient attention to this part of their program by the Board. The M1inister of Health has therefore taken steps to have this program transferred from the JFPA to the NFPB. Plans to accomplish this by April 1, 1970, were tentative and unclear. The definition of a revised FV program, to be operated directly by the NFPB, should be a first order of business of the Board and its chief executive immediately after their appointment after enactment of the new statute (para. 4.05). During negotiations it was agreed that the Board would submit a revised EV program for Bank approval no later than November 1, 1970, and would implement the approved program by December 31, 1970. Present Maternity Facilities 4.17 Between 65,ooo and 70,000 babies are born in Jamaica every year. The proportion of women delivering in hospitals has increased steadily in recent years, reaching 405 in 1968. Of the 26,000 hospital deliveries about 15,000 (nearly 60%) occur in the Victoria Jubilee Hospital (VJH), the only government maternity hospital in the metropolitan area and the key element in the Bank project. Plthough it is adjacent to and a component part of the Kingston General Hospital, the VJH has its own Medical Director, its own professional and non-professional staff, and its own budget (see Annex 5). 4.i8 The prestige of the VJH awong the lower classes is great. The VJH regularly delivers 20-25%a of all births in the country and two-thirds of all births in the Kingston metropolitan area. The demands on its serv- ices have outgrown the building's capacity, resulting in serious overcrowding for both patients and staff. This condition seriously interferes with the provision of FP activities at the hospital, the key facility in the NFPB's post-partum nrogram. An experimental 10-bed neighborhood maternity center which opened in mid-1969 at Tivoli Gardens has k.ept only four of its beds occupied, on average; the traditional reliance on the VJE among Kingston women is believed to explain this slow start. There is a charge of J$ 6.30 which women are expected to pay early in their preg"ancy at the time when they are receiving antenatal care in the hospital's antenatal clinic (they also pay 20 cents per clinic visit); however, many women are unable or unwilling to pay until late in their pregnancies, although most of them do so at that time.  - 12 - The hospital never turns anyone away for inability to pay or for any other reason; many women who have not been attending the hospital's clinic turn up at the hospital unannounced but in labor. 4.19 At present the hospital is able to meet the demands put on it only by (a) discharging women as rapidly as possible and (b) putting two women to a bed when no empty ones are available. The average period from admission to discharge is about 1-2/3 days, about one-third are discharged within 24 hours of admission; fewer than one-fifth remain 72 hours or longer. It is common to have 210-220 women occupying the hospital's 165 beds. This condition is continuous throughout the year as there is no seasonal pattern of deliveries at the hospital. The Bank project will approximately double the number of beds at this key hospital. This expan- sion is not needed to accommodate an expected increase in the number of women presenting themselves for delivery (the demand is expected to remain at approximately its present level of 15,000); the expansion is needed to achieve a standard of one bed/one woman and to permit each woman to remain 3 to 4 days instead of 1 to 2. The extension of stay will permit a much more effective FP program at the hospital. 4,.20 From a family planning point of view, the most serious result of overcrowding is the enforced discharge of patients without adequate opportunity to educate them about family planning and to tell them about the availability of services in the communities to which they will return. During the second half of 1969 the NFPB did assign to the VJH a five-man team that has managed to talk briefly with a majority of the women before discharge. The team has its only "office" and consulting room in a heavily- used basement corridor. There is no room for private talks with women nor for film or slide showings, lectures, or demonstrations. 4.21 Overcrowding also affects the hospital's rnidwifery training program. Two training courses are offered, one for up-grading public health nurses by giving them specialist training in midwifery, the other for trainirg women who will work as midwives either in hospital or domiciliary practice. At present both these courses are conducted in an old house opposite the hospital under conditions of severe overcrowding in both lecture and demonstra- tion rooms. The Banlk project will provide modest but greatly improved quarters for the hospital's midwifery training program. 4.22 In the country at large 60% of all births occur at home. Outside the urbanized Kingston - St. Andrew Corporation (KSAC) area three-quarters of all births occur at home. This is not so much a matter of preference as of the availability of maternity facilities which women can hope to reach when labor-starts. Some rural women are close enough to the parish hospital to use it; many are not and have no choice but to deliver at home. Each of the island's 12 rural parishes (i.e. all units of local Government out- side the KSAC area) provide midwifery services for home deliveries; however, two-thirds of all home deliveries are attended not by the trained district midwives but by a class of private, untrained, village women called "nanas " Both the Government midwives and the nanas charge similar fees of around JA ;  - 13 - the dominance of rural home deliveries by the nanas primarily reflects the difficulties of communications and transport between midwives' homes and rural villages and the increasing reluctance of midwives to make night calls in lonely areas from which they may have to return unaccompanied. These administrative considerations re-enforce the Ministry of Health's medical preference for institutional over domiciliary midwifery. t.23 Senior medical personnel in the Ministry of Health and elsewhere in Jamaica strongly favor delivery in attended maternity facilities when- ever feasible. They also believe that a large number of Jamaican women would prefer non-home delivery if given this choice. The 10 Rural Maternity Centers (RMC's) that are part of the Bank project will make it possible, for the first time, for many rural women to have their babies outside their homes if they wish to do so. The BMC will be a new institution for Jamaica and there cannot be certainty about the strength of demand for their use. Experience with similar facilities in other countries is limited to local facilities in a few, countries. Despite this uncertainty, the Ministry and the flFPB3, as wqell as the Bank, believe that this innovation can provide a highly effective means of access to rural women for FP purposes as well as providing much-improved conditions for delivering babies and a more efficient way of using midwives. (See Annex 8). Finances 4.24 In its first two fiscal years (ending March 31, 1970) the Board operated with total budgets of almost exactly J$ 4OO,OCO and J$ 500,000. The Board's FY 1970 budget is equal to 3.5% of the total budget of the Ministry of Health. The FY 1971 budget is expected to be around J$ 600,000. The Board has made rough projections of its budgets through 1975/76 when it expects to spend J$ 915,000. The basis for the projections to 1975/76 is not clear and cannot be given much weight (see Annex 6, Table 2). 