India - Family Welfare (Assam, Rajasthan and Karnataka) Project

Document of The World Bank FOR OFFICIAL USE ONLY -- _ ) & 2C -,,, Report No. 12771-IN INDIA STAll APPRAISAL REPORT FAMILY WELFARE (ASSAM, RAJASTHAN AND KARNATAKA) PROJECT NAY 26, 1994 MI CROGRAPH I CS Report No: 12771 IN Type: SAR South Asia Country Department II (India) Population and Human Resources Operations Division Ths. docament has a resticted dIsutIon and may be used by recipiet ody In the performae of thelc ofi ff duties Its cooke-t may not odhewise be disbosed wiou Wodd Baok authoriz  CURRENCY EOUIVALINTS (As of December, 1993) Currency Unit = Rupee Rupee 33.9 - US$ 1.00 Rupee 1.0 - US$ 0.03 METRIC EOUIVALENTS I Meter (M) = 3.28 Feet (ft) 1 Kilometer = 0.62 Miles FISCAL YEAR April 1 - March 31  FOR OFFICIAL USE ONLY ANM - Auxiliary Nurse-Midwife ARI - Acute Respiraty Infections CBR - Cnude Birth Rate CDR - Crude Death Rate CDD - Control of Diarrhoeal Diseass (progam) CHC - Community Health Centre CIF - Cost,n lsuance, Freight CMHO - Chief Medical and Health Officer CPR - Contaceptive Prevalence Rate CSSM - Child Survival and Safe Motherhood (project) DGS&D - Directorate-General of Supplies and Disposal EFC - Expenditure and Finance Committee (GOI) FRU - First Referal Unit FW - Family Welfare GNM - General Nurse-Midwife GNP - Gross National Product GOI - Government of India HAC - Health Advisory Committee HFWTC - Health and Family Welfare Training Centre HMLS - Health Management Infonration System ICB - InteTnational Competitive Bidding ICDS - Integrated Child Development Services (rogram) IDA - Intratoa Development Association IEC - Information, Education and Communication IMR - nifant Mortality Rate IPP - India Population Project (I uough VM) LCB - lowCl Competitive Bidding LHV - Lady Health Visitor MCH - Maiernal and Child Health (care, services, program) MIS - Managemt Information System MPHW - Male Multi-Purpose Health Worker(s) MOHFW - Ministry of Health and Famdly Welfare MSS - MAhi&a Swastha Sangha (women's group) MTP - Medical Ternination of Pregnancy NGO - Non-Govenmental Organisation ORS - Oral Rehydration Salts/Solution PHC - Primary Health Centre PHN - Public Health Nurse PMO - Principal Medical Officer PMP - Private Medical Practitioner PVO - Private Voluntary Organisation PWD - Public Wor Departnent RNI - Rate of Natural Increase SC - Sub-Centre SIHFW - State Institute for Health and Family Welfare SMO - Senior Medical Officer TBA - Traditional Birth Attendant TFR - Total Fertility Rate UIP - Universal Immunisation Program UNFPA - United Nations Fund for Populaton Activities Tbis document has a resticted distibuton and may be used by rociients only in the Pefman h offlci duties. Its contents may not othewse be disclosed without World Bank autorzato  DODIA FAMILY VVELFAR(A$SAM4 RAJASTHAN AND K]UATIAKAPOJ Page No. Basic Data ........ . ......................................... iv Credit and Project Summary ....... ............................. v I. POPULAION ISSUES AND THE HEALTH OF WOMND AND CHILDREN IN DIA ............................................ 1 A.DemographicTrends andIssues ............................. 1 B. Child and Maten Health ................................ 2 II. GOVERNMT POLICES AND PROGRAMS IN POPULATION AND MATERNAL AND HIl.LDL HEALTH ......... ............. 3 A. Population Policies and Progrms ..... ....................... 3 B. Policies and Programs in Maternal and Child Health ....... ......... 4 m.TH mm LkN PAMiLY WNELFARE PROGRA ............................. s A. Structure and Scope .................................... s B. Perfornance, Problems, Issues ............... 6 C. IDA nvolvement and Experience in Family Welfare ..... .. ......... 10 IV. THIM PROJCT ............................................. 15 A. Project Rationale and Scope . .............................. 15 B. Ptoject Objectives ..................................... 16 C. ProjectContent . ................... .................... 18 D.PPhnningfor TbalandotherSpecialPopuationGroups .............. 25 This report is based on the findings of an appraisal mismion that visited India in December, 1993. The mission comprised Althea Hill (rask Manager and Mission Leader), Claudia von Monbart 0Senior Economist), K.B. Banerjee (Public Health SpeciaList), R. Sethuraman (Fincial Specialist), Bnt Jacobson and Subbash Chakravarty (Architect Consultants), Joyce Lyons and Jennifer Huddart (Craming Consultants), Bonani Kakkar (IEC Consultant), Bruce Geimt (MIS Consultant) and Pradeep Kakkr (Mnagement Consultant). Frances Plunlett (SAPH) also contibuted to the appraisa. The Lead Adviser waS Tom Merrick (Senior Population Adviser, PHW and Peer Reviewers were Ane Tiker PN, Ricbard Heaver (Manila Res) and Scott Guggenheim (ENVSP). The report was produced by Jane Bekker. The Prqject is endorsed by Ricbard Sklnik, Chief, Population and Hunman Resources Operations Division and Heinz Vergin, Director, litia County Department.  ii V. . ..PROJE.r.C=..E.............E.......M.Nrr.R.NG28 A. Costsnats ............................... ......... 