India - Reproductive and Child Health

Report No. PIC2555 Project Name India-Reproductive and Child Health (@) Region South Asia Sector Targeted Health Project ID INPA10531 Borrower India, acting by its President Implementing Agency Ministry of Health and Family Welfare Government of India Beneficiary Government of India Date this PID Prepared March 12, 1997 Appraisal Date February, 1997 Projected Board Date May, 1997 1. Project Objectives. The Government of India (GOI) proposes to implement a nationwide Reproductive and Child Health Program (RCH) through its Family Welfare Program (FWP) to be financed by GOI as well as several External Agencies. This project represents the World Bank's financing support for the RCH Program. The proposed project would assist GOI to improve the performance of its FWP in reducing maternal and infant mortality and morbidity, and unwanted fertility, thereby eventually contributing to stabilization of population growth. The specific objectives of the project would be to: (a) improve management performance by nationwide implementation of policy change referred to as the "target-free approach" (see 1/), and institutional strengthening for timely, coordinated utilization of project resources; (b) improve the quality, coverage and effectiveness of the FW services; (c) progressively expand the scope and content of existing FW services to include more elements of a defined essential package of reproductive and child health (RCH) services (see 2/), and (d) in selected disadvantaged districts and cities, expand access by strengthening FW infrastructure while improving its quality. 2. Project Approach. The project is proposed to the first of two overlapping 5 year operations (RCH 1 and RCH 2) that would provide financing support for the FWP over an estimated eight year period. It is proposed that at the end of 24 months of RCH 1, a mid-term evaluation would be implemented. Lessons learnt would be used to (a) if necessary, modify the design of the remaining portion of RCH 1, and also (b) form the basis for appraisal of RCH 2. 3. Project Description. The project would be nationwide, and would include three major components: 3.1. Improving Management performance through (a) decentralized planning and modified monitoring system, (b) institutional strengthening, and (c) RCH research for management. In the sub- component on decentralized planning and modified monitoring system,  the project would finance: (i) development of capacity at district and sub-district levels for more responsive activity planning based on assessment of local needs in all districts in the country, and (ii) rapid surveys of clients and communities and assessments of service quality. In the sub-component procurement and technical support, the project would finance: (i) agencies to provide procurement support at state and national level, and (ii) institutions, including NGOs, to provide technical support in areas such as training, IEC, rapid surveys, and program monitoring and evaluation at national and state levels. In the sub-component on enhanced program management capacity, the project would finance: consultants and additional staff at national, state and district levels for program monitoring, supervision and trouble shooting, and to provide focused attention for program planning and implementation in weaker states. In the sub-component on RCH research for management, the project would finance studies particularly to evaluate new approaches, and workshops and publications to promote the dissemination of research findings and utilization of research in policy and program management. 3.2. Improving quality, coverage and effectiveness of an Essential package for reproductive and child health. The project would finance (a) training; (b) IEC and (c) upgrading of service delivery. Training and IEC would be financed in all districts nationwide that are not receiving similar support for these activities from any other project. Service delivery would be progressively upgraded, starting with a few blocks in each district. Districts have been broadly categorized into three categories (A, B, and C) according to projected needs. Differential packages of inputs have been designed by MOHFW to meet the differing needs of A, B, and C category districts. The packages would include drugs, medical equipment, limited numbers of selected categories of contractual staff who have critical clinical skills, minor civil works. States and districts would prepare detailed implementation plans and annual work programs to coherently operationalize the training, IEC and upgrading of service delivery and align the services to the specific needs of local communities. A few districts would experimentally introduce schemes for referral transport, use of community volunteers, contracting of private sector facilities to provide essential services and provision of services through the Tribal Welfare departments. 3.3. Improving access in specially disadvantaged districts and cities. The project would focus additional investments in 24 districts and cities where health and social indicators are much below the state's average. Such additional investments would finance strengthening infrastructure (including civil works, vehicles and additional contractual staff), community mobilization, implementation of innovative participatory approaches such as special schemes for community workers, NGOs and increased mobility for referrals and for service delivery staff. 4. Project financing. With contingencies, this project cost would be on the order of $300 million. IDA would finance approximately 85w, or about $247 million; the balance would be -2 -  financed by the Government of India. The cost and financing figures are tentative at this time. 5. Program Implementation. The Ministry of Health and Family Welfare, Government of India would be responsible for implementation of the RCH Program through the State Departments of Health and Family Welfare who supervise the District Family Welfare Bureaux (or, in some states, the Zilla Parishads) that would be the executing agencies. 6. Program Objective Categories, Poverty and gender aspects. The FWP is aimed at poor and underprivileged women and children in rural and urban poverty areas. The project, through the FWP, would increase access to wider range of good quality health care for larger numbers of such beneficiaries, and would facilitate them to adopt healthier behavior. Indigenous Populations. - In several states, tribal populations have especially poor health status indicators. This project would place them in high priority categories for district specific reproductive health care action plans. The guidelines that have been developed by MOHFW reflect this priority. Project development and implementation have taken full account of Operational Directive 4.10. 7. Environmental Aspects. The proposed project would not raise any environmental concerns. Attention would be given to the adequate disposal of medical wastes where relevant. 1/ The "target free approach" is a management policy shift. It removes management incentives that have placed excessive focus on achieving annual method-specific contraceptive acceptor targets, and introduces a "bottom-up" need-based management approach focusing on provision of good quality care to meet fertility and health needs at different stages of the life cycle such as adolescence, birth spacing and limitation together with healthy sexual activity, and pregnancy and child birth. 2/ A package of essential RCH services has been defined by GOI for (a) prevention and management of unwanted fertility, (b) management of pregnancy and childbirth, (c) child survival (including immunization, diarroeal and acute respiratory illness, and newborn care), and (d) reproductive tract infections. Contact Point: Public Information Center The World Bank 1818 H Street N.W. Washington, D.C. 20433 Telephone No.: (202) 458-5454 Fax No.: (202) 522-1500 Note: This is information on an evolving project. Certain components may not necessarily be included in the final project. Processed by the Public Information Center week ending April 4, 1997. -3 -