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

Dommt of The World Bank FOR omciaL USE ONl Rept No. P-6336-IN *MEMRANDUM AND RECONIEIMATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUJTIVE DIRECTORS ON A PROPOSED CREDIT OF SDR 62.7 MILLION TO INDIA FOR A FAMILY WELFARE (ASSAM, RAJASTHAN AND KARNATAKA) PROJECT MAY 26, 1994 MICROGRAPHICS Report No: P- 6336 IN Type: MOP This document has a restricted distribution and may be used by recients only in de pormace of their offcial dWues, Its contents may not otherwise be disdosed without World Bank auorizatio.  CURRENCY EQUIVALENTS (As of December, 1993) Currency Unit = Rupee Rupee 33.9 US$ 1.00 Rupee 1.0 - US$ 0.03 METRIC EQUIVALENTS 1 Meter (M) = 3.28 Feet (ft) 1 Kilometer 0.62 Miles FISCAL YEAR April 3. - March 31 ABBREVIATIONS AM ACRONYMS CSSM - Child Survival and Safe Motherhood (project) FW - Family Welfare GOI - Government of India IDA - International Development Association IEC - Information, Education and Communication MCH - Maternal and Child Health (care, services, program) MIS - Management Information System MOHFW - Ministry of Health and Family Welfare NGO - Non-Governmental Organisation UIP - Universal Program of Immunisation WID - Women in Development  FOR OFFICIAL USE ONLY INDIA FAMILY WELFARE {ASSAM. RAJASTHAN AND KARNATAKA) PROJECT CREDIT AND PROJECr SUMMARY Borrower: India, acting by its President Beneficiaries: States of Assam, Rajasthan and Karnataka Amount: SDR 62.7 million (US$88.6 million equivalent) Terns: Standard, with 35 years maturity On-Lending Terms: Government of India to the States of Assam, Rajasthan and Karnataka in accord--e with standard arangements for development assistance to States. Financing Plan: Local Foreign Total IDA 81.4 7.2 88.6 GOI 15.2 - 15.2 Total 7.2 103.8 Egimated 1isbursments: E. FY96 FY97 FY E2299 FY PY2001 FY2002 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 Rate of Retun: Not applicable Poverty Category: Program of Targeted Interventions. The project supports overall strengthening of the Family Welfare program, which is designed to deliver free pnmary health and family planning services to poor women and children. One of its main components covers extension of services into poor and underserved areas, including trbal, nomad and isolated populations, plus strengthening of outreach to poor rual families. Special stategies for service delivery to tribal, nomad and other isolated groups are included in the project. Staff ApW Report: Report No. 12771-IN This docu_mt has a restrcted distribton and may be used by ecipients only in the pefanc of ther officia dudes Its contents may no otheoise be discosed vithout Wra Dak authoizaton.  MEMORANDUM AND RECOMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO INDIA POR A FAMILY WELFARE (ASSAM, RAJASTHAN AND KARNATAKA) PROJECI 1. The following memorandum and recommendation on a proposed credit to India is submitted for approval. The credit, for SDR 62.7 million (US$88.6 million equivalent), would be on standard IDA terms with 35 years maturity. The credit would help finance a Family Welfare (Assam, Rajasthan and Karnataka) Project. The proceeds of the credit would be passed on by the Government of India (GOI to the three States in accordance with standard arrangements for development assistance to States. 2. Sector Background: The Indian Family Welfare (FW) program has had many successes in loweng both fertlity and childhood mortality through provision of famiy planning and maternal and child r.ealth (MCH) services. Its successful Universal Programme of Immunisation has played an important role in the steep decline in infant mortality over recent years. The program has also, as the major provider of family planning services, been largely responsible for steep rises in contraceptive prevalence and declines in fertility over the last 15 years. Nationwide, India's infant mortality rate now stands at about 80, its total fertility rate at about 4, and its contraceptive prevalence rate at around 45 percent of eligible couples. 