India - Second Population Project

Document of The World Bank FILE COPY FOR OFFICIAL USE ONLY Report No. 2668-IN INDIA STAFF APPRAISAL OF A SECOND POPULATION PROJECT January 15, 1980 Population, Health and Nutrition Department This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS US$1.00 = Rupees (Rs) 8.60 /1 GOVERNMENT OF INDIA FISCAL YEAR: April 1 - March 31 MEASURE (METRIC SYSTEM) 1 meter (m) = 3.28 feet (ft) 1 kilometer (km) = 0.62 miles (mi) /1 Until September 24, 1975, the Rupee was officially valued at a fixed Pound Sterling rate. Since then it has been fixed against a "basket" of currencies. As these currencies are floating, the US Dollar/ Rupee exchange rate is subject to change. Conver- sions in this report have been made at US$1.00 to Rs 8.60 which represents the projected exchange rate over the disbursement period.  FOR OFFICIAL USE ONLY ABBREVIATIONS AAAI - Association of Advertising Agencies of India ANK - Auxiliary Nurse Midwife A.P. - Andhra Pradesh State BEE - Block Extension Educator CBR - Crude Birth Rate CDR - Crude Death Rate CHW - Community Health Worker DANIDA - Danish Agency for International Development DHIEO - District Health Information and Education Officer DT - Diptheria and Tetanus Immunization DPT - Diptheria, Whooping Cough and Tetanus Immunization GOI - Government of India HIEO - Health Information and Education Officer HSF - Health Supervisor Female HSM - Health Supervisor Male IDA - International Development Association IEC - Information, Education and Communication IUD - Intra-Uterine Device LHV - Lady Health Visitor MCH - Maternal and Child Health MIES - Management Information and Evaluation System MPWF - Multipurpose Worker Female MPWM - Multipurpose Worker Male NORAD - Norwegian Agency for International Development NRR - Net Reproduction Rate ODA - British Overseas Development Administration PHC - Primary Health Center RHFWTC - Regional Health and Family Welfare Training Center SIDA - Swedish International Development Authority TT - Tetanus Toxoid Immunization UNDP - United Nations Development Program UNFPA - United Nations Fund for Population Activities UNICEF - United Nations Children's Fund U.P. - Uttar Pradesh State USAID - United States Agency for International Development WHO - World Health Organization This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contenst may not otherwise be disclosed without World Bank authorization.   DEFINITIONS Crude Birth Rate Number of live births per year per 1,000 population. Crude Death Rate Number of deaths per year per 1,000 population. Rate of Natural Difference between crude birth and crude death rates; Increase usually expressed as a percentage. Rate of Population Rate of natural increase adjusted for (net) migration, Growth expressed as a percentage of the total population in a given year. Age Specific Fertility Number of live births to women in a given age group Rates per 1,000 women in the same age group, in a given year. It is usually calculated for five-year age groups. Total Fertility Rate The average number of children that would be born per woman if she were to live to the end of her childbearing years, and bear children according to a given set of age-specific fertility rates. The Total Fertility Rate often serves as an estimate of the average number of children per family. Net Reproduction Rate The number of daughters a woman would have under prevailing fertility and mortality patterns, who would survive to the mean age of childbearing. Infant Mortality Rate Annual number of deaths of infants under one year per 1,000 live births during the same year. Maternal Mortality Rate Number of maternal deaths per 1,000 births attri- butable to pregnancy, childbirth, or puerperal complications (i.e., within six weeks following childbirth). Life Expectancy Average number of years expected to be lived by children born in a given year if mortality rates for each age/sex group remain the same in the future. Age Dependency Ratio Number of people 14 years and under plus people 65 years and over, divided by the population aged 15 to 64 years. Tehsil/Taluk Sub-divisions of districts. Equivalent Steriliza- An index of overall family planning performance tions calculated by adding the number of sterilizations performed over a period of time, one-third the number of IUDs inserted, one-eighteenth the number of equivalent conventional contraceptives users, ,and one-ninth the number of equivalent oral con- traceptive users. These weights are derived from an assessment of numbers of births averted by different contraceptive methods in India.   INDIA STAFF APPRAISAL OF A SECOND POPULATION PROJECT BASIC DATA Total Area ... . ............. 3,287,600 km2 Total Populati2n (estimated as of mid-1979) . .652 million Density per km (March 1979) ..195 Rate of Natural Increase of the Population (1976) ..... ........ 1.9% /I Crude Birth Rate (1976) ..34.4/1,000 /1 Crude Death Rate (1976) ........................ . ........... 15.0/1,000 TL Life Expectancy at Birth (1977). 51.0 Infant Mortality Rate (1976) ..134.0 Maternal Mortality Rate (1972) ..50/10,000 Urban Population as Percent of Total Population (1971) .. 19.9% Adult Literacy Rate (1976): Males .......................... ............................ 48.8% Females ......................... ........................... 23.2% Primary School Enrollment (1976): Males ........................... o .......................... 94.0% Females ......................... ........................... 63.0% Age Structure (1977): 0-14 .......................... ............................ 42.0% 15-64 ........................... ............................ 55.0% 65 and over ................................................ 3.0% Population per Physician (1977) ..3,135 Population per Nurse (1976) ..6,320 Percentage of Eligible Couples Effectively Protected Against Pregnancy (1978) ..22.7% Per Capita Gross National Product (1977) . .US$150.0 /1 Latest official GOI estimates.   INDIA STAFF APPRAISAL OF A SECOND POPULATION PROJECT Table of Contents Page No. I. POPULATION GROWTH AND HEALTH SITUATION ................... 1 A. All India Trends .................................... 1 B. Project States and Districts ........................ 5 II. NATIONAL FAMILY WELFARE PROGRAM .......................... 7 A. Historical Overview ..... ....................... 7 B. Current National Goals and Strategies ... ............ 10 C. Family Welfare Program Organization .............. ... 11 D. Program Performance .................................. 16 E. Current National Policy . . .18 F. Program Constraints and Weaknesses . ...... 19 G. External Assistance ................................. 21 III. FIRST POPULATION PROJECT ................................. 23 A. Project Description .............. .. ................. 23 B. Assessment of the Project ........... .. .............. 24 C. Service Levels Achieved ............................. 24 D. Other Project Programs ............. .. ............... 25 IV. THE PROJECT .............................................. 28 A. Project Concept, Objectives and Design .............. 28 B. Summary Project Composition .......... .. ............. 31 C. Detailed Project Description ........................ 33 V. PROJECT COST, FINANCING AND DISBURSEMENT . . 55 A. Cost ........................ ........................ 55 B. Financing ........................................... 57 C. Disbursements and Audit ............................. 57 D. Procurement ...... .............. ..................... 58 VI. PROJECT IMPLEMENTATION ................................... 58 A. Project Management ............... .. ................. 58 B. Implementation of Civil Works ......... .............. 61 VII. PROJECT JUSTIFICATION AND RISKS .......................... 62 VIII. RECOMMENDATIONS .......................................... 63  Table of Contents (Continued) ANNEXES 1 Government of India's Policy Statement of June 1977 2 An Illustrative List of Performance Indicators for Evaluation of Project Activities 3 Estimated Base Project Cost by Expenditure and Functional Categories (U.P., A.P. and combined U.P. and A.P.) 4 Estimated Schedule of Disbursements 5 Accounting Procedures 6 Summary Implementation Schedule 7 Selected Documents and Data Available in the Project Files CHARTS 1 Simplified Organization of Health and Family Welfare Services in Uttar Pradesh 2 Simplified Organization of Health and Family Welfare Services in Andhra Pradesh 3 Organization of Project Management--Uttar Pradesh 4 Organization of Project Management--Andhra Pradesh MAP IBRD 14519r - States of Uttar Pradesh and Andhra Pradesh  I. POPULATION GROWTH AND HEALTH SITUATION A. All-India Trends Population Size 1.01 India's population, currently estimated at 652 million in mid-1979, is the second largest in the world, exceeded only by the People's Republic of China. According to the 1971 Census, the population numbered 548 million at the end of March 1971 (see Table 1 below). Table 1: INDIA: SELECTED CENSUS DATA Average Estimated Estimated Census Decade Annual Crude Birth Crude Death Census Population /1 Increase /. Growth Rates per 1,000 Rates per 1,000 Years (millions) ( Rates /1 Population /2 Population /2 1901 238.3 49.2 42.6 1911 252.0 5.73 0.56 48.1 48.6 1921 251.2 (-0.30) (-0.03) 46.4 36.3 1931 278.9 11.00 1.06 45.2 31.2 1941 318.5 14.23 1.34 39.9 27.4 1951 361.0 13.31 1.26 41.7 22.8 1961 439.1 21.64 1.98 41.1 18.9 1971 547.9 24.80 2.24 36.9 14.9 /1 Government of India, Ministry of Health and Family Welfare. Yearbook of the Family Welfare Programme in India, 1976-77. /2 United Nations, The Population of India, 1974. 1.02 Data from decennial censuses dating back to 1871 provide reasonably good information about the growth rate of India's population. Population growth was slow up to 1921 because of frequent epidemics of plague and cholera, famines, and the influenza epidemic of 1918-19. During 1921-51, the average decennial growth was around 13%; during 1951-61 it increased rather sharply to 21.6% and 24.8% during 1961-71. The sharp acceleration of the rate of population growth during 1931-51 is generally attributed to the control of malaria and infectious diseases, including tuberculosis, during the 1950s. International migration has had virtually no effect on India's total population size in this century. 1.03 India's rate of population growth of 2.1% is moderate by developing countries' standards. Comparison with growth rates of India's neighboring countries shows India among the moderately growing: Bangladesh, 2.8%; Iran, 2.6%; Nepal, 2.6%; Pakistan, 3.0%; Sri Lanka, 2.0%; Thailand, 2.4% (all 1977 figures). The average annual rate of population growth for low income develop- ing countries as a whole in 1977 was 2.5%. It is the magnitude of absolute growth--presently about 14 million additional people a year--together with widespread poverty and pressure on the land which creates severe difficulties in India.  -2- Fertility 1.04 The trend of fertility over the last intercensal decade (1961-71) was undoubtedly downwards. Most studies suggest a crude birth rate (CBR) of 44-45 at the beginning of the decade (as opposed to the official figure of 41.1; see Table 1 above), or a total fertility rate of 6.4-6.6, and a decline of about four points in the CBR between 1961-71. It is difficult to know precisely when this decline occurred, but a large share of it can certainly be explained by the considerable advances in family planning which occurred after 1965. (Since the family planning program was most successful in urban areas, this is corroborated by the appearance of a significant rural/urban fertility differ- ential at the end of the decade.) Some of the decline is attributable to changes in the age-distribution and a modest rise in the age-at-marriage; but the major share of the decline seems to reflect reductions in marital fertil- ity. This trend in fertility decline appears to have continued in the 1970s, and a 1976 CBR of about 36-37 is probably correct. The official CBR for 1976, the latest year available, was 34.4, but the nationwide average marks wide state differentials ranging from 40.0 in Uttar Pradesh to about 28.0 in Karnataka and Kerala. Mortality 1.05 Table 1 also shows the long-run downward trend in mortality as measured by the crude death rate (CDR). As in the case of the CBR, the offi- cial figures are likely to be an underestimation of the true value of the CDR. A CDR of about 19 per 1,000 for the latter half of 1961-71 is implied by most studies on life expectation. 1.06 Mortality decline seems to have slowed down in the latter half of the 1961-71 decade. This trend has continued in the 1970s. The official CDR figure of 15 per 1,000 for 1976 (the latest year available) is almost identical with the comparable figure for 1971. In previous decades, reductions in mortality were largely won through eradication programs and communicable disease control. Most of these campaigns did not depend greatly upon the active participation of the population itself. The resulting mortality decline need not necessarily have been associated with corresponding declines in morbidity or socio-economic improvements. But beyond a certain mortality level, further gains depend upon various forms of socio-economic development, particularly improvements in nutrition, sanitation and housing. Since improve- ments in these areas are occurring very slowly in India, the observed levelling off of the mortality decline is not surprising. Official estimates of infant mortality range between 130 to 140 for rural areas during 1968-71 and around 81 to 86 for urban areas during 1970-71. The extent of under-reporting of infant deaths normally exceeds that for other age groups; for the country as a whole infant mortality is estimated to be quite high, between 130 to 150 per 1,000. About 30% of all children die before the age of five. Over the last 50 years, the infant mortality rate has fallen less rapidly than adult mortality. The CDR has decreased by two-thirds during this period while the infant mortality rate has only dropped by half, with the result that the differential between infant and adult mortality rates is greater now than 50 years ago.  -3- Morbidity 1.07 It is estimated that in any given week in India, one quarter of the nation's population is ill. The prevalence of illness in the course of one week is 29.5% in rural areas and 13.1% in urban areas, for an overall rate of 26.2%. Most of those who are sick are reported to be afflicted with dysenteries, diarrheas and respiratory diseases, implying inadequate potable water supplies, substandard sanitation facilities and inadequate housing. 1.08 The disease patterns in India have shifted dramatically over the last 50 years. Starvation and major epidemic diseases have disappeared as statistically significant causes of death. Despite this, malnutrition is still of major importance as an underlying contributor to death. The interaction between malnutrition and infection throughout the developing world has been widely documented. In the case of India, although malnutrition rarely appears as an overt cause of death, it has been estimated that it is responsible for more child fatalities than all other causes combined. 1.09 The leading causes of death in India now appear to be non-specific dysenteries, diarrheas and upper respiratory infections. A 1969 Government survey listed "cough" as the cause of 24.5% of deaths, "fever" of 20.6%, and diarrhea of 9.2%. These are all linked to gastro-intestinal and respiratory illnesses. India's Five-Year Plan for 1978-83 cites tuberculosis, gastro- intestinal infections, malaria, filariasis, infectious hepatitis, rabies, hookworm and other infectious diseases as accounting for 17.2% of morbidity and 20.8% of mortality in 1970. Preventable diseases such as diptheria, whooping cough, polio, tetanus, smallpox and measles contributed 9.4% of mortality and 1%. of morbidity. Smallpox, however, has since been eradicated. Age and Sex Distribution 1.10 The population of India is a youthful one. In 1971, 40.8% of the population was under the age of 15 and the median age of the total population was 19.4 years. Sex distribution data from the 1971 Census show that males outnumber females in the total population and in all age groups until age 65. In fact, there is evidence that the ratio of males to females has been growing larger for perhaps as long as a century. This striking trend and the resulting sex distribution reflect traditional cultural norms which have placed greater value on male children, and which have consequently led to greater male life expectancy. Population Projections 1.11 Table 2 below shows a projection of the likely course of population growth in India, assuming that a net reproduction rate (NRR) equal to one (replacement level) would be achieved around the year 2020. At this time, the total population would have reached 1.2 billion persons, an increase of about 83% over present levels. Because of the in-built momentum for growth, however, the population would continue to grow for many decades after achievement of a NRR equal to one, and would stabilize at about 1.6 billion by the middle of the 22nd century.  - 4 - Table 2: INDIA: BIRTHS, DEATHS AND RATES OF NATURAL INCREASE, 1980-2025 Average Annual Rate of Population Natural Crude Birth Rate Crude Death Rate Projections Increase per 1,000 per 1,000 Years (millions) /1 (%) Population Population 1980-1985 673.8 2.01 33.3 13.1 1985-1990 745.2 1.94 31.8 12.4 1990-1995 820.9 1.79 29.7 11.8 1995-2000 897.7 1.61 27.3 11.2 2000-2005 972.8 1.43 24.8 10.5 2005-2010 1,044.6 1.25 22.5 10.0 2010-2015 1,112.1 1.09 20.5 9.6 2015-2020 1,174.1 0.92 18.6 9.4 2020-2025 1,229.4 0.88 18.2 9.3 /1 Population total given for first year of five-year interval. Source: Population Projections, World Development Report, World Bank, 1979. 1.12 A population experiencing declining fertility after a period of rapid growth will exhibit some relative contraction of the base of the pop- ulation age-pyramid. Table 2 only shows population totals, but the more detailed projection on which this table is based forecasts a decline in the population 0-4 from 16.2% of total population in 1971 to 11.7% in 2000, and a slighter decline in the age group 5-14 (the school-age population) from 24.7% in 1971 to 22.1% in 2000. In absolute terms, the projection implies a large growth of the school age population--with concomitant need for additional expenditures in this sector just to maintain present percentages of literacy-- in the period 1971-80, from 137.6 million to 174.5 million, or an annual growth rate of about 2.7%. By contrast, average growth rates for 1980-90 and 1990-2000 would be about 0.8% and 1.2% respectively. 1.13 The population of working age, 15-59, would increase both in absolute and relative terms. In relative terms, it would increase from 53.4% of total population in 1971 to 59.6% in 2000. In absolute terms, it would increase from 297.6 million in 1971 to 579.7 million in 2000. The labor force would increase from 219.3 million in 1971 to 475.6 million in 2000, or at an average annual growth rate of about 2.7%. As a percentage of the total population, the labor force would go up from 39.4% in 1971 to 48.9% in 2000. Thus, as fertility declines, the ratio of dependents to persons in the labor force will fall, and if work opportunities can be provided for the growing labor force, the growth of per capita income will accelerate. However, the task of provid- ing productive employment to a labor force growing at 2.7% per year would be very challenging indeed. 1.14 India does not conform to the experience of many developing countries reporting fast urbanization. It remains a predominantly rural society, with about 20% of the population residing in urban areas. There is little basis  -5- for envisaging 'any sharp alteration of past trends in this regard, and recent projections of the future urban population are that it will be about 29% of the total by 2000. This does not imply a very high rate of urbanization, but at the same time there is no ground for complacency with respect to the problems faced by India's cities and towns. Even with the low and slowly increasing rate of urbanization, India's urban population in 1971 numbered about 109 million, and it will grow to about 282 million by 2000 (according to the population projection of Table 2), or at an average annual growth rate of about 3.3%. India's urban centers already find their infrastructure over- strained, and fairly large investments will be necessary to prevent a further deterioration in civic amenities. 1.15 If fertility does not decline to the extent assumed in Table 2, the tasks of employment creation, of providing enough additional school facilities to prevent a deterioration of present educational levels, and of allocating additional resources to urban areas infrastructure to prevent deterioration in current per capita levels of urban public services, would be correspondingly enlarged. Attainment of the fertility reduction assumed in Table 2 would imply a considerable increase of efforts by the family planning program; the percentage of couples effectively protected by contraception would have to increase from about 22.7% at present to about 51.6% by 2000, or an increase in absolute terms from about 25 million couples to about 85 million. This will require a substantial increase in resources allocated to the family welfare program. B. Project States and Districts 1.16 The project will be implemented in six districts of eastern Uttar Pradesh--Azamgarh, Basti, Deoria, Ghazipur, Mirzapur and Varanasi--and three districts of south-eastern Andhra Pradesh--Anantapur, Chittoor and Cuddapah (Map: IBRD 14519r). Uttar Pradesh (U.P.) 1.17 The state of U.P. had an estimated population of about 99.3 million in March 1979, which makes it by far the most populous state in India. The official estimated CBR in 1976 was 32.5 per 1,000 in urban areas and 41.2 per 1,000 in rural areas (combined 40.0 per 1,000), which are considerably above the corresponding all-India figures (28.3, 35.8 and 34.4 respectively). Official CDRs in 1976 were 12.9 per 1,000 in urban areas, 21.7 per 1,000 in rural areas, and 20.5 per 1,000 combined. These figures are also well above national averages, which were 9.5, 16.3 and 15.0 respectively. The percentage of population residing in urban areas was 14% in 1971, considerably below the national average of 20% in that year.  -6- Table 3: INDIA: SOCIO-ECONOMIC DATA ON PROJECT AREAS Uttar Pradesh Andhra Pradesh Three Six Project Whole Project Whole All- Districts State Districts State India Population /1 1979 (in millions) 15.9 99.3 6.8 49.7 640.7 Density 1979 (per sq. km.) 415 337 136 179 194 Urban 1971 (%) 8.8 14.0 15.2 19.3 19.9 Area sown/ geographical area 1975-76 (%) 69.0 /2 66.3 /2 37.1 40.7 52.0 Irrigated area/ cropped area 1975-76 (%) 36.1 /2 30.8 /2 22.0 30.8 25.1 Area sown more than once 1975-76 (%) 30.9 /2 27.8 /2 5.8 13.3 16.8 Registered factories 1971 (Z) 9.2 100.0 9.2 100.0 -- Population engaged in non-agri- cultural activities 1971 (X) 13.9 100.0 11.2 100.0 -- Literacy rate 1971 (%) 19.2 21.8 24.7 24.6 29.5 Number of persons per radio set 1976 126 71 n.a. 38 37.0 Population per re- gistered physician 9,770 /3? '7,105 /3 17,900 /3 13,000 /3 3,140 /1 Based upon original estimates of Expert Committee on Population Projection, Registrar General of India. /2 Relates to 1966-67. /3 Only physicians in Government service are included. Source: Data made available to the mission from various Government sources. 1.18 The six project districts in U.P. had an estimated combined popu- lation of about 15.9 million in March 1979, or about 16% of the total state population. Analysis of the socio-economic data summarized in Table 3 above indicates that the project area in U.P. is average in terms of industry, literacy, and institutional infrastructure compared to the state. 1.19 Morbidity patterns in both U.P. as a whole and the six project districts do not deviate significantly from national patterns. Hospital statistics for the 1971-73 period indicate that 35%-40% of all cases treated in hospitals pertain to gastro-intestinal and respiratory diseases. Other major categories are anemia, 3.7% in the six districts and 3.2% in U.P.; diseases of nervous system and sense organs, 8.0% and 7.3%; diseases of the genito-urinary system, 6.0% and 2.5%; diseases of the skin and muscle-skeletal system, 10.3% and 9.9%; and accidents, poisoning and violence, 6.4% and 8.9%.  -7- Andhra Pradesh (A.P.) 1.20 The state of A.P. had an estimated population of about 49.7 million in MWrch 1979, being the sixth largest state of India in population size. The official estimated CBR in 1976 was 29.8 per 1,000 in urban areas, 34.7 in rural areas, and 33.8 combined; these figures do not differ markedly from all-India averages. Official CDRs in 1976 were 9.4 in urban areas, 15.6 in rural areas, and 14.5 combined. Again, these figures are very close to national averages. 1.21 The three project districts in A.P. had an estimated combined popu- lation of about 6.8 million in March 1979, or about 13% of the population of the state. Analysis of the socio-economic data summarized in Table 3 indicates that the project districts in A.P. are average or marginally better in terms of literacy and institutional infrastructure but are less developed in terms of agriculture, industry and housing compared to the state. II. NATIONAL FAMILY WELFARE PROGRAM A. Historical Overview 2.01 Voluntary family planning activities started in the 1920s but were very limited in scope. Private interest in spreading the idea of limiting family size resulted in the formation of the Family Planning Association of India in 1949. Although there was clear recognition of the problem of exces- sive population growth by Indian leaders, there was no consensus as to how this problem should be solved, primarily because of the influence of Gandhian philosophies of self control. In April 1952, however, the Government of India (GOI) appointed a Population Policy Committee under the chairmanship of the Minister of Planning and a Family Planning Cell was created in the Directorate General of Health Services. The First Five-Year Plan documents, presented to Parliament in December 1952, referred to a program for "family limitation and population control" for which Rs 6.5 million was allocated. This was the genesis of the first official national family planning program in the world. 2.02 Initial activities under the First Five-Year Plan (1951-56) were limited to a few pilot projects and some studies. One conclusion of the Family Planning Research and Programs Committee established in May 1953, was that "as far as possible, new family planning centers should be developed in association with institutions for the health protection of mothers and children." Under the Second Five-Year Plan (1956-61) Rs 50 million was allocated for the establishment of rural and urban family planning clinics and the provision of grants to states, local bodies and voluntary organizations for family planning work. This essentially clinical approach was modified in the early 1960s by the establishment of a nationwide community extension program in family planning through the extension health services provided in rural areas. The new program was to undertake educational work to produce group support for the program and to supply contraceptives. A program goal was proposed to accelerate the adoption of family planning in order to reduce  - 8 - the birth rate to 25 per 1,000 by 1973. To emphasize the link between family planning and family health, the family planning centers were renamed Family Welfare Planning Centers. A "cafeteria approach," which provided a broad choice of contraceptive methods including sterilization, various mechanical ancL chemical methods, and rhythm, was to be a key element of the program. 