India - Child Survival and Safe Motherhood Project

Documenti T'iie World 1 ! I ( i ' N ;, e ,+i t! t>; ) I 1XN V ( Ar AI';il'I I I 1 . . ... Iz, r,l Ut , A: N}11 ) \.' ' FOR OFFICIAL ''! Report No. 9489-IN STAFF APPRAISAL REPORT INDIA CHILD SURVIVAL AND SAFE MOTHERHOOD PROJECT AUGUST 27, 1991 Asia Country Department IV (India) Population and Human Resources Operations Division This document has a restriced distidbution and may be used by recipients only in tbe performance of their officiid duties. Its contents may not otherwise be disclosed without World Ban authorizsfioa  CURRENCY EQUIVALENTS (As of June 15, 1991) Currency Unit = Rupee Rupee 24.40 a US$ 1.00 Rupee 1.00 = US$ 0.041 METRIC EQUIVALENTS 1 Meter (m) = 3.28 Feet (ft) 1 Kilometer (km) = 0.62 Miles FISCAL YEAR April 1 - March 31 ABBREVIATIONS AND ACRONYMS ANM - Auxiliary Nurse Midwife ARI - Acute Respiratory Infections CHC - Community Health Center DTC - Divisional Training Center DTT - District Training Team FP - Family Planning GOI - Government of India HA(F)(M) - Health Assistant (Female) (Male) HERO - Health Equipment Repair Organization HFWTC - Health and Family Welfare Training Center HG - Health Guides HW(F)(M) - Health Worker (Female) (Male) IEC - Information, Education and Communications LHV - Lady Health Visitor MIS - Management Information System MOHFW - Ministry of Health and Family Welfare MCH - Maternal and Child Health MTP - Medical Termination of Pregnancy NGO - Non-Governmental Organization ?HC - Primary Health Center PPC - Post-Partum Center SHTO - State Health Transport Organization SMC - Social Marketing of Contrp eptives VHG - Village Health Guide UNFPA - United Nations Fund for Population Activities UNICEF - United Nations Children's Fund UIP - Universal Immunization Program  FOR OMCIAL USE ONLY DSFXMTIONS Crude Birth Rate Number of live births per year per 1,000 population. Crude Death Rate Number of deaths per year per 1,000. Natural Increase Rate Difference between crude birth and crude death rates; usually expressed as a percentage. Population Growth Rate Rate of natural increase adjusted for (net) migration, expressed as a percentage of the total population in a given year. Contraceptive Prevalence The percentage of married women of reproductive Rate age who are using a modern method of contraception at any time. Total Fertility Rate The average number of live children that would be born per women 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 live-born daughters a cohort of females would bear under a given fertility schedule and a given set of survival probabilities, from birth to the end of the childbearing years. Perinatal Mortality Mortality related to the period between 28 weeks gestation and one week postnatal. Infant Mortality Rate Annual number of deaths of infants under one year per 1,000 live births during the same year. Child Mortality Rate Annual deaths of children 1-4 years of age per 1,000 children in the same age group. Materna Mortality Rate Number of maternal deaths per 1,000 births attributable to pregnancy, childbearing, or puerperal complications (i.e., within six weeks following childbirth). Morbidity Any departure, subjective or objective, fromt a state of physiological or psychological well- being. In this sense, sickness, illness, and morbid condition are synonymous. Morbidity Rate The frequency of disease and illness in a population. This document has a restricted distribution and may be used by recipients orly in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  - il - DEFINITIONS (continued) Prevalence Rate The number of persons having a particular disease at a given point in time per population at risk; usually expressed per 1,000 persons per year. Life Expectancy Average number o! 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. Low Birth Weight (LBV) Infants weight at birth less than 2,500 gr. LBW may be associated with either pre-term (less than 37 weeks gestation) or full-term but small for dates (38 weeks or more) of gestation. Toxemia of Pregnancy Group of metabolic disturbances occurring during gestation or shortly after delivery, characterized by the appearance of hypertension, edema, and proteinuria (preeclampsia) and, in severe case, convulsions and coma (eclampsia). Puerperium The period after completion of the third stage of labor until involution of the uterus is complete, usually six weeks. Puerperal sepsis Infection of the reproductive organs caused by septic childbirth conditions (also called puerperal fever). Risk A probability that an unfavorable outcome related to morbidity or mortality will occur within a stated period of time or age. Dependency Ratio Population 14 years or under and 65 years of age or over as percentage of active population (aged 15 to 64 years). lndicates proportion of population that needs economic support.  - lli - INDIA CHILD SURVIVAL AND SAFE NOThEBOOD PROJECT Table of Contents Page No. BASIC DATA.. .... .. ...... t .*......... .... vi CREDIT AND PROJECT StMMARY .............. .. ...... .... vii I. FAMILY WELFARE IN INDIA A. Introduction ... ....... * ...... ........... B. The National Family Welfare Program ..................... 1 C. Perfoi2ance of the Family Welfare Program ............... 2 D. Problems and Issues in the Family Welfare Program ....... 2 II. GOVERNMENT PLANS AND POLICIES IN FAMILY WELFARE A. Health and Population Policy ............................ 8 B. Financing of Family Welfare .................. ... too ... 10 C. IDA-Assisted Population and Nutrition Projects and Sector Strategy. .. to ........ .. .... ..... ... 12 III. THE PROJECT A. Rationale and Strategy ..... ... ............ ....... .. 17 B. Project Goals and Objectives ..... ........ 21 C. Child Survival Program ...................... ........ 22 D. Safe Motherhood Program .. .. . ..... 25 E. Institutional Systems Development .......... 29 IV. PROJECT COST, FINANCING, IMPLEMENTATION AND DISBURSEMENTS A. Coss............................ 34 B. Financing Planlan.. ................... ...t ............. 36 C. Recurrent Cost and Sustainability Implications........... 36 D. Status of Preparatione p a rn.. .. .. ............ 37 E. Project Implementation.. 00 .. ... 38 F. Monitoring, Evaluation and Operational Research .... . 39 G. Disbursementss...... .... .......... ...................to. 39 H. Procurement .. .. ....... . . . .. ..... 40 I. Accounting and Auditing. .. ....... .. ................. 43 V. BENEFITS AND RISKS A. Benefits ......................... 44 B. Risks .......................... 44 VI. AGREEMENTS REACHED . ... .... ..... . ....... . .... . 45 This Report In baosed on the findings of missions to India from November 27 - Decmbr 14, 1990 and April 22 - May 14, 1091. The Project Team Included R. Cambridge, Principal Economist-Took Manager, S. Habayeb, Senior Public Health Specialist, A. Andonyndis, Senior Architect, D. Odbh, Senior Economist, P. Peas., Senior Procurement Specialist, R. Heaver, Senior Operations Officer, NDO, M-lr F Plunk.tt, Demognrpher, A. Contractor, Physician, NDO, and the following consultant specialists: D. Foster, Human Resource Devolopment; Mo. M.T. F uerstetn, Safe Mothorhood, Ma. W. Lynn, lnformation, EducatIon and Communications, Ms. P. Randall Social Mobilzation and R. Sethuraman, Government Finance. Ms. S. Pak and J. Mongol assisted In preparing the Report. The Peer Reviewero were Mr. J. Greene, Principal Nutrition Speciailt, Ms. S. Stout, Health Speciallst, end Ms. A. Tinkor, Health Specialist. The project was endorsed by Mr. Richard Skolnik, Chlf, Population and Human Resourceo Division and Mr. Heins Vergin, Director, Indio Country Department.  - iv - Page No. TABLES 3.1 Problems/Issues, Project Interventions and Expected Outcomes .... IS 4.1 Costs by Component ......................................................... ;aS3 4.2 Costs by Categorieo of Expenditure ............................. 35 4.3 Procurement Arrangements ........... . . .. . *.... . .. . . . .. . . . .. . . . . . 42 ANNEXES 1. India: Vital Statistics (CBR, CDR, IMR, MHR) ............... ...... 48 2. Organization of Medical and Health Services .................... 50 3. The National Family Welfare Program ........................... 52 4. Performance Achievements of the Maternal and Child Health Program .................................. .. . . .. . . . . . 54 5. Health and Family Welfare Education and Training Programs ....... 56 6. Concurrent iCvaluation of the Family Welfare Program ............ 73 7. National Health Policy and Safe Motherhood Strategy ............ 76 8. Phasing of Districts Selected for UIP Plus and Safe Motherhood Implementation ........................................................... 