China - Maternal Child Health 6

 ICRR 11483 Report Number : ICRR11483 ICR Review Operations Evaluation Department 1. Project Data: Date Posted : 06/25/2003 PROJ ID : P003634 Appraisal Actual Project Name : Cn-maternal Child Project Costs $139.0 $129.0 Healt(hlth6) US$M ) (US$M) Country : China Loan /Credit (US$M) Loan/ US$M ) $90.0 $90.0 Sector (s): Board: HE - Health (96%), Cofinancing 0 0 Central government US$M ) (US$M) administration (4%) L/C Number : C2655 Board Approval 94 FY ) (FY) Partners involved : No cofinancing, but close Closing Date 06/30/2001 06/30/2002 collaboration with UNICEF, UNFPA, WHO Prepared by : Reviewed by : Group Manager : Group : Denise A. John R. Heath Alain A. Barbu OEDST Vaillancourt 2. Project Objectives and Components a. Objectives The principal goal of the project is to assist the Government in reducing maternal and child morbidity and mortality in the poorest areas of China. The specific objectives are to : improve the quality and effectiveness of maternal and child care, especially that provided by primary health workers at villages and townships and by referral levels; increase access, affordability and utilization of basic maternal and child health care; and improve the planning, resource allocation, coordination and management of maternal and child care services . b. Components The project financed four main components, the first three of which were targeted to 282 of the most economically disadvantaged counties (including one autonomous municipality ) in eight of China's poorest provinces (Chongqing, Gansu, Guaangxi, Jiangxi, Inner Mongolia, Qinghai, Shaanxi, Sichuan and Yunnan ). These components are: 1. Basic Health Care Delivery (base cost US$67 million), including: improvements to maternal care at primary, referral-level and emergency care; improvements to child care, including immunization and nutrition, management of acute respiratory infections and diarrheal diseases, immunization against neonatal tetanus; health education, including promotion of breastfeeding and improved weaning practices, other area -specific programs. Key inputs include essential equipment, limited rehabilitation of facilities and program support . In addition, under this component, provinces would institute special programs, including the establishment of a fund, to subsidize the costs to the poor of basic maternal and child health care and thus increase their access to these services. 2. Health Workers' Training (base cost US$29 million), including: establishment of a system of regular refresher training which can be sustained and replicated by the project provinces; short -term and long-term courses with focus on improving maternal and child health service skills and management; and development of comprehensive packages of teaching, learning, reference and assessment materials, building on earlier and ongoing program experience in China . Key inputs include development, improvement and production of training materials, training of trainers, operating costs of training program, limited rehabilitation and expansion of training facilities and equipment. 3. Management Improvement (base cost US$2 million), including: improvements to planning and coordination capacity; improvements to the quantity and quality of supervision at different levels; improvements to the function and use of the management information and surveillance systems for maternal and child health services. 4. National Level Program (base cost US$2 million), including: project management, supervision, monitoring; coordination of interactions between governmental departments and project provinces; preparation of clinical protocols and other training materials and training of trainers; provision of technical support to project provinces; carrying out of national level research and studies; preparation and appraisal of second round of province proposals for project financing (4/8); dissemination of project experiences to other areas . c. Comments on Project Cost, Financing and Dates  The credit was fully disbursed with a one -year extension of the closing date . Total project costs were 93% of those projected at the time of appraisal . 3. Achievement of Relevant Objectives: Despite some gaps in information (fact that initial baseline study was not repeated at end of project and continuing weakness of MIS), the ex-post external evaluation and provincial annual reports provide evidence that most provinces met the outcome targets to reduce maternal mortality, infant mortality, under -five mortality and neonatal mortality. Impact on MMR and IMR was confirmed by another project -financed study, which documents a significant decrease of the cause-specific mortality rates for mothers and children in most provinces financed by the project, and which links these gains to the impact of the project . The basic health care and training components have together contributed to improved quality and effectiveness of MCH services in the eight provinces; utilization of selected services has increased; and access /affordability seem to have increased modestly in some provinces . Coordination and management of maternal and child care services have improved . 