28 B. FinancingPlan ............. . . ........................ 30 C.RecurmentCostsandSustinability ........................... 30 D. PbrojectImplementation .................................. 31 E. Status of Project Prepaation ....... . . . 33 F. Monitoring and Evaluation . ........ 35 G. Disbursements ........... .. . 36 H. .....ent .. ........ ... ...... 37 1. Accounting and Auditing: ............ ........... 41 VI. BENEFrS A SKS ....................... 41 A. Project Benefits ............. . 41 B. Prject Risks ................................ 42 ViI. AGREEMIENS REACHED ....................... 43 A-NE AnnexI: Latest Demographic Data and Family Welfare Key Indicators for al India and Major States. An= 2: Outlnen of the Action Plan for Revamping the Family Welfare Program Anm@ 3 Key Program and Demogrphic Indicaors. Ann 4: Summary List of Civil Works to be Undertaken under the Project in Assam, Rajasthan and Karnat Ape 5: Model Plans for Sub-Centre Buildings in Assam, Rajasthan and Kamataka) and Special Techniques and Procedures for Construction. iinnexI: Criteria for Selection of Communities and Sites to Receive Newly-Constructed Sub-Centre Buildings: Assam, Rajasthan, Kamata. A_ 7: List of Communities Selected to Receive New Sub-Centre Buildings in First Year of Project: Assam, Rajasthan, Kamataka. Mm A Design for Boat Clinic, Assam. Ami& 9: List of Vehicles to Be Provided under the Project in Assam, Rajasthan and Kanataka. Anmex 1 Community-Based Volunteer Schemes: Assam, Rajasthan and Karmaak An& 11: Summary of Traing Programs and Strategies: Assam, Rajasthan, KamaaZ Annea 12: Summary of Strategies for Improving Family Welfare Program Logistics in Assam and Rajastfan. Annx 13: Summary of IEC Strategies: Assam, Rajasthan and Karataka. Ann 14: Summary of Stategies for Improving MIS in Assam, Rajasthan and Knataka and General Stategy for Improving Family Welfare MIS through Introduction of EMIS. Annex15: Indicative List of Innovative Schemes: Assam, Rajastan, Kamataka. Annex : Major Findings of Training Needs Assessments and Benefiary Needs  iii AssessmentsDone as PM of Projec Preparation: Assm, Rajastn, A1 : Sfor Improving Famiy Welfr Services to Tribal and Migratory Groups: Assam, Rajastiar, K,rnatam. Annex: Detaed Cost Table Ann 19: Delails of Expenditures & Diumet Annex 20: Summary Analyses of Sustiability of Proect Iwesmt and Recurrent Cost Implications in Assam, Rajasthan and Karnaka. Annex 21: Lis of StaffCommittee Members ad Orgnigams of Project Mana ent Structure: Assam, Rajasthn, Krataka AM 2: List of Additional Posts Creted undet te Project: Assam, Rajasn and KamtwaS AMa 23: OutLine of Scope and Methodology for Baseine Surveys and Other Evaluae Surveys and Studies. Ann 24: Outline of Layout and Content for Six-Monthly Proe Reports. Anne 25: Superion Plan. An2: 2 Outie of the mplmentaion Voluime and Plans. Annx27: Seleed Douments m Proet Files 1 Linags of the Projed to tie Action Plan for Revamping the Pamily Welfe Program ...... .................... . 9 2 Lessons Appled from IDA Expince i Famiy WYelfareLending . ........................... *e...... 13 3 Key Projea Intmediat bdion ........... . . . . . . . . . ......... 17 4 CostbyConmpoent .................................. . 28 5 Costs by Category of Exowditure ........................... . 29 6. nArrangemnents ........ ..................... . . . . 38  iv IDMA FAMILY -WELFARE (ASSAB4 RAJtASTHAN AND K&NAAKM}POlC BASIC DMT FOR ALL-INDIA Total Area (1991) 3,287,253 hm2 Total Population (Census count) (1991) 846 million Density per hn2 (1991) 257 Percent Urban (Census count) (1991) 26 Per Capita Gross Domestic Product (1991) US$ 256 Totd Fertiity Rate 1/ (1991) 3.6 Life Expetancy at Birth 1/ (1991) 61 hifant Mortality Rate 1/ (1992) 79 Matnal Mortaity Rate 2/ (1993) 5501100,000 Crude Birth Rate 1/ (1992) 29/1000 Crude Death Rate 1/ (1992) 10/1000 Rate of Natual Inncrese / 11992) 1.9% Age Struchue: Percent 0-14 years (1991) 36 15-64 years 60 65+ years 4 Adult Total Liteacy Rate (Census count) (1991) 52 Adult Female Literacy Rate (1991) 39 P:imary Schol Enrollment, Boys 3/ (1991/2) 117 Primary School Enrollment, Girls 3/ , (199112) 88 Population per Physician (1990) 2,460 Percent of Births Attended 1/ (1990) 44 by Trained Personnel Contraceptive Prevalence Rate 4/ (1993) 43 1/ Registrar General, data from India Sample Registration System 2/ WHO estimate 3/ Data from the iDepartment of Education, Ministry of Human Resource Development 4/ Data from MOHFW Note: Data from the World Bank World Development Report, 1993, where not otherwise noted.  