India - Reproductive and Child Health Care Project

Document of The World Bank Report No. 16393-IN PROJECT APPRAISAL DOCUMENT INDIA REPRODUCTIVE AND CHILD HEALTH PROJECT April 29, 1997 Population and Human Resources Operations Division Country Department 11 South Asia Region  CURRENCY EOI)IVALENTS (As of January 1997) Currency Unit = Rupee Rupee 35.87 = US$1.00 Rupee 1.0 = US$0.02787 METRIC EQUIVALENTS 1 Meter (m) = 3.28 Feet (ft) 1 Kilometer = 0.62 GOVERNMENT FISCAL YEAR April I - March 31 Vice President Mieko Nisliimizu Country Director Robert S. Drysdale Division Chief Richard Skolnik Task Manager Indra Pathmanathaan  ABBREVIATIONS AND ACRONYMS ANM Auxiliary Nurse-Midwife ARI Acute Respiratory Infections CDR Crude Death Rate CDD Control of Diarrhoeal Diseases CHC Community Health Centre CIF Cost, Insurance, Freight CMHO Chief Medical and Health Officer CPR Contraceptive Prevalence Rate CSSM Child Survival and Safe Motherhood DALY Disability Adjusted Life Years DGS&D Directorate-General of Supplies and Disposal EC European Commission EmOC Emergency Obstetric Care EsOC Essential Obstetric Care FMPW Female Multi-Purpose Worker FRU First Referral Unit FWP Family Welfare Program GNP Gross National Product GOI Government of India ICB International Competitive Bidding ICDS Integrated Child Development Services IDA International Development Association IEC Information, Education and Communication IMR Infant Mortality Rate LCE Local Capacity Enhancement MCH Maternal and Child Health MIS Management Information System MOHFW Ministry of Health and Family Welfare MSS Mahila Swastha Sangha MTP Medical Termination of Pregnancy NGO Non-Governmental Organization NFHS National Family and Health Survey PHC Primary Health Centre PMO Principal Medical Officer PSA Procurement Service Agency PVO Private Voluntary Organization RCH Reproductive and Child Health RTI Reproductive Tract Infection SCOVA State Committee on Voluntary Agency SIHFW State Institute of Health and Family Welfare STD Sexually Transmitted Disease TFR Total Fertility Rate UIP Universal Immunization Program UNFPA United Nations Fund for Population Activities UNICEF United Nations International Children Emergency Fund USAID US Agency for International Development   (i) INDIA REPRODUCTIVE AND CHILD HEALTH PROJECT CONTENTS Page No. BLOCK 1: Project Description ....................................................2 1. Project Development Objectives .................. ..................................2 2. Project Components ....................................................2 3. Benefits and Beneficiaries ...................................................4 4. Institutional and Implementation Arrangements .................................................5 BLOCK 2: Project Rationale ....................................................6 5. CAS Objectives Supported by the Project .................................................... 6 6. Main Sector Issues and Government Strategy ...................................................6 7. Sector Issues Addressed by the Project and Strategic Choices ............. ..................8 8. Project Alternatives Considered and Reasons for Rejection .............. .................. 10 9. Major Related Projects Financed by the Bank ................................................. 11 10. Lessons Learned and Reflected in the Project Design ...................... ................. 12 11. Indications of Borrower Commitment and Ownership ...................... ................. 12 12. Value Added of Bank Support ................................................... 13 BLOCK 3: Sumnnary Project Assessment .................... ............................... 14 (The complete assessments are in Annex 11 and in the Project Files) 13. Economic Assessment ................................................... 14 14. Financial Assessment ................................................... 16 15. Technical Assessment ................................................... 18 16. Institutional Assessment ................................................... 20 17. Social Assessment ................................................... 22 18. Environmental Assessment ................................................... 24 19. Participatory Approach ................................................... 24 20. Sustainability ................................................... 25 21. Critical Risks ................................................... 26 22. Possible Controversial Aspects ................................................... 27 BLOCK 4: Main Credit Conditions ................................................... 27 BLOCK 5: Compliance with Bank Policies ................................................... 29  (ii) ANNEXES 1: Project Design Summary ................................. 30 2: Detailed Project Description ................................. 33 3: Estimated Project Costs .................................. 48 4: Economic and Financial Analysis ................................. 49 5: Financial Summary ................................. 61 6: Procurement and Disbursement Arrangements. ................................. 62 7: Project Processing Budget and Schedule ................................. 73 8: Documents in Project File ................................. 74 9: Status of Bank Group Operations in India ................................. 78 10: India at a Glance ................................. 81 11: Institutional, Social & Technical Assessments ................................. 83 12: Critical Implementation Data ................................. 114 13: Status of Preparation ................................. 130  INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT INTERNATIONAL DEVELOPMENT ASSOCIATION South Asia Regional Office Country Department II PROJECT APPRAISAL DOCUMENT India Reproductive and Child Health Project Date: April 29, 1997 [ ] Draft [x Final Task Manager: Indra Pathmanathan Country Manager: Robert S. Drysdale Project ID: PA-10531 Sector: Population Lending Instrument: SIL PTI: [x] Yes [ ] No Project Financing Data [ Loan [x] ITF [] Guarantee [ ] Other Credit [Specify] For Loans/Credits/Others: Amount: US$248.3 million SDR179.5 million ........ .................................................. . . ................................. ............................. .. .. .. . ........ ....... ... ...... ..... ... ................ ............. . ............................I............................. Proposed Terms: [] Multicurrency [] Single currency Grace period (years): 10 years [ Standard [] Fixed [] LIBOR-based Variable Years to maturity: 35 Commitment fee: 0.5% Service charge: 0.75% ...........:.. ........... ........................................ ................................... ..................................................................................... ...... ................................................................................. ......... Financing plan (US$m): Source Local Foreign Total Government 60.5 0 60.5 Cofinanciers Nil Nil Nil IBRD/IDA 224.5 23.8 248.3 Other (specify) Nil Nil Nil O ther (specify) ...................................................................................... Borrower: GOI Guarantor: Responsible agency(ies): m Estimated disbursements (Bank FY/US$M): 1998 1999 2000 2001 2002 Annual 30.0 55.0 62.0 106.6 55.2 Cumulative 30.0 85.0 147.0 253.6 308.8 Expected effectiveness date: August 15, 1997 Closing date: March 31, 2003  Project Appraisal Document Page 2 Country: India Project Title: Reproductive and Child Health Block 1: Project Description 1. Project Development objectives (see Annex lfor key performance indicators).' The project would assist the Government of India (GOI) to improve the performance of its Family Welfare Program (FWP) in reducing maternal and infant mortality and morbidity, and unwanted fertility, thereby eventually contributing to stabilization of population growth. The project objectives would be to assist the FWP to: (a) improve management performance by nationwide implementation of policy change referred to as the "participatory planning approach,"' and institutional strengthening for timely, coordinated utilization of project resources; (b) improve quality, coverage and effectiveness of existing FW services; (c) progressively expand the scope and content of existing FW services to include more elements of a defined package of essential reproductive and child health (RCH) services;2 and (d) in selected disadvantaged districts and cities, increase access by strengthening FW infrastructure while improving its quality. 2. Project Components (see Annex 2 for a detailed project description and Annex 3 for a detailed cost breakdown): The proposed project would be a sector investment project with a strong policy and program content, and is envisaged to be the first in a two-part financial support for the Family Welfare Program to implement a nationwide policy change. It is estimated that nationwide implementation of program strategies would require a project cost of about US$600 million (with US$480 million IDA financing). This project would provide Interim Trust Fund (ITF) financing of US$284.3 million for a five-year period and would focus on strengthening institutional capacity (program management and monitoring, funds flow, procurement support, technical assistance from specialized consultant institutions) particularly to improve implementation in weaker states and in operationalizing some of the newer technical interventions, such as referrals for essential and emergency obstetric care and reproductive tract infections, in which there is limited experience. Close continued monitoring, together with a mid-term evaluation at the end of the first two years, would form the basis for appraising the second follow-on project expected to begin in year three and cover a further five-year period, as indicated in the diagram below. In order to gain efficiency and reduce transaction costs the second project would utilize much of the documentation prepared for the first project, updated to reflect changes in project design and content. RCH 1(5 Years) t I RCH 11 (5 Years) Evaluation Year: 1 2 3 4 5 6 7 8 1 The "participatory planning approach" formerly known as 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 childbirth. 2 A package of essential RCH sefvices has been defined by GOI for (a) prevention and management of unwanted fertility, (b) management of pregnancy and childbirth, (c) child survival (including immunization, diarrheal and acute respiratory illness, and newborn care), and (d) reproductive tract infections. (See Annex 11, Attachment 2).  