4.25 The following table summarizes the NFPW3s budget for fiscal 1970 ending March 31 (fuller details are shown in Annex 6): J$ 000's % Headquarters' salaries 70.8 15.7 Transportation & subsistence 25. 5.1 Sessional fees 108.9 21.7 Education & promotion 101.9 20.3 Supplies (contraception) 4i2.0* 8.4 Subsidies (private agencies) 30.0 6.o Cytology 22.6 h.5 Misc. items under 15.0 each 92.2 18.3 502.8 100.0 *Excluding USAID-financed supplies of approximately J$ 125,000.  - 14 - Sessional fees and expenditures for education and pronotion are the two largest items in NFPB's budgetj it follows that evaluation of the cost- effectiveness of the clinic network, the staffing patterns used, and the work of the Board's Family Planning Health Education Officers deserve special attention. The two studies proposed as part of the project (paras. 5.21 and 5.22) will help the Board start studying the first two of these problems. The Board's Health Education Officers constitute a specialized group that parallels the general Health Education Officers in the Ministry of Health. IJhile their work can probably be justified in the initial years of the program, the need for the continuation of this rather expensive separate group should be reviewed by the Board and by the first External Review team (see para. 5.24). 4.26 An immediate decision that will have major budgetary implications is the resolution of the role to be played by Encouragement Visitors (see para. 4.16). If, for example, the Board took over the 120 EV's which had been on JFPA's payroll early in 1969, and paid them at J$ 25 per week, this would immediately increase its budget by about 30%. The Bank believes that for the next year, at least, the Board should not employ more than 50 EV's and should gain experience in their use before making commitments for scaling up the program. The EV's snould initially be used for service outside the KSAC area, where other recruitment methods seem feasible at much lower cost. 4.27 The semi-autonomous status of the Board has not led it to adopt salaries and emoluments that are significantly higher than those of regular Ministry personnel. The M4inistry's control over the Board's budget is likely to prevent the latter from developing a preferential salary structure, which it does not need and which would only be a source of friction between the Board and other Government bodies. 4.28 The Board is receiving rmajor financial assistance from the United States Agency for International Development. USAID is providing, on a grant basis, about US$ 150,000 of contraceptive supplies annually; this represents about 75% of the Board's supply requirements and 25% of its total budget, No external aid is being received from any other foreign source, official or private. USAID is expected to continue this assistance for the fore- seeable future. TJSAID has also provided technical assistance to the Board in the fields of health education and administration (the latter on a short- term basis only). Prospects for a Successful Population Program 4.29 There are strong general reasons for believing that a National Family Planning Program will be successful in Jamaica. The adootion of family planning as Government policy has been supported by both major political parties; the Program has not become involved in partisan politics. There is no significant religious or cultural opposition to such a policy. The Government's commitment to the policy is based as much on a conviction of the Program's contribution to raising per capita incomes and to minimizing pressure on the budget as it is on grounds of health and social welfare.  - 15 - The Government appears determined to give the Program adequate funding. The medical professions strongly support the Program and have become closely identified with it. Literacy is high (over 60%), distances are short, the medical and public health services already cover the island fairly well, and cormunications are relatively easy. The country has had over 30 years' experience with private family planning services, although these have reached only a small part of the population. The Government Program, begun in 1967, has made a promising start. It has not suffered any serious embarrassments or setbacks as a result of the few criticisms which have occasionally been voiced. 4.30 There are also specific cultural and demographic reasons for confidence that a well-run family planning program would succeed in Jamaica: (a) Women appear to want fewer children. As an example, in a survey on fertility conducted as early as 1953, 1,400 women from the lowest socio-economic groups were interviewed. This survey showed that their desired family size was no larger than that found in many developed countries. This finding was contrary to the widespread belief that poorer Jamaican women were strongly motivated to have a large number of children. (b) Women can be reached relatively easily. About 30% of all births occur in 22 public hospitals, and the Victoria Jubilee Hospital in Kingston alone accounts for nearly 20% of all Jamaican births. Another 26% of all deliveries are made with the help of about 300 District Midwives. Thus well over one- half of the women bearing children in any one year (or about 35,000 women per year) can be reached with relatively little effort and can be educated on the advantages and methods of family limitation. (c) Recent demographic trends are encouraging. The decline in fertility of the last three years began largely independent of conscious Government efforts. This is an indication of a general disire of the population to limit their fertility. Most family planning programs that have been successful have accelerated a decline in the birth rate which had already started. (d) The present death rate of just under 8/1,000 is already low and cannot decline without large improvements in health conditions. This means that reductions in the birth rate will not be offset by reductions in the death rate. (e) Two other ex-British Islands of the Caribbean, i.e. Barbados and Trinidad and Tobago, have had somewhat longer experience with national FP programs than Jamaica. Broad cultural similari- ties justify the hope that the acceptability of FP programs in those countries will be repeated in Jamaica.  - 16 - V. THE PPOJECT Summary Description 5.01 The project consists of both construction and technical assistance elements designed to extend and improve the government's national family planning program. Project funds will be devoted primarily to the construc- tion of key maternity facilities to provide expanded opportunities for educating and motivating women during their post-partum recovery period when they have high receptivity to FP information. Family planning activities in the project facilities Will be part of a complex set of FP activities through- out the island. The Bank's primary interest is in helping the government develop an effective and economical national program. Therefore, the project also contains four technical assistance elements which, while small in anount, will have an important impact on the success of the national program. 