v IDIA Erm= WLFARE (ASSAM. RAASTI AD KARNATAKA)1RWEt pltE AND PRO.Iff SUARY :9mgw. EIndia, acting by its President States of Assam, Rajastian and Karnataka hmti: SDR 62.7 miion (US$88.6 million equivalent) Terms: Standard, with 35 years maturity Oe4mm Temr: (lGovemment of India (GOI) to the States of Assam, Rajasthan and Karnatasa: in accordance with standard arrangements for development assist;nce to States The prqject would strengthen and improve the functioning of GOI's Family Welfare (FW) program in Assam, Rajastian and Karnataka, imth the objective of thereby lowering current levels of fertlity and matnal and childhood mortality in the three sates. The PW program would be strengthened through five components: (1) stengthening of FW service delivery, including extension and upgading of infrastructure through construton of subo-centres and Primary Health Centres and upgrading of Community Health Centres to serve as first referral units for obstetic emergencies, and strengthening of outreach and community linkages through setting up of mobile clinis and establishment of community volunteer networks; (2) improvement of Family Welfare service quality, including rationalisation of taining institutions and planning, improveme-lt of program logistics, and promotion of Non-Governmental Orgnisation and privasector involvement; (3) strengthening of demand generation activities through improved Information, Education, and Communication planning and activities; (4) strengthening of program management and implementation capacit; (5) a fund for innovative schemes aimed at improving service quality, and for preparation of Family Welfare investment proposals for the heavily tribal North-Eastem states. _The project should lead to improved access to, demand for, and quality of Family Welfare services in Assam, Rajasthan and Rataka, particularly among poor, remote and tribal  vi populations. Improvements would be assessed through service and community-based indicators of program performance and effectiveness. As a result of such improvements, matenal and child health should improve, and fertility and maternal and childhood morlity decline, both statewide and among these populations. Trends in these indicators would be assessed through popuiation-based surveys and servce statistics. The major risks relate to the current weak implementation capacity of the states, the possibility that infastcture and programs put in place by the project will not be maintained and fully funded during the project and after closure, and the new and innovative nature of many of the programs to be set up. In addition, there are still minor lingering securty concerns in Assam. To minimise these risks, program management will be strengthened under the project; project and program coordination fostered; state Family Welfare budget allocations reviewed in advance each year, civil works tightly managed and spesd and their maitenance assmred during the project; and new and innovatie p'rograms piloted, evaluated, and phased in gradually. Security risks caiinot be addressed directly, but project investnent and program strengthening should help maintain the program through any periods of stress. Es_mated NotLocal Forign Total -US$miion Strengthen Health & F.W. Service Delivery 46.0 4.1 50.1 Improve Quality of F.W. Sevices 21.1 0.9 22.0 Icase Demand for F.W. Senrices 10.0 0.3 10.3 Improve Management 8.2 0.6 81 Iunvative Schemes 4.0 0.1 4.1 Total Base Cost 89.2 6.0 95.2 Physical Contingencies 7.2 0.6 7.8 Price Contingencies 0.2 0.7 0.8 Total aL ject Cost 96.6 7.2 103.8 Including Taxes and Duties of US$5.3 million  vil Financing Plan: Local Fcrelgp Total IDA 81.4 7.2 88.6 50I 15.2 - 15.2 lawl "A LsZ L Estimated VisbursementsfM P9 E7 EY29 F E20 PY20 0 Xf1 Fy20 Annual 3.4 8.6 13.0 15.9 16.4 14.2 14.2 3.0 Cumulative 3.4 12.0 25.0 40.9 57.3 71.4 85.6 88.6 Rat of Reb: Not applicable erty Catepry: groam= of, lIed Intevftions. The project supports ovefall strengthening of the Family Welfare progran, which is designed to deliver free pimary health and family planning services to poor women and children. One of its main components covers extension of srvces into poor aiJ undersrved areas, inlduding tribal, nomad and isolated populations, plus stengthening of outreach to poor nu families. Special stategies for serice delivery to triba, nomad and other isolated groups are included in the proect.  IND FAMIL WELFAR (ASSAM, ItAJ,SHA AND KATNAKO P;OEC I. WELUaT101 ISSUES AND THE HtEALTH DE WOMEN AND CEDM -N IND1MA A. Demographic Trends and Issues 1.1 India has the second largest population in the world, enumerated in 1991 at 846 million or 16 percent of the world's total. TLe national rate of population growth has hovered around 2 percent per annum since Independence nearly 50 years ago, the product of steadily declining mortality combined with compensating falls in fertlity. There are signs of a gradual slight decline in the growth rate, but a major further drop in fertility wil be needed to offset continued falls in mortality and achieve genuine low growth. India's population has more than doubled since Independence, and at a growth rate of 2 percent will double again in another 35 years. The percentage of the population Iving in urban areas has also grown steadily to a current level of about 26 percent. 