Project Appraisal Document Page 3 Country: India Project Title: Reproductive and Child Health Component Categoy Cost % f (US$m) I. Improved Management Performance (a) Expand existing monitoring system and decentralize planning. Expansion of the existing service delivery data through regular client Consultants, 15.9 5 polls and technical assessments of quality, rapid assessments of materials, community and NGO perceptions by independent agencies, and training surveys, and technical support for more responsive decentralized activity training planning. (b) Institutional strengthening through: (i) Procurement and Technical Support Appointment of consultant agencies to provide procurement Consultants 15.0 5 services and technical support in training, IEC, community surveys and other technical areas. (ii) Research for RCH management Evaluative studies, workshops and publications to promote Workshops, 4.0 2 use of findings. studies, materials (c) Enhanced program management capacity Enhancement of capacity to plan, supervise and monitor RCH Additional 13.7 4 Program implementation (including district and city sub-projects) staff, through additional staff and individual consultants at national, state consultants, and district levels. materials, travel allowances II. Nationwide Improved Ouality. Coverage and Effectiveness, and expanded content of the Essential Package of RCH services (a) Upgrading service delivery Upgrading quality and scope of services through improved Civil works, 131.5 42 clinical and communication practices and establishment of referral drugs, procedures from the community to the appropriate facility. The project medical would finance equipment and drugs from an approved essential list, equipment, minor renovations, hiring selected contractual services (such as contractual anesthetists, obstetricians), referral funds and defined schemes to services, improve access and staff mobility in remote areas. It would also support consultants, pilot experimental schemes designed for tribal areas and urban slums. operation and maintenance  Project Appraisal Document Page 4 Country: India Project Title: Reproductive and Child Health Component Category Cost ( US$m) % of Total (b) Training Upgrading competence of FW workers and managers Training, 34.7 11 by training in relevant technical and clinical skills for all additional staff components of the RCH package, interpersonal counseling workshops skills, improved gender sensitivity, program management including convergence with WCD services, IEC and community mobilization. (c) IEC Improving health and care-seeking behavior among Consultants, 5.9 2 target populations and increasing community participation and materials responsibility for reproductive and child health. The project would finance communication-needs assessments, consultancies for development of IEC strategy, media and materials support, training, communications activities by NGOs and community groups, and rapid assessments and monitoring of behavior change. III. Local Capacity Enhancement-Improved Access in selected disadvantaged districts and cities (a) District and city sub-projects In the most disadvantaged districts and urban slums, in Civil works, 91.2 29 addition to the inputs provided under the project component drugs, medical "Essential RCH services", the project would focus and non-medical investments for expansion of physical infrastructure, equipment, strengthening human resources for Family Welfare and consultants, implementing innovative approaches to meet needs of local contractual priority groups. The project would finance civil works, NGO services, IEC, schemes, honoraria for community health (link) workers, and vehicles, women's village health committees. operation and maintenance Sub-Total 311.9 100 Physical Contingencies 21.7 Price Contingencies -24.8 Total 308.8 3. Benefits and Beneficiaries. The project would benefit poor women and children below age five living in rural areas and urban slums throughout India by improving health during reproductive years and early childhood, respectively, and by enabling couples to space or limit births. More specifically the project would: (a) Reduce fertility. The project would reduce unwanted fertility among the 30 million women reported in the 1993-94 National Family and Health Survey (NFHS) to have 'unmet contraceptive needs', namely, not using contraceptives although they wished to space or not  Project Appraisal Document Page 5 Country: India Project Title: Reproductive and Child Health have any further births. Reduced fertility would contribute to empowerment of women. While project benefits would go directly to those couples who use the FW services, there are also economic and environmental benefits of a reduced growth of population to society as a whole. (b) Reduce health risks for women. The project would also decrease the health risks and burden of disease associated with pregnancy and childbearing among the 220 million women in the reproductive age group in India, in particular, the largely poor rural women particularly in districts with high concentrations of scheduled tribes and scheduled castes, and poor women in urban slums. (c) Increase in child survival. The project would increase child survival in the 0-4 year age group by (i) increasing program coverage to an estimated 10 million additional children over the five year period and improving effectiveness of ongoing interventions, and (ii) reducing poor maternal health which is estimated to be associated with 30% of deaths of children under five years of age. (d) Increase the effectiveness of past investments by GOI and IDA. In addition to the benefits derived from new activities, the project would support the re-vitalization of the health care and family welfare physical infrastructure across the country and promote changes in management practices. This can be expected to significantly increase the demand for, and utilization of, existing resources. (e) Encourage decentralization and local ownership. The Institutional Strengthening and Local Capacity Enhancement components are expected to encourage decentralization and build capacity within a centralized program, and increase involvement and ownership of RCH activities at lower levels of government. The outcome is expected to be improved implementation and more responsible use of resources. 4. Institutional and implementation arrangements: Implementation period: 1997 to 2001 Executing agencies: District Family Welfare Bureaus or Zilla Parishads (District Councils) under the supervision of State Family Welfare Departments Project coordination: Ministry of Health and Family Welfare Project oversight: Ministry of Health and Family Welfare Accounting, financial reporting and auditing arrangements: (See Annex 6 for details). Each participating state would create a separate budgetary item, and maintain identifiable project accounts at state, district, and institutional levels. Monthly consolidated state expenditure reports would be prepared and a consolidated state audit would be required annually through auditors acceptable to IDA. Monitoring and Evaluation arrangements: Agreed project benchmarks would be monitored by MOHFW through: (a) service delivery and utilization data from the Management Information System (MIS); (b) financial and physical performance data from state project directors; (c) data from technical quality assessments by service supervisors; and (d) rapid assessments of service coverage, quality and facilities by independent agencies, and of technical quality of training and IEC by competent agencies. From this system, MOHFW would provide to the Bank semi-annual summary progress reports, including information on agreed indicators (see Annex 1). This would be supplemented with data from a joint monitoring system to be established by GOI to include GOI and all donor agencies that support the FWP so as to avoid separate monitoring mechanisms by each donor agency. Through this mechanism there  Project Appraisal Document Page 6 Country: India Project Title: Reproductive and Child Health would be (i) field visits during project supervision; (ii) review of the selected data from a wide range of indicators used by MOiIFW for Program monitoring: and (c) review of studies, evaluations and lessons learnt through work done by MOFIFW and project states and their agents, as well as other independent agencies. Achievement of development objectives would be assessed through a mid-term evaluation and project completion evaluation. For such evaluations, in addition to special commissioned studies, data from the Sample Registration Survey (SRS) system, and a proposed National Family Health-type survey expected to be funded by USAID, would be utilized. Block 2: Project Rationale 5. CAS objective(s) supported by the project: The Bank's Country Assistance Strategy (CAS) for lndia, discussed by the Executive Directors on June 20, 1995 (Report No. 14509-IN), provides the basis for supporting the Governmeit's attempt to accelerate the pace of sustainable economic and social development. The progress report discussed by the Executive Directors on September 5, 1996 (Report No. IDA/R96-154/1) confirms this approach. The development of human resources is integral to both objectives. The Bank's specific objective in this respect is to support the restructuring of social programs to increase their effectiveness, improve the quality of life, and provide thle poor with increased opportunities to participate more fully in the economy. The proposed project directly focuses on this objective within the hiealth sector. It will support a comprehensive reorientation of India's Family Welfare Program in line with that proposed by GOI and supported in Bank Economic and Sector Work. The participants in the public sector's Family Welfare Program are predominantly from the poorest sections of society. Other more general objectives of the CAS include reducing poverty, strengthening institutions, increasing the role of beneficiaries in project design and implementation, and enabling women to participate more fully in the development process. Each of these is supported by the project. 6. Main sector issues and Government strategy: (a) Main sector issues:3 Two fundamental issues affecting the sector have influenced project design: (i) inadequate slowing of population growth despite a long established family planninlg program, and (ii) major disparities betweeni different states and urban and rural areas in hiealthi and fertility, reflecting differences in socio-economic status, level of political commitment and management capacity. The sector issues addressed by the project are: (i) a heavy burden of disease among women and childreni for which highly cost-effective interventions are available; (ii) higih levels of unwanted fertility: (iii) underutilization of the existing large infrastructure of public sector facilities and manpower while poor women and children continue to have inadequate access to the services they need; (iv) prograin distortions caused by an excessive focus on method-specific contraceptive acceptor targets and use of financial incentives; (v) poor quality of care associated with shortages of supplies, drugs and. particularly. female staff and improper behavior of staff contributing to client dissatisfaction; (vi) inadequate funding, inflexible, poorly coordinated, top-down management, and inadequate support for front-line workers; and (vii) inadequate mobilization of private and NGO resources. (b) Government strategies to address these issues: (i) GOI is adopting a nulti-sector approach to population stabilization. Strategies include improving the performance of the Family Welfare Program through measures that are 3 References: (1) India's Family Welfare Program: Towards a Reproductive and Child Health Approach, June 1995. (2) World Bank, Improving Women's Health in India, Development in Practice, 1996. (3) India: Policy and Finance Strategies for Strengthening Primary Health Care Services, May 1995.  Project Appraisal Document Page 7 Country: India Project Title: Reproductive and Child Health described in the next paragraph. improvinig the nutritionlal status of women and children thirough ntitritionlal supplemenitationi to pregnanit women and younlg children, targeted investmenlts to reducC communllicable diseases sucih as tuberculosis. malaria and AI)S that pOSe ani additioIlal buirdenI to pooI wvoincii anid cllildrein; inlcreasinig investimnenit in girls' educationi, improving the status o0'womieni throughi empowerment strategies and increased econlomliC opportullities. ii) Withiin the Family Welfare Program strategies include policy, program manlagemilenit and service deliver-y ciangcs. 