2.03 To carry through these new program approaches, a Commissioner for Family Planning was appointed in 1965 and a Department of Family Planning established in the Ministry of Health in April 1966. Time-bound targets were introduced and, after trials, the Intra-Uterine Device (IUD) became an impor- tant program method. In 1968, the GOI launched the innovative scheme whereby condoms were distributed through the retail channels of leading distributors of consumer goods. At the GOI request, the United Nations sent two advisory missions to evaluate the program, one in 1965 and a second in 1969. In November 1969, a special meeting of the India Consortium was devoted to a review of the national family planning program and the need for external assistance. Expenditures between 1966-67 and 1969-70 increased by three times for India as a whole. 2.04 Prior to 1966, national performance statistics are incomplete. The intensified activity of the late 1960s resulted in a significant increase in the numbers of acceptors. From just under 1 million equivalent sterilizations in 1965-66, 2.1 million were recorded in 1967-68. In the 1970s the national program was administered on the basis of the structure which had been estab- lished, with the objective of consolidating program approaches and successes of the earlier period. It was marked by innovative approaches and by efforts to inject momentum into a program which had begun to show a decline in program performance. In 1972, the Medical Termination of Pregnancy Act came into force, providing for the termination of pregnancy on health, humanitarian and eugenic grounds. IUD insertions had declined rapidly from a peak of 910,000 in 1966-67 to 355,000 in 1972-73. The number of sterilizations had also fallen from a 1967-68 peak of 1.84 million to 1.33 million in 1970-71. In response to this decline, the program organized mass vasectomy camps which resulted in a peak of 3.1 million sterilization cases in 1972-73. This policy was discontinued because of administrative shortcomings, poor quality of services, and questionable motivation practices. This resulted in a dramatic decline to 942,000 sterilizations in the following year. As performance varied so did the national targets. In 1968, the stated goal was to reduce the birth rate from 41 to 23 per 1,000 by 1978-79 whereas the Fourth Five-Year Plan (1969-74) declared its objective to be a reduction in the annual birth rate to 32 per 1,000 by 1974, and to 25 per 1,000 "in another 5 to 7 years" (i.e., 1979-81). These goals were amended in the draft Fifth Five-Year Plan to achieve a reduction in the birth rate of 30 per 1,000 by 1978-79 and 25 per 1,000 by 1983-84. 2.05 By 1975 it was clear that the program continued to lose momentum, despite steady increases in the distribution of condoms from 961,000 equivalent users in 1968-69 to 3.5 million in 1975-76. A surge in performance coincided with the declaration of a national Emergency on June 25, 1975. Although not included in the Government's comprehensive 20-point economic program, commit- ment to the success of the family planning program became a feature of the  - 9 - following months. In April 1976, the Ministry of Health and Family Planning produced a formal statement of national population policy. Recognizing the relationship between population and development, the statement lists 16 specific population-related measures. They included increasing the minimum age of legal marriage, making the volume of central government financial assistance'to state governments partly dependent on family planning perform- ance, freezing the representation in the Parliament and the State Legislature on the basis of the 1971 Census, according higher priority to female literacy, increasing sharply the amounts of monetary compensation for individual sterilization acceptors, and permitting interested state governments to propose legislation for compulsory sterilization. 2.06 Between 1975 and early 1977, there was a dramatic increase in family planning performance, as a result of a vigorous, and sometimes over- zealous, pursuit of acceptors by the machinery of government. As a result of these efforts, 8.3 million persons were sterilized in 1976-77--some 6.5 million alone in the period July-December 1976. Sterilization was the method most emphasized during this period, with the number of IUD acceptors actually falling and condom acceptors increasing only marginally. As 1976 drew to a close, there were rapidly mounting indications that substantial resistance to the intensive family planning drive was developing, especially in the northern region and particularly against vasectomies. Monthly performance figures, although high in comparison with pre-drive levels, were beginning to decline. Reported program excesses became an issue in the elections which led to the change in Government in March 1977. 2.07 Despite early assertions that the Government supported a family planning program which would henceforth be completely free of pressure, the program came virtually to a halt, particularly in the northern Hindi- speaking states of U.P., Bihar and Madhya Pradesh. Following an evalua- tion, the Government committed itself to following existing policies closely. In a policy statement issued on June 29, 1977, the Government called for a purely voluntary program, rejected "hard targets" for performance and directed the thrust of the new Health and Family Welfare program to those underserved, primarily in rural areas; in other respects the statement was similar to that issued 14 months earlier. The Government has subsequently reiterated its commitment to the program, reiterating the need for the inte- gration of family planning with basic health, particularly maternal and child health (MICH). In October 1977, the rural health scheme was launched which features the training and support of village community health workers (CHW). An act fixing the minimum legal age-at-marriage at 21 for males and 18 for females was passed in March 1978. 2.08 In 1977-78, the year following the Emergency, program performance fell to a level characteristic of five years earlier as the following table shows:  - 10 - Table 4: INDIA: ABSTRACT OF PERFORMANCE OF FAMILY PLANNING METHODS DURING 1973-74 to 1978-79 (In millions) Family Planning Methods 1973-74 1974-75 1975-76 1976-77 1977-78 1978-79 Sterilizations: 0.94 1.35 2.67 8.26 0.95 1.48 Vasectomies (0.40) (0.61) (1.44) (6.20) (0.19) (0.39) Tubectomies (0.54) (0.74) (1.23) (2.06) (0.76) (1.09) IUD insertions 0.37 0.43 0.61 0.58 0.33 0.55 Equivalent conventional contraceptives users /1 3.01 2.52 3.25 3.69 3.24 3.60 Eligible couples effectively protected (%) 14.9% 15.1% 17.2% 23.9% 22.8% 22.8% Equivalent sterilizations 1.2 1.6 3.1 8.7 1.2 1.9 /1 Mainly condoms. Performance, as measured by equivalent sterilizations, improved in 1978-79 by 63% over the previous year but was still 42% below that of 1975-76, the pre- Emergency year. B. Current National Goals and Strategies 2.09 By early 1978, it became clear that a reduction in the targeted CBR to 30 could not be achieved by mid-1979. In only nine months since the end of the Emergency, it became clear that the severe drop in performance, particularly sterilization, was having an adverse effect on the percentage of eligible couples effectively protected by contraception, normally an indicator insensitive to performance shifts over short periods. Accordingly the Central Council for Health and Family Welfare declared in January 1978 that the goal of attaining a birth rate of 30 per 1,000 would be deferred back until 1983. To attain this, the percentage of couples effectively protected would need to be raised from the then current level of 22.8% to about 36%, an increase from 27 million to 42 million couples. On the basis of present performance, it is doubtful whether even this target can be achieved; there is evidence that the prevalence rate is still declining slightly. Whilst a CBR of 30 by 1983 remains the official target, there is evidence that further revision may not long be delayed. Late in 1978, the Planning Commission established a working group on population policy which produced an interim report in March 1979. The report is a significant pointer to recent thinking on population policy. One of the major recommendations is the adoption of a long-term goal of a NRR of 1 by the year 1996 for all-India, which implies a birth rate of 21 per 1,000 or a reduction from the current official estimate level of 33 per 1,000 by 12 points. Achievement also implies a contraceptive prevalence rate of about 60%. Although acceptance of this target would not deny the continued use of short-term goals, it does reflect a growing consensus that  effective population control implies considerable socio-economic development and that the whole process of moderating fertility can be viewed only in the long term. 2.10 The Government's first priority was to dispel concerns about the program which had built up prior to March 1977. To some extent this has been achieved but there remain in many parts of the country a latent suspi- cion that family planning (or family welfare) is equated only with sterili- zation, a feeling which pre-dates the Emergency period by many years. In addition to reaffirming the voluntary nature of the program, the following points have been emphasized: a. integration of family planning with basic health, particularly that of mothers and children, in a family welfare program; b. direction of the program towards those now underserved, mainly in rural areas; c. expansion and redirection of the program's motivational activities from heavy reliance on mass media to a more interpersonal approach; d. encouragement of participation by community organizations and voluntary bodies; e. establishment of village level, voluntary CHWs and intensification of the dai (indigenous midwife) training program; and f. involvement of all departments of Government in the program. C. Family Welfare Program Organization 2.11 Under the Constitution, policy-making for population matters, including family planning, is the joint responsibility of the states and the central government, but program implementation is a state responsibility. The family welfare program (which comprises family planning and MCH care), however, is of national importance and is centrally sponsored to the extent that all expenditures incurred by the states are met from GOI funds. The GOI's Ministry of Health and Family Welfare is responsible for overall program direction, guidance and evaluation. At central level, the Central Health and Family Welfare Council, headed by the Union Minister of Health and Family Welfare, meeting annually, advises on broad policy issues. The Council's membership comprises all state health ministers, representatives of selected voluntary and labor organizations, some Members of Parliament and eminent personalities active in the field of family welfare. In overall charge of the Department of Family Welfare in the Ministry of Health and Family Welfare is  - 12 - a Secretary to the GOI. The Additional Secretary and Commissioner of Family Welfare coordinates the activities of five major divisions dealing with policy, technical matters, information activities, the organized sector (industries and major national organizations such as the railways), and evaluation. Throughout India, stationed in the capitals of the major states, are 16 Regional Directors of Health and Family Welfare responci.ble to the center for liaising with and advising state governments on program implementa- tion and feeding back information. 2.12 In U.P. the Health and Family Welfare functions are under the overall guidance of the Health Minister. He is supported by a Commissioner-cum-Health Secretary and staff in the State Secretariat. Program implementation is the responsibility of the Director of Medical, Health and Family Welfare Services, who reports to the Health Secretary (see Chart 1). One of the seven Additional Directors is responsible for Family Welfare. His office (known also as the State Family Welfare Bureau) has five divisions dealing with operations, education and information, training, demography and evaluation, and MCH. Two state-level committees are responsible for providing policy guidance for the family welfare program. One of these is a sub-committee of the Cabinet with the Chief Minister as Chairman. This is the most important policy decision-making body. A second committee, chaired by the Commissioner-cum- Health Secretary, is the State Family Welfare Publicity Coordination Committee, which takes decisions on information and media campaigns. U.P. is divided into 11 Revenue Divisions, in each of which is a Joint Director, Ministry of Health and Family Welfare, responsible for coordinating the program in the districts in the Division. The functions of the Joint Directors are, however, limited and essentially those of review; reference to the need to strengthen their ties to the organization is made in para. 4.65(c). At district level, implementation is the responsibility of the District Chief Medical Officer. Districts are now divided into three areas, in each of which a Deputy Chief Medical Officer is responsible for all health and family welfare activities. Throughout India, three deputies are posted per district regardless of the size of the district, its population or number of health facilities. In the project area in U.P., districts vary in population from 3.3 million to 1.8 million and in number of primary health centers (PHCs), for example, from 32 to 16 for the same districts. The peripheral rural unit of administration of the family welfare program is the PHC, in charge of a medical officer, and covering an average population of about 100,000. 2.13 In A.P., the administration of health and family welfare services is similar to that of U.P. (see Chart 2). In the Directorate of Medical and Health Services, there are two Directors, one dealing with medical education, large teaching hospitals and specialized hospitals, and the other responsible for all other health and family welfare services. The latter is assisted by six Additional Directors, one of whom is responsible for Family Welfare and MCH services. There are six administrative regions in A.P., each having a Regional Director of Medical and Health Services to whom have been delegated functions relating to finance and staff. In the districts, the District Medical and Health Officer administers a structure similar to that in U.P. An analysis of administrative strengths and weaknesses and proposals to remedy the latter are contained in the following sections.  - 13 - Delivery of Family Welfare Services 2.14 The base from which family welfare services are delivered is the PHC, an organizational unit which provides basic health and family welfare services for a community development block with an average population of about 100,000. The medical officer in charge is supported by a second doctor, both of whom are heavily involved with curative services. These doctors are mostly male and the treatment of women and, to a lesser extent, children is frequently left to a Lady Health Visitor (LHV) or an Auxiliary Nurse Midwife (ANM). A third doctor will be posted to the FHC in response to demand for services expected to be generated by the CHW scheme. The doctors share the supervision work and hold clinics in the subcenters attached to the PHC. Each subcenter, staffed by an ANM, serves a population of about 10,000. It is recognized that it is impossible for a paramedical worker to cover a population of that size and the area covered is divided into an intensive area (3-4,000 people) and a twilight area where services are available only on request. The ANM's most important functions concern the health of mothers and children, delivering babies, providing family planning education and distributing condoms, supporting CHUWs and dais, and arranging for clinics run by the PHC doctor and LHV. ANMs and LHVs are allowed to prescribe oral contraceptives and, once trained, LRVs may insert IUDs. At the PHC, there are also several unipurpose workers employed by vertical health programs such as malaria. 2.15 Three schemes introduced in the last five years which affect the delivery of family welfare services are being phased in gradually throughout India. The first was the Multipurpose Workers Scheme introduced to provide an integrated approach to delivering a package of primary health care services including, inter alia, family planning, MCH and nutrition services to the community. Under this scheme, comprehensive services are provided by a team comprised of one male and one female worker at the subcenter level, at a rate of one subcenter for 5,000 persons to be achieved by the end of the Seventh Plan (1988). The Multipurpose Worker Female (NPWF) is an ANM whose training and functions will not change. The former unipurpose male workers will now become the Multipurpose Worker Male (MPWM). After an 18-month retraining period, the MPWM will be concerned primarily with detecting malaria cases, identifying communicable diseases, motivating family planning acceptors and distributing condoms, identifying cases of malnutrition, environmental sani- tation, and record-keeping. The supervisory system will also be intensified; LHVs will be designated Health Supervisor Female (HSF) and male workers such as Sanitary Inspectors and Family Planning Assistants will become Health Supervisor Male (HSM). 2.16 In October 1977, the GOI introduced its Rural Health Scheme by starting the training of CHWs in selected districts. CHWs are appointed by village communities at an average ratio of I CHW to 1,000 people. The com- munity is responsible for supervising the CHW's work which is done in his or her spare time after normal employment. After three months' training at a nearby PHC, the CHW is given an honorarium of Rs 50 per month and provided with medical supplies and drugs for a maximum of Rs 600 per year. The CHW is expected to educate and involve the community in measures of promotive and preventive health care, treat minor ailments, motivate the community towards acceptance of family planning, report communicable diseases and vital events,  - 14 - and be concerned with improving environmental sanitation. The GOI also announced in 1977 that it would intensify the training of dais. The objective is to train at least one dai per village of about 1,000 people. The four-week training period emphasizes hygienic deliveries, the need for immunization, family planning motivation, and case referral to the subcenter or PHC. The dai is provided with a delivery kit, replenished as necessary. She is not paid an honorarium but receives Rs 2 for reporting a birth. During training, the dai works closely with the MPWF who works in her village area. Status of Services 2.17 The six districts of eastern U.P. selected for program intensifica- tion under the proposed project have poor coverage of services. Each of the 148 community development blocks in the project area has a PHC staffed by two doctors. The overall doctor/population ratio is, however, very low. In 1971, there was one doctor for 9.770 people in the six project districts, which compared with 1:7,105 for U.P. as a whole and 1:3,140 for India. Comparable ratios for countries at a similar stage of development include 1:18,160 for Indonesia, 1:9,350 for Bangladesh and 1:3,970 for Pakistan. By contrast, there was one doctor for every 515 persons in the United States in 1976. With respect to subcenters, 1,355 had been established in the project districts by March 1979. This yields a ratio of 1:9,810 based on 1971 popula- tion (the present norm for establishment of subcenters being 1:10,000 based on 1971 population figures), but the growth of population to mid-1979 eroded this ratio to 1:11,500. The Fifth Five-Year Plan had aimed at a target of 1 subcenter for 8,000 people by March 1979. Using the 1973 Committee on the Integration of Health and Family Planning's estimate that an ANM could effec- tively serve a population of 4,000 at most, about 10 million people in the six districts are beyond the range of effective MCH services. Of the 148 PHCs, 42 are located in inadequate, rented quarters which fail to meet the lowest standards of adequate space and hygiene. Only 150 of the 1,355 established subcenters have a properly constructed building. Equipment at PHCs and subcenters is, by and large, old, insufficient or broken. 2.18 The status of services in the three selected districts of A.P. is very similar. The doctor/population ratio for doctors in government service is 1:17,900 compared with 1:13,000 for the state as a whole. The estimated overall doctor/population ratio is 1:3,500 for A.P. There are 62 PHCs, each currently serving an average population of about 93,000 people. The work of 14 PHCs is carried on in rented quarters. Of the 508 established subcenters, 219 have adequate buildings. The subcenter/rural population ratio using 1971 Census data is 1:9,984 and using the mid-1979 projection, 1:11,378. Sub- centers effectively serve about 35% of the rural population. Their equipment and vehicles are inadequate and old; of 190 health/family welfare vehicles in the three districts, 29 have been condemned and 76 are over 10 years old. Program Support Activities 2.19 The delivery of services is supported primarily by three sets of activities--information, education and communication (IEC) activities, train- ing, and research and evaluation. Although since the 1960s the program was  - 15 - directed towards community extension, the emphasis in IEC work has been on the use of such mass media as press, radio, films, wall posters and exhibitions. Controlled by a mass education and media unit in the Department of Family Welfare national IEC programs have been heavily centralized. In 1975, in an effort to redirect activities, the Association of Advertising Agencies of India (AAAI) was retained to prepare strategies in U.P., A.P. and West Bengal. Although imaginatively designed, only part of the strategies--particularly the use of films--was put into effect. This circumstance was due to the weak infrastructure for IEC activities. Although District Chief Medical Officers and PHC doctors are responsible for directing such activities, they have not had any training in this work and specialized staff support is inadequate. At the PHC level, the Block Extension Educator (BEE) and at district level, the District Health Information and Education Officer (DHIEO) are supposed to carry out IEC work under the technical guidance of an Assistant Director, Evaluation and Information, at state level. In practice, neither educators nor officers spend sufficient time in their ascribed functions. IEC activities have contributed to creating a significant degree of awareness of the family planning program. However, many believe that family planning only consists of sterilization and much needs to be done to translate awareness into motivation, for acceptance of contraception. 2.20 Training of staff for the family welfare program is carried out by medical colleges, paramedical training schools and Regional Health and Family Welfare Training Centers (RHFWTCs). The training of doctors is carried out in medical colleges, largely on classical western patterns, with emphasis on curative medicine. MPWFs receive 18 months' training at basic paramedical schools. The RHFWTCs are responsible for training district IEC staff, trainers (PHC doctors) for multipurpose worker training, and short courses for district medical staff. In the U.P. project area there are medical colleges at Gorakhpur and Varanasi, a RHFWTC at Varanasi and six basic paramedical schools. The A.P. project districts are served by a medical college at Tirupathi and one outside the project area at Kurnool; the RHFWTC serving the area is also at Kurnool. There are no basic paramedical schools in the project districts. PHC doctors and LHVs receive instruction at RHFWTCs in order to train multi- purpose workers, CHWs, and dais at PHCs. 2.21 At state level, responsibility for research and evaluation rests with a Demographic and Evaluation Cell under the Additional Director for Family Welfare. These cells collect service statistics relating to MCH and Family Welfare work from the records of ANMs (or multipurpose workers). These returns from ANMs are collated by a statistical clerk at PHC level and a statistical assistant at district level. Data are routinely checked by staff from the Demographic and Evaluation Cell but little evaluation is carried out. Other primary health statistics are collected by the same mechanism but collated at state level by a Vital Statistics Unit. Performance data for all India are compiled by the Evaluation Division of the Department of Family Welfare in New Delhi. Most of the program's evaluation is contracted by this Division to other organizations such as the National Institute of Health and Family Welfare or the 12 Demographic and Research Centers around the country. The latter are attached to universities and wholly subsidized by the Government  - 16 - which has not, in the past, made maximum use of their resources. Important program evaluation work is carried out by an evaluation unit in the Planning Commission. Much program evaluation in India is demographic rather than operational in orientation, but the population centers established under the first project have made very useful operational evaluation studies. D. Program Performance 2.22 Even before the Emergency, the family planning program's perform- ance was showing a gradual upward trend. In 1973-74, 14.9% of eligible couples were effectively protected, a measure which takes into account the varying effectiveness of contraceptive methods. Two years later, it had risen to 17.2% and in 1976-77 jumped to 23.9% after the intensive drive. Since then there was a slight decline to 22.8% in 1978-79, but, by June 1979, the percentage of couples effectively protected had risen to 23.9%. This compares with 27% in the Philippines, 16% in Bangladesh and 18% in Indonesia. 1/ Program progress has, however, been cyclical in nature, swinging from peaks during which particular methods have received attention to troughs in which the reaction to these methods has become apparent. With vasectomy, for example, 2.6 million operations were performed in 1972-73 when the special camp approach was tried on a massive scale. Loss of impetus and administrative shortcomings produced a slump in the following year when only 400,000 vasectomies were reported. The decline between 1976-77 (the Emergency year) and 1977-78 from 6.2 million vasectomies to 190,000 was even more dramatic. The peak year for IUD insertion, 1966-67, when 900,000 acceptances were recorded, has never been matched. With the exception of 1976-77, the number of tubectomies has risen gradually and even after the intensive drive of that year, the fall-off, from 2.1 million to 736,000 cases, was not as great as that of vasectomy. In 1978-79 there were estimated to be 3.36 million users of condoms--distributed free through clinics or at nominal cost through retail outlets--a figure slightly below the 3.69 million recorded in 1976-77. In February 1979, 89.3% of the couples effectively protected were protected by sterilization, 4.0% by IUDs and 6.7% by conventional contraceptives (mainly condoms). 