1.2 During the last 50 years, national life expectancy has risn from under 35 years to 60 years, while infant mortality has fallen from at least 200 to just under 80 per thausand births. The fall in childhood mortality has beer. particularly marked over the last few yas. This overall decline in mortality has been primarily due to ircreasing control of communicable and epidemic diseases, such as malaria, cholera, smallpox, tuberculosis and the communicable diseases of childhood, coupled with the virual elimination of penodic famines and general improvements in the food supply and nutrition. 1.3 During the same period, national fertility has dropped from a total fertility rate (TFR) of more than six births per woman to 3.6, with most of the decline occurring during the las 20 years. The fall is due in part to a steady rise in the average age at maniage for girls from under 16 years to nearly 19 years, but mainly to the increasing use of birth contmr among married couples to a current contraceptive prevalence rate (CPR) of over 40 percent There is conceem, however, that the increase in contraceptive use appears to bave stalled over the last few years. In combination with continued mortality decline, such a stall is liklly to prevent any further reduction in poplatn growth. 1.4 These national figures conceal large variations across the vast population of India (see Annex 1). Generally speaking, mortality and fertility are lower in the south than in the north. The southemmost slates of Kerala and Tamil Nadu are close to replacement-leve ferlity, while Kerala has achieved a life expectancy of over 70 years and an infant mortality rate (IMR) under 20. By contra, the big northern states such as Uttar Pradesh, Madhya Pradesh, Rajasthan and Orissa still suffer infant mortaity rates in the range of 89 to 114, while U.P, Rajasthan and Orissa also have total fertlity rates ranging from 4.6 to 5.1. It is these states that primarily impede national progress to levels of mortality, fertility and growth  2 similar to those of China. 1.5 India does not have the natural resource base to sustain such a huge and rapidly growing population Wefznitely. Population density has already reached 257 persons per kn2. Land is becoming increasingly scarce, leading to fragmentation of holdings, underemployment, and the growth of the landless rutal class. In turn, urban nmigation is producing constant growth in outlying slum populations for which cities cannot afford to provide services. Other natual resources, such as forests and water supplies, are under severe pressure. 1.6 In India, human resource development has suffered from under-investment and under-financing in the education, health, nutrition and population sectors, particularly at the lower levels. Over ten percent of girl children still receive no education at all, and less than Lalf of either boys or girls enrolled in primary school manage to complete it. Fifteen percent of the population are still not covered by any health or Family Welfare services, while the national Integrated Child Development Services (ICDS) program covers only half of children in need. In turn, this failure to develop human resources to their full potential will increasingly act as a drag on the national development effort. D. Child and Maternal Healt 1.7 Childhood levels of mortality and morbidity in India are still very high (see Annex 1). The national infant mortality rate has declined markedly in recent years, but is still nearly 80 per thousand births More than ten percent of Indian children still do not survive their first five years of life. The major causes of death in childhood are similar to those found throughout the developing world, namely respiaoly infectons, diarrhoeal disease, malnutrition, low birthweight, malaria, tetanus and the communicable diseases of childhood, notably measles. The effects of poor birth spacing and excessively early childbearing on the health of the children born have not been well studied in India, but are kinown to be important in other high-fertility countries. Deaths from all of these causes are largely preventable. 1.8 A peculiarity of Indian mortality pattems, rarely found outside South Asia, is the marked female disadvantage in childhood and through the young adult years. As a result, there is a significant male surplus in India's population, with the current sex ratio standing at 108 males per 100 females. The female it o-tality disadvantage has been found for as long as reliable mortality estimates go back in time, but has been declining gradually. It is a partcular feature of northern India and is considerably lessened or even absent in most of south India. 1.9 At present, national IARs are much the same for boys and girls, and female life expectancy recently rose slightly above male life expectancy. However the female disadvantage persists from early childhood up to the age of 35 years, after which it disappears. It is particularly marked in early childhood and in the early childbearing years.  