3. Yet the FW program still suffers from well-known problems. These include: rigid targets and incentives; inadequate financing, partcularly for maintenance and drugs; inadequate staff training, supervision and living conditions; inadequate outreach and community linkages; limited Information, Education and Communication (EEC) efforts; and limited choice of contraceptive methods. These problems are compounded in remote or backward areas by poor management; difficult transport and access; cultural resistance to modern MCH care and family planning; and lack of basic FW infrastructure. 4. Government Actions: GOI is addressing these problems through the 1992 'Action Plan for Revamping the Family Welfare Programme in Inrl-a". C.,anponents include: (1) national consensus-building on FW issues (2) improvement ot service quality and outreach, including upgrading of FW infrastructure and workers' living conditions and skills; (3) special initiatives in India's 90 most backward districts; (4); modification of current systems of targets and incentives; (5) a broadened contraceptive method mix with more use of spacing methods by younger couples; (6) intensification of the UIP and MCH programs; (7) upgrading of FW services in urban slums; (8) revitalisation of community-based link worker schemes; (9) strengthening of FW fieldworker training; (10) intensification of IEC; (11) greater involvement of NGOs; and (12) strengthening of intersectoral coordination. 5. This Plan is being implemented with najor support from IDA-assisted operations. The 1992 Child Survival and Safe Motherhood (CSSM) project strengthens the national MCH program. The 1992 Soci Safety Net Credit improves FW drug supplies and services in the 90  2 districts. Improvements in FW service quality, urban services, taining, community-based linkages, IEC, and NGO involvement are covered for the States and cities included in Area Projects (see below). A new high-level Population Commission is worldng on policy formulation, intersectoral coordination and national consensus-building. State Action Plans are being prepared to implement the national Action Plan. Incentive and target systems are being relaxed or dismantled. To promote a broader method mix, production of upgraded condoms, IUDs and oral pills is being boosted, clinical trials of implants have begn, injectables have been licensed for private-sector use, and improved vasectomy techniques are being introduced. 6. The proposed project will support implementation in Assam, Rajashn and Kamataka of Action Plan oomponents covering serice quality and outreach, fieldworker training, communty linlkge programs, EEC and NGOs, besides strengthening referral care for deliveries. It will also promote a broader method mix through appropriate project monitoring indicators and pilot schemes to improve access to tenporary methods, such as creation of networks of community depot-holders and distributors of contraceptive stocks. 7. IDA Experience in the Sector: Beginning in 1973, IDA has supported nine prcjects in population/primary health care in India. Eight have supported investment in FW program strengthening, with similar scope and approach, in a range Jf states or cities ('Area Projects'). Assam and Rajasthan are almost the only states not yet covered under this series. In the projects that have closed or are neaing completion (the First through the Fifth Population projects), physical and programmatic objectives in civil works, service delivery, taining and I1C have been largely fulfilled (see Schedule C for PCRs). Impact on mortality and fertlity was nuxed in the first three projects (all limited to a few selected districts), but has been substantial in the Fourth and Fifth projects. In the on-going projects (the Sixth and Seventh and CSSM), progress is mixed, with better performance in the better administered and monitored staes and programs. 8. Major problems encountered include: slow start-up; difficulties in integrating project and program management; persistent delays in flows of funds to the projects; slow pace of disbursements regardless of implementation progress; poor quality of civil works; and failures to absorb and sustain project initiatives after closure. The basic approach of the projects appeas sound if implemented well; the quality of project and program management and the long-term commitment of the state or city to the project and to the FW program are key determinhats of project success. 