5.02 The project provides for the design, construction, and equipment of two types of facilities, both of which will provide expanded opportunities for FP education- (a) A new 175-bed wing at the Victoria Jubilee Hospital (VJH) in Kingston and the remodelling of parts of the present old structure. This building will also contain space for the hospital's midwifery school. The expanded and remodelled hospital will have a capacity of 332 beds as compared with 165 at present. (b) Ten Rural Maternity Centers (RMC's) at strategic locations across the island, each with a capacity of b. to 8 beds. 5.03 The project also contains the following four technical assistance elements: (a) a 3-6 month study of possibilities for rearranging some of the present functions performed by doctors, nurses, auxiliary nurses, and clerks to relieve pressure on the time of the more highly-trained people, who are in short supply (para. 5.22). (b) a study of the service-delivery system in the Kingston- St. Andrew Corporation (KSAC) area to see how to make the best use of professional staff and physical facilities (para. 5.21). (c) the provision of a Training Adviser, if needed, to help the F B in planning and mounting an expanded training effort (para. 5.23). (d) An annual review by a small external team of the progress of the Program during the disbursement period (para. 5.24).  - 17 - Cost Estimates 5.04 Total project cost is estimated at US$ 3.0 million; approximately 75% of this will be spent on the VJH, 20% on the 10 WMC's, and 5% on technical assistance. The major components are listed in the following table (see Annex h for details): J$ 000s U,$ 000's Local Foreign Total Local Foreign Total I. CONSTPUCTION COSTS Victoria Jubilee Hospital 699.1 926.2 i,625.3 838.9 1,113.4 1,952.3 Rural M4aternity Centers 221.0 136.0 357.0 265.2 163.2 42B. Total Construction Cost 920.1 1,062.2 1,982.3 l,10.l 1,276.6 2,380.7 II. STUDIES & TECHNITCAL A7SSISTPNCE 30.0 50.0 80.0 36.0 60.0 96.0 III. CONTINGENCIES (20%) 190.0 222.4 412.4 228.0 257.3 495.3 Total Project Cost 1,14h.1 1,333.5 2,474.7 1,368.1 1,603.9 2,972.0 IV. INTEFFqT AND COINITNISrIT CH'PGES DUPING CON7TFUCTION - 250.0 - _ 300.0 _ Total Foreign Exchange NIeeds - 1,58h.6 - - 1,903.9 - The estimates for the VJH have been worked out in collaboration with archi- tects in the i'inistry of Communications and Works. Costs per square foot are in line wyith recent costs for comparable construction in the country. Furniture and equipment costs are based on suppliers' lists and recent quotations. Professional fees have been agreed in principle by all parties concerned. Technical assistance costs are estimates of Bank staff. The contingency item includes provision for both technical changes and price escalation in equal proportions. Inflation of both domestic and foreign costs is assumed at a weighted average rate of 5% p.a.; since not all costs will be burdened with four years' escalation, an overall price allowance of 10%f is considered reasonable.  - 18 - 5.05 The Bank loan would finance the project's total foreign exchange costs of US$ 1.6 million plus the estimated US$ 0.3 million of interest and commitment charges during construction. The loan amount has been rounded up to US$ 2.0 million. ProJect Facilities 5.o6 The Victoria Jubilee Hospital (VJH) will be expanded to twice its present bed-capacity by constructing a new six-story wing on land opposite the existing building (the "old wing") and by remodelling the latter. The two wings will be joined by a linking bridge across the present hospital-owned road that will runbetween the two wings, The land on which the new wing will be built is already owned by the hospital; two old structures now on the property are about to be demolished to make room for the new VJH wing and for a new internes' residence for the parent Kingston General Hospital. There is enough land to accommodate both the new wing and the internes' residence, which is not part of the project. 5.07 The new wing vill house 183 beds,. The majority will be grouped in wards designed so that infants will "sleep in" alongside their mother's bed; this arrangement saves on construction space and by allowing mothers to attend to their babies, will reduce staffing requirements. Limited provision is made for nurseries to care for those babies who cannot be left in the wards. In addition to all facilities needed for normal deliveries and post-partum recovery, the new wing will provide space for the Hospital's midwifery school, its administrative offices and reception area, and a number of consulting offices for doctors. 5.08 The new wing will have a gross area of approximately 60,000 sq. ft. The allocation of space to specific uses has been worked out by the hospital adviser (see para. 5.25) in close consattation with the Medical Director of thle VJH and is well-suited to the functions to be performed. Design and space standards are adequate but modest; they were significantly reduced during appraisal. The building will not be centrally air-conditioned; however, individual air-conditioning units will be installed in a number of key rooms. 5.09 The total number of beds in the Hospital before and after the project is as follows: After 1974 1970 Old Wing New Wi Total 1. Antenatal 18 48 - 48 2. Intensive care - 6 - 6 3. 1st stage labor/deliveny 24 - 33 33 44. Surgical (including abortions and ligations) 15 55 - 55 5. Lying-in or post-partum 108 5_4 150 204 Total 165 163 183 346 i/ For technical reasons the loann documents refer to the New WrTing as having 150 beds3 this represents the number of post-partum beds, the balance consisting of first-stage labor and delivery "units" (beds).  - 19 - 5.10 The existing structure will not be demolished but will remain in service after remodelling that will cost US$ 144,000 (less than 10% of total VJH project costs). The remodelling will leave the present building with 163 beds. All the antenatal, intensive-care, and surgical facilities and beds will be in the present building. The new wing is planned for handling normal births and recoveries, not for surgical or intensive-care cases. After the expansion, three-fourths of the post-partum beds will be in the new wing, one-fourth in the old. 511 In addition to doubling the antenatal and lying-in capacity for normal births, the project will increase from 15 to 55 the number of beds for surgical patients, ie e. those requiring abortions or tubal ligations (female sterilization). The abortions to be performed in the VJH are not related to family planning, since the government program does not include abortion as one of its birth-prevention methods (Jamaican law on abortion is strict). Nevertheless, a certain number of emergency cases arise where abortions are necessary to protect the mother, and a maternity hospital, working within the framework of national law, must be prepared to perform this operation. Voluntary sterlization through tubal ligation stands on a different footing: ligations are not controlled by law and such sterili- zation, under careful controlsi/, is part of the NFPB's program. It is hoped that the number of ligations performed at the VJH can be increased from the present number of 300 p.a. to 600 to 1,000 p.a. Since VJH will remain exclusively a maternity hospital, no general obstetrical surgery will be performed; this will continue to be done at the adjacent Kingston General Hospital. The project will provide six specialized beds for in- tensive care maternity patients. Since no significant change in the number of deliveries is expected, the number of first-stage labor beds remains almost unchanged. 5.12 As a result of the project, the country's largest maternity hospital will offer, for the first time, adequate opportunities for con- ducting an effective program of post-partum FP education. 