3 The causes of the disadvantage in early childhood are thought to be prefetenial feeing and care for boys, including preferential recourse to medical treatment. The causes in the early childbearing years are thought to be largely related to the high level of matemal moftty and the continuing poor nutrition of women, again the product of the low status of girls and young women. 1.10 Maternm morality in India is among the highest in the world. The maten mortality ratio is estimated at around 550 deaths per 100,000 deliveries, implying that about 20 percent of all deaths to Indian women of childbearing age are matemal deaths. The most important causes of mautenal deaths in India are sepsis and hemorrhage, which together account for 40 to 50 percent of deaths. Other major causes are toxaemia, obstructed labour and abortion. Anaemia, which is a chronic condition of most Indian women, is an important contributing factor throughout, as well as unhygienic delivery conditions at home and reluctance on the part of families to take women with high-risc pregancies or complicated deliveries to health facilities for assistance. H. GOVUtNERNT POLCIDES AND PROGRAMS IN lbOl!UATIO AND AIATENL ANDCID BIEAM1 A. Population Pollcies and Prgam 2.1 Concern in India over the rapid growth of population, and its adverse consequences for national development and living standard improvements, has been high from Independence onwards. As a result, a national family plaing program was stated as early as 1952. It has continued in existence ever since, first as a free-standing program and later, since 1977, integrated with the MCH (matenal and child health care) program into te Family Welfare program. Government commitment and support for the family planning program has flucuatd over its 42 years of life, but has generally been strong. Recent evidence of commitment has been its effective protection under Idia's stuur adjustment program. 2.2 Technically speaking, the family planning program has always suffered from flaws of design and implementation which have limited its effectiveness and impact (see paras. 3.9-3.11), as well as from persistent underfunding relative to total needs in the sector. There has also been a lack of attention to interventions oter than famUily planing services which might increase demand for smaller families and birth control, such as iprvements in the education and stats of women. In response, GOI has caried out periodic r cgs of the program and has relied increasingly on donor funds for invesment financing. 2.3 The most recent effort at restuctuing the Family Welfare program, including the family planning program, is the uAction Plan for Revamping the Family WeLfare Program in India, issued by the Ministry of Health and Family Welfire (MOHFW) earuy in  4 1992. This laid out a central strategy for improving the performance and impact of the entire program (see para. 3.12 and Annex 2) and led to creation of a national population commission intended to address these and other issues and interventions in the population sector. State Plans were next to be prepared. Substantial progress has been made on implementation of the national Plan but there is still much to be done at both national and State level (see paras. 3.12-3.14 and Annex 2). Formal State Plans for Assam, Rajasthan and Karnataka were drawn up during preparation for this project, with the project's design and content fully taken account of in their formulation. B. Poflcies and Programs in Maternal and Child Health 2.4 In the first two decades following Independence, India's public health services focused largely on curative and hospital care, together with vertical control progams for such diseases as malaria and leprosy. With the development of the primary health care philosophy in the 1970s, however, attention turned to the establishment of primary health services and preventive care, and to the creation of an appropriate infrastructure and trained workforce on the base of the already existing network of health facilities and staff. Matnal and child health (MCH) care became the focus of this effort, and MCH programs were established. Finally, the link with family planning was recognised and formalised and servce delivery for the two sectors was integrated under the title of the Family Welfare Program in 1977. 2.5 Within MCH, the emphasis was at first on child health, as elsewhere in the world. In the mid-1980s, the very successful Universal Immunisation Progmm (UIP) was launched, which now covers 85 percent of children and may have been responsible for the recent large drop in infant and child mortality. Other programs also began to be developed, including the Control of Diarrhoeal Diseases (CDD), interventions to control Acute Respiratory Infections (ARI) and the provision of supplements of Vitamin A and iron. 2.6 Tle Family Wela program had always included antenatal, delivery and postnatal care as one of its basic services, but maternal care at first took second place to child health care. In response to the worldwide Safe Motherhood initiative in the mid-1980s, attention has become increasingly focused also on the high leveis of maternal morbidity and mortality in India. 