'I'hIC po0lic( cha17017geS illCiude: a. remloval of -targets system'" to improve maniagemiienlt practices: b. remioval ol'the payment ot'inceintives to 'animily planning and related wvorkers. and encouragement to states to modifv and phiase out thie schielmies for paymtcil of compensation to flmairly planniiing acceptors; c. imlprovilng llaliciLSIiahilik hy consolidat ing and streno,ting in lastrlucttilci aind permilitting onlx I im ited cxpanisionl of'sub-ceinters to provide services to the hilly, tribal andc ulicovere(d areas: d expanding access by eucouriunini use of'avaiilahbc N(i() and prixatc sector services to lill critical skill gaps in thc pulblic sector- C. icriCasinog acccss to FW scrvices through coordinating FW and Department of' Womeni and Child D)evelopimcut (W('D) outreachi work-ers, and FW and Ministry of'Rural )evelopment coninunitu level investmients: and t'. increasing domilestic and `6oreign assistance for the sector wvithi greater emphiasis on performiance-based f-uLidinig ot'state level activities. (iii)T-le changes in [ am ilv Weloare lProgrami mang'nlg',n inluCIdCe: a. improvinig effectiveiless through district level planning anid imoniitorinig that is imlorc responsive to local needs and includes a vwi ide range ot optional innoxative approaches: b. improvinig tquality of care and attenitioni to clienl needs in tihc IWP; c. increasinig programii sustainiability and utilizationi thlroughi increased comImulllity involvemilenlt and responisibility for the Family We]lfare Program throughi the lPancliayati Raj system: and d. improvinig referral services. (iv) Clianges in seirvice deliverv include revitalizing the exteilsive networ-k ot'rtiral hiealti facilities througih better supiplies ot'drugs and equtipimlenlt, training, anid better information, education and couniselinig for clients and comlimiiuniities in order to ili1prOVC utilizationi and el'ectivecness.  Project Appraisal Document Page 8 Country: India Project Title: Reproductive and Child Health 7. Sector issues to be addressed by the project and strategic choices. S.: . t Sectorlssues addressed by the project Strategic choices Despite a long established family planning This project would address constraints in both the supply- and program: demand-side constraints to reduce unwanted fertility, and (a) fertility remains higher than acceptable, implement highly cost-effective interventions for reducing maternal particularly in the less developed northern and childhood illness and deaths. On the supply side, interventions states; focus on attracting clients to use services by improving quality, and (b) burden of disease among women and by providing an integrated package that would meet the differing children is high despite the availability of needs of clients who are at different stages of the life cycle (young cost-effective interventions; and couples wishing to space or delay childbirth, pregnant women and (c) there are major inter-state disparities in newborn children, couples wishing to limit families, sexually active health and fertility, cultural and institutional men and women). On the demand-side the project would address characteristics. inappropriate health behavior and promote appropriate health-care seeking behavior by more focused, better quality needs-based information and communication (IEC) about reproductive health and relevant services to clients, decision makers in the family and communities. Other demand-side determinants of population growth, namely, large family size and early age at marriage leading to high population momentum, are being addressed by IDA-funded projects in Education. Allocation ofproject inputs to states would be based on criteria that include both population and epidemiological characteristics. Rationale for continued support for public The Family Welfare Program aims to provide a service that would financing of Family Welfare services even (a) generate positive externalities with multiple benefits to society though public sector facilities are and future generations and includes public goods; (b) reduce underutilized and private sector facilities are inequity in society by reducing the burden of disease and high readily available. fertility among poor women and children, thus enabling poor women to participate in economic activity; and (c) build a base of healthy human capital essential for economic growth. Although private sector facilities are widely available, they focus mainly on curative services and the overwhelming proportion of women and children obtain preventive services from the public sector. Furthermore, private facilities capable of providing the higher technology required for treating obstetric and childhood illness complications, and the more effective though provider-dependent contraceptive methods such as sterilization and intra-uterine devices, are concentrated in urban areas. Contact with private sector providers costs about one to two and a half times more than contacts with government providers, and poor women and children are unlikely to use private providers. There is little experience and knowledge about the cost and effectiveness of mobilizing the private sector and NGOs on a large scale to cater to the needs of the rural poor. USAID is financing a major initiative for this purpose in Uttar Pradesh, but the results are as yet unclear. Therefore the main project strategy would be to strengthen the public sector services while facilitating increased mobilization of private sector resources (see below).  Project Appraisal Document Page 9 Country: India Project Title: Reproductive and Child Health Sector issues addressed by the project Strategic choices Contributory factors for inadequate Improving program performance program performance: (a) Policy change to remove contraceptive targets has been announced. (a) program distortion due to targets and (b) Planning process and authorities are being progressively incentives. decentralized to districts and states which are now required to prepare (b) the tendency of planning to be their own detailed implementation plans based on local needs. centralized, guided by norms and Capacity for such planning is being strengthened. centrally determined targets, and (c) Monitoring systems are being revamped to monitor annual inadequately responsive to local needs achievements against expected outputs. since the FWP is 100% centrally funded; (d) State eligibility for infrastructure expansion in disadvantaged (c) the tendency for inflexible and poorly districts and cities (LCE component) would require states to coordinated management of vertical demonstrate commitment by filling staffing gaps for Female Multi- programs at the local level; and purpose workers, and to re-assign dormant centrally-funded posts to (d) lack of ownership of the program by critical service delivery sites. states/districts. There is under-utilization of public sector Improving quality. coverage. effectiveness and access family welfare infrastructure and (a) Nationwide upgraded in-service training of FW workers; manpower although there is a continued progressively phased upgrading and expansion of the scope of heavy burden of disease among women services, and better focused IEC through the application of strategies and children. described in paragraph 6 (b). Contributory factors are: (b) Strengthening of infrastructure through focused investments in (a) poor quality services that do not meet selected disadvantaged districts and cities. the needs of the community; (b) inadequate understanding of health needs of pregnant women and the consequences of neglecting such health needs, particularly among poor and disadvantaged communities; and (c) inadequate access particularly for poor women from scheduled castes and tribes, minority groups and urban slums. There is inadequate mobilization of Strategies include contractual arrangements for (a) filling critical skill private and NGO facilities. gaps at primary health centers and first referral hospitals through short- term hire of private sector personnel; (b) specialized training and IEC inputs from NGOs; and (c) private medical practitioners to increase contraceptive choice and alternatives to unsafe abortion practices. Front-line workers are unable to cover Measures are being planned for increased coordination with outreach their catchment area population in several and community services of the Women and Child Development weaker districts because workload has Department and the Ministry of Rural Development. Within GOI become unmanageable due to population norms for staffing, a limited number of additional outreach staff would growth and expansion of program be recruited to serve in districts where population growth has activities. outstripped the capacity of existing staff. Insufficient attention to issues such as The design provides (a) a vehicle for continued policy dialogue, (b) potential for greater private (NGO and continuing evaluations and reviews, and (c) significant flexibility for for-profit) sector involvement, more implementing recommendations of the evaluations and reviews porous boundaries between Health and through annual-and state-specific modifications to implementation FW to achieve better impact, and plans. strengthening the implementation of maternal health strategies.  Project Appraisal Document Page 10 Country: India Project Title: Reproductive and Child Health 8. Project alternatives considered and reasons for rejection: Altern*tive consideredI 1 Reasons for rejection Alternate project designs considered The Family Welfare Program has operationally functioned as several almost were: vertical programs, such as CSSM, family planning, externally funded L A time-slice operation in support "projects," urban FW. Therefore there was no coherent basis for a time-slice of the FWP. operation. The RCH program would weld these several 'programs' into a coordinated program which, when operational, could be considered for a time- slice operation. 2. Further state-specific investment * Project impact would have been constrained by the distortions caused by projects using designs similar to the targets and incentives system. the Population Projects for * Project implementation would have been hampered by constraints similar strengthening family welfare to those experienced by existing projects (see paragraph 10). systems and outreach capacity in * This is the tenth IDA (ITF) project in this sector. Hence project design weaker states (notably the north- should develop greater GOI responsibility for monitoring state and district east states and Hindi-speaking implementation performance with less hands-on guidance from the Bank. northern states) or for urban poor in mid-size cities that have not had any IDA project for Family Welfare. 3. Nationwide program investment * The issue of unwanted fertility would not have been addressed. for a second Child Survival and * Constraints in Family Welfare Program management as described in Safe Motherhood (CSSM) project section 7 would have continued to limit effectiveness and impact. to strengthen and expand the child * Same reason as 2.3 above. survival and safe motherhood interventions to all states. 4. A totally district-based approach * Districts need the conceptual framework and technical guidance provided across the whole country focusing by the FWP. on those districts with the worst * Training and information programs are more cost effective across a whole health indicators and highest state. levels of fertility. 