2.23 Oral contraceptives have thus far been available only on a very limited scale in pilot programs. In 1978-79, (11 months) the number of year-round users, calculated from the number of cycles distributed, was estimated at only 91,000 nationwide. Since the passage of the Medical Termination of Pregnancy Act in 1972, considerable care has been exercised in the approval of facilities and staff licensed to perform abortions. In 1978-79, 313,000 abortions had been performed compared with 247,000 in the previous year. Estimates of the number of illegal abortions range from 2 to 4 million annually. 2.24 Not unexpectedly in a country as large and diverse as that of India, there are considerable variations in inter-state family planning performance. From the 23.97% all-India average of couples effectively protected in June 1/ Statistics for Bangladesh and the Philippines from survey data; for Indonesia from program data.  - 17 - 1979, the range in the major states was from 34.1% in Maharashtra and 30.5% in Haryana to 12.2% in Bihar and 11.4% in U.P. The comparable figure for A.P. was 26.2%. Criticism of program performance results, in part, from the program's failure to achieve its targets or "expected levels of performance" (as they were termed since April 1977 for IUDs and conventional contraceptives, and subsequently for sterilizations). The family planning targets have been predicated on the basis of targeted reductions in the all-India birth rate. As noted above (para 2.04), the demographic goals on which the targets have been premised have had to be continuously revised downwards. Nortman has pointed out with specific reference to Indian target setting that "too great a disparity between aspiration and achievement is frustrating and demoralizing." 1/ Tension has been created between policy-makers and administrators and the result has been urgent, short-term solutions to a problem which can be resolved only in the long-term. Adherence to the goal of reducing the birth rate to 30 per 1,000 by 1983 implies a 67% increase in contraceptive use over five years, a task Nortman describes as of "extraordinary magnitude." A level of 2 million equivalent sterilizations per year is required merely to keep the birth rate from rising; in 1978-79, this level was 1.9 million (Table 4). Performance in U.P. and A.P. 2.25 Of the 15 most populated states, U.P. has the lowest percentage of couples effectively protected--11.4% in June 1979. Of these, 80% were pro- tected by sterilization, 14% were protected by IUDs, and 6% by other methods (mainly condoms). U.P.'s performance in family planning has fluctuated with national performance. In 1976-77, 927,500 equivalent sterilizations were recorded; in the following year, only 70,362. Performance doubled last year to 134,000. U.P. was particularly affected by the intensive drive in 1976-77. In that year 690,000 vasectomies and 148,000 tubectomies were performed; the corresponding figures for 1977-78 were 1,290 and 12,200 and, for 1978-79, 4,489 and 24,300 respectively. IUD acceptors have shown a gradual upward trend since the introduction of this method in 1965-66 and reached their highest peak last year. Of the estimated 1 million couples effectively protected by IUDs in India in June 1979, about 30% are attributed to the U.P. program. Legal abortions have also risen steadily from 350 in 1972-73 to 65,300 in 1978-79. Performance in the six districts reflects that of the state as a whole with the percentage of couples effectively protected ranging from 14.5% (Mirzapur District) to 7.2% (Basti District). 2.26 Performance in A.P. has been substantially better, 26.2% of eligible couples being effectively protected. Of these couples, about 98% were pro- tected by sterilization and the rest by IUDs and other methods. Here the effects of the intensive drive were less marked. By February 1979, A.P. had achieved 58.5% of its expected level of sterilization performance for 1978-79, whereas U.P. had achieved only 3.8%. Over the last six years, A.P. has consistently ranked seventh of the major states in the percentage of couples effectively protected. Although the number of vasectomies in 1978-79 (47,000) is well below that of 1976-77 (572,000) the number of tubectomies was higher last year than in any previous year, 1976-77 excepted. The number of IUD 1/ Population and Development Review, Vol. 4, No. 2, 1978.  - 18 - insertions has fluctuated markedly since 1965-66, showing an upward trend since 1973-74 to a total of 192,000 last year. Condoms distributed without cost have dropped severely from a peak of an estimated 569,500 users in 1974-75 to 29,000 in 1978-79. Measured in terms of equivalent sterilizations, performance in A.P. is well above the pre-Emergency levels but lower than the peak years 1968-69 to 1972-73. Here, as in U.P., there is clear evidence of rising demand for female contraceptives and a marked fall in demand for contraception from males. The demand for abortions, however, appears to have levelled off at about 11,000 annually over the last three years. In the three project districts, the percentage of couples effectively protected varies from 30.6% in Cuddapah District to 23.1% in Ananthpur District. In all three districts performance was better in 1978-79 than in the previous five years, 1976-77 excepted. The choice of methods in the three districts shows the same charac- teristics as that of the state as a whole. MCH Performance 2.27 With respect to MCH services, there are six programs for which official targets are set annually: (a) tetanus toxoid immunization (TT) for expectant mothers, (b) diphtheria, whooping cough and tetanus immunization (DPT) for children aged 0-2 years, (c) diphtheria and tetanus immunization (DT) for children aged 2-11 years, (d) prophylaxis against nutritional anemia among mothers, (e) prophylaxis against nutritional anemia among children, and (f) prophylaxis against blindness among children due to vitamin "A" deficiency. For India as a whole, progress in all these programs has been significant. Between 1975-76 and 1977-78, the annual number of beneficiaries for all six programs combined increased nationwide from 16.8 to 44.1 million. The increase in U.P. was from 1.1 to 3.4 million beneficiaries and in A.P. from 1.6 to 3.3 million. In spite of this progress, coverage is still very limited. Thus, for example, in the six U.P. districts included in the First Population Project, the percentage of children with immunization against DPT by the end of 1977-78 was only 6.6%. The corresponding percentage for DT was 6.2%. 2.28 An important indicator of the status of MCH services is the percent- age of deliveries conducted by trained personnel (including trained dais). For A.P., this amounted to about 11.5% in 1975-76, the latest year available. For the combined six U.P. districts included in the First Population Project, it amounted to 11% in the same year (but had climbed to 20.7% by 1977-78). The percentage of pregnant women who registered with health staff in A.P. in 1975-76 amounted to 38%. For the six U.P. districts mentioned above, in the same year, it reached 9.8% (and was up to 23.9% in 1977-78). These figures indicate that, despite about a 200% increase in U.P. and about a 100% increase in A.P. in TT and DPT immunizations over the past four years, MCH coverage in the sates to be included in this proposed project is far from satisfactory. The same situation also prevails in most of the rest of the country. E. Current National Policy 2.29 Following the elections of March 1977, the Government's priority was to dispel concerns about the family planning program built up prior to that date, establish its commitment to the program, and evaluate  - 19 - its policy. The steps taken have been enumerated in para 2.10 above. In essence, the Government's strategy has been to exert steady pressure for the provision of integrated health and family planning services whilst increasing public support for a voluntary program to reduce fertility. The Government has tried to avoid major pushes that cannot be sustained and which, quite apart from their political implications, have resulted in the past in damaging cycles in program performance. In addition, the Government is concerned with directing the program towards underserved groups, particularly in rural areas. Although voluntary sterilization will be retained as a terminal method sug- gested for families with three or more children, greater emphasis will be placed on spacing methods, including IUDs and oral contraceptives. There is also evidence that the Government is turning away from the monolithic, central- ized program with assistance based on rigid input/population ratios to one in which resources are channelled to the areas now poorly served by family welfare services and where fertility and mortality remain at comparatively high levels. Increasing emphasis is being placed on state initiatives. The past year's performance holds out the hope that the demand for family planning services and the capacity to deliver these services is returning to the level of pre-Emergency years. This reversion would provide a stable base on which to build an effective program and so make progress in lowering fertility and mortality levels. F. Program Constraints and Weaknesses 2.30 Despite limitations induced by low levels of income, literacy, and industrialization, and high levels of infant and child mortality, the perfor- mance of the India program has not been as poor as many analysts have suggested. Fertility declined by 16% during the period 1965-75, one of the larger declines among countries with a similar socio-economic background. The effectiveness of expenditure in the Indian program was at least average for countries in this region as suggested by an analysis of average annual expenditures on family planning programs during the period 1972-76, and the percentage of married couples of reproductive age practicing contraception by 1977. The program, however, fell short of the expectations. If there is to be sustained growth, the program's capacity to deliver good quality family welfare services must be improved and expanded. In order to ensure effective growth, the following weaknesses and constraints need to be removed: (a) Services. Coverage for MCH services is inadequate, with, at most, services available to 25% of the rural population. Peripheral facilities are often in rented, inadequate premises which are unattractive. Inadequate public transportation and the absence or inadequacy of rural roads curtail the acces- sibility of the community to the PHC or subcenter. Equipment is old and inadequate, as are vehicles; (b) Staff. Apart from lady doctors, staff is not generally in short supply at the present ratios laid down by center and state govern- ments, but these are inadequate to provide effective service coverage. There are serious problems of staff motivation and  - 20 - orientation. The training of doctors is strongly oriented towards curative medicine with little, if any, attention to preventive and community medicine and management. Paramedical staff training tends to be mechanical. In U.P., ANM's have had to be recruited from Kerala because of local attitudes which regard nursing as a less than desirable profession and low educational standards among the classes who have not such attitudes; (c) Support strategies. Activities aimed at motivating potential acceptors of family planning services and informing communities about the benefits of family welfare have lost direct contact with the people. They have relied mainly on the use of mass media, even in situations where the reach of media was limited to, in the case of U.P., 12% of the population. Although ANMs and BEEs were considered to be the principal agents of the pro- gram's IEC activities, they receive little or no training and no direction. Not even in the state health and family welfare services are the new Government policies and programs, which should do much to redress these deficiencies, fully understood; this is even more true of other state departments w:Lth whom there is little cooperation and less coordination; (d) Administration. The managers of the program and the PHC doctor, District Chief Medical Officer and State Directorate staff have had no special training in management and their ability to direct, coordinate and supervise the planning and delivery of services is less than adequate. These circumstances are also in part due to an overly-centralized organizational structure, especially in U.P., which inhibits consultation and decision-making at the appropriate levels. With organizational reform, the introduction of the Multi- purpose Workers Scheme and its reassertion as a firm Government policy, there is much better integration between family planning and health services than previously, but improved management, particularly at district and PHC levels would speed up the process. Consultation between the Directorate of Health and Family Welfare and other Government departments is minimal; (e) Planning. In the past, there has been little, effective planning of family welfare programs. Although states are responsible for implementation, the center's sponsorship and 100% financial support often resulted in weak state commitment, poor integration of state and center funds in providing facilities, and the inhibition of the integration of family planning and health services. Performance targets do not adequately take account of availability or quality of services. The professional ability to plan and develop programs on a rational basis needs to be strengthened. Programs tend to be developed intuitively or on the basis of political and/or adminis- trative pressures. Until recently, MCH services were given very low priority vis-a-vis family planning work; and  - 21 - (f) Evaluation and research. Service statistics are collected and published in a timely fashion but feedback to district and block workers is negligible. There is little analysis except to cal- culate how far requested levels of performance have been achieved; reporting and evaluation are essentially quantitative in character. India has considerable resources for research and the resultant literature regarding the country's family planning policy and program is vast. Such research has, however, largely been the preserve of academics. The program has not been able to trans- late research findings into operational terms adequately. In order to remove these constraints, the rate of expenditure on the program to provide a wider and more effective program coverage is being accelerated by the GOI. Outlays for the health and family welfare sector for the period 1978-83 are planned about 78% higher than those planned for the period 1974- 79. Efforts are being made to seek a substantial increase in external assis- tance for this sector. G. External Assistance 2.31 The earliest forms of foreign assistance to the program, fellowships and consultants, have been provided by the Ford Foundation and the Population Council since 1964. In that year India requested the United Nations to send an advisory mission on family planning and an evaluation mission was mounted in 1965. Towards the end of the 1960s, the annual population growth rate of 2.5% and the addition of some 13 million people annually to its population were matters of serious concern to the Government in relation to its socio-economic development programs. The Government enlisted support from bilateral sources-- the Governments of Denmark, Japan, Sweden and the United States--for the pro- vision of commodities. The principal criteria in the acceptance of this aid was the unavailability of commodities--such as condoms, printing presses and audio-visual equipment--in India. Some assistance from multilateral sources-- experts, equipment, fellowships--was also provided. In March 1969, a second United Nations mission provided an external review and evaluation of the program. 2.32 In November 1969, at the request of members of the Aid Consortium, the Bank organized a special meeting in Stockholm for representatives of the Consortium countries and of the GOI to consider the India program. In parti- cular, the United Nations' report evaluating India's family planning effort was discussed. In a series of informal discussions which took place in the preceding months the donors had examined the need for and extent to which foreign assistance could assist the program. The Government's view expressed at the Stockholm meeting was that "...the import requirements of the program are marginal and in this sense, the family planning program needs very little straight foreign exchange support. Any assistance from abroad will, therefore, need to finance local currency which can be used for augmenting the allocation of Rs 300 crores for the program in the Fourth Plan. It also follows that such assistance should in principle be an add-on to the normal forms of aid available to India and unless this is so, external assistance cannot in real  - 22 - terms supplement domestic resources." 1/ Although it was not a pledging meeting, several donors present, including the Bank, gave notice that they were interested in assisting the India program. 2.33 External assistance to the program continued throughout the 1970s although direct assistance provided by the U.S. Agency for International Development (USAID), which had amounted to some US$30 million by 1972, was terminated in 1973. In June 1972, an agreement was signed between the GOI and the states of U.P. and Mysore (now Karnataka) on the one hand and Inter- national Development Association (IDA) and Swedish International Development Authority (SIDA) on the other hand, for a project with a total cost of US$31.8 million equivalent (see Section III below). In 1974, the Government signed an agreement with the United Nations Fund for Population Activities (UNFPA) under which the UNFPA committed US$38 million to the program for five years. The assistance covers some thirty projects encompassing activities such as support for the expansion of the sterilization program (US$15.0 million), multipurpose workers training program (US$8.6 million), training of dais (US$7.1 million), appointment of ANMs and female health workers (US$4.6 million) and strengthening field-level infrastructure (US$2.7 million). Other United Nations agencies such as UNICEF, WHO, ILO and UNDP assist in the implementa- tion of some of these projects. By December 31, 1978, US$32.4 million had been utilized. Support has also been forthcoming from bilateral agencies such as SIDA (condoms), the British Overseas Development Administration (ODA) (improvement of sterilization facilities), Norwegian Agency of International Development (NORAD) (hospital postpartum program), Danish Agency for Inter- national Development (DANIDA) (building for the National Institute of Health and Family Welfare and equipment for drug research) and Federal Republic of Germany's Kreditanstalt (KFW) (printing equipment and raw film stock). Non-governmental assistance has been provided by a number of agencies, including the International Planned Parenthood Federation which supports the activities of the Family Planning Association of India. 2.34 In 1978, the Government made approaches to several international agencies for assistance in financing family welfare activities under the Sixth Plan (1978-83). The Bank, SIDA, UNFPA, DANIDA and the ODM were requested to assist in the development of the family welfare program in selected districts of selected states. Project preparation is underway in U.P. and A.P. (IBRD and SIDA), Rajasthan and Bihar (UNFPA), Madhya Pradesh and Tamil Nadu (DANIDA) and Orissa (ODM). Discussions on possible assistance from USAID have just started. The UNFPA sent a basic,population needs assessment mission to India in November 1978 and, as a result, proposes to provide grants amounting to US$100 million equivalent over the period 1980-84. Of this, US$48 million would be made available for general budget support for agreed projects at national level, US$32 million for the area-specific projects in Rajasthan and Bihar, US$10 million for assistance to non-governmental activities, and US$10 million would be held as an unprogrammed reserve. 1/ GOI Statement, Stockholm, 1969, p. 43.  - 23 - III. FIRST POPULATION PROJECT 3.01 Following the Consortium Meeting in November 1969, the Government requested the Bank to assist in the development of a comprehensive demonstra- tion program in selected districts of U.P. and Mysore (now Karnataka) states covering a population of some 20 million. These states were selected because they reflected different levels of socio-economic development. In contrast to most multilateral and bilateral assistance which had been providing one or two program inputs, the Bank-assisted project was designed to provide a variety of inputs to the program in a specific geographical area. The project was appraised in 1971 and agreements with the GOI, U.P. and Mysore, as well as the Kingdom of Sweden, were signed in June 1972. IDA made available a credit of US$21.2 million and SIDA a grant of US$10.6 million to cover project costs. A. Project Description 3.02 The first population project is an experimental demonstration proj- ect intended to test the efficacy of various program inputs, and to evolve, through experimentation, ways and means for attaining better performance of the national program to reduce the rate of population growth. The Govern- ment's planned primary health service pattern was only partially complete in the selected districts due to shortage of staff and facilities. The project objective was to complete the health infrastructure and provide training facilities and equipment to implement the program. Additional inputs for an urban program, intensive rural program and supplementary nutrition program were provided to assess their impact on fertility decline within the existing socio-economic conditions. Population centers in each of the two state capitals, Lucknow and Bangalore, were established to refine experiment design, develop a management information and evaluation system (MIES), evaluate performance and recommend changes in the program for improving performance. The project also supported development of health management units at the Indian Institute of Management, Ahmedabad, and Administrative Staff College of India, Hyderabad. These units assisted the state governments, parti- cularly the population centers, in research and management systems design as well as management training. Project inputs included the construction and equipment of facilities, including inter alia, paramedical training schools, the provision of transport, equipment, technical assistance for overseas training, and the provision of staff salaries, maintenance and commodities which constituted the incremental costs of supplementing the Government's program. 3.03 The project became effective on May 17, 1973. Implementation of project infrastructure proceeded steadily. Approximately 1,400 of a total 1,545 buildings were completed by January 1976, a period of 2-1/2 years. The need to strengthen the professional supervision of civil works was iden- tified for future projects. Staffing patterns were substantially completed and the necessary vehicles were procured by the end of 1976. After some initial staffing problems, the population centers gradually built up an institutional capability. Early implementation problems related to the  - 24 - relationships among the various project units, the Management Institutes and state Governments were resolved, and there is now complete, functional inte- gration of the project units with the ongoing state health and family welfare programs. 3.04 In 1976-77, just as the project infrastructure was completed, and the supporting institutes were becoming functionally effective, intensive family planning drives were launched during the Emergency. These drives affected the research work and experimental strategies, masking the result of the project inputs and inhibiting evaluation. The project. was, therefore, extended by two years to June 30, 1980. By December 31, 1979, US$20.2 million (95.3%) of the IDA credit and US$10.1 million (95.3%) of the SIDA grant had been disbursed. B. Assessment of the Project 3.05 The discussions on the project began in 1969 and it was appraised in May 1972. The intervening years since have seen marked changes in both conceptual basis (from narrow family planning programs to multi-sectoral popu- lation activities characteristic of the current state of wisdom in the field) and operational conditions (the drives during the Emergency). These provide the broad contextual background in which the project was implemented. C. Service Levels Achieved 3.06 Since the project is not complete and a project evaluation is cur- rently in progress, it is difficult to estimate the impact of the project on mortality and fertility rates. An analysis of available service statistics suggests: a. Family planning services in U.P. During the 10-month period April 1978 to January 1979, project districts (11.4% of state population) accounted for 16.8% of sterilizations, 19% of IUDs and 15.4% of other methods in the whole state, nearly 50% higher than non-project districts. Since 1977, the rate of medical terminations of pregnancy per 1,000 population is three times that of non-project districts. During the five-year period 1974-79, the project districts had 30% higher performance in terms of equivalent sterilizations compared to socio- economically matching districts; b. MCH services in U.P. In terms of percentages of antenatal women registered and percentage of deliveries conducted by trained staff during 1977-78, the project districts averaged 50% to 100% more (roughly 20% to 30% of all pregnant women were covered) compared to matching districts. The target achievements for TT, DPT and DT from 1974-75 to 1977-78 increased from 21.5% to 87.2%, 6% to 151.5%, and 20.5% to  - 25 - 111.1% respectively as compared to an increase from 13.1% to 58.6%, 6.4% to 109.2% and 24.0% to 77.8% in the whole state. Thus in 1977-78 the target achievements were 40% to 50% higher in project districts; c. Family planning services in Karnataka. The project areas have consistently increased their share in state performance in terms of acceptance of family planning methods as measured by equivalent sterilizations. During the ten-month period of April 1978 to January 1979, project areas, constituting 31.4% of population and targets, accounted for about 39.0% of the state's total performance, whereas in 1973-74, the project areas accounted for 31.7% of the state's performance; and d. MCH services in Karnataka. During the period April 1977 to December 1978, the project areas, constituting 31.4% of the state's population, contributed about the same for DPT and DT immunizations and 42.7% for TT immunization to the perform- ance in the whole state. 