India - Child Survival and Safe Motherhood Project

 Child survival and safe motherhood project Report No: ; Type: Report/Evaluation Memorandum ; Country: India; Region: South Asia; Sector: Primary Health Including Reproductive Health Chi; Major Sector: Health Nutrition & Population; ProjectID: P010387 The India Child Survival and Safe Motherhood project, supported by Credit 2300-IN for US$214.5 million, was approved in FY92. The credit was fully disbursed and closed on September 30, 1996, 12 months after the original closing date. The United Nations Children’s Fund (UNICEF) provided parallel financing of $67.8 million, which was fully disbursed. The Implementation Completion Report (ICR) was prepared by the South Asia Regional Office. The ICR does not include comments from UNICEF. Rather, UNICEF participated with government , nongovernmental organizations (NGOs), and other stakeholders in a workshop discussion of plans for the completion report. The borrower’s evaluation of the project is included as Appendix B. The purpose of the project was to enhance and expand the maternal and child health (MCH) part of the Government of India’s (GOI) national family welfare program. To achieve this, the project financed the incremental costs of expanding the national MCH program and enhanced its child survival and maternal health (safe motherhood) activities. The increment was the difference between Seventh Plan outlays and GOI’s proposed expenditures for the Eighth Plan period. The specific objectives of the project were to: (i) expand the universal immunization program to include additional curative, preventive, and promotive services; (ii) strengthen safe motherhood activities through training, provision of supplies and equipment, and establishing first referral units (FRUs) for secondary level obstetric and neonatal care; and (iii) increase the effectiveness of all service delivery activities. The project was national in scope, with phased introduction of activities at the district level. The project succeeded in modifying the strategic emphasis of the family welfare program. MCH now receives higher priority in district plans and in field workers’ activities, and program philosophy now emphasizes quality and client responsiveness. The effort to enhance child survival services was partially met. Services additional to the basic immunization program activities lag behind the immunization program. Traditional birth attendants’ (lay midwives) training was partially completed, and anecdotal evidence suggests that family welfare workers are better able to identify high risk births in advance. The establishment of FRUs was much less successful. No information is available on the number of obstetrical and neonatal emergencies managed at FRUs. Few FRUs have the full complement of specialists needed, and family welfare workers are not systematically referring high risk cases to FRUs. Efforts to improve effectiveness in service delivery were also only partially met. Training programs for medical officers and paramedics are significantly behind schedule. The information, education, and communication program was more successful, although progress to stimulate community participation, employ social marketing methods, and cooperate with NGOs and private medical practitioners are not discussed in the ICR. Beyond the provision of hardware, plans to strengthen program monitoring were not implemented. Key indicators of performance are not reliably available at the national or state level, and field workers are not using management information systems to plan their activities. A number of studies planned to identify program improvements were delayed or not completed. Equipment procurement and maintenance was improved with UNICEF’s assistance. The project’s core activities are continuing beyond the close of the project through GOI support and with assistance from a follow-on project. The ICR rates the outcome of the project as satisfactory, sustainability as likely, institutional development as modest, and Bank performance as satisfactory. The Operations Evaluation Department (OED) agrees with the ratings of sustainability and institutional development, but, noting that efforts to improve the effectiveness of service delivery were largely unsuccessful, rates project outcome as marginally satisfactory. OED rates Bank performance as satisfactory. Although project design made unrealistic assumptions about Bank and borrower capacity to expand and enhance program effectiveness, and gaps in the program monitoring system were not resolved during project supervision, the Bank introduced important innovations in the management of supervision which should contribute long run improvements in development effectiveness. An important lesson to be drawn from the project, noted in the ICR, is that the expansion of activities in a service delivery program requires major adaptations in program strategy. The addition of more complex activities to basic immunization, as well as activities that rely on changes in consumer demand, may require adaptation of program activities to local conditions and thus would benefit from decentralized approaches to program management. Second, efforts to make programs more effective must include mechanisms, such as field-oriented monitoring systems and supportive research, to enable learning and adaptation. Third, large and complex programs require systematic management training to be successful. These lessons have been incorporated into the design of the follow- on project, which emphasizes linking performance measurement to the allocation of project resources, district level planning, and extensive management training. The ICR is satisfactory and gives a concise and frank description of the project’s achievements and shortcomings. Plans for improving the national program, mentioned in the government’s contribution to the ICR and embodied in a follow-on project, provide a plan for the future operation of this project, which is a slice of the national program. A more complete examination of the constraints to improving program effectiveness and comments from the cofinancier would have strengthened the report. No audit is planned, although the project will be assessed in the context of a planned sector impact study in India.