2.7 Under the Eighth Five-Year Plan (1991-95), a maternal and child health plan was developed to move forward in both maternal and child health. The plan called for packages of interventions for each aspect to be delivered through the Family Welfare program. The child health package was conceived as building on the base of the successful UEP and was entitled UIP Plus. Besides immunisation, it would include the ARI, CDD and Vitamin A and iron supplementation interventions, as well as newborn baby care. The safe motherhood package would include: antenatal care (regular check-ups, tetanus immunisation, anaemia control, screening and referral of high-risk cases); care at delivery (trained assi.4ance during delivery by traditional birth attendants (TBAs) or Family Welfare staff, together with timely  5' referral to properly-equipped higher-level facilities when necessary); postnatal care; and promotion of safe birth spacing and timing. In addition, first referral units for complicated delivenes would be made accessible through upgrading of Community Health Centres (CHCs) or district hospitals. This plan is now being implemented under the IDA-supported Child Survival and Safe Motherhtood (CSSM) project (see paras. 3.13, 3.21, 3.23). m. THE INDIAN FAMILY WELFARE PROGRAM A. Structure and Scope 3.1 The Family Welfare program provides the primary health care level in the Indian public health care system. Its focus is on women and children and on preventive health, and it is oriented towards the fidral and urban poor. In practice, many services offered Sy the program are also available and obtained from NGO and private sector providers of both allopathic and traditional systems of medicine, who overall provide around 80 percent of aU health care in India even among the poor. This is particularly the case for maternal care and all curative care. For some Family Welfare interventions, however, the program is almost the sole provider of services to the poor, notably for immunisation and sterilisation. 3.2 Because of thie national importance attached to the family planning program, the Family Welfare program is almost entirely centraUlly-funded, except for a few small but important items such as maintenance of Family Welfare facilities and salaries of male Multi- Purpose IHealth Workers (MPHWs). The program is however implemented by the states. By contrast, most financing of "health services" (comprising the hospital network and vertical disease-control programs for malaria, tuberculosis, leprosy, AIDS, etc) as well as their implementation are the responsibility of the sates, with some assistance from the centre to the disease-control programs. 3.3 The core Pamily Welfare program infrastructure in rural areas consists of Prhia Health Care Centres (PHCs), Community Healtn Centres (CHCs) and sub- centres. The key institution is the PHC, which is intended to cover a population of 30,000 and is the administrative headquarters of the preventive care system. Clinics providing minor curative care are also run at the PHC, and there are in-patient facilities for observation and medical treatment. They are also used for sterilisation and immunisation camps. PHC staff complements include one or more medical officers, who run the clinics, provide any in- patient treatment, and supervise the preventive care system. The medical officers are assisted by a complement of four or more support staff, consisting of Health Assistants (HAs), Multi- Putpose Health Workers (MPHWs) or Lady Health Visitors (LHVs), plus a Community Health Worker. 3.4 The sub-centre is the lowest level of Family Welfare institution and is often called the outreach arm of the program. There are generally around six sub-centres  6 depending from each PHC, each sub-centre serving a population of around 5,000 in one or more villages. In hilly, tribal or other remote areas, the population covered may be lowered to 3,000. The sub-centre is staffed by one Auxiliay Nurse-Midwife (ANM), also known as a female MPHW or Junior Health Assistant. She is responsible for promoting and delivering all preventive matemal and child health services in her community, as well as for motivation for family planning and supplies of pills and condoms; occasionally she may also be trained to insert IUDs. She will also provide some minor curative care. ANMs are super-rised in the field mainly by the LHVs (who are usually promoted ANMs), but also by the PHC medical officers during the regular monthly meetings at the PHCs. A male MPHW is sometimes also present. 