5.13 The project will construct 10 Rural Maternity Centers (RHC's) at strategic locations throughout the island. No such institution now exists in Jamaica and their construction represents an innovation in the island's health-delivery system. The objective is to provide a small rural center which will be devoted exclusively to maternity and FP purposes -- primarily the delivery of babies by resident midwives but including some antenatal care by nurses, and FP education. The decision to introduce these facilities coincides with a growing recognition of weaknesses in the present system of midwifery services, now organized for home delivery by itinerant district midwives employed by parish councils (see para. 4. 2W). With the RMC's, many nore rural women will have a choice of having their babies outside the home at a place where trained medical help is in attendance. More of the rural midwives will be stationed at the RHOC's and fewer will have to travel to homes, resulting in better utilization of midwives. The RMC environment will provide an opportunity for post-partum FP education that does not exist under home delivery conditions. 1f The VJH has developed its own procedures to make certain that womer requesting ligations understand that this will prevent then from havirig additional children; if mareied, both partners must sign a statement authurizing the operation.  - 20 - 5.14 All 10 RMCIs will be of the same standard design, with adaptations for individual sites. They will be one-story masonry structures that will include a reception and administrative office, a doctor's office and examina- tion room, a delivery room, a ward for post-partum lying-in, and living quarters for one resident midwife. The design will be such that if demand grows beyond initial capacity the structure can be expanded at low cost. Estimated capital cost for a fully-equipped P14C is J$ 36,000; operating costs have been estimated at J$ 6,300 including the salary of the resident midwife but excluding any allowance for other medical and FP personnel who would visit the facility on a periodic basis (see Annex 8). 5.15 Each RMP would be under the jurisdiction of the District Medical Officer, the chief representative of the Ministry of Health in each medical district (snaller than a parish). He will work closely with the Public Health Nurse for the district; these are almost invariably women of high prestige whose association with and regular visits to the RMC's will be important. The Family Planning Education Officer for the parish (an employee of the NFPB) will visit each RMC on a regular schedule. The resident mid- wife will be in charge of day-to-day administration; she will be assisted by other midwives in the district who will come in on a daily basis, by one ward assistan-L, and by a kitchen and custodial staff of four. The doctor, Public Health Nurse and FP Education Officer will come from outside to visit the REC once or twice a week, normally on days when clinic sessions are scheduled. These intended administrative arrangements should be con- firmed during negotiations. 5.16 The estimated use of the RPC's is uncertain as it will depend on (a) the population of the assumed catchment area, (b) the crude birth rate assumed for that population, (c) the assumed proportion of mothers who will be delivered in the RMC in preference to delivery at home, and (d) the number of days a woman remains at the RMC. The catchment area for a RMC is defined very crudely by the distance a woman about to deliver can be expected to travel with confidence of reaching the Maternity Center before labor starts. A maximum radius of 4 miles has been accepted for planning purposes. Locations have been selected partly on the basis of estimated populations of 8,000 or more within this approximate radius (see Annex 7). Assuming a birth rate of 35/1,000, a population of 8,000 can be expected to have 280 deliveries per year. If all 280 mothers elected to have their babies at the 4MC, and all remained at the Center four days, they would require 1120 bed-days. Since this is 25% below the theoretical capacity of a h-bed Center, it seems clear that the basic design,which permits any number of beds up to 10, will provide ample capacity. This will accommodate any occasional 'Ibunchingil of arrivals that may occur. In the early years underutilization, not inability to meet the demand, is more likely to be the main problen,at some locations, at least. The size of facility being built is the smallest that can provide the services needed. 5.17 It has not seemed practical to try to assure high utilization of the F6iC's by linking them to special transport services. The main problem  - 21 - is often a womanIs ability to get to a road from her dwelling in the bush; once at the road she has reasonabole hooe of finding country transport to the Center, but the expectation of being able to make advance arrangements to meet her wi-th, say, an ambulance is too l,ow to make any regular provision (the linistry of Health's 60 ambulances, posted about the country, will nevertheless stand ready for delivery to RH!C's wihere prior arrangement does prove feasible). 5.18 Locations for all 10 RMCTs have been agreed with the I4inistry of Health and instructions have been issued to acouire building sites. An inventory of utility services has also been made for each location (see Annex 7). 5.19 The purpose of building the 10 RMC's described above is to make a significant start in providing for the rural nopulation exactly the same expanded opportunities for maternity care, and for access to FP information during a mother's post-partum recovery that the VJH will provide for the Kingston metropolitan area. The main difference will be that the WIC's will not handle surgical cases. Project Technical Assistance 5.20 The encouragement of greater efficiency in the administration of the family planning programn is an important objective of the project. To this end the project includes funds for (a) a study of the optimum scheduling arrangements for the FP c'linics and staff serving the metropolitan Kingston area, (b) a job-study to look for ways of making the best use of highly- trained doctors and trained nurses, (c) a training adviser who can assist the LTFPB in developing an overall training program to provide the skills needed at all levels in the program, and (d) an annual external review by international experts in the administration of family planning programs. 5.21 The scheduling study of the Kingston-area program would try to identify ways for getting the most out of available facilities and staff for a given level of expenditure. At present 30 of the 34 KSAC health clinics conduct family planning sessions either once per %.Teek or less; 4 clinics are open every day (each session consisting of half a day). Sessions are nornally scheduled in the afternoons, since session staff members are engaged on otlher work during the mornings. No clinics hold regular evening sessions. The tradition of interspersing family planning sessions in the schedules of multi-ourpose clinics, plus the difficulty of recruiting staff for single-purpose clinics (which would be open all week for family planning uork exclusively), have largely determined the pattern of service offered. To date, no adequate study has been made of how well this meets the needs of the public or of the extent to which a greater variety of arrangements, perhaps on an experimental basis, might increase the number of acceotors. The 3-4 month study will cost less than  - 22 - US$ 10,000. Preliminary terms of reference will be found in Annex 10. 