4. Significant Outcomes/Impacts: Among the project's major achievements in the 8 provinces are: markedly improved inpatient and outpatient facilities for pregnant women and sick children at county and township levels; a greatly strengthened and effective three -tiered system of MCH care, capable of identifying, appropriately referring, and treating high -risk pregnant women and sick children, as well as the establishment of an integrated emergency care team at the county level; targeted health education programs, adapted to different cultural groups and languages, and directed to families, communities and service providers; increased clinical communications, including supervision and support from higher levels to county and township hospitals; increased and improved space and facilities for training, management and health education activities and elimination of differences in rates of prenatal care, clean delivery and hosital delivery between (disadvantaged) participatory and non-participatory counties. The project succeeded in introducing on a pilot basis financial assistance to subsidize the poor in meeting the cost of some of the most basic maternal and child health care, although challenges remain with regard to effective coverage, targeting, and sustainability of local level financing. Overall, the training system was successfully established, although in some cases delays in producing training materials caused reliance on materials that pre -dated new MCH norms and standards . Training skills were improved and long- and short-term training exceeded original targets and contributed significantly to above-mentioned improvements in service capacity and performance . 5. Significant Shortcomings (including non-compliance with safeguard policies): Persistence of high level of maternal deaths at home or in transit to the hospital, and low rate of poverty fund beneficiaries receiving support for delivery complications are indicators that health education has yet to convey fully effectively knowledge about complications of delivery and the importance of taking timely action . Management improvement was only partially achieved . The quantity and regularity of supervision was increased with project support, but it is unclear if there was any qualitative improvement in communication skills, supervisory techniques or procedures. In addition, although the use and quality of the existing MIS system and outputs improved, the MIS was used essentially as a reporting tool, but not as a management tool . These shortcomings were to have been addressed in the specialized management training activities, which didn't fully trickle down to the county and township levels where they were intended to be applied . 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Satisfactory Satisfactory Institutional Dev .: Modest Substantial Impact significant at national and provincial levels, especially with regard to : functional coordination of multiple services working with women and children; collaboration with research/training institutions; establishment of norms and standards; MCH management system established; three-tiered MCH health network established; poverty reduction fund laid foundations for addressing critical issue of ensuring health care access to poor and vulnerable. Note that Annex 5 of ICR also gives "Substantial" rating. Sustainability : Likely Likely Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Satisfactory NOTE: NOTE ICR rating values flagged with ' * ' don't comply with OP/BP 13.55, but are listed for completeness. 7. Lessons of Broad Applicability: Among the most salient of lessons learned cited in this ICR are : the importance of undertaking comprehensive orientation of key actors at all levels of the system with regard to the project's design and underlying approach, encompassing both clinical and epidemiological aspects of MCH, as well as management applications to ensure strong leadership, sound strategic management and close supportive supervision at the provincial level; the value of understanding and fully exploiting the linkages and synergies of the various project components to optimize efficiency and effectiveness of individual and collective efforts; the importance of evaluating all training programs for their relevance, validity and impact, as well as the importance of linking training to supervision activities, both conceptually and structurally the possibilities and opportunities to overcome the social and economic obstacles in access to health care by the poor, as well as the protection of families from the impoverishing effects of health care . Approaches will require more finetuning and additional operational research with a view to simplifying financial arrangements, finding more flexibility and variety in financing arrangements, and according greater attention to cost containment. 8. Assessment Recommended? Yes No 9. Comments on Quality of ICR: The ICR provides a critical and balanced assessment of project performance and outcome . It is clearly written, and ratings are fully coherent with the assessment (the one exception being the "modest" rating of Institutional Development, which may warrant an upgrading to "substantial". As noted in section 6 above, Annex 5 of the ICR gives a "substantial" rating for Institutional Development, while it is rated "modest" in the main summary.). The ICR might have provided more information, analysis and insight on the innovative poverty relief fund, which was set up locally to improve access of poorest mothers and children to MCH services . This initiative addresses an issue that is critical to achievement of the MDGs. Experience and lessons that would point to ways and means of building on and improving efforts to address inequities in service access and to secure the health and wellbeing of poor and vulnerable groups would be instrumental in improving prospects for achieving health and poverty -related MDGs -- in China and possibly elsewhere.