3.5 The original design of the Family Welfare program included community linkages with the sub-centre through a system of community-based volunteers called Health Guides. These workers assisted the ANMs in promotion of MCH and family planning services and acted as a Liaison between them and the community. This scheme has been largely abandoned, and no substitute has yet been put in place. The only remaining links are through the village traditional midwives or TBAs (dais), who are supervised in an informal fashion by the ANMs and sometimes trained by them. 3.6 The CfC is one step up fiom a PHC, and is often crated from one by Upgrading. There is generally one per sub-district, and each is intended to cater to a population of 100,000. CHCs are supposed to provide specialist services, including minor surgery, and to be staffed by specialists, including a physician, surgeon, gynecologist, dental ugeon and pediatrician with support staff to match. Again, they are also used for camps. 3.7 These Family Welfare facilities, staff and services are supported by state-level training, MEC and MIS institutions, and managed from the state Health and Family Welfare department. However much of the content of the program and its support services, as well as maement systems of targets, norms and incentives, are centrally determined and controlled from MOHFW. 3.8 The urban Pamily Welfare system is broadly similar to the rural structure, except that the lowest level is called the health post and has a doctor, the maternity home or Post- Partum Centre takes the place of the PHC, municipal or Government hospitals take the place of the CHC, Public Health Nurses (PHNs) take the pLace of LHVs, and community linkage schemes have been or are being established in the largest cities. Management is done from municipal health departments. B. Performance, Problems, Issues 3.9 The Fanily Welfare program has had many successes. The UIP program has maised immunisaronrates for children to 85 percent from a starting point of ess than 40 pect in 1985, and recently received an extremely favourable evaluation from international experts. Contraceptive prevalence has rsen from around 20 percent in the late 1970s to more  7 than 40 percent today. Both childhood mortality and fertility have fallen significantly over the past decade. Yet despite these achievements, the Family Welfare program continues to suffer from long-standing problems of implementation throughout India. If not solved, they threaten further progress in i-ducing fertility and maternal and childhood mortality. 3.10 These problems are well-known. Program financing is inadequate for total needs, particularly for recurrent costs of maintenance and medical supplies. Program management is weak and over-entralised. The progran has been driven by mechanical, rigidly-administered and counterproductive systems of targets, norms and incentives. Supervision is punitive and/or inadequate. Training has been of poor quality. Workloads for lower-level staff are unrealistically high and their living conditions are often poor. Systens of outreach and community linkages are inadequate. Too little attention is paid to IEC. Although the Family Welfare program is designed to provide a wide range of family planning methods (male and female sterilisation, the pill, the IUD and condoms, backed up by MTP services in the event of contraceptive failure), the range of choice acually open to couples is extremely limited, with female sterilisation often the only option made available in practice. 3.11 These generic problems are co-npounded in poor or backward states vmd distrcts by their characteristically poor management and implementation capacity, difficulties of transport and access, cultural resistance to modern MCH and family planning services, and lack of adequate basic Family Welfare infrastructure. Taken all together, they tend to result in low morale among Family Welfare staff and dissatisfaction and low utilisation of services by the community. 3.12. The Action Plan for Revamping the Family Program drawn up by the MOHFW in early 1992 is designed to address many of these issues (see the summary in Annex 2). Its twelve components include: (1) generation of national consensus and policies for the Family Welfare program; (2) improvement of the quality and outreach of FW services, including creation, consolidation and maintenance of new and existing FW infrasucture and improvements in FW workers' living conditions and skills; 3) special initiatives in the 90 most backward districts of UP, MP, Bihar and Rajasthan, based on disaggregated, micro- level planning; (4) modification of the current system of targets and incentives for adoption of (female) sterilisation to make it more flexible and effective, including removal of rigid, centrally-imposed targets, discontinuation of payments to motivators, and devolution of more responsibility to the States; (5) promotion of a broader contraceptive method mix and greater use of spacing methods by younger couples; (6) upgrading and intensification of the performance of UIP and MCH programs; (7) improvement of FW services in urban slums; (8) salvage and revitalisation of community-based link worker schemes; (9) raonalisation and strengthening of FW field worker taning; (10) rvitalisation and intensification of IEC efforts (with specal mention of Rajasthan's integrated IEC bureau as a model); (11) greater involvement of NGOs; and (12) strengthening of intersectoral coordination between the FW program and other relevant Government agencies through creation of a high-level population commission and corresponding State and district-level bodies.  