5.22 The job-study is a response to the serious and increasing short- age of skilled medical personnel on the island, especially doctors and trained nurses, but also including midwives, The acceleration of inter- national migration among medical personnel in recent years has reduced the numbers of both doctors and nurses in Jamaica. The shortage of professional staff is a major constraint on the NFPB in the scheduling of family planning sessions. It is believed that a study of the relationship between specific functions and tasks on the one hand, and required professional qualifica- tions and training on the other, would reveal possibilities for economizing on the use of scarce professional manpower, especially if others with lower qualifications can be up-graded through special-purpose training. The Ministry of Health would assume responsibility for the study which would be conducted, it is hoped, by a faculty member at the Mona campus of the University of the WFest Indies just outside Kingston. Total cost of the study, which would take 4-5 months, should be less than US$ 15,000. Pre- liminary termis of reference are given in Annex 11. USAID has expressed interest in financing both the KSAC clinic-scheduling and the job-content studies. 5.23 The provision of a Training Adviser to the NFPB is needed to see that continuous attention is given to this important aspect of the program. The Board has already conducted a considerable amount of training but an increase in the scale of effort is likely to be required during the next 2-3 years, e.g. to assist the development of the EV program (para. 4.16), to expand population and family planning content in training of health personnel, and to implement reconmendations resulting from the job-study (para. 5.22). The adviser's work will involve working closely with other senior personnel in government who have responsibility for the education and training of medical and para-medical personnel. The function may need an overseas adviser; if a qualified Jamaican can,however, be recruited as a Training Officer, then no adviser and no loan provision would be needed and the loan provision would be cancelled. 5.24 The project also includes provision for an annual external review of the I\UPB Program for each of the disbursement years. These will be key years for the improvement of the program in order to realize the benefits expected from the project. The purpose of such a review by outside experts is to assist the government in establishing and maintaining high standards of cost-effectiveness, i.e. so that the Board, the government, and the Bank will have an independent judgment on whether or not the program is being conducted at acceptable levels of efficiency and to identify specific problems requiring special attention. Draft terms of reference for the annual external review will be found in Annex 13. The estimated cost is US$ 25,000 for the four disbursement years. The experts would be appointed by the government with Bank assistance and approval. Responsibility for organizing and supervising the external review, and for the two studies, would rest with the Ministry of Health, and not with the Project Committee described in para. 5.28.  - 23 - Design, Tendering, and Procurement 5.25 All project facilities will be designed by private Jamaican architectural and engineering firms. The firm of Wilson Chong and Associ- ates, working in partnership with Caribbean Planners (engineers), has been selected by the government to design the VJH. The firm of Shearer and Morrison will design the RMC's. Both firms will also be responsible for supervision during construction. "lthough the selection of both firms has been approved by the Bank, contracts have not yet been signed, signing of these contracts will be a condition of loan effectiveness. The Ministry of Communications and Wborlks, which has overall responsibility for the con- struction of government buildings, has retained as hospital advisers the British architectural finm of Llewellyn-Davies, Weeks and Partners, specialists in hospital design. This firm has prepared the functional program and cost estimates for the VJH; the program has provided the basis for the present cost estimate and will be used by Wilson Chong and Associates as the basis for their design. 5.26 The project has been split into two parts both of wjhich will be offered for international tender. The VJH construction contract will be submitted to international tendering in line with normal Bank practice. The second part includes the 10 Rural Maternity Centers; these will likewise be offered for international tender, although the work may be too small to interest contractors outside Jamaica. Tendering for these smaller facilities will be on the basis that any domestic contractor on the MCW's approved list, or any foreign contractor, may bid for any one or more of the RMC facilities, evaluation will be on the basis of choosing that combina- tion of bids which yields the lowest evaluated overall cost. This system encourages bids from smaller but qualified local contractors as well as foreign contractors~ it has been used with success on Bank projects in other countries. 5.27 All furniture and equipment items are expected to be imported; they will be procured under one or more separate international tenders as recommended by the architects and approved by the Bank. If practicable, items common to ooth the VJH and the EWC's will be procured under combined tenders. The government has requested and the Bank has agreed to a 15% domestic preference for any furniture and equipment tenders received from domestic manufacturers. In the case of exceptional items which the architects and the Bank may agree are unsuitable for international tender, and for which contracts would not exceed US$ 5,000, bids may be requested from selected local suppliers. Coordination and Sunervision 5.28 Proper planning, design, and construction of the VJH and FB'C facilities will require continuous consultations and decisions among the architects, the hospital adviser, and the Ministries of Health, of Communica-  - 24 - tions and Works and of Finance. It has been agreed that these functions will be exercised by two ad hoc groups, a policy-making Project Committee and an administrative Project Team. The Project Committee would include senior representatives from the Ministries of Health, Communications and Works, and Finance. The representative of the Ministry of Health would serve as chairman. The Project Team would be responsible to the Project Committee; it would concern itself with details of planning and execution, with carrying out decisions of the Project Committee, and with reporting back progress and problems to that Committee. Membership of the Project Team would consist of representatives from the Ministry of Health and Communications and Works, the Senior Medical Officer of the VJH, the archi- tects, and, as reouired, the hospital advisers. Individuals representing each constituent organization have been named. 