3.07 Utilization of beds in maternity homes in urban areas, annexes to district hospitals, and selected PHCs has consistently improved over time. However, it continues to remain low for the 24-bed annexes to PHCs. Investiga- tions into causes of low utilization have suggested the need for changes in working methodology, sorting out problems of organizational control and the need for popularization of these annexes, and steps have been taken to this effect. D. Other Project Programs 3.08 Although the nutrition component in U.P. faced several difficulties, the nutrition component in Karnataka showed that it is feasible to establish an organization to distribute supplementary food in the context of the delivery of family welfare services, as about 95% of target beneficiaries attended distribution centers for more than 90% of distribution days. The most recent survey reports prepared by the National Institution of Nutrition in Hyderabad, showed, however, that despite the increase in the upper age limit of the child target group (from 24 to 60 months), sharing of food supplement continued in 75% of the households covered. Improvements in nutritional status have been negligible, with no impact on the growth status of beneficiary children. Two of the more important conclusions of a mid-term review in Janaury 1976 were that the replicability of supplementary feeding on a national scale was suspect on grounds of impact and cost (US$0.15 per week of supplementary food for a child less than four years). The review also decided that five years was too short a period to determine whether a lowering of infant mortality through improved nutrition led to a lowering of fertility. There has been evidence that special nutrition education mobile teams have had an impact on dietary habits; the experiment has not been concluded but here again repli- cability is doubtful due to cost considerations.  - 26 - 3.09 Two mobile teams in each of the four intensive districts were pro- vided for intensive IEC and service activities. Difficulties were experienced in staffing and operating these teams and performance, cost and operational considerations led to their discontinuation. Mobile training teams were able to provide inservice training to the target groups, despite the program's additional massive training efforts to introduce multipurpose workers and CHW schemes. Attempts continue to be made to improve quality of training. 3.10 The project is unique in that it permitted experimentation with additional inputs as well as in routine program operations, within its natural setting unlike pilot experiments which operate in an independent organizational environmeat. In Karnataka, five different strategies are being tried, including the involvement of a voluntary agency in managing the program in a PHC, introducing new management methods at PHCs, delegating more responsi- bilities to paramedical staff, involving non-health Government agencies, and testing the effect of non-cash incentives. In addition, a few combinations of these strategies are also being tested. In U.P., experiments were made in the area of dai training, intensification of condom distribution in rural areas, data collection of vital events, and the involvement of traditional medical practitioners. While the estimate of quantitative impact for most of these program changes is not fully available, valuable lessons have already been learned in terms of process dynamics. These lessons include an appreciation for required changes in planning and evaluation, better activity planning at the periphery (made difficult by other organizational constraints) and need for greater managerial capability in the area of human resources. 3.11 Population centers took longer to establish an institutional capabil- ity than envisaged, thus providing a better;'perspective of the time element in the maturing process of an institution (role definition, goal clarification, establishment of sound personnel practices and, above all, an institutional culture). In spite of these difficulties, the population centers designed and implemented a number of baseline surveys, operational research programs and service statistics systems. They have produced a substantial amount of infor- mation on program operations as evidenced by newsletters, reports and seminars. The exercise of their monitoring functions has had an important impact on performance. In taking over the two centers rather than allowing them to become units of the central Government, the states have recognized the value of an operational research unit working closely with program administrators. 3.12 Many observers and evaluation missions have suggested better organi- zation and management as offering the best potential for improving the Indian program. For the first time since the program's inception, attention was paid to the management aspects of the program by affiliating two management insti- tutes with the program. Training, better supervision, improved activity planning and increased commitment were identified as having a marked effect on program performance. Studies were carried out for improving supplies of drugs and medicines, reorganization at district levels, and management of urban programs. In particular, the following elements of management assistance were found useful and requiring further support by the program administrators:  - 27 - a. MIES simplifies record keeping, saves time, establishes criteria for judging performance of service units and provides feedback to program administrators. Similar but separate systems were established for each of the states; these are now being merged. The new system, which includes all primary health services data, will be tried out at district level before being adopted for the whole state; b. Management training to improve capabilities of PHCs and district level medical officers will be extended to cover the entire project area; and c. Management consultant services (never previously used by state governments) will be used to concentrate on specific program problems. 3.13 Several lessons have been learned about the processes of project and program implementation: a. Project management was established with little respect for Indian administrative practice. A separate project implementation structure under a Project Governing Board was set up and was, in the initial stage, distinct from program management. The separate structure was useful in making the project inputs available for a considerable extension of program services and in general keeping the project before the attention of the highest level of state Government. However, no mechanism existed by which feedback could be channeled into the routine state programs. Close liaison with state authorities was forged only after considerable time and effort; b. Better organization and improvement of management continue to offer possibilities for program improvement. Within overall guidelines relating to policy, strategies, aud financial restraints, program planning should be decentralized to state and district levels. The divisional level structure needs to be strengthened and district level organization needs to be rationalized. Better activity planning, supervision, monitoring and feedback are required to improve performance of service units and field staff; c. Sevice outreach constraints encountered include oversize catchment areas for subcenters, limited staff mobility and shortage of lady medical officers; and d. While improvements in quantity and quality of services will result in improving performance, more emphasis is needed on demand generation activities. With hindsight, it was a mistake to anticipate that the program's routine IEC activ- ities would be adequate. Carefully conceived strategies of local applications should have been devised and community  - 28 - involvement sought to generate demand for services. An improvement in general socio-economic conditions will affect both determinants of fertility and ability to provide ser- vices and, therefore, linkages should be established with such developmental programs. IV. THE PROJECT A. Project Concept, Objectives and Design 4.01 The project has been designed by the GOI as part of the development of its family welfare structure and strategy model which is expected to be in position throughout India by the end of the Seventh Five-Year Plan (1988). It is part of an acceleration in program development targeted towards 32 districts in seven states, selected according to criteria which indicate their relative backwardness in terms of socio-economic development, health services infra- structure, and high fertility and mortality levels. For these area-specific programs, the GOI has sought external assistance from the UNFPA for Rajasthan and Bihar, from DANIDA for Tamil Nadu and Madhya Pradesh, from the ODA for Orissa, and from IDA and SIDA for U.P. and A.P. 4.02 The project is based on the GOI's long experience and mixed success with its family planning program, including that derived from implementation of the first population project referred to in para. 3.13. The project wil'l have as major objectives the lowering of infant and child mortality, the improvement of the health status of mothers and children, and the lowering of fertility. 4.03 Principles to be followed in the delivery of the family planning aspects of the family welfare program are to be found in the Government's policy statement of June 1977 (see Annex 1) and the Interim Report of the Planning Commission's Working Group on Population Policy issued in March 1979. They include: a. Family planning will be an integral part of a program embracing all aspects of family welfare, particularly those which are designed to protect and promote the health of mothers and children; b. Efforts will be entirely voluntary in respect of contraceptive acceptance; c. All methods of contraception, both male and female, will be promoted with equal emphasis and it will be left to every couple to decide which method of contraception, if any, it would wish to adopt; and d. The family welfare program will be primarily directed towards those currently underserved, particularly in the rural areas.  - 29 - The project will lend support to the accelerated implementation in the project districts of the integrated national family welfare program. The activities to be supported for this purpose are outlined in a document prepared by the Ministry of Health for area programs. This model plan covers the intensity of services to be provided and levels of facilities and staff required. It also outlines the objectives and strategies of support activities such as training, information, education and communication, and monitoring and evaluation. 4.04 The service delivery system envisaged for primary health care is as follows: one dai and one CHW per 1,000 population are to provide services at the village level (see para. 2.16). A health sub-center is to be established per population of 5,000 staffed by a MPWF and a MPWM. The MPWF provides MCH and family planning services and nutrition education while the MPWM treats minor ailments, promotes hygiene and sanitation and provides family planning services. Four MFWFs and four MPWMs are supervised by a female and a male health supervisor respectively. The organizational base for the primary health care system continues to be the PHC where curative services are provided and paramedical staff is trained (see para. 2.14). The referral facilities are to be provided by 25% of upgraded PHCs which will have 30 beds each, and staff including specialists such as pediatricians and obstetricians/ gynecologists. More specialized referral facilities are provided by district hospitals and medical college hospitals. The urban areas are served by centers providing MCH and family welfare services. The structure of the service delivery system envisaged is sound in design and similar to those being developed in other countries in the region, such as Thailand and the Philippines. While the peripheral levels of staffing specified in the above guidelines are adequate, a PHC can effectively serve only about 50,000, or about half of its present population. However, the expansion of the number of PHCs is constrained for the time being by lack of resources. 4.05 Within the framework of the guidelines, the project has been designed by task forces established in U.P. and A.P., respectively. The project proposals were prepared after extensive discussions with Government officials, community leaders and staff responsible for the delivery of family welfare services. For the first time within the official program, an attempt has been made to respond to the needs of the program in a district context without, however, losing sight of the need for state and national replicability. The design is based on five premises. Firstly, that increased family planning acceptance will be possible only through the development of a variety of activities which together promote an improvement in the socio-economic environment of the population below the absolute poverty income level, which in 1977 constituted 47% of the urban and 52% of the rural population of India. Secondly, a signi- ficant decrease in fertility is not attainable in the short-run over a period of, say, five years. Thirdly, that family planning acceptance is intimately related to impraved family health, particularly improvement in the health of mothers and small children. Fourthly, that in seeking to attain both improved family health and increased family planning acceptance, it is necessary to improve the quality and utilization of existing basic health/family welfare services and extend their currently limited coverage. And fifthly, that strengthening and expanding service infrastructures are not, of themselves, sufficient but need to be supported by communities themselves which have been  - 30 - provided with the necessary information and ability to make the maximum use of it. The project design provides linkages as appropriate and possible with other development activities which also have a bearing on fertility levels, for example the national adult education program. 4.06 The lack of an effective vital registration system precludes a satisfactory assessment of current vital rates and inhibits forecasting. The estimation of changes in MCH coverage and contraceptive acceptance in the project districts, up to and by the end of the five-year implementation period, also poses serious problems caused by inadequate data and unreliable methodology. However, estimates of the order of magnitude of expected changes have been prepared (para. 7.03). Scanty data on utilization of facilities, in both the family planning and MCH fields, also restrict the establishment of reliable quantitative performance objectives. Although there is a perceived underutilization of facilities, such as PHCs and subcenters, it is difficult to assess the extent of underutilization because it depends on the one hand on the characteristics of the clientele, and on the other hand on a multitude of program variables, which affect the performance of individual staff. Consider- able care needs to be exercised in setting performance objectives, because, as noted above in para. 2.25, the setting of unrealistic targets has had an adverse effect on program performance. Instead of being used as management tools, they have often--and particularly during the Emergency period--been used to hold individuals accountable for obtaining large numbers of family planning acceptors. Immediately after coming to power in 1977, the Janata Party Government abolished targets for these reasons. Later, however, they were reinstated as "expected levels of achievement." An important project activity will be to undertake baseline surveys and establish a system which can set objectives. These objectives will be modified in the light of results of surveys and program experience. 4.07 Improved coverage and quality of services, and efficiency of re- source use, all necessary to achieve the project objectives, can be realized through the following efforts: (a) More staff and facilities should be provided and staff mobility should be improved; (b) Improved training procedures in professional skills should be developed and utilized for training medical and paramedical staff;. (c) IEC activities should be decentralized, improved and expanded to support the integrated nature of the program and reinforce demand for both MCH/family planning services; (d) Community involvement should be an important feature in program development; a sequence of activities including orientation training camps, advisory committees, and more active participation in program activities are envisaged to generate and maintain community involvement; (e) Other departments of Government, communities and local organizations should be involved in the program through suitable organizational structures and activity linkages;  - 31 - (f) Within overall guidelines relating to policy, strategies and financial restraints, program planning should be decentralized to state and district levels; and (g) Program management should be improved by better activity planning, supervision, monitoring and feedback of perfor- mance statistics, and the program should be well coordinated. 4.08 The project, for which a five-year period is proposed, will have five major functional components corresponding with the five major areas of the program: (a) service delivery; (b) training; (c) IEC activities; (d) monitoring and evaluation and operational research; and (e) program and project management. It also provides support for a number of innovative activities. B. Summary Project Composition 4.09 In summary, the project will comprise the following inputs: a. Salaries and other related operating costs (drugs, supplies, etc.) for incremental staff, including: i. 447 male and 2,332 female multipurpose health workers (to reach ratio of one male and one female worker for 5,000 population); ii. 118 male and 628 female health supervisors (to reach proportion of one female supervisor for every four multipurpose female health workers and one male supervisor for every four multipurpose male health workers); iii. 7,583 rural traditional birth attendants (to reach ratio of one per 1,000 population); iv. 9,216 CHWs (to reach ratio of one per 1,000 population); v. 101 medical officers for PHCs (to achieve staffing of three medical officers per PHC), and 120 medical specialists in gynecology and obstetrics with supporting staff for those PHCs upgraded to include a 10-bed ward and operation theatre (two specialists per upgraded PHC); vi. staff for two maternity homes and 11 urban family welfare centers; vii. communications staff at state, divisional and district levels; and viii. project management staff at state, divisional and district levels.  - 32 - b. Construction, furniture and equipping of: i. 1,987 subcenters for provision of health services in rural areas; ii. 10-bed ward and minor surgery room for 60 PHCs; iii. buildings for 117 PHCs now functioning in small, unhygienic and totally unsatisfactory rented accommodation; iv. 19 minor surgery rooms for other existing PHCs; v. 2 maternity homes in urban areas; vi. 7 obstetric/gynecological centers to be attached to rural women's hospitals; vii. 2 hostels for 60 students each, and 3 hostels for 30 students each for training female multipurpose workers; viii. 46 training wings for PHCs; ix. hostel and training wing for Population Center at Lucknow; and X. 1 maintenance workshop for vehicles, and 1 for equipment. c. Vehicles as follows: i. 108 jeeps to replace obsolete vehicles at PHCs; ii. 63 ambulances for selected PHCs; 2 ambulances (one each) for maternity homes; iii. 2 jeeps for the equipment maintenance workshop; iv. 14 mini-buses for training of multipurpose workers; 1 mini-bus, 1 car, and 1 jeep for Population Center at Lucknow; v. 49 jeeps and 6 cars for the project construction units; vi. 10 cars and 6 jeeps for project management at state and district levels; and vii. 40 vans for IEC activities. d. Training costs consisting of salaries of incremental training staff, materials, and student stipends for the training of: i. community health workers;  - 33 - ii. rural traditional birth attendants; iii. male and female multipurpose health workers; iv. male and female health supervisors; v. medical officers; and vi. communications staff. e. Equipment for IEC as follows: i. 36 sixteen mm film projectors; ii. 36 generators; iii. 36 public address systems; iv. 210 slide filmstrip projectors and 9 battery-operated projectors; v. 210 cassette tape recorders; vi. 9 complete video sets and 30 video sets for replay only; and vii. equipment for offset press. f. Production and purchase of IEC materials, including educational kits for field work, cassette tapes, video tapes, films, film- strips, manuals, exhibitions, press ads, hoardings, posters, books, etc.; g. Funds for improvement of service statistics, project evaluation and operations research; and h. Funds for innovative activities to be developed during the project after agreement between IDA and the GOI on the basis of criteria outlined in para. 4.66. C. Detailed Project Description Service Delivery 4.10 In order to bring basic health/family welfare services within the reach of 70% of the rural population of the project districts (compared with 35% at present), a subcenter staffed by one MPWF and one MPWM will be estab- lished at a ratio of one to 5,000 people. Chittoor district in A.P. has been brought into the MPW scheme; none of the U.P. project districts has been covered. The scheme will be introduced into all the project districts. The increase in intensity of services and conversion to the Multipurpose Workers  - 34 - Scheme will mean that, in addition to converting the appropriate existing staff, the number of MPWFs will need to be doubled, one-third more MPWMs will be required, and the supervisory staff for females increased by about 65% and for males by about 35%. 4.11 In U.P., of the 3,130 MPWFs required, 1,355 will be available at the start of the project leaving 1,775 to be posted during the project. For A.P., 557 MPWFs need to be recruited, trained and posted to achieve the necessary strength of 1,195. In both states, the deficits will be made up by local training in the project districts, to avoid draining staff from other dis- tricts. The position with regard to MPWMs is less serious; 447 are needed in A.P. and 902 in U.P. There is an overall surplus of 1,087 HSM in U.P., many of whom came from the eastern part of the state and who would not object to transfers to their home areas to work as MPWMs, despite a downgrading of post (but not salary). In A.P., the 447 MPWMs required will be trained and posted during the project period; state laws in A.P. do not allow the transfer of staff between the six administrative regions into which the state is divided. 4.12 To further extend the availability of primary health services, all districts will be covered by the CHW and dai schemes immediately. In U.P. 15,660 CHW would be required, of whom 9,855 are already, trained and in position, leaving 5,805 to be selected and trained. There are already, 2,571 CHWs in the A.P. districts and a further 3,411 need to be selected and trained. Dais are also being recruited on the same scale as CHWs. In U.P. districts considerable progress has been made in recruiting and training dais; of the 15,660 needed only 2,801 remain to be trained. Only 1,200 dais have been trained in A.P. districts leaving 4,782 to be recruited and trained. 4.13 CHWs are recruited by the community to which they belong and are not subject to supervision by the Multipurpose Workers of the Government program. This policy has been adopted deliberately to foster community involvement which, inter alia, emphasizes a bottom-up rather than a top-down approach, encouraging the need to meet local problems with local solutions. CHWs are, however, supported by the staff of the family welfare program and have regular contacts with them. The scheme was started in October 1977 and two evaluations were made in mid-1978, although it was recognized that this was too early to be of much operational use. Problems encountered in the scheme relate to the difficulty of identifying a group from whom the CHWs can be selected and to whom they can be made responsible. In many areas, the scheme was seen as a response to unemployment and mainly unemployed males were selected. There is little doubt, however, that the Government initiative is an important one in that it directs attention to the needs of rural areas, lessens the dependence for health care on professionals and provides a basis on which to build community involvement activities. 4.14 A training program for dais was initiated as early as 1960 but it was not until 1977 that the GOI decided to extend and strengthen it to achieve the goal of having at least one trained dai in every village, about I for every 1,000 people. Research data from the Population Center in Lucknow shows that about 65% of dais are between 30 and 49 years of age and conduct about 6.7 deliveries monthly. About 65% had other occupations such as agricultural labor but the income from midwifery, although small (about Rs 40 or US$5 per month) formed about a third of the family income. Of the group covered in the  - 35 - survey, 83% had become dais because it was a family tradition. The avail- ability of s trained dai who can conduct hygienic deliveries, refer difficult cases to the MFWF and follow-up postnatal cases is an important element in the attempt to reduce maternal and infant mortality and morbidity, as well as provide motivation for family planning acceptance. 4.15 Health supervisors for male and female Multipurpurse Workers will be posted at a ratio of 1:4 workers of each sex. In U.P., 222 males and 487 females are needed to complete the number of supervisors required for each type worker; the corresponding figures in A.P. are 118 and 141 respectively. Female supervisors are drawn from the ranks of MFWFs and given six months training to upgrade their supervisory and technical skills. Male supervisors are drawn from the supervisory ranks of previous vertical programs, such as those dealing with leprosy and malaria, and given six-months' training. In order to improve contacts between female supervisors and MPWFs, supervisors will be posted to a sub-center and from there supervise the activities of four MPWFs. 4.16 Due to financial constraints, there is a considerable 'backlog in providing adequate buildings for subcenters in both A.P. and U.P. The project will provide for the construction, furnishing and equipping of 1,987 subcenters in the project districts--the number of subcenters required to meet the old target of 1:10,000 people (as per mid-1971 population estimates), plus 20% of the number of subcenters needed to achieve the new target of 1:5,000 people (as per mid-1981 population estimates). Provision of facili- ties for all subcenters would have added a further US$10.2 million to con- struction costs. In light of current and anticipated available funds, the provision of facilities for all sub,centers India-wide would be difficult to achieve at a scale of 1:5,000 people. The GOI has, therefore, decided that the program should aim to cover about 50% of the required facilities by the end of the Seventh Plan (1989). In the project districts, construction of subcenters in the number indicated above would allow achievement of this target by the end of the project period. The remaining subcenters will function in rented buildings and will be supplied with the necessary equipment. 