79 9. Costs of the National MCH Program .............................. 83 10. Bilateral and Multilateral Assistance to Health and Family Welfare ........................................................... 85 11. IDA-Assisted Population and Nutrition Projects ................. 87 12. Universal Immunization Program ................................. 93 13. National Program for the Control of Diarrhoeal Diseases and Policy on Management of Diarrhoeal Disease through ORT .......... 101 14. Social Marketing of Oral Rehydration Salts ...................... 104 15. Acute Respiratory Infections in Children ir, India .............. 109 16. Social Marketing of Contraceptives ........................... 114 17. Key Indicative Operational Components for s'-"!e Motherhood ...... 122 18. Work Routines for Field Workers .......... .................... 133 19. Information, Education and Communication :;srategy ... . 139 20. Functional Guidelines for Field-level Recordkeeping . 153 21. Ensuring the Quality of Drugs in India .. 154 22. Schedule of Appointment of Additional Staff ..... 156 23. Project Costs: Summary Costs by Component and Time .. ............. 157 Summary Costs by Categories of Expenditure and Time .. 158 Sunumary Costs by Component and Categories of Expenditure . 159 24. Basis of Cost Estimates .......... . ... ....... . 160 25. Financing Plan by Categories of Expenditure .......... 166 26. Project Additionality and Sustainability ... 167 27. Coordination between Ministry of Health and Family Welfare and the Women and Child Department .... . 178 28. District Planning Guidelines ... ........ 183 29. Key Indicators ....... .. ..... . .............. .. ... 186 30. Operational Research and Scudies . .................... .188 31. Forecast of Annual Expenditures and Disbursements .. 196 32. Rationale For Recommended Methods of Procurement . . 197 33. Supervision Plan ................. .. ...... .......... . 209 34. Selected Documents in the Project File . ............ 214  'ago No. CHARTS 1. Maternal and Child Health Services Beneficiaries Immunization (1970-1988) ...................................... 218 2. Maternal and Child Health Service Beneficiaries - Prophylaxis Program (1986/87 - 1987/88) ....................... 219 3. Indiat Distribution of Childhood Deaths ...................... 220 4. India: Sex Ratio 1901-1991 ........ . ..... ................... . 221 5. India: Distribution of Maternal Deaths ....................... 222 6. Implementation Phasing of the National MCH Program ............ 223 7. Maternal Mortality Rate (MMR)s The Effects of Health Interventions . ...... ........... .. .............. 224  - vi. - INIA CHILD SURVIVAL AND SAn MOTHEEHOOD PROJECT BASIC DATA Total Area 3,287,253 km2 Total Population 1/ (1990) 850 million Density per km2 - (1990) 259 Total Fertility Rate (1988) 3.9 Crude Birth Rate (1989) 30.5/1000 Crude Death Rate (1989) 10.2/1000 Rate of Natural Increase (1989) 2.0X Life Expectancy at Birth (1985) 55 years Infant Mortality Rate (1989) 91/1000 Maternal Mortality Rate (1985) 50/10,000 Urban Population as Percent of Total Population (1991) 23.3X Literacy Rate (age 7 and above) (1991) Males 64S Females 39? Primary School Enrollment (1983-84) Males 92X Females 59Z Age Structure 1/ (1990) 0-14 37? 15-60 59? 60 and over 4? Population per Physician (1983) 2,10 Population per Midwife/Nurse (1983) 2,251 Current Contraceptive Prevalence Rate 2/ (1988) 40 Per Capita Gross Domestic Product 1/ (1988) US$313 1/ Bank estimate. 2/ Operations Research Group Survey.  - vii - INDIA CBILD SURVIVAL AND SAfl NOTERUHOOD PROJECT CREDIT AND PROJECT SUMHARY Borrovers India, acting by its President Beneficiaries: States and Union Territories of India Amount: SDR 160.9 million (US$214.5 million equivalent) Tt -s: Standard, with 35 years maturity On-lending Terms: Government of India (GOI) to the States and Union Territories of India: In accordance with standard arrangements for development assistance to States and Union Territoriea. Description: The project would support enhancement and expansion of COI's Maternal and Child Health (MCH) Program for the 1991-1995 period. It would cover the incremental costs associated with the program. It would be na- tional in scope, but with an emphasis on specific districts where