5.29 Normal suoervision of the contractors would be a responsibility of the local architects; the latter would be responsible to the Ministry of Communications and Works, not to the Project Team. Project Timetable 5.30 A preliminary timetable for both construction components of the project has been fixed (Annex 9) and has been approved by the hospital adviser; the consulting architects have been asked to confirm or revise this schedule. According to this schedule, tender documents for the VJH will be issued in March, 1971, with construction starting in September. Construction would take two years, so that the new wing would be ready for occupancy about September 1, 1973. (Bremodelling of the existing building can start before the new wing is fully completed but the re- modelling is not likely to be completed before January 1, 1974.) Project preparation has proceeded somewhat ahead of schedule, so that it may be possible to compress the hospital schedule by about six months. Designs for the 10 FIC's should be completed and approved by August 1, 1970, with tender documents issued by September 1. Work on the first units should start about January 1, 1971. All 10 Centers should be ready for occupancy within 12 months thereafter. Site acquisitions may slow down this timetable for the RBMC's, although construction can proceed without having to wait for government to secure a clear title to land if the terms of sale have been concluded with the seller. 5.31 The four technical assistance components of the project cannot be scheduled as precisely. ,he first annual external review is intended to be conducted during the late summer of 1971, with subsequent reviews at approximate annual intervals thereafter until the loan closing date in 1974. The three other components should be implemented as early as suitable people can be found. Preliminary discussions indicate that (a) the study of the Kingston-area facilities and staff can be done in the summer of 1970, (b) the study of skill-requirements can be started this summer and completed before the end of the year, and (c) a suitable Training Adviser can be appointed before the end of 1S70.  - 25 - Financing and Disbursements 5.32 The Bank loan will finance foreign exchange costs of the project estimated at US$ 1.6 million and interest and commitment charges during con- struction of US$ 0.3 million (these are being r-ounded up to US$ 2.0 million as the loan amount). USAID has expressed a willingness to assume primary responsibility for financing two of the four technical assistance elements, namely, the research studies on the Kingston-area facilities and the study of skill-requirements. If this arrangement is confirmed, Bank funds for these twfo components, totalling US$ 25,000, wiould serve as a contingency reserve for the studies in question; they would be used only if the USAID funds should not become available or if they should be inadequate in amount. If not used for this purpose, these study funds would be cancelled unless required for either of the other two technical assistance components. All costs of the project not covered by the Bank loan, including any cost over- runs, will be borne by the Government of Jamaica. 5.33 The following table shows the main categories of expenditure under the project, plus financial charges on the Bank loan during construction, and the estimated foreign exchange requirements for each category. The foreign exchange component of the construction contracts has been estimated on the assumption that they would be awarded to foreign firms; if domestic firms should win the contracts the foreign exchange percentage for the civil works might drop from 50% to 40-45%. In view of the small sum involved, no adjustment in the loan amount would be made to reflect the slightly lower foreign exchange cormonent under domestic contractors; this would imply Bank financing of local currency costs equal to 3-6% of total project costs. Categories of Expenditures Total Cost Foreign Exchange F.E. % (approx.) US$ million I. Civil Works 1.82 0.89 50% Victoria Jubilee Hospital 1.50 o.80 5% Pural Maternity Homes 0.32 0.09 27% II. Professional Fees Design, hospital adviser, supervision of construction 0. 2 0g.09 33% III. Furniture and Equipment 0.32 0.30, 95% TV. Studies and Technical Asst. 0.10 0.06 60% 2.50 1.3 54% V. Contingencies 0.50 0.27 55% Total Project Costs T. 514% VI. Interest and similar charges up to Dec. 31, 19714 0.30 0.30 100% TOTAL FEiANCIAL REQUIPEMENTS 3.30 1.91 60%  - 26 - 5.34 Disbursement arrangements are designed to facilitate loan administration and to assure reimrbursement of the full foreign exchange component up to a maximum of US$ 2.0 million. Disbursement for "furniture and equipment" would be at 100% of the c.i.f. value in the case of foreign suppliers and/or of ex-factory price in the unexpected event that local suppliers might tender and be awarded contracts for certain items. The local currency content of any furniture and equipment contracts won by local manufacturers would be too sreall to justify a differential disburse- ment percentage. Reimbursements for all other categories, viz., civil works, professional services, and studies and technical assistance, would be at a uniform 50% of approved total expenditures. 5.35 A rough estimate of the phasing of project expenditures and of loan disbursements is as follows: (uS$ 000's) '70 '71 '72 '73 '74 Tootal Droject expenditures 300 800 876 876 120 2,972 Loan disbursements 100 500 550 550 300 2,000 5.36 The main impact of the project on the government's recurring costs will occur outside the budget of the NFPB. The budget increases directly attributable to the project will occur in the operating costs of the Victoria Jubilee Hospital and of the 10 Rural Maternity Centers. The operating costs of the VJH will rise from their present level of about J$ 40oo,o0o to slightly under J$ 800,000 in the first full year after completion of the project (Annex 5). Perhaps a quarter of this increase would occur without the project; nevertheless, the project is likely to add, directly, around J$ 4oo,000to J$ 500,000 to the government's annual recurrent costs. By fiscal year 1975 the national FP program (total NFPB budget plus the increases in VJH and REC operating costs attributable to the project) is likely to be costing the government around J$ 1.5 million. This prospective level of recurrent expendi-ture is acceptable assuming the program attains reasonable levels of effectiveness. 5.37 Although the project's direct effects on recurrent costs will be modest, there is a danger that its indirect effects might add to over- all budgetary needs. The government must guard against an inflation of  - 27 - staff, act-ivities, and standards as a result of the attention to be given a new high-priorit'y activity. This danger mlakes it doubly important to develop cost standards for program activities that can provide a basis for evaluating budgetary trends. The first External Review should concern itself with this problemi.  - 28 - VI. SOCIO-ECONOMIC CONSIDERATIONS 6.01 The government is keenly aware of the social and economic implica- tions of the present high rate of population growth. Concern for this problem was first officially expressed in the draft Five Year (Development) Plan, 1963-67, in the following terms: "The government will seek to bring about a greater awareness of the implications of rapid population growth and population pressure in the island and of the natural problems arising, as well as the effects of excessive child bearing on the lives and prospects of individuals. The government will encourage the spread of informa- tion and techniques for the spacing or limitation of families for the benefit of those persons who desire them." The government views efforts in family planning as a necessary complement to its efforts in economic development. In the provision of family planning services, the concept of voluntary participation is emphasized. The government is responding to the desire of families to limit and space their children. These private desires coincide with the goals of the government for social and economic development. To meet these goals, family planning services should be provided as rapidly as possible to all couples who wish to plan their families. 