5. Greater focus on supporting It is more cost effective to increase the utilization and the quality of existing measures to reduce the infrastructure and to limit civil works activities than to making existing infrastructure gap and reach institutions more effective. Government norms. 6. The incorporation of private The private health sector for reproductive health care is not generally available providers into the mainstream of in rural areas, and about 80% users of modern contraceptives use public sector the project. sources. Those who do use private sector do so only for items that require simpler technological support. The first priority is to improve the quality in the sector most likely to be utilized by the poor. Alternate technical interventions Traditional birth attendants (TBAs) have been trained extensively in previous considered were: projects and are providing low technology interventions. Further gains would 1. Increasing the focus on training not be possible without adequate linkage to health services and supervision by traditional birth attendants and health workers, and their effectiveness in detecting and dealing with rural practitioners. complications of pregnancy and childbirth is doubtful. There is a large workforce of trained health workers. Therefore, the focus of the project would be on upgrading health worker skills, making them more accessible to communities, forging closer links between health workers, and practicing TBAs forging closer links between communities and hospitals that can provide a higher level of technology 2. Increasing investment in small Complications of pregnancy and childbirth and childhood illness may be rural hospitals closer to categorized as (a) those requiring a fairly low level of technology, and (b) those communities. requiring specialized skills and hospital care. It was assessed that the first category could be managed largely by adequately trained nurses placed in existing primary health centers (covering 30,000 population). Small rural hospitals are unlikely to retain the specialized staff required to manage the second category of conditions. Therefore, it was decided to focus on early recognition of such complications and strategies for transporting them to sub- district and district hospitals  Project Appraisal Document Page 11 Country: India Project Title: Reproductive and Child Health 9. Major related projects financed by the Bank and/or other development agencies (completed, ongoing and planned): Funding agency, geographic coverage Focus and linkage to proposed RCH project and Project Population (and similar) projects: IDA Population IV - IX in 12 major states In 14 major states and the 6 largest cities, these projects established a and 6 cities, namely West Bengal, Andhra foundation on which to build interventions in the RCH project through Pradesh, Uttar Pradesh, Madhya Pradesh, strengthened FW support systems, and increased access through better Bihar, Gujarat, Haryana, Jammu Kashmir, outreach capacity and quality. Punjab, Assam, Karnataka, Rajasthan, Bombay, Madras, Bangalore, Calcutta, Delhi, and Hyderabad. ODA in Orissa. UNFPA in Rajasthan eastern districts. DANIDA in selected districts of Madhya Pradesh and Tamil Nadu Child Survival and Safe Motherhood. This project expanded the focus of the nationwide FWP by introducing (nationwide) several of the interventions that would be continued and strengthened for IDA, UNICEF, SIDA, CIDA (completed). reproductive and child health. Specifically, it (a) added ARI and CDD to the UIP child survival interventions; (b) introduced outreach for safe motherhood; and (c) provided most of the equipment and technical guidelines for first referral units for safe motherhood. Integrated Child Development Services ICDS and WCD projects would have synergy with the proposed RCH project (ICDS) & Women and Child Development by enhancing nutrition in women and children, and extending the outreach (WCD). capacity of the FWP. In Bihar, Madhya Pradesh, Maharashtra and Rajasthan. State Health Systems (SHS). SHS projects will establish referral systems and strengthen referral facilities IDA (ongoing) in Andhra Pradesh, that would serve reproductive and child health care needs. Karnataka, Punjab, West Bengal. _ Tuberculosis Control: II 3 districts in 15 Reduction of the burden of disease due to TB would enhance the impact of states IDA (planned). RCH on women's health. AIDS Control: IDA (ongoing) - nationwide. AIDS/STD interventions developed for risk groups in AIDS project will be adapted and implemented for all women served by FWP. Innovations in Family Planning Services: The USAID project funds several aspects of RCH such as quality USAID (ongoing) in Uttar Pradesh. improvement, social marketing, and NGO involvement for family planning. Reproductive and Child Health: European The EC is considering parallel financing for a Sector Investment Program in Community (planned) nationwide. Family Welfare for a cost of ECU 200 m-illion. Reproductive and Chxild Health: ODA West ODA is financing a project preparation phase in West Bengal analyzing Bengal. sectoral issues and potential for effective interventions including RCH. USAID (proposed); selected districts in Funding of the RCH interventions. Independent nationwide evaluation of Madhya Pradesh; National Family Health program impact and progress towards fertility and mortality reduction. Survey 2. UNFPA (1997-2001) Support for (a) implementing the Reproductive Health Approach in 40 selected districts, (b) strengthening capacity for population and development activities, and (c) advocacy on key issues related to reproductive health _____________________________________ including strengthening of IEC capacity in selected states. UNICEF (1997-2001) UNICEF will work in close partnership with the Bank-financed activities for RCH and focus support particularly on community mobilization, training of trainers, and development of IEC capacity. WHO Technical support for developing appropriate training strategy, clinical management guidelines, midwifery training for nurses, and integrated management of the sick child. Rockefeller and Ford Foundations, ODA, Evaluation of innovative approaches, assessment of cost of RCH interventions Population Council in different settings, other priority research topics related to implementation of RCH. SIDA Support for RCH is being considered, but the focus has yet to be decided.  Project Appraisal Document Page 12 Country: India Project Title: Reproductive and Child Health 10. Lessons learned and reflected in the project design (from completed and on-going projects financed by the Bank and other development agencies): Family Welfare projects: Common implementation problems in the state-based Population Projects have been: (a) initial slow disbursement due to delayed start up of project activities, particularly in staffing, cumbersome state level approval and funding procedures; (b) inadequate integration with related FWP activities at national, state and district levels and poor coordination with other related projects; (c) inadequate commitment at state and district levels leading to inadequate technical support for training and IEC, weak community involvement and lack of supervision of construction; and (d) in weaker states, inadequate and delayed release of funds, frequent changes in project officials and poor project management. In the centrally managed Child Survival and Safe Motherhood (CSSM) project, problems have been the initial poor procurement capacity, vertical approach with inadequate coordination at state and implementation levels, significant delays in implementing the Safe Motherhood component, and inadequate reporting of implementation progress. Similar projects funded by ODA, DANIDA, UJNICEF and USAID have experienced comparable problems. Technical and social problems experienced in the Family Welfare Program have been (a) over-emphasis on achieving contraceptive acceptor targets leading to neglect of other reproductive health needs, (b) inadequate information, counseling and poor services for birth spacing needs particularly for younger couples, and (c) inadequate detection of complications of pregnancy, lack of referral procedures for complications that are detected, and inadequate, inaccessible and insensitive services at facilities capable of treating such complications. Lessons from related projects: The Bank's education portfolio, through the District Primary Education line of projects, has had initial success in addressing problems similar to those experienced in the Family Welfare projects by using registered societies to reduce procurement and funding delays and decentralize responsibility, and requiring formnal annual reviews and work program proposals for management control. USAID, which is implementing a ten-year project in Uttar Pradesh, has had difficulty establishing and maintaining an autonomous society for Family Welfare but is making progress in introducing performance-based funding. Project design features that reflect lessons learned: These are: (a) decentralization of responsibility for implementation planning, definition of expected program performance, and performance monitoring of state and district levels; (b) refinement of the Center's responsibility in program management, from detailed program planning and guidelines to definition of program strategies, technical guidance and quality standards, monitoring and trouble shooting; (c) full integration of project activities with all FW program activities through integrated project management structures at national and state levels; (d) linkage of annual state project budgets to formal annual GOI reviews using criteria agreed with the Bank; (e) strengthened capacity for procurement through the use of consultant agencies and other special units to be known as Procurement Support Institutions; (f) establishment of state level registered societies to expedite flow of funds from the Center to district level implementing authorities, and (g) strengthened quality of small, scattered civil works by use of detailed technical manuals developed and approved during project preparation. 11. Indications of borrower commitment and ownership: (a) As of April 1996, the Family Welfare Program declared the end of the "targets" system, and distributed a manual entitled, Manual on Participatory Planning (formerly known as the Target Free Approach) which provides guidance to districts on the implementation details of a revised monitoring system and decentralized planning system.  