9. IDA Lending Straty and Rationabl for Involvement: The Bank Group's Country Stratgy (May 12, 1994) is to support GOI's efforts to provide an enablng envirmment for broad-based, efficient, private sector-led growth, while accelerating human resource development. A major element is enhancement of access to ano quality of basic social services for the poor. Assistance to the FW program, which focuses on services for the poor, is centrl to this strategy. It not only provides 4irect health benefits to poor mothers and young children but also contnbutes to human capital development through fertiliy reduction, which cuts population growth and dependency burdens, permitting greater investment in fewer children.  3 10. The project would complete the Bank's long-tenn program of FW investment with support to Rajasthan and Assam, plus follow-up in Karnataka on previous projects which did not realise their ful potential. It is intended that sectorially and policy oriented operations will follow, addressing major weaknesses in key aspects of the program, that will support the more generalized implementation of the 1992 Action Plan. This project is a bridging operation, which in itself will improve FW program performance in Assam, Rajasthan and Karnataka and furthermore strengthen the program's structure for implementation of future policy changes. 11. hroledi Qbleetives: The project has two intrrelated objectives. The first is to strengthen and improve the functioning of the FW programs of Assam, Rajasdtan and Karnataka. The second is to lower curent levels of fertility and maternal and childhood mortality in the three states. Achievement of these objectives will be assessed through key project indicators related to the aims and objectives of the Action Plan. 12. jeet Decriplion: The project has five major components. Component (1) will strenethen Famly Welfare service delivery through extension and upgrading of FW inrstructure in underserved areas and strengthening of outreach and community linkages; it will support: upgrding or rehabilitaton of facilities; establishment of ancillary mobile clinics; transport for outreach and supervision; and community linkage and participation systems using community volunteers. Component (2) will improve Family Welfare service quality through support of: strengthening and rationalisation of taining institutions and programs; supplementary equipment, drugs and other medical supplies; improvements in logistics systems for medical supplies and transport; and involvement of NGOs and private medical practitioners (PMPs). Component (3) will strengthen demand generation activities through support of: strengthiening and atiolion of IEC institutions; IEC training for service providers and community volunteers; JEC materials production; and selected IEC activities. Component (4) will strengthen pu= ranam d iem entatim capacly through support to: development of state Mnement Infornation Systems (MIS) and planning capabilities; development and monitoring of strategies for populations with special needs; an office building for the Assam PW department; and upgrading of staffing and equipment in the Ministry of Health and Family Welfare (MOHFW)'s Area Projects Division. Component (5) will support two flexible funds for (a) small pilot innovative schemes to imprwe service deliverya and (b) prlion of pgLrXsa for Family Welfare investment in the heavily tribal and underdeveloped states of Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland and Tzipura in the Northeast. 13. Social Aspects of Project Design: Poerty and Gender Aspct5: The main beneficiaries of the FW program, which provides free MCH and family planning services, are poor women and children. The project focuses on service delivery to the underrved and isolated communites of each state, which are generally also the poorest. Indig u fPaulatioQn: The project covers states whose populations are 4-16 percent tribal, plus 2 percent nomad in Rajasthan, and is in full compliance with Operatonal Directive 4.20. Beneficiary needs assessments showed that health and fertlity-related disadvantages among these remote, isolated and scattered groups were largely due to poor access to FW services, plus some special cultural featus. he project will implement speci tribal/nomad service strategies, whose key elements  4 are mobile sevices, improved transport for providers, experimentation with smaller coverage norms and relaxed facility construction and staffing standards, emphasis on community participation, specially-tailored EEC strategies, heavy NGO involvement, and special monitoring. 