8 3.13 Progress has been made on putting most parts of this strategy into action, with major support from WDA-supported opertions (see paas. 3.16-3.24). The Child Survival and Safe Motherhood (CSSM) project of national scope, which is now completing its second year of implementation, is designW to support and strengthen the overall package of MCHI interventions included in the Family Welfare program, including birth spacing methods. In addition, special attention is being given to the creation of facilities for high-risk deliveies in the 90 backward districts. Under the Social Safety Net Credit, which became effective in December, 1992, GOI has begun to increase the standard allocation of drugs to Family Welfare centres and plan and implement special interventions (micro-planning for service improvements, augmentation of drug supplies, upgrading of facilities, posting of female doctors) in the 90 backward districts. Most of the major concerns of the components covering service improvement, urban schemes, field-worker training, community-based link workers, IEC and NGO involvement are being addressed in the States and cities covered by IDA-supported Area Projects, including the Fourth, Fifth, Sixth and Seventh Popuation Projects plus the Family Welfare (Urban Slums) Project, as well as by those covered by other donors. 3.14 On the Government side, a high-level Population Commission has been set up as a sub-committee of the National Development Council, a council which comprises all Chief Ministers of States. This Commission has undertaken and stimulated work on policy formulation, intesectoral odinadon and generation of national consensus. The preparation of State Action Plans, intended to put the Action Plan into implementation at State level, has begun. ITe package of incentives and targets underpinnig the dominance of steilisation is being gradually dismantled from the Centre; payments to motivators for steriLisation have been discontinued and targets for sterilisation acceptors have been devolved to the States and de-emphasised. Correspondingly, targets for spacing methods are being increased and emphasised. Several initial steps have been taken on the promotion of a broader method mix: Production of upgraded condoms and IUDs is due to begin shortly; production of oral pills has been restored from the temporary crisis of the past two years; clnical trials of implants have been initiated; injectables have been cleared for use in the private sector (with the intention of incorporating them in the Family Welfare program as soon as their popularity and acceptability bave been demonstated); and planning has begun for re-introduction of vasectomy using new and improved surgical techniques. Consideration and formulation of next step on program reform and development has begun. 3.15 This project would play an essential role in the implementation of the Action Plan in Assam, Rajasthan and Karnatka, as shown in detail in Table 1. It will ufilise key indicators relating to Plan goals and objectives for project monitorng and evaluation. It would support implementation of the Action Plan components covering service quality and outreach improvement, field-worker training, community-based link worker programs, IEC and NGOs (components 2,8,9,10,11) in Assam, Rajasthan and Karnataka. In addition, it would help support stngthening of MCH programs in these states through establishment of First Refenal Units (component 6) and the speial initative for 90 districts (component 3) tough FW program strengthening in Rajastfan. The project would also seek to advance  9 central and state-level progress on modifying the incentive/target system for sterilisation and promoting a broader method mix, throughi choice of appropriate key indicators for progress in fimily planning diversification and support of pilot schemes for mcre effective delivery of tenorary methods, including state-wide use of a network of community-based link workers who would hold stocks of contaceptive supplies and distribute them to users. able 1 sUa of Ihe rotect to Oe Acieo PHua or vanagg the FamEv We. r Pian Comonetll Corespoding Specific omens In Project Rerence 1. NadoW Strong JEC conent including auenin to opinn leaders Annex 13 on EC Stateges 2. St o Olity, Constuction t, ebabiiin of infastructue includi in Pams. 4.12-4.14,4.17 temote ad tribal areas Deav lopmt of nm baining modules iludig conunucauns Parm. 4.31, Annex 11 on akflla Training Sategis Mainanm usym for buildings, equinwtd, vehicles Pams. 4.16-17,4.24-26, Amnex 12 on Logidics Annex S on Model Building Plans Sunpervson yrov ene throgh better daff motbit Pan. 4.18 NW Planin8 State Ptoposals Improvement in ANM in, wtoring condio tuhug b f Parms. 4.15,4.18,4.19, SC dn, bee mobility, additional ain, communy- ad corresponding Annxes based a""ol workers 3. aDe