Project Appraisal Document Page 13 Country: India Project Title: Reproductive and Child Health (b) During FY96, there has been a gap in external assistance for the CSSM activities due to the revised scheduling of the project planning cycles of most external agencies to coincide with GOI's five-year planning cycle. During this period, GOI has demonstrated its commitment to the activities initiated under CSSM (to be continued and expanded under RCH) by mobilizing additional domestic funds to ensure that the core CSSM activities are continued. (c) MOHFW has requested all external agencies interested in providing support for the FWP to link the next cycle of their projects to the proposed MOHFW RCH program. (d) MOHFW has published a booklet entitled A Paradigm Shift describing the key features of the proposed program. The booklet is used as informational material about the FWP. (e) During project preparation. MOHFW organized more than 20 meetings/seminars to discuss the project with State Family Welfare Secretaries, NGOs, state training institutions from health and related sectors, the Department of Women and Child Development, and the Ministry of Rural Development. (f) Several state officials have been invited by MOHFW to participate in project planning and have contributed to: (i) identification of key policy commitments to be required of states; and (ii) preparation of a 5-volume manual containing detailed technical standards for implementation planning, service delivery, training, civil works, financial monitoring and procurement that will be used during project implementation. (g) MOHFW officials from the Center participated with the Bank's mission in a logical framework analysis exercise for the project and will replicate the exercise with state teams. (h) GOI in its Approach paper to the 9th Five Year Plan clearly enunciated its support for the FWP. Further, it has been recently re-iterated that the entire amount of external assistance available in any given sector is to be added to the normal plan resources (nett budgetary support) to obtain the overall amount (gross budgetary support) available to the sector. 12. Value added of Bank support: (a) Bank inputs during project preparation have assisted MOHFW to: (i) move to the "target-free approach" with full participation of a wide range of stakeholders (see section on Participation); (ii) develop technical guidelines and standards for adapting and applying the recommended package of essential RCH services under various situations of resource and institutional constraints; (iii) rationalize the resource needs and utilization of available resources; and (iv) develop a framework for implementing RCH that has attracted other donor investments, including major funding from EC which is new to this sector in India. (b) Bank support for the project would: (i) enable larger numbers of priority clients to be served by the FWP; (ii) expand the range of essential services offered by the FWP; (iii) assist GOI to refurbish the existing infrastructure and revitalize its manpower, thereby bringing value added to past investments; and (iv) modernize program management approaches so as to achieve greater efficiency and effectiveness. (c) Without Bank support, it is unlikely that: (i) GOI would have addressed the most fundamental issues relating to modernization of program management such as removal of contraceptive targets; (ii) health problems of women during pregnancy, childbirth and sexual activity would  Project Appraisal Document Page 14 Country: India Project Title: Reproductive and Child Health have been addressed; and (iii) attempts would be made to improve effectiveness of child survival interventions except for immunization. Block 3: Summary Project Assessments Detailed assessments are provided in Annex 11 entitled Institutional, Social and Technical Assessments. 13. Economic Assessment. (a) Public investment in family welfare services can be justified in principle on the grounds of both efficiency and equity. Some services have characteristics of public goods, e.g., IEC, and more importantly, several provide positive externalities or benefits to individuals beyond those receiving the service. Infant immunization programs for communicable diseases is an example. Another is the improvement in maternal health and nutrition which increases the survival chances and well-being of children leading in turn to lower fertility levels. Lower fertility may then lead to environmental and economic gains for the existing population. In the absence of public financing, the effective demand and provision of these services is likely, in many cases, to be below the socially optimum level. Equity arguments in favor of subsidized health services are strong in India, where the most recent survey of poverty suggests that over one third of the rural population has access to Rs. 5 or less a day. The public provision of health services, in addition to their financing, is justified when private provision does not exist, the public sector is a more efficient provider, or consumers exhibit a clear preference for public services. (b) Recent IDA sector work in India concluded that while some reproductive and child health services may be provided by the private sector and NGOs, the public sector will have to continue to play the central role, especially for the poor. According to the recent National Health and Family Welfare Surveys, 79 percent of individuals using any form of modern contraceptive are supplied by the public sector. In rural areas the share is 87 percent. Only 11 percent of all women and 6 percent of rural women who have recently given birth did so in a private institution. Virtually all infant immunizations are provided by the public sector. Overall, the vast majority of the population in general, and the poor rural population in particular, are dependent currently on services provided by the public sector. For the future, recent extensive survey research in Uttar Pradesh indicates that of the large group of women with unmet demand for contraception, the percentages who intend to use public (as opposed to private) sector services in the future for sterilization, IUD, pills and condom supplies are 89, 81, 64 and 50 percent, respectively. Among rural women, the percentages are significantly higher - 93, 87, 68 and 62 percent. Of 157,000 private practitioners, only 28 percent offer contraceptive methods, mainly pills and condoms, and under 15 percent of all private health sector staff have received family planning training in the past three years. While the results are not presented with a rural/urban disaggregation, it can be safely assumed that these percentages are significantly lower in rural areas. In some areas of family planning and reproductive health, the private sector does not provide services. When it does, the substantial use of the altemative public services, particularly for clinical services, suggests that the financial charges are beyond those that can be paid by many, particularly rural, families. However, where the private sector is capable of providing goods and services efficiently they should be encouraged and the possibility of public subsidies considered. The current USAID-supported project which encourages the development of the private sector in providing family planning services in Uttar Pradesh will generate valuable lessons over the project period. (c) Even if the public financing and provision of health services can be justified in principle, there is a need to provide services in the most economically efficient way. No single, universally  Project Appraisal Document Page 15 Country: India Project Title: Reproductive and Child Health accepted tool of economic analysis exists to measure efficiency in the sector. In project preparation, attention has been given to various measures of cost effectiveness, trends in unit costs, simulations of cost recovery and cost reductions and to a very partial use of cost benefit analysis. More details are provided in Annex 4. (d) The child health interventions follow the standard cost-effective protocols for vaccinations recommended by WHO/UNICEF. The basic set of vaccinations being extended in coverage were evaluated in the 1993 World Development Report as being among the most cost effective of all health interventions. A detailed cost effectiveness study undertaken in Andhra Pradesh in 1996 as part of the Department's sector work on health sector reform estimates that the cost per disability adjusted life year (DALY) gained for the universal immunization program is around $8, which compares well with the estimate of $12-17 in the World Development Report. The WDR defined a cost-effective intervention as one where the cost/DALY gained is below $250. (e) The reproductive health interventions are anticipated to achieve multiple objectives, including increased health status of women of child bearing age and of their children, and reduced levels of fertility and population growth. (i) Health status. Previous Bank studies have estimated the cost per DALY saved through treatment for RTIs/STls at $10-15 and for the diagnosis and early cure of cervical cancer at $150-250. The Andhra Pradesh study broadly confirms these estimates. The cost/DALY gained for the provision of referral care for complicated pregnancies was estimated to be $2, urban pregnancies with little complication $18; neonatal care for perinatal conditions $60, and rural pregnancies with little complication $100. Again, all are significantly below the $250 level suggested by the WDR and are well below recent estimates for similar interventions in West Africa. These studies focus on women's health. There are also significant impacts of reproductive health interventions on child health. It is estimated that in India, one third of under-five mortality could be prevented if mothers were more healthy and obstetric complications were appropriately managed. (ii) Reduction in fertility. Interventions aimed at widening the range of available contraceptive methods and increasing the use of all family planning and safe motherhood services, particularly by the poor, have the objectives of increasing choice and personal empowerment and of reducing fertility and mortality. The value of improved choice cannot be measured. Regarding reductions in fertility, again it is problematic to measure quantitatively the outcome. A narrowly defined benefit-cost analysis compared the costs of previous government family planning activities with the benefits measured in terms of savings in public expenditures on social services and food distribution subsidies arising from the estimated decrease in population increase resulting from the family planning program. The results implied an IRR of 11.3 percent. (f) The cost effectiveness of different contraceptive methods was measured with the unit of effectiveness defined as one couple year of protection. Since sterilization involves a single operation, and the effects are permanent, the cost effectiveness is high. This is followed by IUD insertion, while condoms and pills, which require regular replenishment, appear least cost effective. Studies in East Asia and Latin America demonstrate the same order of ranking. However, the markets for the various contraceptive methods are different and, for significant periods in a woman's reproductive years, the methods do not all compete. Sterilization cannot help younger, lower parity couples who wish to limit the number of children and control the spacing of births but are not ready to end childbearing. For a further significant decline in  Project Appraisal Document Page 16 Country: India Project Title: Reproductive and Child Health fertility in India, the behavior of young couples will now need to change and the family planning program will need to respond. It will be difficult to sustain the current very high levels of sterilization. In many states the focus will have to shift to non-terminal methods for younger and lower parity women and men even though these are more costly and require a more efficient delivery system. As the objective of the program widens to one of meeting peoples' reproductive goals rather than just preventing births the distinction in the measurement of effectiveness for terminal and non-terminal methods will become increasingly important. (g) Calculation of the unit cost of the family planning program per couple year of prc ,tion and birth averted over time indicates that real costs have decreased across the country as a whole while significant variations exist between states. In