6.02 The project would improve the effectiveness of the family planning program. This would lead to important social and economic benefits. On the social side, the provision of better maternity services and fewer pregnancies would improve the health of mothers. Maternal mortality - one of the main causes of death for women of childbearing age - would be re- duced. The availability and more extensive use of contraception would reduce the number of unwanted pregnancies resulting either in induced abortions under unsafe conditions (and often leading to death) or in un- wanted children. Parents of smaller families can give greater care to their children, resulting in better health and lower infant mortality. Among the poorer sections of the population, fewer children would mean less malnutrition. This is particularly important in the case of young infants, when malnutrition can have permanent crippling consequences on their physical and mental development. Family planning services would thus lead to an inprovement in the quality of life, particularly among the low income section of the population. On the economic side, the family planning program would gradually affect demographic trends; these changes in turn would have important economic implications. 6.03 The demographic effects begin with the reduction in the annual number of births as a result of the program. It is estimated that the effect of the VJH component of the project alone would be to make the total population in the year 2000 about 3% smaller than it otherwise would  - 29 - be and the labor force about 1.6% smaller. But beyond this, and beyond the direct effects of the Rural Maternity Centers, the project is expected to influence the whole national family planning program. The impact of the program is estimated to be some 4 times as large as that of the VJH component of the project; this would lead to a population perhaps 12% smaller and a labor force 6.4% smaller in the year 2000 than they wfould otherwise have been, i.e., a population of around 2.58 million instead of 2.94 million and a labor force of about 1.27 million instead of 1.36 million, assuming no change in the present participation rate. Further- more, a successful national family planning program would lead to the more widespread use of contraceptive methods among all groups of the population, not just those couples registered in the official program, the impact on population trends would be correspondingly enhanced. 6.o4 The decline in fertility will lead to an improvement in living standards in the near team by changing the age structure of the population and thereby reducing the number of consumers in relation to the labor force. Each child must be fed, clothed, medically cared for and educated. A smaller number of children means that the same resources are available to a smaller population. At the family level, more food, clothing, etc., is available per member of each family practicing family planning. For the government, resources that would have been needed to educate and care medically for the additional population are now freed for other uses. Whether these resources are invested or consumed, general living standards will improve. Both these private and public improvements contribute to changes (e.g. better education and further employment of women) which encourage attitudes favorable to smaller families. 6.05 Unemployment is particularly acute in Jamaica, a densely populated country with a high level of unemployment, considerable rural under-employment, and limited possibilities for creating new jobs in industry or agriculture. The availability of land suitable for intensive agricultural development is extremely limited, and the exploitation of other natural resources (notably bauxite and tourist attractions) offers no more than moderate scope for additional employment. The family planning program will eventually help provide a solution to this problem by limiting the number of potential entrants to the future labor force. This effect will be considerably delayed since persons wzho will be entering the labor force in the next 15 to 20 years have already been born. Since the principal effect of the limitation on the future labor force will be to reduce unemployment, the family planning program is not likely to have a significant effect on the volume of output even in the long run. 6.06 In summary, the project wsill improve the conditions under which deliveries are performed and make for a more effective family planning program. Such a program will have important social benefits, consisting primarily of improvements in the health and welfare of mothers and children. It 11 also lead to better living standards and will help alleviate the long-run unemployment problem.  - 30 - VII. REramTIo0 7.01 During negotiations, agreement was reached on the following points: a. The content of a draft statute establishing the NFPB as an administrative statutory body responsible for the govern- ment's family planning program, specifying the minimum key representation to be provided on the Board, and defining the role of the Board's chief executive officer and his relation to the Board (paras. 4.04 and 4.05). b. Not later than November 1, 1970, the government will submit a revised Encouragement Visitor program for Bank comment; it will implement the revised program not later than the end of 1970 (para. 4.16). c. By November 1, 1970, the government will submit for Bank comment a description of the proposed administrative arrange- tnents under which the gNC's will operate, together with pro- posals for changes in the administration of the district midwifery services resulting from the introduction of these new facilities (para. 5.15). d. The government will conclude arrangements with USAID whereby the latter will assume responsibility for working out final arrangements for the studies of (a) the Kingston-area facilities and (b) the medical and para-medical skills needed by FP teams. These arrangements would be submitted to the Bank for comment. USAID is expected to finance these studies, with Bank funds being available in case USAID funds are not forthcoming or are insufficient (para. 5.32). e. The government will cause the NFIPB to appoint, by December, 1970, either a Training Officer or a Training Adviser accept- able to the Bank. If a Jamaican should be appointed, the loan provision for this post would not be needed and would be cancelled (para. 5.23). 7.02 Enactment of the NFPB statute, appointment of the Board, and appointment of a chief executive officer acceptable to the Bank, are conditions of loan effectiveness. 7.03 The project is suitable for a Bank loan of US$ 2.0 million with a tern of 20 years including a grace period of 5 years.  