14. Project pIlementatlon: The project will be implemented by the states, with supervision by the Area Projects Division of MOHFW. Each state will set up a high-level empowered committee to make major policy decisions, authorise transfers of project funds from the centre to the project, and monitor overall project progress. A project management unit will implement the project under its guidance, staffed for extensive field monitoring of civil works. After project closure, unit facilities, equipment and staff will be merged into regular program management. Project-program coordination will be built into management routines. 15. froject CoQ: The total cost of the seven-year project, including duties and taxes, is esfimated at Rs. 4,409.8 million (US$103.8 million equivalentj. IDA would finance US$ 88.6 million equivalent, covering 89.9 percent of costs net of taxes. The cost net of taxes is Rs. 4182.7 million (IJ$98.5 million equivalent). A breakdown of project costs and the financing plan are shown in Schedule A. Retroactive financing of up to US$1.0 million will be provided to cover eligible expenditures incurred after December, 1993 to facilitate ongoing start-up activities. Schedule B shows the amounts and methods of procurement and the disbursement schedule. A timetable of key project processing events and the status of Bank Group operations in India are presented in Schedules C and D. The Staff Appraisal Report, Report No. 12771-N, dated May 24, 1994 is being distributed separately. 16. Project %Mhftainabity: The FW program is financed almost entirely by GOI, but a few important expnses are borne by the states. In the three project states, about 94 percent of FW expenditure is currently met by GOI and the remaining 6 percent by the states. Additional annual recurrent costs generated by the project after closure are estimated at a total Rs. 155 million. Given an unchanged funding split, GOI's share would amount to Rs. 146 million, the equivalent of only 1.2 percent of GOI's total FW budget this fiscal year and clearly sustainable. The states' share would amount to Rs. 9 million, which is equivalent to increases of 9-12 percent in each state's non-GOI financed FW budget for this fiscal year, but a very small share of overall state expenditure. In addition, it should be noted that these investments are being carried out as the Government of India is implementing a reform program, aw important aim of which is to reduce the role of government in some sectors but to strengthen public financing of high priority human resources investments. 17. A0 rtache: At negotiations, GOI provided an assurance that it would: (a) carry out with IDA an annual review of resource requirements for the project for next fiscal year, to detennine that there will be full provision for project activities; and 0) implement the Action Plan for Revamping the Family Welfare Program. The states provided assurances that they would: (a) establish the full project management structure by October 30, 1994; (b) engage all other key additional personnel by December 31, 1994; (c) ensure that adequate and timely. resources for the maintenance of FW facilities are provided and that facilities are adequately maintained; (d) ensure adequate supplies of drugs and other medical materials to FW facilities;  5 (e) implement the State Action Plans; (f) utilise agreed key project indicators related to national and state Action Plan objectives for project monitoring and evaluation; (g) implement their tribal strategies fully. The state of Kanataka also provided an assurance that it would: (a) carry out a program of adequate rehabilitation of existing FW facilities; and (b) firnish satisfactory evidence of the program's satisfactory implementation. 18. - roject Beneftgs: The project would improve FW service quality in Assam, Rajasthan and Karnataka, increase access to FW services in poor and underserved areas, increase demand for FW sres, and strengthen program management. Improved program effectiveness is expected to increase service utilisation, and hence achieve better health for r.others and children and accelerated, mutually reinforcing, declines in fertility and maternal and childhood mortality. Eventually, fertility would fall low enough to bring about a decline in population growth in the three states and nationwide. State goals for the year 2000 are a birth rate of 20 or 21 per 1,000 population, a contraeptive prevalence rate of 60 percent of all eligible couples and an infant mortality rate of 50 per 1,000 live births. 19. ProjetB Risks: The project carries several risks, most of which are endemic in FW- support projects, but can be reduced if not eliminated through careful project design: (a) Based on past project experience, the risk of poor implementation is significant in all thee states. To minimize this risk, tight specifications and control measures have been built into the project for past problem areas, such as design, management, supervision and maintenance of civil works and mechanisms for strengtheniag and coordination of program and project management. (b) Likewise, the risk that project-created infrastructure and programs will not be maintained is everywhere substantial. This risk has been mimized through project agreements on building and drug budget maintenance during the project period and by building in project-program coordination and management strengthening measures. (c) A third risk is that many of the proposed approaches and programs are new and untested, particularly regarding outreach and community linkage schemes and mobile services. To minimize this risk, the project design calls for pilots, evaluations and gradual phasing-in of new programs. (d) Assam also faces the risk of an unpredictable secririty situation. Control of this risk is beyond the scope of the project, but security problems have not interfered with project preparation and, in the judgement of COI and the state, are unlikely significantly to jeopardise FW investment. 20. Reeommendation: I am satisfied that the proposed credit will comply with the Articles of Agreement of the Association and recommend that the Executive Directors approve the proposed credit. Lewis T. Preston President Attachments Washington D.C. May , 1994  6 SHEDULE A FAMILY WELFARE (ASSAM. ASHAN AN) KARNATAK) PROJET ESTIMATED COSTS AND FINANCING PLAN Estimated Project Costs: ( Mile US Mili % X TOW -iInip B8 Locd hnriza~~~L- ToW a LoZ l -TOt x Q gee Sta_ F.W. SavicDdiay 1,559.8 139.2 1.699.0 46.0 4.1 50.1 8% 53% aptovo Qualiq ofF.W. Senrica 714.1 30.8 744.8 21.1 .9 22.0 4% 23% InrasiagDemandfor F.W. Savice 339.2 8.1 348.0 10.0 .3 10.3 3% 11% Ma-04eWtlp-ovaeOt 276.9 21.0 297.9 8.2 .6 S.S 7% 9% inmovalivschme 134.5 2.8 137.3 4.0 .1 4.1 2% 4% Toal BASELNR cOm 3.024.5 202.5 3.227.1 89.2 6.0 9S.2 6X 100% ft-ysialGCotingaici 244.4 20.3 264.7 7.2 .6 7.8 8% 8% PucCoatiugalcia 835.5 82.5 918.1 .2 .7 .8 78% 1% Togal lROJICT COSts 4,104.5 305.3 4409.S 96.6 7.2 103.8 7% 109% flnandng lan: Local Foreign Total I US$ Million Government 15.2 - 15.2 IDA 81.4 7.2 88.6 TOTAL PROJECT COSTS 96.6 7.2 103.8  7 SCHEDULE B Page I INDA FAMILY WELFARE (ASSAM. RA1ASTHAN AND KAMNATAKA_) PROJECT SUMMARY OF PROPOSED PROCUREMENT ARRANGEMENTS Procuren Method Intemnational Local Competitive Competitive Bidding Bidding Other N.B.F. Total CIVL WORKS civil Wo*s - 36.19 6.60 - 42.78 (32.57) (5.94) (38.50) GOODS V-w/ehicls 3.99 - 0.30 - 4.29 -'3.19) (0.24) (3.43) V'ehclks for Field Staff - 5.48 - 5.48 (439) (439) Furiture -2.71 0.98 - 3.69 (2.17) (0.79) (2.95) Equipment & Healh Kits - 6.69 2.43 - 9.12 (5.35) (1.94) (7.29) Tiniqg Maedral & Books - - 2.02 - 2.02 (1.92) (1.92) Consumables - 1.84 - 1.84 (1.35) (1.35) Medicines & Medical Matedal - - 3.04 - 3.04 (2.22) (2.22) TECHNICAL ASSISTANCE Prqject PreaPation & Inlemention - - 14.92 - 14.92 Suppott (cludes Grans, nnovative Schenws) (14.17) (14.17) 1nsitonl Developmm e lcudes - - 4.74 - 4.74 IEC & trainig (3.79) (3.79) MISCELLANEOUS Salares of Additional Staff - - 4.56 4.56 (3.37) (3.37) Honoarium to Commuy Voluns - - 2.83 - 2.83 (2.09) (2.09) T.A.JD.A. of Staff - - 0.27 0.27 Ciil Works Operaion & Maim - - 1.73 1.73 (1.24) (1.24) Equip & Fleet Opa-ration & Mawt - - 2.55 - 2.55 (1.87) (1.87) TOTAL 3.99 45.58 54.00 0.27 103.84 (3.19) (40.09) (4531) (88.S8) NO : Figures i parhis are the respective a fince by IDA  8 SCHEDULE B Page 2