current prices, the cost per couple year of protection and birth averted increased by 30 percent between 1991/92 and 1995/96 while the Government consumption deflator increased by 42 percent. The average cost per couple year of protection in 1995/96 was Rs. 128. Most major states were close to the average. Significant outliers were Bihar, Orissa, Rajasthan and Kerala. Greater utilization of existing infrastructure in the first three of these states through the project's measures to increase demand by more adequately catering to clients needs would reduce these unit costs. Already, international comparisons show that unit costs in India are low. The cost per couple served is roughly one third that in Bangladesh. However, there is also international evidence that unit costs start to rise once contraceptive prevalence is above 40-50 percent-just above the current rate in India. (h) The potential for generating significant resources through user charges is relatively low. Estimates of the revenues expected by imposing charges equivalent to 10 and 15 percent of variable recurrent costs of the whole family welfare program were calculated. At those rates, the levels of cost recovery would be sufficient to pay for additional services resulting only in increases of 1.6 and 2.3 percent in the existing level of couple years of protection. The imposition of user charges for reproductive and child health services cannot be implemented unilaterally but as part of a general policy on charging for health services. The issue is being discussed with state governments within the context of the IDA-supported State Health Systems projects. Currently there is greater potential to reduce pressures on public resources through the revision of measures which provide free contraceptives (mainly condoms) and compensation for sterilization. Provision of free contraceptives and compensation for sterilization, however, absorb almost one sixth of the Government's Family Welfare budget, and cost seven times the amount that could be raised by cost recovery at the highest of the above rates. The Government's intention is to reduce further real expenditures on these items. Their removal would likely have a greater impact on the unit costs of family planning funded through the public sector than would the introduction of cost recovery. 14. Financial Assessment: (a) The Family Welfare Program is fully funded by the Central Government with substantial donor support. Expenditures increased by 40 percent in real terms between 1990/91 and 1995/96. Over the past two decades they have increased from 14 to 18 percent of total health expenditures. The distribution across states is largely driven by population levels, and per capita expenditures are significantly less unequal than for health expenditure as a whole. While not necessarily reflecting the differential needs across states for family welfare services, the distribution does at least allow the same level of service in resource poor states as in the richer ones. This reflects GOI's intention to ensure that a program with large social benefits and externalities flowing across state boundaries is implemented nationally. Donor support  Project Appraisal Document Page 17 Country: India Project Title: Reproductive and Child Health has been equal to 20-25 percent of total expenditures. Between FY1994-97, the annual average IDA support was Rs. 335 crores, around $93 million a year. (b) The activities to be supported under the project are a subset of the total activities devoted to improving reproductive and child health planned for the next five years. Past budgetary allocations for the family welfare program have provided a physical and manpower infrastructure appropriate for a family welfare approach which has concentrated largely on the delivery of a very narrow range of contraceptive methods. The orientation towards a more comprehensive approach requires substantial additional inputs introduced in an integrated way. This justifies supplementary donor assistance. The new integrated approach will be implemented largely through the maternal and child health activity of the Family Welfare budget. The budgetary allocation for this item, plus compensation for sterilization, in 1996/97 is US$125 million of an overall departmental budget allocation of US$431 million. Over the Ninth Plan period, 1997/98 - 2001/02, it is tentatively planned to increase expenditure on reproductive and child health to an average of US$280 million a year, with recurring costs of US$244 million. Assuming that all activities apart from reproductive and child health remain funded at their current real levels, the Family Welfare budget would require a 40 percent real increase by the final year of the Ninth Plan if all of the planned expansion of RCH is implemented. The project will support part of this increase. It will not finance some of the existing activities at all (e.g., compensation, grants to existing sub centers), will finance only the expansion of others (e.g., IEC, safe motherhood in the current maternal and child health activity) and will finance all costs of specific new activities (e.g., treatment for RTIs). The project will not finance any activity currently being provided apart from expansions resulting from changes in coverage and/or scope. In the event of other donors being willing to fund existing activities, IDA will need to be satisfied that the GOI funds released remain within the family welfare sector. During the project life, GOI will be required to provide evidence to this effect. (c) The fiscal burden of the project during implementation is manageable but will require an increased financial commitment by GOI. As a share of total GOI revenue expenditure, the overall Family Welfare budget is 1.2 percent. As a share of total government expenditures (Center and state), the budget is just 0.4 percent. GOI counterpart funding for the project will be equivalent to around 3 percent of GOI own-expenditures on Family Welfare in 1995/96. (Issues related to the project's financial sustainability are discussed below in section 20.) (d) The new family welfare approach being implemented by GOI will result in some savings within the current budget. Real expenditures on the free distribution of contraceptives, as well as compensation for sterilization and health guides, are already being reduced and will be reduced further during the project period. Currently they consume around one sixth of the program's budget. The financial implications of going beyond these measures and charging for a proportion of the costs of medical services, drugs and vaccines have been calculated as part of project preparation. The opportunities to charge for activities which require universal coverage for effectiveness such as immunizations, and which help implement the right of every woman to have safe deliveries, are limited. However, limited cost recovery is being piloted in the IDA-supported State Health Systems Project. This may escalate and result in the recovery of a small share of the costs of reproductive health drugs. (e) While the Family Welfare Program is a central scheme, part of its success depends on the quality and quantity of health personnel and infrastructure funded by the state governments. The project does not fund additional staff or health sub-centers in any major way. However, one of the main criteria for states becoming eligible for the funding of sub-projects is the  Project Appraisal Document Page 18 Country: India Project Title: Reproductive and Child Health requirement that at a minimum they maintain current shares of expenditure on health. This level should ensure that those states which are interested and able to implement additional programs are systematically improving their overall health care provision. 15. Technical Assessment. (a) The technical aspects of the RCH program as developed by MOHFW have been assessed by the Bank, with assistance from WHO, UNICEF and UNFPA. The program approach aimed at reduction of unwanted fertility, i.e., births to women who say they want to space or not have additional children but who are not using a method of fertility regulation, is in accordance with the recommendations of the 1994 International Conference on Population and Development (ICPD), which reviewed and made recommendations to make family planning programs more effective. Contraceptive use in India is dominated by female sterilization, and unwanted fertility is particularly high among couples who need spacing methods. The technical quality and quantum of birth spacing methods are generally acceptable. However, the quality of technical advice about use of such contraceptives and the competence of health workers in providing clinical contraceptive methods is inadequate. The project appropriately focuses on training and IEC to address these shortcomings. IEC would address some of the underlying causes of unwanted fertility such as health concerns associated with methods of fertility regulation, distrust of providers, and opposition by husbands and family members, male involvement and responsibility. Training would focus on better information on modem contraceptives and greater choice of methods, increased focus on individual client needs and improved technical quality of services. Further, the increased use of temporary contraceptives would require an un-interrupted, sufficient and conveniently accessible supply of the contraceptives. Logistics systems are being strengthened through a UNFPA-financed project. Schemes to: (i) permit outreach workers to sell condoms, (ii) increase the participation of social marketing agencies at state level, and (iii) increase the involvement of NGOs and private providers are expected to improve access to services. However, the reduction of unwanted fertility is a "moving target" because improvements in female education and employment and other factors are expected to escalate the rate of increase in the pool of couples who wish to limit their fertility either by spacing or limiting births. Expectations of program achievements should recognize such factors. The challenge for the Family Welfare Program is to meet the needs for fertility regulation not only of the existing pool of couples with unmet need but also the escalating rate at which additional couples are expected to desire suitable methods of fertility regulation. (b) The Essential Package of RCH services addresses conditions that are responsible for a heavy burden of disease in India and consists of interventions recommended in the 1993 WDR as highly cost effective. Several of the interventions were initiated under the recently completed CSSM project. A recent evaluation of the Safe Motherhood component of CSSM by MotherCare, an NGO, indicated that maternal health needs more emphasis than received to date (see Annex 11). If the complications of pregnancy such as anemia, hemorrhage, obstructed labor and postpartum infections that continue to be major causes of maternal death are detected early and managed appropriately, maternal morality and morbidity would be much reduced. This could be achieved through the provision of Essential Obstetric Care (EsOC) closer to the place of residence (such as at the PHC level which should be able to handle 85% of matemal complications), while Emergency Obstetric Care (EmOC) requiring surgical interventions, blood transfusion and anesthesia could be provided at a higher level, namely the Community Hospitals or First Referral Units (FRUs). MOHFW, with input from WHO, SEARO and CARE, has adapted the Standards for Midwifery Practice for Safe