MIIBEX 1 JAMAICA POPULATION, BIRTHS AND NO. OF DELIVERIES IN PUBLIC HOSPITALS AND BY DISTRICT MIDWIVES BY PARISHESS 1964-1968 1964 1965 1966 19`7 1968 1. Kingston and St. Andrew A. Population 476,035 493,619 511,483 525,290 5422,432 B. No. of Births 23,126 23,352 24,284 23,211 22,606 i. In Hospitals 15,000 14,590 15,312 16,018 14,889 ii. By Dist. Midwives 1 634 2 164 1,710 1,764 14b7 Sub-total 16,6 T6,7 17,022 17,782 16,336 2. Clarendon A. Population 177,839 182,833 186,047 188,482 192,180 B. No. of Births 6,150 6,192 6,059 5,532 5,307 i. In Hospitals 402 404 416 393 429* ii. By Dist. Midwives 2 322 2 655 2 4459 2 142 1,685 Sub-total v7t30 m i t 2 2,114 3. St.Catherine A. Population 166,801 171,195 176,041 179,130 183,641 B. No. of Births 6,109 6,330 7,084 6,309 6,344 i. In Hospitals 195* 292* 1,501 1,445* 1,765* ii. By Dist. Midwives 2,580 2 494 2 1614 1,776 1,592 Sub-total 2,775 3,221 4. St.Elizabeth A. Population 125,344 128,223 131,077 133,088 155,696 B. No. of Births . 4,356 14,490 4,510 4,329 3,950 i. In Hospitals 264 378 599 361 380 ii. By Dist. Midwives 1 472 1 277 1 1449 1 208 1 101 Sub-total 1 TM X m T  ANNKX 1 Page 2 1964 1965 1966 1967 1968 5. St.Ann A. Population 123,487 126,121 128,803 130,529 133,224 B. No. of Births 4,208 4,079 4,121 3,980 3,893 i. In Hospitals 350 406 429 518 693 ii. By Dist. Midwives 1 494 1 474 1,762 1,125 931 Sub-total Tt11 1880 2,191 1, 1,624 6. Manchester A. Population 120,699 123,593 126,531 128,555 131,391 B. No. of Births 4k517 4,444 4,674 4,351 4,284 i. In Hospitals 448* 1,228 749* 1,588* 1,412* ii. By Dist. Midwives 13724 1,698 1 772 1 560 1 416 Sub-total 2,172 2,926 2 TTm 7. Westmoreland A. Population 118,195 120,827 123,229 124,621 126,988 B. No. of Births 4,273 4,079 3,927 3,538 3,h68 i. In Hospitals 955 1,071 1,030 1,167* 950* ii. By Dist. Midwives 986 1,173 1,029 982 834 Sub-total 1,941 2,02M 2,2149 1,784 8. St.Mary A. Population 100,379 102,790 105,055 106,630 108,929 B. No. of Births 3,480 3,571 3,595 3,492 3,390 i. In Hospitals 1,017 1,068 1,072 1,333* 1,104 ii. By Dist. Midwives 1,096 1,224 1,138 893 1 333 Sub-total 2,113 2,292 2,210 2,226 2 9. St.James A. Population 92,253 95,057 97,819 99,893 102,469 B. No. of Births 3,768 3,865 3,966 3,844 3,585 i. In Hospitals 938 1,460 1,206 1,236 1,44o* ii. By Dist. Midwives 1 216 1,059 1 044 1,040 1,098 Sub-total 27 2,216  ANEX 1 Pa ge 3 1964 1965 1966 1967 1968 10. St. Thomas A. Population 73,230 74,812 76,453 77,428 79,145 B. No. of Births 2,485 2,487 2,547 2,406 2,553 i. In Hospitals 489 492 532 593 624 ii. By Dst. Midwives 948 957 1 064 913 862 Sub-total 1,437 1,449 1 ,5o6 1,486 11. Portland A. Population 68,664 70,187 71,532 72,380 73,600 B. No. of Births 2,218 2,318 2,284 2,165 1,875 i. In Hospitals 750 910 643* 1,071* 170 ii. ByTPist. Midwives 785 589 477 359 380 Sub-total 1,535 1,499 1,120 1,3-0 550 12. Hanover A. Population 58,384 59,874 61,265 62,312 63,813 B. No. of Births 2,198 2,228 2,198 2,165 2,123 i. In Hospitals 383 333 366 431 424 ii. By Dist. lid&tives 687 729 874 829 798 Sub-total 1,070 10 1,240 1,260 1,222 13. TrelavMy A. Population 60,916 62,482 63,737 64,739 66,141 B. No. of Births 2,378 2,333 2,115 2,116 2,021 i. In Hospitals 552 608 640 476* 624* ii. By Dist. Midwives 1 136 1,183 1 014 915 9L9 Sub-total L; 1,791 1,391 1,573 Country Totals (in 000's) A. Population 1,762 1,810 1,859 1,893 1,940 B. No. of Births 69.3 69.8 71.4 67.4 65.4 i. In Hospitals No. 21.7 23.2 24.5 26.6 26.1 % (i over B) 31 33 34 39 40 ii. By Dist. Midwives No. 18.1 18.7 18.0 15.5 14.4 % (ii over B) 26 27 25 23 22 iii. Manas & others (%) 43 40 41 38 38 * Data incomplete. Source: Ministry of Health November, 1969  ANNEX 2 JAMAICA POPUIATIOiJ PROJECT Anticipated crude birth rate 1966 - 1980 Expected birth Year rate 1966* 38.9 1967* 35.9 1968* 31X.2 1969 31.8 1970 29.6 1971 28.1 1972 26.6 1973 25.3 1974 24.0 1975 23.0 1976 22.0 1977 21.0 1978 20.0 1979 19.0 1>80 18.0 *Preliminary actual figures from the Registrar General's Department. NOTE: 1. Assumptions re decline in the crude birth rate are taken from the Board's 3-year Program (1968-71) Ref: Schedule 1. (Demographic Background). 2. Other assumptions: Starting from the 1968 figure, the birth rate should be down to 31.8 in 1969 and thereafter a steady decline until the crude birth rate is down to below the 20's. ASSUMPTIONS: (1) One-third (1/3) of the patients admitted in the first year drop out, also one-third in the second and third years of the projection and thereafter one-half of the new and old patients taken together. (2) At least 24,000 new patients will enter the Board's program each year. This is based on the present performance of approximately 2,000 new patients each month, which is somewhat higher than the Board's target of 20,000 new acceptors each year. Projections are based on clinic performance over the past 12 months, October 1968 - November 1969. Source: National Family Planning Board. December, 1969  ANNEX 3 Table 1 JAM-A,ICA POPULATION PROJECT Service Statistics, National Family Planning Program by Mv-onth for Period November 1968 through January 1970 New Hissed Month Patients Revisits Visits Active* Pap Smears/% 1968 Nov. 3,353 144 218 3,305 1,385 (41) Dec. 2,096 877 1,234 887 (?) 94 Total 5,449 1,021 1,452 4,192 2,329 1969 Jan. 3,028 1,646 1,464 3,379 1,207 Feb. 2,908 2,295 1,806 5,431 - March 2,999 2,892 2,744 14,061 1,051 April 2,579 4,302 2,642 16,075 1,123 May 2,664 4,671 2,773 17,965 1,138 June 2,122 5,110 3,204 19,253 969 (46) July 2,287 5,110 3,204 20,016 1,026 (45) Aug. 1,795 5,141 3,292 20,124 844 (47) Sept. 1,988 6,002 3,163 20,413 792 (ho) Oct. 2,067 5,871 3,203 19,820 767 (37) Nov. 2,133 9,286 3,320 23,021 906 (42) Dec. 1,823 6,899 4,150 23,h83 739 (41) Total 28,293 59,516 34,773 10,562 1970 Jan. 2,084 7,957 3,838 24,843 972 (47) * Active is defined as patients registered on first visit to a clinic. Source: National Family Planning Board March, 1970  Table 2 JANaICA POPULATION PROJECT Number of New Acceptors and Re-visits by Parish: Jan. - Dec. 1969 Sessions New Re- Total Parish Clinics* Held Acceptors visits Attendance K.S.A.C. 35 1,490 11,320 2h,068 35,388 St. Thomas 4 97 523 498 1,021 Portland 8 111 1,380 2,8h9 4,229 St. Mary 8 270 1,286 2,688 3,974 St. Ann 14 632 2,014 ,670 6,684 Trelawny 8 218 904 1,701 2,605 St. James 7 310 2,061 6,733 8,794 Hanover 8 192 958 3,536 4,494 IW,estmoreland 5 103 752 1,590 2,342 St. Elizabeth 7 134 1,417 2,995 4,412 Manchester 13 326 1,622 2,766 4,388 Clarendon 6 138 1,589 1,194 2,783 St. Catherine 14 319 2,174 3,00?9 5, 176 Sub-Total 28,000 58,290 86,2)0 Unspecified by Parish 393 1,302 1L,69 Grand Total 137 4,340 28,393 59,592 87,985 * As at December 31, 1969. Source: National Family Planning Board March 20, 1970  ANNEX 3 Table 3 JAMAICA POPULATION PROJECT Parish Targets for New Acceptors: April 1969 - March 1970 Balance of Target New Acceptors (to be reached Parish Target Apr. - Dec. '69 Jan. - Mar. 170) K.S.A.C. 8,000 8,818 * St. Thomas 800 437 363 Portland 1,100 988 112 St. Mary 1,200 909 291 St. Ann 2,000 1,427 573 Trelawny 700 613 87 St. Jarmes 1,500 1,621 * Hanover 1,000 707 293 Westmoreland 1,700 1,C63 637 St. Elizabeth 1,700 1,098 602 Manchester 1,600 1,199 401 Clarendon 1,600 1,160 440 ,t. Catherine 1,800 1,694 106 All Parishes 2b,700 21,734 2,966 * These Parishes have already exceeded their targets. Source: National Family Planning Board March 20, 1970  UI^TEx 3 Table 4 JAI4AICA POPULATION PROJECT New Acceptors Classified by Number of PFrevious (a) Live Births and (b) Pregnancies Live Births 1969 % Pregnancies 1959 % One 3,4184 12.3 One 3,109 10.9 Two 4,583 16.1 Two 4,207 14.8 Three 4,614 16.3 Three 4,276 15.1 Four 4 ,212 14.8) Four 3,973 1 0) Five 3,304 11.6) Five 3,44h6 12.1) ) 52.9 ) 5743 Six 2,548 9.0) Six 2,646 9.3) Seven & ) Seven & ) Over 4,966 17.5) Over 6,204 21.9) None 682 2.4 NJone 532 1.9 Total 28,393 100.0 28,393 100.0 Source: National Family Planning Board March 20, 1970  ANNEX 3 Table 5 J