4.17 The construction of subcenters is viewed in a long-term perspective of institutional development as part of the Government's commitment to provide good quality primary health care in rural areas. Once established, the sub- centers will serve as focal points both for providing services and coordi- nating the work of health personnel. A small survey of ANMs conducted by the Population Center in Lucknow, shows that, in general, the people in the village in which they worked were happier with a new building and felt that they could get better service than that available at the old, rented facili- ties. The AMls thought that their services had improved because improved facilities attracted more mothers with their children. The most serious con- cerns referred to poor maintenance and the fact that about 10% were situated about 3 kilometers from the nearest village. The maintenance situation in respect of small, scattered, isolated buildings is difficult. Lack of staff, severe climatic extremes and low priority for such buildings result in poor maintenance in spite of an annual allocation of funds for maintenance. During negotiations, the Government gave assurances that the states shall each make appropriate allocation of funds and facilities for the maintenance of all the buildings used for PHCs and subcenters in the project area. In selecting sites  - 36 - for subcenters to be constructed or rented under the project, the Government gave an assurance that the states shall each ensure that subcenters will be sited within the inhabited area of the village where they are located. 4.18 Each of the PHCs in the project districts now has two doctors and a third will be posted during the project, to cope with an increasing work- load, arising particularly from the introduction of the CHW and dai schemes. No difficulty is forecast in either state in posting the additional doctors. Every effort will be made to post at least one lady doctor to a PHC. Despite the fact that 20%-30% of places in the medical schools in both states are reserved for female students, there are severe problems in recruiting women doctors for rural areas. The senior doctor at a PHC takes administrative responsibility; service delivery, field visits and supervisory responsibi- lities are divided among the three doctors on a geographical basis. To strengthen the delivery of MCH services, one of the three doctors will take a nine-month course in pediatrics. Of the 210 PHCs in the project districts, 117 are functioning in inadequate, often rented accommodations. The project will provide for construction and furnishing of facilities to overcome this deficiency. In addition, minor surgery rooms will be provided in the remain- ing 19 PHCs. 4.19 In addition to improving staffing levels and facilities at the peri- phery to make services available to a greater number of people, it is also necessary to ensure that referral services of an adequate quality and of reasonable proximity to peripheral service points are strengthened. The development of health facilities differs from state to state depending upon past political history, capacity to absorb Central Government expenditures, ability to develop the infrastructure from its own resources, and the respon- siveness of communities to provide facilities. In U.P., a typical project district will have a district hospital, a hospital in the headquarters of each tehsil (other than that in which the district hospital is situated), hospitals for women, a variety of small dispensaries, both allopathic and indigenous, as well as PHCs. According to GOI standards each PHC facility should have basic administrative and technical rooms, and a rural family welfare annex, which is provided from Central Government funds specifically for MCH and family planning services and includes a minor surgery room, staff quarters and garages for vehicles. Over the years, however, lack of basic planning has resulted in, for example, the construction of family welfare annexes not attached to the main center and which may be in a rented building, perhaps two kilometers away. In A.P., the overall situation is essentially similar but there is a more intensive coverage of taluk (the A.P. term for tehsils) hospitals and there are no hospitals for women. 4.20 In order to strengthen referral facilities the GOI introduced the scheme of upgrading 25% of PHCs in 1972. Strengthening will consist of adding a minor surgery theater, a 10-bed ward, and laboratory services, providing furniture and equipment and posting an obstetrician/gynecologist and a pedia- trician. This effort will provide referral facilities for complicated matern- ity and pediatric cases, female sterilization and medical terminations of pregnancy. It will reduce the workload of district hospitals, bring better care closer to the people and provide sterilization facilities as a routine family welfare service, largely obviating the need for special camps with their attendant pressures on individuals and reduced standards of care. The  - 37 - specialist staff will also visit other PHCs in the adjacent blocks. In A.P. there are proportionately more dispensaries and taluk hospitals than in U.P., and they will be included in the number to be upgraded. Taluk hospitals, which essentially provide curative services, vary in size from 4 to 72 beds in A.P. project districts. An urban family welfare center is attached to each taluk hospital and provides MCH aad family planning services. Dispensaries are small curative facilities usually staffed by a physician and supporting staff. All facilities to be upgraded will be located according to criteria based on population distribution, ease of communications and identified economic growth nodes. 4.21 In U.P., rural female hospitals for women comprise the first tier for female referrals. The project will improve facilities at 7 of 24 such hospitals in the project districts by providing a minor surgery theater and six-bed ward for obstetric and gynecological referrals, female sterilization and medical termination of pregnancies. The remaining 17 are being upgraded with help from the ODM. Such facilities were provided in the first project and have been fully utilized. 4.22 In urban areas, the national program provides for an urban family welfare center in towns with more than 10,000 population. The centers provide both static and outreach MCH and family planning services. There are three types depending upon the size of population to be served. To complete the coverage of centers in the urban areas of the six districts in U.P., 11 centers will be provided in small towns of 10,000-17,000 people. The mater- nity homes in Bangalore and Lucknow, provided under the first project, have proved very successful in providing for deliveries, maternity complications and family planning guidance, as well as female sterilizations and medical terminations of pregnancy. Varanasi is the only large city in the six project districts in U.P. and here the two Government and three non-Government mater- nity institutions are inadequate and over-crowded. The project will provide two 30-bed maternity homes in two slum areas of Varanasi which do not now have such facilities. The coverage of facilities for MCH/family planning service delivery in the urban areas of the A.P. districts is adequate and needs no supplementation. 4.23 One of the program's major problems is the lack of staff mobility which affects supervision in particular. Not only are the required vehicles in short supply, but many are old and costly to maintain. In the project districts of U.P., of a total of 416 vehicles, 55 have been condemned and 156 are more than ten years old. A similar situation exists in A.P. where, of the 190 vehicles, 29 have been condemmed and 76 are more than ten years old. The project will provide one four-wheeled vehicle for each of 108 PHCs, where replacement is needed. To provide adequate transport for referral cases, the project will also provide for one ambulance at each of the 60 ten-bed PHCs to be upgraded under the project, one ambulance for each of three already upgraded ten-bed PHCs, and two ambulances for the maternity homes in Varanasi. All vehicles will probably be diesel vehicles as diesel fuel is cheaper than petrol and is generally more easily available; all GOI vehicles are being gradually converted to use diesel fuel. 4.24 Two factors affecting staff mobility are the inadequate allocation of funds for petrol, oils and lubricants and inadequate maintenance facilities. The present GOI rate is Rs 7,000 per annum for each vehicle, of which Rs 2,500  - 38 - is for petrol, oils and lubricants and Rs 4,500 for maintenance. These rates were set in 1972 when petrol was Rs 1.40 per litre compared with Rs 4.18 today. For U.P. state vehicles the allowance is only Rs 4,500, consisting of Rs 3,000 for petrol, oils and lubricants and Rs 1,500 for maintenance. Today these allowances are sufficient only for 4-5,000 kilometers annually. The GOI now provides subsidies for 100% of these estimated running costs of family welfare vehicles and 25% for health vehicles (i.e., ambulances). It now proposes to provide for 75% of the running costs of all vehicles supplied initially from central funds to a maximum of 10,000 kilometers per annum. During negotiations, the Government gave an assurance that the states shall make appropriate allocation of funds and facilities for the operation and maintenance, on a uniform basis, of all the vehicles used for health and family welfare purposes in the project area. 4.25 There are severe problems of mobility in rural areas or where lack of suitable roads prohibits the use of vehicles and no public transport facil- ities exist. The only effective transport is the bicycle and the project makes provision for bicycle advances for those health supervisors and multi- purpose workers who wish to purchase them. Cultural factors inhibit females using bicycles but these are gradually being broken down. Bicycles were provided for the ANM training schools in the first project and ANMs were taught to ride them with considerable success. The project, therefore, also makes provision for advances for ANMs who wish to use bicycles, leaving propriety or otherwise to the judgment of individual staff. 4.26 Inadequate maintenance of vehicles is a serious constraint on mobility, vehicles being off the road for an average of three months at a time for major repairs such as an engine overhaul. The problem derives from the difficulty of obtaining sanction for repairs and from the availability of maintenance facilities. In U.P., the District Chief Medical Officer can sanction Rs 1,000 per vehicle annually, leaving Rs 1,500 for the sanction of the state-level family welfare authorities in Lucknow; both amounts are pooled. It is proposed that in U.P. the Joint Director, Health and Family Welfare, at divisional level will have the authority to sanction repairs to a vehicle up to Rs 5,000 at any one time from the pool he will hold. In the U.P. districts there are regional maintenance workshops for health and family welfare vehicles at Gorakhpur and Varanasi, as well as adequate private facilities, and they have mobile maintenance units attached to them. The situation is considered satisfactory in the light of financial constraints which inhibit replication throughout the state. 4.27 In A.P. there is an effective State Health Transport Organization workshop at Hyderabad. Here, the main problem is to decentralize facilities and the project therefore provides for the construction of a regional workshop at Cuddapah. This effort in turn will provide better support for the mobile maintenance units operating in the project area. 4.28 In addition to ensuring that PHCs and subcenters, which will be con- structed to expand and improve service facilities, are equipped, the project also provides for the procurement of equipment to bring existing facilities to an adequate standard. In both A.P. and U.P., UNICEF has provided equipment within the last five years for about one-half of the existing subcenters and  - 39 - these will not receive equipment under the project. In the course of appraisal, equipment lists for PHCs and subcenters have been reviewed and modified to make them consistent with the services which will be provided at these facil- ities. The maintenance of medical equipment also presents problems. In U.P. there is a small workshop for the maintenance of electric and mechanical health equipment at state level, with two mobile maintenance units, at Aligarh and Allahabad. The latter workshop covers the district of Allahabad and the project districts of Mirzapur and Varanasi. Each PHC doctor has a small fund (Rs 5,000 per annum) for equipment maintenance. Assistance for the extension of the maintenance system is being sought from UNICEF for the districts of eastern U.P. In A.P., a workshop capable of undertaking essential health equipment repairs has been established in the Institute of Preventive Medicine in Hyderabad with a small branch at Guntur in coastal A.P. For minor maintenance, the state has contracted the work of two small firms. This has not been satisfactory because of the wide dispersal of facilities and lack of interest on the part of contractors to undertake small, routine maintenance jobs. To provide for preventive maintenance of equipment in the project districts, the project provides for the establishment of a second regional maintenance unit at Cuddapah. Provision is made for a workshop, equipment and two four-wheel drive vehicles; staff and operating costs will be funded from the state budget. 4.29 For all new facilities and incremental staff to be financed under the project, provision will be made for the corresponding complement of drugs and supplies according to GOI standards. Training 4.30 To provide staff for the extended coverage of family welfare ser- vices and to improve their quality, training is an important element of program activity. It consists of basic training and inservice training, both of which cover, in varying degrees according to the type of staff in training, the following four modules: a. management, primarily for doctors and paramedical supervisors; b. orientation towards the new family welfare concepts and GOI policies for all program staff; c. upgrading of professional skills, such as improved MCH practices for doctors, IUD insertion techniques for HSFs and training for MPWFs in dispensing oral contraceptives; and d. communication skills for all program staff. 4.31 Once selected by the community, CHWs undergo training for a three- month period at the nearest PHC, conducted by the PHC doctors (who have been trained as trainers for this purpose) and the health supervisors. Sub- jects covered include: (a) principles of personal hygiene; (b) environmental sanitation; (c) prevalent infectious diseases; (d) nutritional needs of vulnerable groups; (e) family planning methods; and (f) maintenance of simple case registers. Training of the 5,805 CHWs required in U.P. and the 3,411 in A.P. will be completed at PHCs in the project districts within the first year.  - 40 - 4.32 Dai training is also carried out by the PHC doctor and health super- visors at PHCs for a period of 30 working days. As with CHWs, it is partly instructional but primarily consists of practical inservice training; one- third of the time is spent at PHCs and two-thirds with the MPWF of the village in which the dai resides. Dai training is focused on hygienic deliveries, postnatal care of the mother and child, family planning methods and the need to work closely with the MPWFs, particularly in referring difficult cases promptly. In U.P., the 2,801 dais needed will be trained during the first year. The training loads in A.P. are much greater, and training will be extended over the first three years of the project. 4.33 PHCs are also the focus for the retraining of ANMs and male health workers for their new role in the MPW scheme. Short reorientation courses are conducted by PHC doctors, who have been trained for the purpose, supported by district training teams. Training is conducted for two days a month over a five-month period. PHC training undoubtedly adds to the load of the PHC doctors but has the following advantages: a. it strengthens the relationships in the system between the community and peripheral workers and between the latter and PHC staff; b. training the doctors as trainers is of itself an impor- tant retraining exercise in MCH and family planning practices; c. it is local in character, much of the training consisting of on-the-job practice in the villages; and d. it spreads the training load from the regional health and family welfare training centers which, however, retain overall supervision of training activities. 4.34 In the project districts in U.P., there are six basic training schools for MPWFs with a total annual intake of 240 trainees. Three of the schools will be augmented by 15 places so that about 1,500 of the number of MPWFs required will be trained during the project period. The other 75 MPWFs will be supplied from the remaindcer of the state's 42 schools. Of the 18 months' training which MPWFs receive, 6 months is practical training spent in the field. There are no schools in the selected districts in A.P. and to meet the anticipated training level of 800 MPWFs, five temporary schools will be created. Classes of 30 students will be attached to each of the three district hospitals in the project area and classes of 55 to each of the two medical colleges. Training will be completed by September 1984. Trainers will be chosen from senior hospital and medical college staff. 4.35 The posts of MPWMs in U.P. will be filled from existing cadres. In A.P., however, there is a shortfall and recruits will be trained at the medical colleges of Tirupathi and Kurnool in batches of 100, each batch undergoing 18 months' training. The basic training of these workers will be completed by the end of 1984. 4.36 Health supervisors are promoted from within the service and receive six months' promotion training. In U.P., the GOI is to establish a school at Ghazipur, which will admit two batches of 60 trainees each year, to train  - 41 - female supervisors. Male supervisors will be drawn from existing cadres. In A.P., male supervisors will be trained at the RHFWTC at Kurnool and female supervisors at the RHFWTCs at Hyderabad and Vishkapatam. 4.37 At present, there are no plans for the reorientation of staff once basic training is completed. This lacuna will be filled during the project by arranging reorientation courses for existing multipurpose workers and their supervisors. Short courses for MPWs will be held at PHCs throughout the project period conducted by PHC doctors assisted by the BEE and the health supervisors. Supervisors will also receive reorientation at PHCs in health related programs, extension education techniques and record maintenance. They will be trained by the district training team headed by the Deputy District Extension Educator. 4.38 The most important cadre requiring reorientation are the medical officers, from the District Chief Medical Officer to the PHC doctors. Start- ing with the District Chief Medical Officers and Deputy Chief Medical Officers and the doctors responsible for PHC management, courses for U.P. staff will be held in Ahmedabad by the Indian Institute of Management. They will be based on the courses introduced under the first project but doubled in length to three weeks' duration. In order to build up a capacity for management training in health and family welfare within the state, staff will be added to the Population Center for this purpose. They will be associated with the Indian Institute of Management, Ahmedabad, staff from the start and gradually assume responsibility for training during the project as the locus of management training is moved to the Population Center in Lucknow for the state as a whole. The project inputs needed to achieve this are covered below (para. 4.63) when the role of the Population Center is discussed. The Indian Insti- tute of Management, Ahmedabad, will receive a specific contract for training doctors and initiating a management training capability at the Population Center. A total of 518 doctors will be trained in batches of 30. 4.39 Because of the bias in their training curricula, most doctors show a preference for clinical practice and little interest in primary health care and the preventive aspects of service delivery. It is, therefore, important to ensure that PHC doctors are given reorientation in MCH and family planning. In addition to improving technical skills, this training will focus on the importance of effectively planning service delivery at PHC level to select carefully risk cases for referral and avoid pressure on upgraded PHCs and taluk-level hospitals by undue referrals. For this purpose, the two medical colleges at Varanasi and Gorakhpur will be used to provide four weeks' training to train 148 PHC doctors during the project. 4.40 To provide for the posts of 37 gynecologists and 37 pediatricians required at the upgraded PHCs in U.P., the state will reserve places on the nine-months courses in each discipline at the nine medical colleges in the state. It is anticipated that the reluctance of doctors to be posted to rural PHCs will be countered by the opportunity of postgraduate specialization. 4.41 In A.P., medical officers will also receive reorientation training in management and MCH/family planning service delivery techniques. The RHFWTC at Kurnool will be used to train 424 doctors during the project period. Courses of four weeks each will be held for both subjects. The management courses will be held with the assistance of the Administrative Staff College  - 42 - of India located in the state capital of Hyderabad. The Administrative Staff College of India was linked with Karnataka state for the first project and developed management training courses for PHC doctors. It will develop case studies and exercises based on A.P. experience, a considerable amount of material for which is already available. Specialist training for the gynecologists and pediatricians to be posted to the 26 upgraded PHC/taluk hospitals will be provided in the medical colleges of Tirupathi and Kurnool. 4.42 Implementation of the training programs in both states will be large, complex exercises, responsibility for which will rest with the respec- tive project coordinators. Because the required training of staff is to be completed within a short period, project inputs in respect of capital costs are minimal. In U.P., they are limited to constructing and equipping a training wing for the Population Center, providing furniture for rented additions to the six Auxiliary Nurse Midwife Training Centers and the RHFWTC at Varanasi, and vehicles for the Population Center, Auxiliary Nurse Midwife Training Centers and RHFWTC. Capital costs in A.P. cover the construction, equipping and furnishing of two hostels for 60 students and three hostels for 30 students, accommodation at 46 PHCs for field training, additions to the RHFWTC at Kurnool, furniture and equipment and vehicles for two MPWM training centers and a minibus for each of the five temporary schools for training of MPWF. Operational costs in both states will cover salaries, vehicle operating costs, and contract payments to supporting institutions such as the Indian Institute of Management, Ahmedabad, and the Administrative Staff College of India, Hyderabad. Information, Education and Communication (IEC) 4.43 Although the acronym "IEC" is used in this component of the project for the sake of brevity, it covers a wide variety of activities, including community education, mass communications, and manpower development. A sound IEC program is now of more importance than ever since the broadening of the concept of family welfare to cover aspects of basic health, such as MCH, emphasis on a full range of contraceptive services, and the inclusion of non-allopathic systems of medicine, dais and CHWs in the delivery system. 4.44 The objectives of the IEC component are to effect the following: a. make available adequate information on the benefits, effects and location of basic health and family welfare services among current and potential users; b. support program staff in their delivery of services; c. promote the formation of community leadership groups supportive of the family welfare program by increasing understanding at the community level of the relationships between population growth and quality of life; d. ensure that all development departments understand the policies and strategies of the family welfare program; and e. improve the demand for and utilization of family welfare services.  - 43 - 4.45 To achieve these objectives the IEC component aims to: a. improve the credibility of field staff by increasing their knowledge, developing their communication skills, promoting their image and providing them with appropriate IEC materials in adequate quantities; b. create a nucleus around the leaders in each community which will be actively involved in and supportive of the family welfare program; c. reorient mass communication activities in support of inter- personal communications which will be the principal IEC strategy; and d. improve the management of IEC activities by decentralizing planning and strategy design, rationalizing the administra- tive structure and developing a monitoring and evaluation system. 4.46 The total population of the project districts is about 22.7 million living in some 34,000 villages. Because individuals may be members of several audiences--as a community leader, parent, or consumer of services--no precise tabulation of specific audiences and sub-groups is possible. The main audience categories are, however, listed below: Category A.P. U.P. a. Couples aged 15-44 1,200,000 3,200,000 b. Village leaders (10 per village) 60,000 280,000 c. CHWs (1 per 1,000) 6,000 16,000 d. Dais (1 per village) 6,000 28,000 e. HFW field staff (1 per 5,000 and PHC level staff) 2,000 6,000 f. District level leaders (100 per district) 300 600 g. Other development workers (20 per block) 1,240 2,960 4.47 The need to revive and strengthen inter-personal communication is derived from three main problem areas. Firstly, the mass media coverage is only about 30% of the total population and much less in rural areas. Secondly, the performance of fieldworkers in bridging the gap between awareness and acceptance has been disappointingly poor, primarily because of the paucity of services and the failure on the part of program management to train staff in interpersonal communication skills. And thirdly, the personal, sensitive nature of the issues and problems which the family welfare program seeks to alleviate requires personal contact which mass media cannot provide. 4.48 The project will promote community education by the following groups of activities: a. orientation training camps for community leaders at village, block and district levels;  - 44 - b. seminars for formal and informal leaders at district and state levels; C. community involvement at subcenter, block and district levels; and d. production of educational aids to support these activities. 4.49 In covering about 80% of the village, block and district-level formal and informal leaders, some 223,000 will be invited to participate in some 6,000 orientation training camps in U.P. during the project period. The initial camps will be held for two days with one-day follow-up camps during the project period. Participants will be drawn from opinion leaders and village officials, CHWs and dais, development workers, teachers and block-level leaders as well as district leaders. In U.P., the aim is to reach about twice as many participants per district than in A.P. because program performance (MCH as well as family planning) has been at a much lower level than in A.P. and the impact of the Emergency was much greater. In A.P., the initial camps will be of three days' duration, followed by one-day annual follow-up camps and will cover about 47,000 leaders. With a greater percentage of eligible couples effectively protected, the orientation training camp strategy in A.P. will be to obtain greater participation with a coverage of some 15 people from every village. Camps for village-level participants will be organized by the PHC and its associated subcenters and for district-level participants by the District Medical Health Officer (or District Chief Medical Officer). In addition to the costs of attendance, the project will provide for the produc- tion of a manual to guide staff in the planning and implementation of these camps, basic equipment such as blackboards, and a single educational kit for each participant. To foster the development of community support, small groups rather than individuals will be selected from villages. 4.50 One of the chief problems of program implementation is its isolation, and therefore lack of support, from other Government development departments. Understanding and cooperation are particularly needed at district, division and state level. The project provides for the costs of holding annual seminars to advise Government staff of new developments in health and family welfare policy, appraise them of progress, identify coordination problems and agree on solutions. Provision is made for reaching a total of 71,000 staff in U.P. and 33,000 in A.P. 4.51 One of the main objectives of the IEC component is to activate com- munity involvement. For this purpose, orientation training camps will be held. However, ways must also be found by which community involvement may be main- tained. Many village-level organizations, such as women's and youth groups, are dormant. Most of the active voluntary organizations are urban-based and their leadership and membership are not representative of the rural poor. The project makes provision for the phased introduction of advisory committees from sub-center through PHC to district level, once the initial orientation training camps have been held. These committees are intended to maintain contacts between program staff and community leaders. The intention is that women should form a substantial part of the membership and that the committees could form the nucleus of women's clubs which have been used to considerable effect by the national family planning program in Indonesia. To stimulate interest further, provision is made for visits within each state by committee  - 45 - members to observe areas in which good program progress has been made, to visit referral facilities, examine development projects and to maintain contact with other community leaders supporting the family welfare program. In consultation with the district education authorities, provision is also made for bringing this program to the attention of school students. 4.52 It is important that these community education activities should be supported by suitable educational materials. The effective use of such mate- rials at the periphery of the program is now inhibited by over-centralization of design and production, poor distribution and inadequate training of field staff in the use of materials. The project makes provision for the design and production of display kits (charts, posters and other visual aids), portable kits of more sophisticated visual aids such as flipcharts and three- dimensional models, and aid-making kits comprising materials for supervisors and BEEs to produce their own diagrams, posters and wall-charts. Instruction on the use of these materials will be included in the retraining courses for these educators and other field staff. Extension Education and Mass Communication 4.53 Mass communication has been the primary IEC activity of the Indian family planning program in the past 15 years. But from its early success in creating awareness comes the problem of translating awareness into acceptance. The point made by a marketing expert at a UNESCO meeting in 1969 that the Indian IEC program was "all warm-up and no sell" is still true today. Because of the success of the promotional symbols of the Red Triangle and the Four Faces, messages and slogans have become exhortative and abstract with little relation to the audiences to which they were addressed. The needs of the program have overtaken the needs of the consumer in designing IEC strategies. The sheer size and heterogeneity of Indian population also militate against the effective use of mass communication alone. One result has been to measure success in terms of numbers--numbers of posters displayed, number of film shows, numbers of meetings--with little attention to the relevance of the themes and messages and to the quality of the media used. Officials are, however, alert to the problems and the difficulties and even before the Emergency, a bold attempt was made to utilize private sector expertise available in the AAAI. This campaign went beyond "awareness-spreading" to persuasive and informative appeals which dealt with specific issues rather than generalized slogans. It was unfortunately interrupted by the Emergency but there were also difficulties created by an inadequate organizational structure which would have inhibited successful implementation. 4.54 Nevertheless, mass communication is an important IEC support activity and the project makes provision for strengthening seven activities in this area: a. Mobile film units and film production. Feature films have a phenomenal popularity as an entertainment medium but most films produced in support of the family planning program have been almost exclusively focused on family planning, urban oriented, didactic in tone and treated themes largely irrelevant to their audiences. The project makes provision for the production of 18 new films for U.P. and 6 for A.P.,  - 46 - the content and style of which will be specific to the proj- ect districts. Their themes will cover, for example, MCH activities, unwanted pregnancies, and community involvement in promoting better health. Provision is also made for the improvement of facilities to show films. There is, at present, one 16 mm film projection unit in each project district but these are more than ten years old and need replacing. One unit can, however, only cover about 6% of the villages in a district each year. With the need to support increased IEC activities, such as orientation training camps, the project will provide for three units per district. Each unit will be equipped with a vehicle, film projector, generator and public address system; b. Radio-tape extension service. Family Welfare "cells" established in All India Radio stations produce pro- grams in which family welfare is the main theme or which support programs for special audiences such as women and farmers. The reach of radio is limited (nationally to about 20% of the population) and the project does not pro- vide further inputs at the broadcasting level. To extend the use of programs prepared by All-India Radio, a radio-tape service will be introduced in the project areas. BEEs will be provided with cassette tape recorders and each month will be sent cassette tapes on one side of which will be dubbed a selection of these broadcasts. The reverse side will be used by BEEs to record interviews with local leaders and program officials, talks, and other family welfare- related events to build up a library of both state-level and local material for use in their communications work. The project makes provision for 210 cassette recorders and the annual production of 12 tapes for each; c. Cultural programs. The program has long used a variety of local, live entertainment, (including songs, dance, drama and puppet shows) with family welfare themes in its commun- ication activities. The project makes provision for inten- sifying their use and capitalizing on their wide, popular appeal. Shows will be arranged in conjunction with orienta- tion training camps, village meetings and health exhibitions. The project makes provision for an average of two shows annually at subcenter villages by local troupes and 500 shows and 200 shows annually, for U.P. and A.P. respectively, by larger troupes organized at district level; d. Filmstrips and slides. The project makes provision for the production of locally oriented film strips and slides to sup- port the BEE and peripheral workers in their IEC activities. Film strips will be prepared and processed at state-level and slides will be produced at district-level. The project provides for a camera for each District HIEO and a slide projector for each of the 210 PHCs in the project area. In addition, each HIEO will have one battery-operated pro- jector for use by BEEs in situations where main electricity is not available;  - 47 - e. Video service. Video has not thus far been used in the India family welfare program, although there is experience of its use in rural extension work and animal husbandry extension. Its use for family welfare is indicated in the draft Sixth Plan. The project provides for the limited use of video services as an extension and training aid. The "intimacy" and direct impact of the video medium is particularly useful for small group meetings and training sessions and can localize subject matter to the level of the needs and interests of a few key individuals in a village. The project will provide for a video unit at each district headquarters and will consist of a video camera, video cassette tape recorder and monitor screen. The unit will use existing vehicles and existing film projectionists will be trained in the use of video equipment. During the third year of the project, the use of video will be evaluated by an external institution, such as the All India Film and TV Institute, the Center for the Development of Instructional Technology, or the Institute of Mass Communications. If the application, effectiveness and technical aspects (such as maintenance and repairs) are found to be positive, the project provides for a second phase of video use under which replay equipment only would be made available to the 20 health and family welfare sub-divisions in U.P. and 9) sub-divisions in A.P. In each phase, only monochrome equipment would be used; f. Extension education in other development agencies. The net- work of extension services which could be used to extend family welfare IEC activities is wide, comprising the pre- and in-service training: of block development officers, agri- cultural extension workers, cooperative officers and social welfare staff. Much of the work of cooperating with these extension workers will form part of the normal duties of BEEs and district IEC staff; it will receive special atten- tion during their retraining. The District Project Officer will play a major role in coordinating these activities, thus giving substance to the existing policy of involvement of other departments in the family welfare program. One other program, however, is new, extensive and important. This is the National Adult Education Campaign initiated in October 1978 with the aim of bringing literacy to 100 million adult illiterates in 10 years. In order to make use of this important audience, the project makes provision for supplying to literacy students supplementary literature dealing with family welfare topics. The material will be designed and produced by agencies with considerable experience in this field, such as Literacy House in Lucknow and Literacy House south in Hyderabad. In addition, special folders on aspects of family welfare work in relation to aspects of extension work such as agriculture, women's development, and cooperatives will be prepared to reinforce the contacts made by family welfare program staff; and  - 48 - g. Outdoor/general publicity. Visual publicity has an im- portant legitimizing and reinforcing role in an IEC program and will be part of the overall IEC strategy used in the project districts. It will, however, be designed to con- vey specific messages to specific audiences and use posters, wall hoardings, cinema slides and exhibition material to convey those messages. The material will make use of the work done by the AAAI and be produced primarily by author- ities at district level to ensure the appropriate context of the themes and messages. 4.55 Attention is required not only to strategies by which IEC activi- ties will be used to support the family welfare program and generate community involvement but also to the problems of administration and implementation. These comprise a weak organizational structure, sporadic and ineffective training for IEC staff, and absence of adequate training for program staff at all levels who need to be involved in communications activities. Typical of the lack of attention paid to these aspects of program implementation is the fact that 50% of the BEE posts in A.P. are not now filled and those BEEs in place are being used mainly for administrative duties. Health education and family welfare IEC activities have not been integrated at state level and those responsible have low and ineffective positions in the bureaucracy. With the exception of the AAAI campaign, little use has been made of the consider- able IEC resources which exist in India outside the Government sector. The system of planning and budgeting at state level has left little scope for initiative at district level. 4.56 The project addresses these problems in five ways: a. Reorganization. In both states, the Health Education Unit and the Mass Education Unit will be merged to form a Health and Family Welfare Communication Unit under the Additional Director, Family Welfare. In U.P., the unit will be headed by a Joint Director and strengthened by the additional posts of program officer (community education) and program officer (extension and development) with supporting staff. Because of the size of the state and its revenue divisions, a pro- gram officer will assist the Joint Director, Health and Family Welfare, at divisional level to plan, coordinate and supervise the communications program in the project districts. At district level, the HIEO will be supported by Deputy HIEOs to work with the Deputy Chief Medical Officers who have responsibility for a geographical area within a district for all health and family welfare activities. At PHC level, the BEE will be redirected to carry out communications functions effectively. In A.P., a post of assistant director will be required to head the new unit. Because of its smaller size, no staff are required between state and district level, and within a district one Deputy HIEO will be posted primarily to support the supervision functions of the HIEO. Communica- tions staff will continue to be administratively responsible to the appropriate health official, i.e., the BEE to the PHC doctor and district staff to the District Health Medical  - 49 - Officer (in A.P.) and Chief' Medical Officer (in U.P.). Tech- nical responsibi]lity, however, will be established from the state level downwards, staff retitled to indicate their func- tions more clearly, and anntual performance reports prepared initially by the next senior technical officer before sub- mission to PHC doctors or District Chief Medical Officers who are now solely responsible for this important career event; b. Training. Having redefined responsibilities and job func- tions, it is clear that no single institution in India is equipped to produce the training of staff which is urgently needed. The project makes provision for two major insti- tutions--the Central Health Education Bureau and the Gandhigram Institute--to develop training programs using specialized institutions (such as the 'Institute of Mass Communication and the National Institute of -Rural Development) to assist on a sub-contract basis. Training will cover all staff and will consist of initial training, refresher training, and follow-up training. The first two phases will be conducted at the place of work by mobile teams. 'For senior officials, the project makes provision for suitable overseas study tours; c. Specialist consultancy. In addition to the institutional consultancy required for IEC training, the project also makes provision for specialist consultancy to be made available to state health and family welfare communication units. Consultants will be retained to undertake indepen- dent reviews of the implementation of the communication strategy, support routine monitoring activities, assess the need for changes, as well as specific campaign designs, pre-testing and evaluation; d. Response to local needs. A major weakness in the present situation is that field-level staff have little opportunity to develop and implement ideas in response to local needs and opportunities. In a modest attempt to correct this, the project will provide funds for innovative IEC activities. A competitive scheme will be designed to allow sub-divisions of districts to submit special project proposals annualLy. The proposals will be judged by a panel at state level on their merits with respect to innovation, replicability and specific needs of the area concerned; and e. Vehicle, equipment and materials. The additional staff will need support in terms of vehicles, equipment and materials for the IEC component. The project provides for three vehicles for U.P. and one vehicle for A.P., furniture for the 17 additional posts in both states, and funds for the provision of IEC library facilities which do not now exist in either state. Monitoring, Evaluation and Operational Research 4.57 The national program has an extensive system of collection and collation of data and several agenciLes are used for their evaluation. The following problems have been identified:  - 50 - a. field staff who collect the data spend an inordinate amount of their time in doing so; b. whilst all statistics relating to health, including MCH and family planning, are collected and tabulated by the same organizational unit up to and including district level, each state has a separate unit for health statistics and family welfare statistics; c. there is little feedback to operational units and inade- quate analysis of data in respect to program performance and needs; d. staff and facilities are inadequate for the tasks of evaluation and feedback; and e. program managers make little use of what information becomes available. 4.58 The problems were tackled under the First Population Project in that a MIES was established for each of the two project areas. Working independently, each of the population centers produced a data collection system which substituted comprehensive forms for a variety of registers the ANM was required to keep. The project strategy called for a MIES which would "link the analysis of performance data to cost and to data from outside the program, undertake a continuous analysis that will respond to the needs of administrators, and provide the organizational and technical conditions necessary for an independent evaluation of the program." In retrospect, this was an ambitious proposal which has only been realized in part. The project paid insufficient attention to the time involved in establishing such a system, involving, as it did, the creation of the population centers as well as a data collection system. With hindsight, its major weakness lay in the premise that a different system would automatically change attitudes. Obvious progress has been made in creating a workable system but less obvious is the uses to which it has been put. Some of the difficulties lie in problems mentioned above in para. 3.13, particularly the separation of project and program in the early stages of the former's development. A long time has been taken to develop the tool and only now is it possible to consider the broader objectives of its use. 4.59 The two systems developed by the population centers have been integrated and an effective system of collecting health and family welfare data has been derived under the aegis of the evaluation authorities in the Ministry of Health and Family Welfare in Delhi. At present confined to 120 PHCs in U.P. and 40 PHCs in Karnataka, the system will be further tested on district scale in each of the two states. It will be introduced into all the districts covered by the second project in U.P. and A.P. and the first project districts in U.P. Up to now, data collection and analysis have been the responsibility of the population centers. In the second project, they will become the responsibility of the State Demographic and Evaluation Cells into which will be merged the Vital Statistics Cells in U.P. and A.P., which have been concerned with health statistics. The Demographic and Evaluation Cells will be guided and assisted by the two population centers in Lucknow (for U.P.) and Bangalore, the state government of Karnataka having indicated  - 51 - its desire to support the project inL A.P., by making available the services of the Population Center in Bangalore on a contract basis. During negotiations, assurances were obtained from the Government that the states shall each under- take a mid-term review of the health and family welfare data collection systems under the project, and shall make available not later than March 31, 1983, the results of such review to the Association. 4.60 With the merger of the two cells and support from the Population Center at Lucknow, the Demographic and Evaluation Cell in U.P. has adequate staff to cope with the changeover to the new system. The Demographic and Evaluation Cell in A.P. lacks the close support of a Population Center and additional staff are required to strengthen it. They will consist of an Assistant Director for Management Evaluation, a Social Scientist, a Statis- tical Officer, a Statistical Assistant, eight Field Education Officers and supporting staff. In addition, two vehicles, additional equipment and furniture, and funds for the provision of a small library are also required. The training schemes, outlined in paras. 4.31 to 4.42 above, will pay par- ticular attention to training all levels of staff in the mechanics of data collection; the system, its uses and importance in program planning and administration. About five analysts and supporting staff in the Ministry of Health, GOI, will be provided by the! project for monitoring and evaluating the accelerated implementation of the national program in 32 districts (para. 4.01). 4.61 The expansion and improvement of family welfare services and sup- port activities on the scale envisaged are expected to lead to significant improvements in the health status of the population covered. Some of these improvements wilL be reflected in a reduction in infant, child and maternal morbidity and mortality rates and fertility rates. These rates are, however, the product of complex, interacting factors, the relationships among which are not clearly understood. Even if an adequate methodology were available, data on the current values of these rates are not available for the project areas. There is, however. need to be able to monitor, not only the progress of proj- ect inputs, but also its impact on the population. The project, therefore, makes provision for baseline surveys in each district to collect data per- taining to, inter alia, the following indicators--infant, child and maternal morbidity and mortality, fertility, including trends in birth intervals and utilization of MCH/family planning services, including characteristics of beneficiaries. Performance data re:Lating to mothers registered for antenatal care, deliveries attended by trained staff, postnatal visits, deliveries referred to hospitals, clinic attendances, contraceptive acceptance, and vaccinations and immunizations will be obtained from the data collection system. Longitudinal surveys will 'be taken annually, following up on a sample of family planning acceptors, and a final complete survey taken in the fifth year of the project. The indicators will thus be monitored annually and the experience gained will be used to refine predictions as to the impact of the services on the health and contraceptive status of the population. The data collected will also be used for a final project evaluation. An illustra- tive list of performance indicators for the evaluation of project: activities is given in Annex 2. 4.62 The project also makes provision for operational research to assist program managers in an ongoing evaluation of project implementation and program performance. Among the types of studies envisaged are:  - 52 - a. concurrent evaluation of IEC strategies; b. impact of orientation training camps and subcenter committees on community involvement; c. identification of bottlenecks in program implementation and recommendations for solution; d. utilization of services; e. effectiveness of the training programs; and f. adequacy of the family welfare services offered at subcenter and PHC level. 4.63 In the first project, the Population Center in U.P. came under the Project Coordinator and was separate from the program. The U.P. Government has decided that it will assume responsibility for the Population Center as of March 31, 1980, the first project's completion date, when it will function as a state institution. The Population Center Director will be responsible to the Commissioner-cum-Secretary Health and a Governing Board established to supervise its activities. It will be the main professional resource for the monitoring and evaluation aspects of the second project in U.P. Instead of channelling funds for project-related activities directly to the Population Center, as in the first project, however, funds for the second project will be carried on the budget of the project coordinator. The Population Center will become one of several agencies or institutions which the project coordinator will be able to contract for services and studies. The Population Center will be strengthened to develop a management training capability (see para. 4.38 above) and the project makes provision for construction, furnishing and equipping of a training wing with hostel and staff accommodation, two vehicles and incremental operating costs. The project coordinator will also develop a specific agreement with the Population Center to carry out the base, longi- tudinal and final surveys, assist with the implementation of the data collec- tion system, and assist in the monitoring of program indicators and project evaluation. For this purpose, the project provides for the establishment of a field unit at Varanasi because of the distance (over 300 kilometers) between Lucknow and the project districts. The field unit will be headed by an Assistant Director, and consist of one research officer, six senior investi- gators and support staff. Provision is made for a vehicle and the costs needed to operate the unit. As to which institute is contracted for opera- tional research will be at the discretion of the project coordinator. Whilst most: of the work will probably be assigned to the Population Center, there may be occasions when other institutions (such as the Population Research Center located at the Benares Hindu University in Varanasi or the Population Research Center in the Department of Economics at the University of Lucknow), may be more appropriate. Continued support on a contract basis is also expected from the Indian Institute of Management, Ahmedabad. The switch from core funding in the first project to contract funding in the second project recognizes the institutional capability which has been established in the Population Center and Indian Institute of Management, Ahmedabad, and the need for monitoring and evaluation to be more closely associated with and directed by program management. It should also assist in ensuring that research is more directly linked to program needs.  - 53 - 4.64 In A.P., the same principles will apply. The implementation of the data collection system will be supported by the Population Center at Bangalore in the neighboring state of Karnataka which will assume responsibility for the operation of the Population Center as of April 1, 1980. The Administrative Staff College of India, Hyderabad, and the Population Center, Bangalore, will also be contracted for specific operational research proposals. Strengthening of Program Management in Project Areas 4.65 In addition to organizational changes which affect program implemen- tation in respect of IEC activities and monitoring and evaluation, overall program management will be strengthened in respect of the project districts in both states in the following respects: a. At present, three Deputy Chief Medical Officers (in U.P.) or Deputy Medical Health Officers (in A.P.) are posted to a district regardless of the size of population or number of PHCs. To ensure that the specific geographical area in which a deputy supervises all health matters is manage- able, deputies will be posted at a ratio of one to about eight PHCs. b. In view of the broader implications of the family welfare policy, the need to obtain community involvement, the importance of involving other development departments, and the urgency of improving the image, not only of family planning but of the other aspects of the family welfare program as a whole, responsibility for the coordination of program activities, which go beyond the health services, will be vested in the District Magistrate (or Collector in A.P.). The Chief Secretary in each state will issue instructions to the District Magistrates defining their functions in respect of responsibility for promoting the Government's new policies and coordinating the implementation of project activities. The responsibility of District Chief Medical Officers for the delivery of all health services, including family welfare, will not be affected. The involvement of the highest admin- istrative echelons of Government has been one of the princi- pal factors behind the success of the national family planning program in Indonesia, which several study tours of senior program officials, funded by the first project and the UNFPA, considered could be implemented in the Indian program. In the first project, an experimental strategy was tried in two sub-divisions of the Karnataka project area involving the Assistant Commissioners. Although problems were encountered because of the transfer of staff, development and revenue departments and local government authorities did become more involved in the program because of the support of the Assis- tant Commissioner. The program should be able to capitalize on the considerable influence which District Magistrates exert. In the climate which has prevailed since the Emer- gency, there are few grounds for anticipating that this influence will be misused. District Magistrates will be supported by the district project officers in carrying out their coordination functions (see para 6.05 below); and  - 54 - c. Because of its size, both areally and in terms of population, U.P. has had a Joint Director, Health and Family Welfare, posted at divisional level (consisting, on average, of five districts) since 1973, to exercise some of the supervisory functions normally carried out by state-level officials. Th-se officers are, however, not supported by adequate specialist staff and there are administrative anomalies such as the fact that there are no differences in the pay scales and allowances between Joint Directors and the Chief Medical Officers whose work they supervise. The project will, therefore, make provision for upgrading the Joint Director and his staff to the levels which apply at the state direc- torate. The staff will be strengthened by the addition of specialists in family welfare, IEC and statistical work, as well as malaria and leprosy. Funds will be provided for support staff, basic office furniture and equipment and vehicles which are not now available and which have to be commandeered. The strengthening of the two offices of Joint Director covering the U.P. project districts will improve supervision, create better technical linkages between state and district, and relieve staff at Directorate level in Lucknow of routine responsibilities, freeing them for more attention to both policy and program issues. There is no need for similar action in A.P. Innovative Activities 4.66 One of the important features of the first project was the provi- sion of funds for experimental strategies and innovative projects, which were made available to the project authorities without the attendant diffi- culties imposed by the normal budgeting system. Schemes to make use of such funds were approved by the project implementation committees and control suc- cessfully maintained in this way. It is very necessary to ensure that such flexibility continues to be available and the project provides US$1.5 million for this purpose. Examples of the type of innovative activity which may be funded are schemes to: (a) involve women more closely in health and family welfare activities by promoting their role as income earners; (b) respond quickly to the health needs of a particular village where, for example, a safe drinking water supply may be lacking and where its provision would lead to considerable improvement in health status; (c) support the activities of a voluntary agency in the family welfare field in a particular village or development block; and (d) introduce family welfare topics in the regular training program of non-health extension workers to secure their involvement. The proposals will have to meet the following criteria: (i) relevance to program objectives; (ii) innovativeness; (iii) feasibility of administration and evaluation; and (iv) replicability. Proposals estimated to cost US$50,000 or less would require the approval of the respective state project committee; those estimated at over US$50,000 would be submitted to IDA for scrutiny. IDA approval of these proposals will be a condition of disbursement (para. 8.03).  - 55 - V. PROJECT COST, FINANCING AND DISBURSEMENT A. Cost 5.01 The total estimated project cost is US$96 million equivalent, of which US$68.2 million is for U.P. and US$27.8 million for A.P. The foreign ex- change component is estimated at about US$16.3 million, 17% of total project costs. Taxes and duties included in total costs are estimated at US$4.0 million. Capital costs for construction, furniture, equipment, vehicles and IEC materials account for US$38.3 million, or 51% of base costs. Incre- mental operational and maintenance costs total US$36.7 million or 49% of base costs. The cost estimates by expenditure and innovative activities category are summarized in the following table. (See also Annex 3.) INDIA: ESIIMATED PROJECT COSTS BY EXPENDITURE CATEGORY S:zary Cost Tables (In thons.nds of Rupe.e) (In thoussands of US Dollars) Percese ef Percentag. of (A,dlr. Pradesh and Uttar Pradesh) Local Foreign Total Local Foreign Total Fogas.o Eachaste 155 Cost rA,it,l Costs. Base Clvil Works 179,700 79,100 258.800 20,900 9.200 30,100 30 40 7,Frnitore 12.900 4,700 17.600 1,500 50 2.050 26 3 Eqlpi.e,t 9 500 5 600 15 100 1,100 650 1,750 37 2 IEC Mac.rials 12,000 5,200 17,200 1,400 600 2,000 30 3 VehIl.s 14,000 6,600 20,600 1,750 650 2,400 27 3 Subtotal, Capital Costs 228,100 101,200 329,300 26,650 11,650 38,300 30 51 02eratio.a1 and Maintenance Cotst Salaries 154,800 - 154,800 18,000 - 18,000 0 24 Vehicle Operational and Maintenance Costs 5,200 4,300 9,500 600 500 1,100 45 2 Other Operational *nd Maintenance Costs 137,600 900 138,500 16,000 100 16,100 1 21 Subtotal, Operation-l and Maintenance Costs 297,600 5,200 302,800 34,600 600 35,200 2 47 rro-ative Activities 10,300 2,600 12,900 1,200 300 1,500 20 2 S.btotal, s4a. Cost 536,000 109,000 645,000 62,450 12,550 75,000 17 100 Cont inzencles flysical 10,300 4,200l 14,500 1,400 600 2,000 29 2.2 PrIce 129.300 34,10(1 163,400 15.000 4.000 19.000 21 25.3 Subtot-l, Contitesnci.s 139,600 36,300 177,900 16,400 4,600 21,000 22 27.5 r;rAL 675.600 1 822.900 78.850 17 S.150 6 000 7 x 5.02 The largest share of project funds--81% of base costs--is allocated to the improvement of the delivery of basic health and family welfare services. A further 7% is identified for training, 8% for IEC activities, 1% for program and project management, and 1% for monitoring, research and evaluation and 2% for innovative activities. A breakdown of costs by functional category is given in the table below. (See also Annex 3.)  - 56 - INDIA: ESTINTED PROJIECr CDSS BY FUNCTIONAL CATEGORY S-ry Coot Table. (In thosand. of Rupees) (In tho-ands of US Doll-rs) Percentag. of Percentage of (Andh,. Pradesh and Uttar Pradesh) Lori Forein Tot.11 Loc.l Foreig. TotSl Foreign Eochange BR.. Cost 7os Costs Streogtheniag of Ser'.e Delivery 429,000 90,400 519,400 49,900 10,500 60,40C 17 81 Training 37,700 6,200 43,900 4,400 700 5,10C 14 7 Infor,atLon, Edacatlon and Concoitlon 43,700 7,900 51,600 5,100 900 6,000 15 8 R ...rch aod Eval "tton 6,200 700 6,900 750 50 8S0 6 1 P,or.ct Mnag-etnt 9,400 900 10,300 1,100 100 1,2- 8 I Innovative Aetlivtis 10,000 2,900 12,900 1,200 300 1,500 20 2 Sobtotal. Base Costs 536,000 109,000 645,000 62,450 12,550 75,000 17 100 Coot ntenCt*s nhy.i.at 10,300 4,200 14,500 1,400 600 2.000 29 2.2 tprio 129,300 34,100 163,400 15.000 4,000 19,000 21 25.3 Sobtotal, Conttng-nLte 139,600 38,300 177,900 16,400 4,600 21,00( 22 27.5 TOTAL 675L600 147,300 _ 822,900 78,850 17 150_ 96, 000 127.5 5.03 The costs of construction and furniture are based on estimates derived from prices current in October 1979, and experience with a similar construction program under the first project. Cost estimates for equipment, vehicles, and materials for IEC production are also based on October 1979 price quotations. Salaries, training costs and the cost of overseas study tours are based on standard Government salary and allowance scales as of October 1979. Estimates of the cost of contracts to be let to consulting institutions are based on experience gained under the first project costed at October 1979 rates. 5.04 The foreign exchange component of the cost of civil works is esti- mated at 30%, of equipment at 37%, and of furniture at 26%, IEC materials at 30% and vehicles at 27%. The only incremental operating costs which have an estimated foreign exchange component cover petrol, oils and lubricants. 5.05 The contingency allowance of US$21.0 million equivalent (22% of total project costs) includes: (a) physical contingencies for unforeseen factors estimated at 5% of the base cost of civil works, furniture and equip- ment; and (b) price contingencies averaging 25% of base costs and physical contingencies. Price contingencies for local costs other than salaries were calculated on the assumption of a 12% inflation rate in FY 1979-80 and 5% annually afterwards. For salaries, a rate of 5% was assumed for FY 1979-80 and afterwards. Price contingencies for the foreign exchange component of project costs were calculated on the assumption of an inflation rate of 10% for calendar 1979, 9% for calendar 1980, 8% for calendar 1981, and 7% there- after. 5.06 Recurrent expenditures of the Department of Medical, Health and Family Welfare of U.P. amounted to Rs 888 million in FY 1978/79. This represented about 7.6% of total state recurrent expenditures in that year. In A.P., recurrent expenditures of the Directorate of Medical and Health Services amounted to Rs 590 million in the same year. This represented about 6.9% of total state recurrent expenditures. The proposed project would add about Rs 66.6 million at May 1979 prices to recurrent expenditures in U.P. in FY 1984/85, the last year of the project. This represents about 7.5% of the state's recurrent expenditures in the health sector in FY 1978/79. In A.P., the corresponding increase in recurrent expenditures would be Rs 28 million, or 4.7% of the state's recurrent expenditures in the health sector in FY1978/ 79. These increments seem reasonable in view of the proportions of the two states' populations that will benefit from the project and the high priority  - 57 - assigned by central and state Governments to the improvement of family welfare services. The planning and finance ministries in both states have received and approved the proposed project. B. Financing 5.07 The total project cost (US$96 million) will be financed by an IDA credit of US$46 million equivalent or about 50% of total project costs net of taxes. SIDA has expressed an interest in providing co-financing for this project of US$23 million or about 25% of total project costs net of taxes. If, however, SIDA, or other co-financing, does not materialize, the balance of US$50 million will be contributed by the GOI and the two state governments. The project would provide retroactive financing of up to US$1 million, for expenditures after July 1, 1979, for essential pre-project activities including the establishment of construction units, the posts of district project officers, preparation of training curricula and manuals for IEC activities; and preparation of baseline surveys. C. Disbursements and Audit 5.08 Disbursements under the Credit would cover: a. 48% of expenditures for civil works (US$17.0 million); b. 48% of expenditures for furniture, equipment, materials, and vehicles (US$5.4 million); c. 48% of staff salaries, as follows: i. for borrower's monitoring and evaluation systems (US$0.3 million); and ii. for states staff (US$8.7 million); d. 48% of operation and maintenance, including studies and study tours (US$10.6 million); e. 66% of the cost of innovative activities (US$1.0 million); and f. unallocated (US$3.0 million). A schedule of estimated disbursements is given in Annex 4. 5.09 As in the first population project, all disbursements would be made against certified statements of expenditures to be supplied by the GOI Ministry of Health and Family Welfare. (See Annex 5.) Supporting documents would be retained by GOI for inspection by IDA during project supervision. During nego- tiations, the Government gave an assurance that the project accounts would be audited annually and the audit reports made available to the Association within nine months after the close of each fiscal year.  - 58 - D. Procurement 5.10 Contracts for civil works covering about 2,000 subcenters, about 40 PHCs, 2 small maternity homes, as well as the rehabilitation and extension of existing buildings, would be small and widely dispersed in time and place; they would not be suitable for International Competitive Bidding procedures. They would, therefore, be let through the competitive bidding procedures of the state concerned, satisfactory to the Association. During the first project, however, difficulties were experienced in securing suitable con- tractors to work in isolated areas and some of the civil works, not more than 30% of the total, would be carried out departmentally under the super- vision of the project construction units. Furniture, equipment and vehicles will be procured under "rates contracts" by the Director General of Supply and Disposals, GOI, or by the Director of Industries at state level which procure economically and efficiently on a national level. Because of the variety and number of items to be procured, as well as the need for adequate maintenance and after sales service, foreign firms would not be interested. Where "rate contracts" do not apply, local competitive bidding procedures, acceptable to the Association, will be used for packages in excess of US$10,000 equivalent. Below that amount, purchases will be made in accordance with state procurement regulations. All the furniture, equipment and types of vehicles required are available from local manufacturers. VI. PROJECT IMPLEMENTATION A. Project Management 6.01 The staff of the GOI's Ministry of Health will exercise the same coordinating functions as it did in the first project. An important feature of implementation will be close coordination with other agencies, such as UNFPA, DANIDA, USAID and the British ODM, to exchange experiences and ensure the smooth development of the various area programs. Coordination will continue to be the responsibility of the GOI's Ministry of Health. At a meeting in Geneva in March 1979 called by the UNFPA to discuss inter-agency coordination, the Indian program was one of three national programs to receive particular attention. The GOI and both multilateral and bilateral agencies declared themselves satisfied with the present situation and no additional coordinating mechanisms are required. However, the project pro- vides staff to strengthen the monitoring and evaluation capability of the Ministry of Health. 6.02 In U.P., a considerable body of project management experience derived from implementing the first project exists but no such experience is available in A.P. Some problems with project implementation were en- countered initially in the first project because the management design did not fully respect Indian administrative experience. It was also largely divorced from the management of the state family planning programs, as separate units were set up for construction, implementation and research and evaluation. These were coordinated by the Special Secretary-cum-Project  - 59 - Coordinator. The management structure of this project has been designed to overcome these problems. The design also reflects the need to avoid attracting undue criticism from non-project areas and to ensure that project specific staff can be absorbed by the program at the end of the project. 6.03 The responsibility for implementation of the program in project areas will be the same as that of program management in the non-project areas. The program functions will be appropriately strengthened as described else- where to provide for expanded tasks of IEC, training, supplies, and research and evaluation. The project management structure is responsible for making project inputs available as well as to ensure expeditious implementation of the project strategy. Thus, the project and program management are integrated wherever possible without, however, leaving unclear the locus of responsi- bility for project implementation. 6.04 The differing size and socio-economic climate of each state and of project areas within the states has resulted in different systems of project management (Charts 3 and 4). Uttar Pradesh (U.P.) 6.05 In U.P., the post of Special Secretary-cum-Project Coordinator will be retained from the first project and appropriate support staff will be provided. He will be responsible for planning, implementation and monitor- ing of the project and for overall coordination of different activities in the project. The project construction unit (the director of which reports to the special secretary) will be strengthened to cope with an increased volume of work;, its organization is described in para. 6.10 below. To inte- grate the project with the program more fully, the specialized staff of the former project implementation unit will be transferred to specialist program units. Program implementation in the six project districts will be the responsibility of the Director, Medical, Health and Family Welfare. To focus attention on the increased, intensified and innovative program activities in the project area, his staff will include a Joint Director, Project Implemen- tation. The main function of the Joint Director is to ensure that the exten- sion and intensification of the program in the six districts is carried out expeditiously. Although the Joint Director will report to the Additional Director, Family Welfare, linkages for operational purposes will be estab- lished between the Special Secretary-cum-Project Coordinator and the Joint Director, Project Implementation. Specialist staff will be provided to various divisions of the Additional Director, Family Welfare, in order to strengthen them and maintain focus on the project districts. Responsibility for the Population Center, which was under direct control of the Project Coodinator in the first project, will be transferred to the state and its Director will be responsible to the Commissioner-cum-Health Secretary. However, in addition to its other responsibilities for the state, the Popu- lation Center will continue to provide research and evaluation services to the project. In order to provide more backing for the program at the district level, cope with the intensification and widening in scope of the family welfare program, and provide coordination and guidance on family welfare activities for all departments of Government, the Chief Secretary will remit responsibility for family welfare program implementation and performance to the District Magistrates. To enable them to cope with this increased respon- sibility, a District Project Officer from either the medical or provincial administrative cadres will be appointed with supporting staff. The District  - 60 - Project Officer's functions will be to support the district construction units, attend to site selection and land acquisition, procure equipmenit and furnishings for the facilities and provide the necessary coordination among Government departments and between them and local Government authorities particularly in carrying out the intensified IEC program; responsibility for the delivery of health and family welfare services will remain with the District Chief Medical Officer. 6.06 The committee system established under the first project proved effective in commanding a high degree of attention to the project, removing bottlenecks in the administrative system and ensuring the effective coordina- tion of the various project activities. The Governing Board, chaired by the Chief Secretary, will be retained together with its executive, the Steering Committee, chaired by the Commissioner-cum-Health Secretary. The Governing Board will be expanded to include the Secretaries of the Departments of Education, Works, Agriculture Production Commissioner, and the Director of Information. It will meet once every quarter to review project progress and suggest ways and means for improving the project performance. The Steer- ing Committee will be expanded to include the District Magistrates of the project districts and its venue moved from Lucknow to Varanasi and other principal towns in the project area in rotation. It will meet at least once a month to monitor progress and ensure coordination among various project activities. At district level, the District Magistrate will chair a District Project Implementation Committee with representatives of the major development departments in the district, as well as those responsible for family welfare, and representatives of local communities and organizations as members. Consideration was given to combining the responsibilities of these committees with the existing family welfare committees described in para. 2.12 above. In view of the advisory nature of the latter, primarily dealing with public relations, their large size and wide concerns (as reflected in their agenda), and the need for the project committees to deal with details of implementation, it was decided that the specific focus of the project committees should be maintained. Andhra Pradesh (A.P.) 6.07 In A.P., the problems of size and distance are much less and the Directorate of Medical, Health and Family Welfare has had a consistently stronger program than that of U.P. Therefore, project management structure is modest compared to that of U.P. The focus of project implementation will be in the Directorate, where an Additional Director for Project Implementa- tion and supporting staff will be appointed. This Additional Director will be responsible for planning, implementing and monitoring of the project and the necessary coordination. The Health Secretariat staff will be strengthened by the addition of a section responsible to the Deputy Secretary to cope with correspondence between the state and central governments, management insti- tutes and the states of U.P. and Karnataka. Responsibility for construction will be that of the state Chief Engineer who will create a special construc- tion unit under a Superintending Engineer; the latter will liaise closely with the Additional Director, Project Implementation. The latter will also liaise closely with the Additional Director, Family Welfare. The project implementation will be carried out through the existing program machinery, strengthened as necessary. The Collectors will have the same functions and  - 61 - support staff as their equivalents, District Magistrates in U.P. As in U.P., newly appointed district project officers from either the medical or provincial administrative cadres, will attend to site selection and land acquisition, procure equipment and furnishings for the facilities, and provide the neces- sary coordination among Government departments and between them and local Government authorities. 6.08 Separate committee structure is not envisaged in A.P. The existing Family Welfare Committee will also serve as Project Advisory body. At district level, the existing District Family Welfare Committee will also serve as District Implementation Committee. B. Implementation of Civil Works 6.09 In both U.P. and A.P., various government agencies and quasi- government corporations undertake construction work. Current commitments and the nature of the second project, which requires the construction of many small buildings over a wide area, make it impossible for these agencies to assume responsibility for the project's civil works program. Implementation of civil works will, therefore, follow essentially the system adopted with a large measure of success in the first project. However, the proposed organi- zation for the implementation of civil works in this project differs from the one adopted in the first project in one important respect. In this project, architects either transferred from the Public Works Department, or engaged as consultants, will be an integral part of the project. 6.10 In U.P., the first project's construction unit still exists, although in an attenuated state as the building program is almost complete. The nucleus exists for the formation of a larger organization than that employed in the first project, the volume of civil works being 2-1/2 times larger than in the first project. The Director of Works will head a unit in Lucknow with three Joint Directors responsible for a headquarters unit (in- cluding architectural, design and engineering responsibilities), a unit for remote subcenter construction, and a unit for other buildings respectively. A construction unit will be established in each of the six districts under a Deputy Director who will be responsible for main buildings and subcenters located in reasonably accessible areas for which acceptable contracts can be obtained after local competitive bidding. To cope with subcenter construc- tion in remote areas, three units, each covering two districts, will be established under a Deputy Director. These units, which will be mobile, will be responsible for supervising force account work using acceptable state procedures. In A.P., the Chief Engineer, Public Works Department, will be responsible for construction and a Construction Unit will be established for this purpose. It will comprise a Circle Office controlled by a Superintending Engineer located in Hyderabad. This unit will have an Architectural Wing and a Structural Engineering Unit. For implementation, an office headed by an executive engineer will be located at each district headquarters. In A.P., it is anticipated that all civil works will be procured by local competitive bidding. During negotiations, assurances were obtained from the Government that the states shall each furnish to the Association for its information and comments not later than June 30, 1980, or such other date as may be agreed between the Association and the state concerned, preliminary type designs for all facilities to be constructed under the project.  - 62 - 6.11 In the first project, procurement of furniture and equipment for buildings was the responsibility of the Project Implementation Officer in each state capital. Difficulties were encountered in synchronizing procure- ment with the completion of buildings. To overcome this problem in the second project, the Deputy Director or Executive Engineer of each district unit will he responsible for procurement of furniture and equipment relating to civil works. The Project Coordinator will be responsible for the procure- ment of other equipment and for all vehicles. The summary implementation schedule is given in Annex 6. VII. PROJECT JUSTIFICATION AND RISKS 7.01 The major justification for this project is that it will provide improved family welfare services to a population of 22.7 million as part of a comprehensive program including service facilities and supporting activi- ties designed for the specific areas which it covers. These family welfare services include both family planning and MCH services. 7.02 The project is expected to improve the provision of these services, and their enhanced utilization, by providing better facilities, trained staff, and a coherent strategy of supporting IEC activities. The project will also make available a wider range of contraceptive services in the context of MCH care. As the first of the intensive area programs to be developed, it is expected to have a significant impact on the design and replication of similar area programs in India. It is particularly important to ensure that these programs are as speedily developed by the states as human and financial resources will allow. Assurances were obtained during negotiations that the states shall each undertake a mid-term review of the progress of the project activities in the respective areas, and shall make available not later than March 31, 1983, the results of such review to the Association. 7.03 Estimates of the increased level of services which the project will provide are difficult to establish because of inadequate methodology, the absence of a firm data base, and factors outside the control of project management which may affect the utilization of services. Nevertheless, the project is expected to help raise the contraceptive prevalence rate in the project districts of U.P. from its present level of 11%-13% of eligible couples to 24%-26% by 1985. For A.P., the comparable expected increase is from 25%-27% to 35%-37%. The percentage of mothers provided with antenatal services is expected to increase, over the same period, from 10% to 50% in the project districts of U.P. and from 20% to 50% in the project districts of A.P. The percentage of deliveries attended by trained personnel is expected to increase from 15% to 75% in the project districts of both states. Finally, the immunization coverage of children aged 1 to 5 years is expected to increase from 5% to 50% in the project districts of both states. 7.04 The difficulties experienced in the first project lay originally in the way in which it was organized (see para. 6.02 above). These should be obviated in the second project because the project is an integral part of the program and, in U.P. at least, there is a strong nucleus of staff who have had considerable experience. The implementation of the physical side  - 63 - of the project proceeded relatively smoothly in U.P. and Karnataka and no inordinate problems are foreseen in the second project. With close program involvement, problems should be minimized. 7.05 Difficulties were also experienced in building up the capability of the two population centers and the population units of the management institutions in Hyderabad and Ahmedabad. All institutions have now been operating for six years and are firmly established. 7.06 The major risks in the second project lie in the development of the strategies which will be adopted to improve the health status of the popula- tion and provide the basis for sustained contraceptive practice. Their imple- mentation involves thousands of staff and millions of people and, as in all attempts to change personal attitudes on a mass scale, the outcome is not easily predicted. VIII. RECOMMENDATIONS 8.01 During negotiations, agreements were obtained from the GOI that: a. The states shall each make appropriate allocations of funds and facilities for the maintenance of all the buildings used for PHCs and subcenters in the project area (para. 4.17); b. Subcenters shall be sited within the inhabited area of the village in which they are located (para. 4.17); c. The states shall each make appropriate allocations of funds and facilities for the operation and maintenance, on a uniform basis, of all the vehicles used for health and family welfare purposes in the project area (para. 4.24); d. The states shall each undertake a mid-term review of the health and family welfare data collection systems under the project, and shall make available not later than March 31, 1983, the results of such review to the Association (para. 4.59); e. Project accounts will be audited annually and the audit reports made available to the Association within nine months after the close of each fiscal year (para. 5.09); f. The states shall each furnish to the Association for its information and comments, not later than June 30, 1980, or such other date as may be agreed between the Association and the state concerned, preliminary-type designs for all facilities to be constructed under the project (para. 6.10); and  - 64 - g. The states shall each undertake a mid-term review of the progress of the project activities in the respective areas, and shall make available not later than March 31, 1983, the results of such review to the Association (para. 7.02). 8.02 For activities costing more than US$50,000 to be financed under the innovative activities component, no funds will be disbursed unless IDA has approved the activity before its implementation, according to the criteria listed in para. 4.66. 8.03 With these assurances, the project is recommended for a Credit of US$46 million on standard IDA terms to the Government of India.  - 65 - ANNEX 1 FAMILY WELFARE PROGRAMME A Statement of Policy MINISTRY OF HEALTH AND FAMILY WELFARE GOVERNMENT OF INDIA NEW DELHI June 29, 1977  - 66 - ANNEX 1 The President in his address to Parliament on March 28, 1977, stated that "Family planning will be pursued vigorously as a whollv voluntary programme and as an integral part of a comprehensive policy covering edu- cation, health, maternity and child care, family welfare, women's rights and nutrition". The Prime Minister has on a number of occasions underlined the vital importance of family planning as a means of individual and national deve- lopment and well-being. This Government is totally committed to the Family Welfare Programme and will spare no efforts to motivate the people to accept it voluntarily in their own interest and in the interest of their children as well as in the larger interest of the nation. 2. Family planning has, however, to be lifted from its old and narrow concept and given its proper place in the overall philosophy of welfare. Itmust embrace all aspects of family welfare, particularly those which are designed to protect and promote the health of mothers and children. It must become a part of the total concept of positive health. At the same time, it must find mneaningful integration with other welfare programmes, viz., nutrition, food, clothing, shelter, availability of safe drinking water, education, employment and women's welfare. It will be our endeavour to bring about this integration in a greater degree. We expect the States to do the same. 3. The change in the name of the programme from family planning to family welfare is a reflection of the Government's anxiety to promote, through it, the total welfare of the family and the community. It is our intention to take the programme forward in the real sense as an investment in man. We wish to make it abundantly clear that in this task there is no room for compulsion, co- ercion or pressures of any sort. Compulsion in the area of family welfare must be ruled out for all times to come. Our approach is educational and wholly vo- luntary. There will,however,be no slackening of our efforts in this direction. 4. The Government attaches the highest importance to the dignity of the citizen and to his right to determine the size of his family. We have no doubt that by and large the people of India are conscious of the importance of res- ponsiblc parenthood; given the necessary information and adequate services, they will accept the small family norm. We will promote all methods with equal emphasis and it will be left to every family to decide what method of con- traception it will like to adopt. Employees of the Union Government, State Governments, autonomous bodies, local bodies, etc., will be expected to set an example and to adopt the small family norm.  - 67 - ANNEX 1 5. We are totally against any legislation for compulsory sterilisation either at the Central level or by the States. Sterilisation, both male and female, is a terminal method and suitable for those couples who have reached the optimum family size. Services for sterilisation will be offered free, of cost to those who voluntarily wish to adopt this method. Similarly other services under the pro- gramme will be available to the people free of charge. The acceptance of volun- tory sterilisation and IUD involves to and fro travel to a clinic, a brief s,tay in the hospital, resulting in possible loss of wages which the majority of our people can- not easily afford. In view of this, it has been decided to retain the provision for monetary compensation. Any medical complication resulting from a voluntary sterilisation operation will be attended to free of cost; and if in an unfortunate case recanalisation becomes necessary, this facility will also be offered to the individual concerned under the best possible profes.innal care without any charge. 6. Nearly 80 per cent of our population lives in villages. Medical services are not able to reach them in an effective way. An integrated rural health scheme is on the anvil and will be implemented shortly. It is of the utmost importance that adequate ante-natal, natal and post-natal care is made available to pregnant miothers. To this end a comprehensive scheme of training of indigenous mid- wives (dais) will be implemented. Under it maternity services will be made available to all mothers who may need them. The programme of immunising children against common diseases such as a whooping cough, diphtheria and tetanus will be expanded further. We expect that the State Governments willgive necessary co-operation and assistance in this direction. 7. The direct correlation between illiteracy and fertility and between infant/maternal mortality and the age at marriage is well established by demo- graphic studies. While on the one hand the Government will pursue its policy of according high priority to the improvement of women's educational level, boti through formal and non-formal channels, it wilt also bring legislation for raising the minimum age of marriage for girls to 18 and for boys to 21. 8. In a federal system, the sharing of Central resources with the States is a matter of considerable importance. In all cases where population is a factor as in the allocation of Central assistance to State plans, devolution of taxes and duties and grants-in-aid, the population figures of 1971 will continue to be fol- lowed till the year 2001. Family Planning and population control is a subject in the Concurrent List, yet the implementation of the Family Welfare Programme is very much the responsibility of State Governments. Assistance for the imple- mentation of the Programme is provided by the Central Government to the States on cent-per-cent basis. In order to ensure a purposeful implementation of the Family Welfare Programme, the principle of linking 8 per cent of Central Assis- tance to the State Plans with their performance and success in Family Wel- fare Programme will be continued.  - 68 - ANNEX 1 9. Population education has so far not received the attention it deserves. The NCERT have developed some models for the introduction of population edu- cation in the school education system. These models have already been adop- ted by the Central Schools Organisation. We would urge that the departments of education in the States should adopt these models, or their modified versions, in the syllabus in the schools. Forty-two per cent of our population is below the age of 15 years. It is this population which will soon be entering in the area of matrimony. We must take steps without any further delay to see that the youth receive population education as part of their normal courses of study. 10. The population of India has been increasing at the rate of about o n e million every month. It has increased by nearly 270 million since 1947 and is today estimated to be 615 million. If the present rate of growth continues, we will be touching the one-billion mark by the end of the century. This rate has to be arrested. The birth rate targets of 30 and 25 per thousand by the end of the Fifth and Sixth Plans respectively can be achieved only with the total and willing participation of the community in the family welfare programme. For this pur- pose it is important that all media of publicity, including motivation through the extension approach, should be utilised fully by the Central and the State Govern- ments. We would very much expect that just as at the Centre we have involved all media units of the Ministry of Information and Broadcasting in the motiva- tional campaigns, in the States also the State Departments of Public Relations and other departments having their own publicity set-ups would be totally associ- ated with the motivational effort. 11. It is of equal importance that trade unions, chambers of commerce, cooperative societies, organisations of women, federations of teachers, village panchayats and all other institutions which can influence public opinion should be associated intimately with the educational campaigns. The village panchayats can play a significant role in this task. Their potential as change-agents needs to receive greater recognition and attention. 12. No programme will succeed unless voluntary organisations particu- larly youth and women's organisations participate in its implementation fully and extensively. So far this participation has been very limited. The Govern- ment wishes to invite the suggestions of voluntary organisations and such public bodies as are engaged in the general task of Family Welfare for evolving suit- able patterns of co-operation and assistance. Full rebate will be allowed I n the income-tax assessment for amounts given as donations for l! amily Welfare purposes to Government, local bodies, or any registered voluntary organisa- tion approved for this purpose by the Union Ministry of Health. 13. While the existing methods of contracepticn will continue to be avail- able to the people, it is important that the search fLr newer methods should be intensified. The Government will give special attention to the necessary research inputs In the field of reproductive biology and contraception.  - 69 - ANNEX 1 14. The programme and the approach for implementation of the Family Welfare ig:%;amme as outlined in the above paragraphs will succeed only if there is willing eo-operation from all in full measure. The Family Welare Programme embraces all the principal areas of human welfare. It will be wrong to leave it only to thUn M'inistry of Health and Family Welfare in the Centre and their counterparts in the States. It is essential that all Ministries and Departments of the Government of India as well as of the States give due importance to this Programme and work for its furtherance. 'The performance of Family Welfare in the States will be intensively and carefully monitored and the Union Cabinet will review the situation in depth at least once a year. Suit- able machinery for ensuring coordination with other connected programmes of welfare may be set up in the States also.  1 70 - ANNEX 2 AN ILLUSTRATIVE LIST OF PERFORMANCE INDICATORS FOR EVALUATION OP PROJECT ACTIVITIES Proiect/Component Obiectives Performance Indicators Dats Sources India Population Project II Improve health and 1. Changes in infant and 1. Base line surveys, follow-up surveys family welfare status child mrtality and mor- of the population by bidity rates, maternal reducing mortality, mortality rates, and morbidity and fertility fertility and mortality rates, 2. Changes in proximate 2. Service statistics, periodic prevalence deterninants of fertility surveys and studies. (contraception, abortion, lautation and reproduc- tive years within marriage) Project Conponents A. Physical facilities and Number 6and percentage) of manpower To improve accessibility 1. Registered mothers I, Service statistics and utilization of health for ante-natal care. and family planning services. 2. Average visits for each 2. Follow-up surveys mother. 3. Mothers vaccinated against 3. Supervision and evaluation Tetanus (TT) reports. 4. Nutritional aids given to acutAmethera and infants. 5. Deliveries by health team, trained dais, and others. 6. Delivery cases referred to otber hospitals. 7. Post-natal visits. S. Contraceptive acceptance. 9. Clinic Attendance. 10. Ismunization for DPT, polio, TB, etc. 11. Morbidity statistics according to diagnosis. 12. Causs. of infant and child mortality. B. Training Component 1. To staff MM /FP services. l Improved staffing. 1. Evaluation of training 2. To improve the quality of 2. nowledge, ittittade and progrms. gcg/FP services, skill of the trinees 2. Service statistics. 3. Increase in the number 3. Special studies. of cltents served. 4. Clients' satisfaction with services. C. Comnunication Component 1. To increase the knowledge l. Changes in knowledge about 1. Special surveys and studies. about benefits snd avail- N3'N issues. 2. Service statistics. ability of RFW services. 2. Changes in knowledge about 2. To create a supportive HFW cervices. environment for 1PFW 3. Counuity's response to RFW services, staff. 3. To increase recognition 4. Participation of leaders in of HFW program as an planning and implementation essential component of of HNW program. development by the staff of other development departments.  - 71-AWNF_3 INDIA: SECOND POPULATION PROJECT ANDhRA PRADESE- -ESTIMATED BASE PROJECT COST BY EXPENDITURE AND FUNCTIONAL CATEGORY (In thousands of Rupees) Service Training IEC Research and Project Innovative Total Delivery _ Evaluation Management Activities A. CAPITAL COSTS Civil Works 67,902 6,668 - - - 74, 570 Furnitore 3,817 1,123 48 35 30 - 5,053 Equipnent 2,917 40 1,290 507 35 _ 4,789 IEC Material - - 4,054 - - 4,054 Vehicles 5,070 490 750 140 200 6,650 Subtotal 79,706 8,321 6,142 682 265 _ 95,116 B. OPERATIONAL AND MAINTENANCE COSTS salaries 36,113 4,975 744 1,240 2,030 45,102 Vehicle Operational and Msintenanco Costa 1,716 385 495 110 275 _ 2,981 Other Operational and Maintenance Costs 19,039 9,469 7,380 1,813 1,000 38,701 Subtotal 56,868 14,829 8,619 3,163 3,305 - 86,784 C. INNOVATIVE ACTIVITIES - - - - - 4,300 4,300 TOTAL BASE COST 136,574 23,150 14,761 3,845 3,570 4,300 186,2(0  - 72 _ ANmEx 3 INDIA: SECOND POPULATION PROJECT UTTAR PRADESH--ESTIMATED BASE PROJECT COST BY EXPENDITURE AND FUNCTICJAL CATEGORY (In thousands of Rupes) Servic- Training IEC Research and Profjet Innovative Total Delivery _ _ Evaluatio MHNaS t Activities A. CAPITAL COSTS Civil Works 181 426 1,660 - - - 183,086 Furnit-re 11.199 758 1" 50 90 12,241 Equipment 7,328 ' - 1,882 - 90 - 9,300 IEC Materials - - 12,054 - 12 054 Vehicles 10,055 600 2,175 65 590 - 13,485 Subtotal 210.008 3,018 16,255 115 770 _ 230,166 B. OPERATIONAL AND MAINTENANCE COSTS S-larie 101,208 1,820 1,844 635 4,152 - 109,659 Vehicle Operationil and HMintenance Coets 3,586 473 1,595 55 605 6,314 Other Oper-ationl and Kinrtence Costs 68,211 15,050 14,451 1,829 1,490 - 101,031 Subtotal 173,005 17,343 17,890 2,519 6,247 - 217,004 C. INNOVATIVE ACTIVITIES - - - - - 8,600 8,600 TOTAL SASE COST 383,013 20,361 34,145 2,634 7,017 8,600 455,770  - 73 - ANNEX 3 INDIA: SECOWID POPUL,ATION PRl0ECT ESTIMATED BASE PROJECT COST BY EXPENDITURE AND FlNCTICOAL CAIWRM (In thousands of Rupee.) S.rvtie Training IEC Rsearch *nd Project Innovative Total Delivery _ _ _ Evalmation Manmsesant Activities A. CAPITAL COSTS Civil Works 249,328 8,328 - - - 257,656 Furniture 15,016 1,881 192 85 120 - 17,294 Equip .ent 10,245 40 3,172 507 125 - 14,089 IEC Materials - - 16,108 - - 16, 108 Vebicles 15,125 1,090 2,925 205 790 - 20,135 Subtota1 289,714 11,339 22,397 797 1,035 - 325,282 B. OPERATIONAL AND MAINTENANCE COSTS Salaries 137,321 6,795 2,588 1,875 6,182 - 154,761 Vehicle Operational end HMintenance Cost. 5,302 858 2,090 165 880 - 9,295 Other Operational and Maintenannc Costs 87,250 24,519 21,831 3,642 2,490 - 139,732 Subtotal 229,873 32,172 26,509 5,682 9,552 - 303,788 C. INNOVATIVE ACTIVITIES - - - - - 12,900 12,900 TOTAL BASE COST 5 43,511 48,906 6,479 10,587 12,900 641,970  - 74 - ANNFY 4 INDIA: SECOND POPULATION PROJECT ESTIMATED SCHEDULE OF DISBURSEMENTS IDA Financing Amount Cumulative FY 1980 June 30, 1980 400 400 FY 1981 September 30, 1980 900 1,300 December 31, 1980 1,200 2,500 March 31, 1981 1,500 4,000 June 30, 1981 1,800 5,800 FY 1982 September 30, 1981 2,100 7,900 December 31, 1981 2,400 10,300 March 31, 1982 2,900 13,200 June 30, 1982 3,300 16,500 FY 1983 September 30, 1982 3,800 20,300 December 31, 1982 4,000 24,300 March 31, 1983 3,800 28,100 June 30, 1983 3,500 31,600 FY 1984 September 30, 1983 3,200 34,800 December 31, 1983 2,900 37,700 March 31, 1984 2,500 40,200 June 30, 1984 2,100 42,300 FY 1985 September 30, 1984 1,900 44,200 December 31, 1984 1,200 45,400 March 31, 1985 600 46,000  - 75 - ANNEX 5 INDIA: SECOND POPULATION PROJECT ACCOUNTING PROCEDURES Procedures to be used by State Governments Project Budget Procedure 1. The project budgets will form part of the annual budgets of the Ministry of Health and Family Welfare of the respective states. Necessary approval of Ministries of Finance and Planning of the states have been ob- tained. However, project accounts will be maintained separately. Neces- sary augmentation of staff for this purpose has been provided for in the project. Civil Works 2. The Director of Works heading the Construction Unit in U.P. and the Chief Engineer, Public Works Department in A.P. will be responsible for civil works. 3. Contracts for civil works are awarded by local competitive bidding. Civil works where no contractors are forthcoming or where bid prices are un- reasonable, and small buildings and structures in remote areas may be built through force account. The procedures followed for this purpose by respec- tive states are considered adequate, with the additional provision that any contract in excess of US$10,000 equivalent will be advertised locally. Local Procurement 4. The Project Coordinator in U.P. and Additional Director (Project Implementation) in A.P. are responsible for procurement of furniture, equip- ment and vehicles. 5. Annually the Director Industries after inviting local competitive bids, publishes a list of authorized suppliers and particulars of items avail- able with specification and unit price for local procurement by the public sector in the state. Rate contracts are also issued by the Director General of Supply and Disposals, Government of India. Procurement is permitted at these prices from any authorized supplier selected by the disbursement cen- ter concerned. Procurement of items not listed by the Director Industries is by local competitive bidding upto a value of Rs 2,000. Purchases over Rs 2,000 require prior approval of the Director Industries who will either specify the price and specification of the item and the name of supplier or instruct that procurement be by local competitive bidding. These procedures are considered adequate for local procurement which would be financed under the proposed IDA credit, with the additional provision that any procurement in excess of US$10,000 equivalent will be advertised locally.  - 76 - ANNEX 5 Accounting, Records Internal Control and Audit 6. Adequate accounts are maintained at block, district and state levels 'tfacilitate the preparation of monthly accounts by each level. Internal control in each level for authorizing, and verifying payments is considered satisfactory. 7. Accounts at PHC level are inspected monthly by the accounts staff of the District Chief Medical Officer. The latter's accounts are inspected periodically by accounting staff from the Directorate of Health and Family Welfare at state level. Project accounts which are kept at state level are inspected regularly by the special projects accounts staff of the Ministry of Health and Family Welfare in New Delhi. An audit team, from the Auditor General's office, audits the accounts annually. Disbursements Against Statemeats of Expenditure 8. For the purpose of credit disbursements against statements of expenditure, the institutional and staffing capabilities after the proposed strengthening of the staff will be satisfactory. The accounting and financial procedures used by the concerned departments in U.P. and A.P. are adequate and satisfactory. 9. A quarterly statement of expenditure will be provided to the IDA by the states. All supportive documents and vouchers will be made avail- able to review missions for examination and will be retained by the states for at least until one year after the closing date of the project. 10. Annual accounts of the project will be submitted for audit within six months of the end of the financial year and audited by the Auditor General not later than nine months after the end of such year. A copy of the audited statement of expenditure will be furnished to the Association, with additional certification by the Auditor General that the proceeds of the credit withdrawn from the credit accounts on the basis of certificate of expenditure have been used for the purpose for which they were provided.  - 77 -rNE INDIA: SECOND POP1ULATION PROJECT UTTAR PRADESH - SUMMARY IMPLEMENTATION SCHEDULE I. Physical Facilities: 1. Construction of Subcenters X3CCXDCaKXDKDC DK~CK1 :K1o 2. Upgradation of PHCs X3CXy0CX:K3C IOK 3. Construction of PHC buildings to replace rented facilities xluKy I X:X1DKXCXyCXCKy NOEKYa XX 4. Construction of operation thea- tars in existing PECs UCOC E CyK DX XC XCN Cy X XDX = KKX 5. Construction of approach roads in existing PHCs uyoKlcxDcxlxux)KYD a yD 6. Provision of elec~ tricAl connectic in existing PHCsXKXGX1UC1 7. Provision of watei supply and over- head tanks to existing PHCs CXY XC CXCK2CXY X XCX XY LK) 8. Establishment of maternity homea at Varanasi  - 78 - CNE INDIA: SECOND POPULATION PROJECT UTTAR PRADESH- SUJMMARY IMPLE24ENTATION SCHEDULE (Cont 'd) 19 9 ~ ~ 91 ~ ?1q1I? AMTIITY DtScUanlo JASICO:NID I. AtIJA 1;ID I1 q I ASfln;,5Fl'pl.-H .iJ?JIJ