Motherhood and will be introducing it in selected states to strengthened EsOC at PHC level. The medical  Project Appraisal Document Page 19 Country: India Project Title: Reproductive and Child Health technology (drugs, equipment, staff skills) to be provided in the RCH package are the least cost and most appropriate for addressing these conditions, and provide access for rural and urban poor (see Annex 11, Technical Assessment for details). (c) Two new interventions, namely management of reproductive tract infections (RTIs) and adolescent reproductive health, would be introduced to address the recent recognition of the high prevalence of RTIs and their linkage to AIDS, and the recognition that one in three adolescent females become pregnant. A high proportion of RTIs in females are non- symptomatic, and currently there is no proven low cost technology that can be used effectively by peripheral health workers for diagnosing RTIs. With assistance from WHO, clinical management guidelines are being developed to introduce interventions gradually in selected areas, and would be evaluated before wider implementation. The interventions would focus on IEC to increase awareness of RTIs and their dangers, and to strengthen diagnostic and clinical treatment capacity of smaller rural hospitals. Strategies for improving adolescent reproductive health are as yet embryonic, and it is expected that developmental work would be done during the early phases of the project. (d) In the child survival component, the immunization interventions have been the most successful, and the FWP aims to achieve elimination of polio and neonatal tetanus. Strengthening of surveillance mechanisms for this purpose is underway and would also be supported by other Bank-financed projects. The cold chain for vaccines has been established, and its maintenance would be strengthened under the RCH project as recommended by UNICEF. The medical technology for improving clinical management of the two major childhood causes of death - diarroheal and acute respiratory disease - has been introduced under the CSSM project. However, the effectiveness with which such interventions have been implemented is inadequate and the RCH program would appropriately focus on further training, improved referral and clinical management procedures. For this purpose, MOHFW, with assistance from WHO and SEARO has adapted the WHO training modules on the Integrated Management of the Sick Child, and will develop appropriate strategies for introducing such training within the framework of the District Training Guidelines. (e) The coordinated human resource development and training strategy proposed by MOHFW's Family Welfare Program is sound (see Annex 11 and the Project Implementation Plan for details). The strategy would address recognized weaknesses, particularly in clinical skills, interpersonal counseling skills and gender sensitivity, and management skills. During project preparation a start has been made in coordinating the inputs that several external agencies provide so as to remove wasteful duplication and optimize synergy. Mechanisms for on-going coordination would need to be established. Experience from CSSM indicates that quality of training becomes diluted and compromised when training initiatives are replicated on a large scale through training teams who are inadequately prepared and under pressure to cover large numbers of trainees. Therefore, training quality would be monitored through indicators based on the award of clinical skill competency certificates and technical evaluations of trained workers (see Annex 1). UNICEF would support capacity development through Training Coordinators at national, regional and district levels, and support the training of core training teams at district level, while specialized consultant institutions would be appointed to provide technical input at state and district levels. An IEC strategy has been developed that relies heavily on improved interpersonal communication by outreach workers, social mobilization and tapping of NGO networks to reach disadvantaged and remote community groups and to sustain a suitable policy environment for RCH-relevant behavior change. However the capacity of weaker states to implement the strategy effectively is doubtful. GOI has recognized the need to build IEC capacity and is enhancing IEC units at  Project Appraisal Document Page 20 Country: India Project Title: Reproductive and Child Health state level. Staff in such IEC units would need to be trained and state-specific IEC strategies would be needed. The Social Assessment and District Modeling study implemented during project preparation has provided insights into approaches for rapid social assessments and the use of such assessments for developing locally relevant IEC strategies. Building on this experience, UNICEF would support the coordinated implementation of rapid social assessments and local IEC strategies with support from specialized consultant institutions to be financed under this project. Such training is expected to enhance the capacity at state, district and block levels for planning and implementing locally relevant IEC strategies using local assessments of communication needs and increasing the skills of all front-line family welfare workers in interpersonal communication. Effectiveness would be monitored through rapid community assessments (see Annex 1). (f) The civil works to be funded under the project consists almost entirely of construction, refurbishment or extensions to a large number of small, scattered rural facilities. Appropriate measures have been developed to address the two problems that have affected such civil works in previous projects, viz., poor quality due to inadequate technical supervision, and inordinate delays before constructed facilities become functional because of poor procurement planning for furniture and equipment. To improve quality, technical standards and guidelines including drawing and technical specifications for standard designs, have been developed (see Civil Works and Design Manual in the project file), and all construction to be financed by the project would be in accordance with the guidelines. Further, supervisory capacity at district, state and MOHFWs level would be enhanced through relevant consultant services and by establishing a Civil Cell in the Area Projects Unit at MOHFW to take responsibility for review of civil works designs submitted by states and districts. 16. Institutional Assessment: (a) Capacity for program management. The Family Welfare Departments (FWDs) at national, state and district levels are relatively efficient and committed organizations that have demonstrated the capacity to reduce fertility and childhood deaths in a vast, predominantly rural and culturally varied country. At the national level and in most states, the FWDs would have the capacity to manage the RCH program activities if their capacity for monitoring, supervision and troubleshooting in weaker districts is enhanced by consultant support as proposed under the project. Since the FWP is a 100 percent centrally funded program, the national level MOHFW would also assume the responsibility for closer supervision and troubleshooting in states that have weaker management capacity. Inadequate horizontal coordination between units within the FWDs has been problematic in the past and would be addressed through the management structures being established under this project. However, coordination between FWDs and the Health Departments that manage communicable disease programs, hospitals and curative services needs to be strengthened. Similarly, coordination needs to be strengthened between FWDs and other departments, notably the Women and Child Department that manages nutrition and early childhood development activities and has an extensive village worker network, the Tribal Welfare Department, and municipalities that manage health and family welfare in urban slums. Coordinating committees would be established under this project. Their effectiveness is likely to evolve gradually. (b) Capacity for managing IDA financing. The FWDs at national level and in the 15 larger states are experienced in managing Bank-financed projects. Since most projects have experienced difficulties in implementing procurement in accordance with Bank guidelines, a key feature of this project would be the use of consultant Procurement Support Agencies (PSAs) that have proven experience with Bank projects. Such PSAs would be responsible for  Project Appraisal Document Page 21 Country: India Project Title: Reproductive and Child Health procurement of goods and institutional services. Detailed preparatory work that has been completed during project preparation is expected to be sufficient to reduce problems in procurement of civil works and individual consultant services. In a few states that have experienced persistent delays and inadequacy in transfer ofproject-funds from state Financial Departments to implementing authorities at district level, an altemate mechanism to transfer project funds from the center to district implementing agencies would be established through a state level Registered Society. Such societies would be formed by expanding the roles and responsibilities of the Standing Committee on Voluntary Action (SCOVA) that manages GOI financing of non-profit NGOs in family welfare. This mechanism would need to be carefully monitored. The capacity for financial management of Bank funds at FWDs national and state levels would be strengthened by additional accounting and clerical staff who would be responsible for project accounts and preparation of statements of expenditure. (c) Capacity for management re-orientation Effective implementation of the RCH program would require major innovations affecting both the philosophy and management of the whole FW Program. Whereas there is strong commitment for such re-orientation at national and most state levels, the capacity for implementing such change is limited at district and sub- district levels, and there have been no mechanisms for systematically using client and community opinions in managing local activities. The extensive training to be financed under the project would contribute to the development of district and sub-district capacity, and the expansion of the existing monitoring system with client polls and community surveys would introduce the necessary feedback mechanisms. However, the process of management re- orientation is complex and difficult and likely to be more rapid and effective in some of the 500 plus districts than in others. Experiential learning of the process has already commenced in several districts that have been given technical support with a.;sistance from several external agencies, and sharing of lessons learnt has been a useful feature during project preparation. The project would support GOI in continuing this process. (d) Capacity for technical upgrading. The Bank assesses that the health system would be able to absorb the complex technical upgrading needed for implementing the RCH program, provided the progressive and graded approach proposed in this project is carefully supervised and monitored, and necessary adjustments are made from time to time to accommodate the varied capacity and needs of different states and districts. (e) The FWDs manage an extensive rural health system of outreach and primary health facilities that has demonstrated very good capacity to cover the vast rural population with health interventions that require limited technology such as immunization, and higher technology