maternal and infant mortality rates are higher than the national average. It would be co- financed by UNICEF and take into account its experi- ence in assisting the GOI in implementing the Univer- sal Imunnization Program (UIP) during the Seventh Five-Year Plan (1985-90). Its specific objectives would be to enhance child survival, prevent maternal mortality and morbidity, and increase the effective- ness of service delivery. These objectives would be achieved through supporting: (a) Child Survival Pro- grams including: sustaining UIP as well as strengthen- ing diarrhoea control programs, the control of acute respiratory infections (ARI), prophylaxis against blindness and eye lesions due to Vitamin A deficiency, enhanced newborn care and the active promotion of breast feeding. These interventions will be called "UIP Plus;" (b) a Safe Motherhood Initiative which would improve maternity care and preventive programs for all women, giving enhanced emphasis to pregnant women with high-risk factors, strengthening essential obstetric care and capabilities to treat obstetric complications, while concurrently promoting birth spacing, timing, post partum counselling, and prophy- laxis and control of nutritional anemia; and (c) Institutional Systems DeveloRment which would include improving and expanding training programs for family welfare workers, expanding information, education and conmunications dissemination, and strengthening exist- ing center and state/district management information, supervision, planning, procurement, logistics, and maintenance systems.  -viii- Benefits and Riskas The project would have several immediate benefits. First, in the absence of sustaining the immunization program, another 250,000 children would die from tetanus, 500,000 would die from measles and 170,000 would risk paralysis each year due to poliomyelitis. Second, the project would assist in subtaining and developing MCH services during a period when the scale of publicly financed social services could be severely and negatively impacted by GOI budgetary constraints. Third, the project wo: ld contribute to a GOI review of its current national MCH policies and to appropriate adjustments in terms of content, targeting and deliv- ery. Fourth, the project allows GOI the time and opportunity to undertake vigorous trials at the dis- trict level of the OUIP Plusw and Safe Motherhood models which are being developed. It is estimated that about 115 million lower-income women and about 190 million children in rural areas and urban slums would benefit from this project. The long-term bene- fit of the project is that it should promote a more efficient and effective national family welfare pro- gram which would lead to significant reductions of ma- ternal, infant and young child morbidity, mortality, and disability, thereby enhancing the quality of life and of India's human capital. There are some risks to the project. It will be difficult, first, to ii.crease the number of activities to be undertaken at the point of service delivery as well as change the way health workers and supervisors perform their tasks. However, ongoing IDA support to the five Populaticn projects should alleviate this risk by strengthening regular on-the-job training and more appropriate supervision. In addition, GOI under the proposed project would implement improved job descriptions and work routines for staff and supervi- sors. The large-scale cooperations between IDA and UNICEF will also assist in reducing the constraints to successful project implementation. UNICEF has exten- sive contacts with the medical community in India and a wide network of offices in the States. This should assist in project monitoring, supervision and evalua- tion. There are also risks associated with the Safe Motherhood Program. The project would include activ- ities to increase awareness and action through Pancha- yats, and Vonen's Groups including Mahilla Mandals and Private Voluntary Organizations. Moreover, IEC pro- grams would be designed to specifically address some local customs which are dangerous to women's survival. Also, local communities, through their representatives and/or with the assistance of PVOs, would be mobilized as an integral part of the planning for Safe Mother- hood in that community.  -ix- Estimated Costs: Local Foreign Total