interventions that can be delivered through a rural camp approach such as sterilization for contraception. The RCH program requires that this be supplemented with (i) a broader range of a simpler technology that is accessible on a continuing basis (such as for birth spacing, uncomplicated pregnancies and childbirth, and milder illnesses in early childhood); and (ii) that clients who need higher level technology have timely and appropriate access to user- friendly hospitals (such as for pregnancy complications). Such upgrading is a particularly complex undertaking in a program that covers more than 500 districts which vary in the institutional capacity of the rural health system and hospitals, as well as the health needs and cultural patterns of the populations. (f) Considerable capacity to provide technical upgrading such as establishment of training institutions, trained trainers, and clinical management guidelines, has been established under previous projects as well as several on-going projects (see paragraph 9). Consultants to provide technical assistance for training and IEC would be financed under the project. There  Project Appraisal Document Page 22 Countty: India Project Title: Reproductive and Child Health are two further critical elements. First, it would be necessary to ensure that various elements of higher technology are matched to the institutional capacity of the particular outreach, primary health or hospital facilities into which they are introduced. Further, such interventions would also need to be appropriate to the health needs and cultural characteristics of communities to be served. For this purpose, MOHFW has provided good guidelines in its Concept Paper and Project Implementation Plan. (See Annex II for detailed Technical Assessment, and the Project Implementation Plan). MOHFW would need to ensure that state implementation plans operationalize the Guidelines appropriately. Particular attention would be devoted to this aspect during appraisal and review missions during project implementation. (g) Second, it would be necessary to establish a chain of technical supervision and back-up from specialists in the hospitals through the rural health system down to the peripheral outreach workers, as well as an effective referral system for early recognition of conditions requiring referral by rural health workers and families, timely transportation, user-friendly reception and appropriate clinical care in the hospitals. This would require (i) much closer coordination at national, state and district levels between FWDs and Health departments that manage hospital services, and (ii) functional linkages between hospital specialists and the rural health staff. For this purpose, authorities have been required to establish relevant committees at national, state, district and sub-district levels to develop and implement appropriate procedures. It is as yet unclear how effective such committees would be. In the four states where the Bank is financing SHS projects, the projects provide a foundation for the development of feasible mechanisms. A system of coordinated supervision of the proposed RCH project and the SHS projects is expected to promote coordination between the state and district FW and Health departments. 17. Social Assessment: (a) Project beneficiaries' reproductive health needs and behavior. Secondary analysis of data from a battery of studies provided information about needs, attitudes and constraints faced by poor women and children who are the potential beneficiaries of the project, as well as about the attitudes and behavior of health care providers in the public sector. The studies were: (i) the 1992/93 National Family Health Survey; (ii) tweny-eight quality-of-care studies funded by the Ford Foundation, USAID, and the Population Council that used interview surveys, focus groups, non-participatory observation, clinical surveys, service utilization and morbidity data; and (iii) state-specific studies on tribal groups and disadvantaged groups in six states (Assam, Andhra Pradesh, Karnataka, Rajasthan, Punjab and West Bengal) and in urban slums carried out in recently approved IDA projects. Almost 80 percent of individuals who use contraception obtain supplies from the public sector, and about 10 percent from the private medical sector. In some states, scheduled castes, tribal groups and some minority groups have higher fertility and worse health status. Among these groups that would be the main beneficiaries of the proposed project, a sizable proportion of couples were giving birth to more children than they wanted although they knew about modem methods of contraception. Many were also not using available health care services during pregnancy, childbirth and early childhood. Among those who had an unmet needfor contraception, there was a low awareness of spacing methods, low exposure to various media channels and disapproval of family planning by husbands. When asked directly, the main reasons for non-acceptance or discontinuation of contraception were fear of side effects (which were due to inadequate and incomplete information about contraceptive methods), poor knowledge and inadequate access to spacing methods. Critical barriers to use of available MCH services were the poor quality of care associated with shortages of supplies and drugs, non-availability of staff, particularly female staff, improper behavior of staff, and lack of referral facilities. Cultural norms and  Project Appraisal Document Page 23 Country: India Project Title: Reproductive and Child Health limited physical access were additional barriers experienced in some geographic areas. From the perspective of health care providers, particularly at the grassroot level, constraints included management pressures to achieve targets for acceptors for sterilization and IUDs, inadequate mobility, shortages of supplies and inadequate support from supervisors, and inadequacy of technical clinical skills and inter-personal counseling skills. (b) Stakeholder analysis. The centerpiece of this project is the implementation of a policy reform process that requires (i) a profound attitudinal and behavioral change in more than 280,000 managers and health care workers to focus on client needs, obtain and use client feedback, and improve the quality of information and clinical care; (ii) institutional changes to support decentralization at national level, 32 state government administrative levels and more than 500 districts that belong to a system that has a long tradition of top-down management; and (iii) establishment of a dialogue between the public sector and NGOs. Furthermore, during the period of project implementation, the Panchayati Raj Institutions are expected to assume greater responsibility in the implementation of the FWP, particularly at the district and sub- district levels, and it is clear that cultivation of responsive and responsible attitudes in communities, especially among Panchyat members, towards reproductive and child health would be necessary to enable them to become partners in the change. The project's Social Assessment has provided the framework for setting in motion a participatory process of dialogue between at least 17 categories of stakeholders as summarized in the next paragraph (see Annex 11 for further details). (c) Stakeholder participation in project design. Two parallel consultative processes that have informed project design are (i) a series of public sector seminars, workshops and consultations organized by the national MOHFW with state government and district officials, the medical establishment, academia and technical institutions, grassroot service providers, the Department of Women and Child Development (WCD), the Ministry of Rural Development and donor agencies; and (ii) a series of nine NGO consultative regional meetings involving more than 250 participants from NGOs, women's groups, and nurses' unions organized by the NGO community. Cross-fertilization between the two processes has been maintained through a significant critical group of individuals who have participated in both processes. The consultative process has developed the differential implementation strategy for the essential package of RCH services to suit the differing cultural and institutional characteristics of different regions in the country. It is also expected to contribute to greater state government ownership and responsibility for FW program management, state flexibility for utilizing private sector and NGO facilities for RCH, and flexibility in the use of monetary incentives or compensation for sterilization. The involvement of other ministries and multiple donors in the consultative process is expected to result in improved efficiency and effectiveness through better coordination and synergy of investments. (d) Scheduled tribes and castes, minority groups, families living below the poverty line and gender issues. The consultative process also provided input to the development of strategies to integrate gender concerns and needs of indigenous people in project design that is expected to result in: * increased responsiveness to local needs through the modified monitoring system; * increased access to RCH interventions for poor women in scheduled castes, scheduled tribes, minority groups, and urban slums by (i) specific investments to increase access to such groups in selected districts and cities through the sub-projects, and (ii) ensuring that interventions and monitoring focus special attention to these groups in all districts; * greater attention to individual client needs and gender sensitivity through the design of relevant training programs and the subsequent monitoring of service delivery;  Project Appraisal Document Page 24 Country: India Project Title: Reproductive and Child Health * improved quality of clinical care and counseling through training and monitoring; * stronger linkages between outreach workers of the FWP and WCD; and * establishment of referral services from the community to appropriate levels of the health system. These measures are expected to specifically increase utilization of available RCH services, reduce childhood and maternal illness and death among these disadvantaged groups. (e) Beneficiary participation in project implementation. The project would support continuing feedback from, and interaction with, project beneficiaries at the grassroot level through a modified monitoring system to supplement the on-going service delivery data. The additional monitoring would elicit client and community feedback through periodic client polls by service providers, as well as rapid assessments of the community by outside agencies, technical quality assessments of services, and involvement of third-party agencies and NGOs in data collection. This mechanism is expected to contribute to more responsive activity planning at the grassroot level, as well as to provide information for monitoring purposes. In addition, two purpose-designed studies are being conducted during project preparation to address issues not covered in available studies. First, a district modeling study is developing and testing a tool kit for use by district level staff for rapid assessments of communication needs in the community, and for developing locally specific communication strategies aimed at appropriate behavior change. Second, a study of panchayats using focus groups and interviews is analyzing perceptions and attitudes of panchayat members towards reproductive and child health. The outputs of these studies are expected to be used during project implementation for: