China - Comprehensive Maternal and Child Health Project (Health VI)

Document of The World Bank FOR OFFICIAL USE ONLY Report No: 25239 IMPLEMENTATION COMPLETION REPORT (IDA-26550; TF-25512) ONA CREDIT IN THE AMOUNT OF SDR 61.9 MILLION TO THE PEOPLE'S REPUBLIC OF CHINA FOR A COMPREHENSIVE MATERNAL AND CHILD HEALTH PROJECT (HEALTH VI) February 14, 2003 Human Development Sector Unit East Asia and Pacific Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS (Exchange Rate Effective November 2002) Currency Unit = Renminbi (RMB) RMB 1.00 = US$ 0.12 US$ 1 = RMB 8.27 FISCAL YEAR January I to December 31 ABBREVIATIONS AND ACRONYMS CAS Country Assistance Strategy CGH County General Hospital CMS Cooperative Medical System EPEE Ex-Post Extemal Evaluation EPS Epidemic Prevention Station FCS Functional Coordination Study FLO Foreign Loan Office, Ministry of Health ICR Implementation Completion Report IMR Infant Mortality Rate MCH Matemal and Child Health MIS Management Information System MMR Maternal Mortality Ratio MOH Ministry of Health NPA National Plan of Action PAR Provincial Annual Reports PIH Pregnancy Induced Hypertension PPH Postpartum Hemorrhage PRF Poverty Relief Fund PUSPH Peking University School of Public Health SAR Staff Appraisal Report TH Township Hospitals WRA Women of Reproductive Age Vice President: Jemal-ud-din Kassum, EAPVP Country Manager/Director: Yukon Huang, EACCF Sector Manager/Director: Emmanuel Jimenez, EASHD Task Team Leader/Task Manager: Enis Baris, ECSHD  CHINA COMPREHENSIVE MATERNAL AND CHI1LD HEALTH PROJECT (HEALTH VI) IMPLEMENTATION COMPLETION REPORT CONTENTS Page No. 1. Project Data I 2. Principal Performance Ratings 1 3. Assessment of Development Objective and Design, and of Quality at Entry 2 4. Achievement of Objective and Outputs 4 5. Major Factors Affecting Implementation and Outcome 9 6. Sustainability 10 7. Bank and Borrower Performance 12 8. Lessons Learned 13 9. Partner Comments 15 10. Additional Information 15 Annex 1. Key Performance Indicators/Log Frame Mairix 16 Annex 2. Project Costs and Financing 17 Annex 3. Economic Costs and Benefits 19 Annex 4. Bank Inputs 20 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 22 Annex 6. Ratings of Bank and Borrower Performance 23 Annex 7. List of Supporting Documents 24 Annex 8. Borrower's Contribution 25   Project ID: P003634 Project Name: CN-MATERNAL CHILD HEALT(HLTH6) Teanm Leader: Enis Baris TL Unit. ECSHD ICR Type: Core ICR Report Date: February 12, 2003 1. Project Data Name: CN-MATERNAL CHILD HEALT(HLTH6) L/C/TF Number: IDA-26550; TF-25512 Country/Department: CHINA Region: East Asia and Pacific Region Sector/subsector: Central government administration (4%); Health (96%) KEY DATES Original Revised/Actual PCD: 12/02/1992 Effective: 12/31/1994 01/26/1995 Appraisal: 02/07/1994 MTR: 06/30/1997 07/02/1998 Approval: 10/18/1994 Closing: 06/30/2001 06/30/2002 Borrower/lmplementing Agency: PRC/MINISTRY OF PUBLIC HEALTH Other Partners: STAFF Current At Appraisal Vice President: Jemal-ud-din Kassum Gautam Kaji Country Manager: Yukon Huang Nicholas C. Hope Sector Manager: Fadia H. Saadah Vinay Bhargava Team Leader at ICR: Enis Baris Jagadish P. Upadhyay ICR Primary Author: Enis Baris; Mark Belsey; Darren Dorkin 2. Principal Performance Ratings (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=Highly Unlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible) Outcome: S Sustainability: L Institutional Development Impact: M Bank Perfonnance: S Borrower Performance: S QAG (if available) ICR Quality at Entry: S Project at Risk at Any Time:  3. Assessment of Development Objective and Design, and of Quality at Entry 3. 1 Original Objective: The goal of the project was to reduce maternal and child mortality and morbidity in the poorest areas of China. To achieve this goal the project would (a) improve the quality and effectiveness of matemal and child care, especially that provided by primary health workers at village, township and referral levels; (b) increase access, affordability, and utilization of basic matemal and child care; and (c) improve the planning, resource allocation, coordination, and management of matemal and child care services. The objective and design of the Comprehensive Matemal and Child Health (MCH) Project (Credit 2655 CHA), also known as Health VI, should be assessed in the context of: a) the major change in the structure and functioning of the rural health system following a shift in agricultural policy from commune to family based production in 1978; b) the regional disparities in the health status of women and children; and c) the weakness, and in some areas a lack of, preventive and basic curative services. In the past, the Cooperative Medical System (CMS) had financed a broad range of cost-effective preventive and curative services while sharing the risks of medically caused financial misfortune. The demise of the CMS shifted the burden of health care costs to the family in a fee-for-service system. Among the activities that suffered were the preventive services and health education (HE). Poor areas were least able to cope with these changes. The loss of the CMS guarantee of reimbursement for matemity and obstetric care became an obstacle to the timely and appropriate use of these services, particularly by the poor. Dependence of the rural health system concerning cost recovery adversely affected matemal and child health. The project goal and strategy were consistent with the Bank's priority of addressing the health needs among the poor in remote populations with particular reference to the health of women and children as noted in the most recent Country Assistance Strategy (CAS) for China (1997, Report No. 16321-CHA). The goal and strategy are also reflected in the Government's "National Plan of Action for Child Development in China" and the "National Plan of Action (NPA) for Women's Development in China" in 1992 which set the goal of reducing infant and under-five mortality by one-third and matemal mortality by one half of the 1990 levels by the year 2000. These goals were reinforced with the "Law on Maternal and Infant Health Care" (1995), which defined the importance of MCH work in rural areas. Health VI had four major components. All components and specific activities were designed to be linked. In addition, it also included an innovative policy initiative directed at removing the financial barriers to care among the poorest women and children. Several of the activities were explicitly designed to study and facilitate the functional coordination of the system of MCH services that had been operating under different administrative structures and technical departments. The implementation of the project was complex, involving the MOH departments of MCH and the Foreign Loan Office (FLO), the provincial governments' Department of Finance and Health Bureaus, and county governments. Despite the complexity, however, quality at entry was considered satisfactory, and the project achieved it development objectives. 3.2 Revised Objective: There was no revision of the project objectives. 3.3 Original Components: The total project cost was estimated at about $139 million. The proposed credit of $90 million equivalent from the World Bank would finance about 65 percent of the total project cost. Of the 879 counties in the eight provinces and one autonomous municipality, the project covered 282 (32%) of those that were the - 2 -  most economically disadvantaged in Chongqing, Gansu, Guangxi, Jiangxi, Inner Mongolia, Qinghai, Shaanxi, Sichuan and Yunnan. The project was estimated to benefit 100 million people among whom there were nearly 20 million women of reproductive age. The four substantive components were: Component A. Basic Health Care Delivery (base cost US$ 67 million) aimed to improve basic MCH services at the village, township, and county referral levels. The service package included essential matemal and newborn care; referral and emergency obstetric care; prevention of neonatal tetanus; child care from birth to five years (including immunization, nutrition, management of acute respiratory infections and diarrheal diseases); and related health education activities. To ensure that benefits under the proposed project are also shared by the poorest, each project province was expected to establish a Maternal and Child Health Poverty Relief Fund (MCH PRF) which would fully or partially subsidize the health care for essential obstetric and pediatric inpatient and outpatient services. At a minimum, the PRF was to target the poorest 5% of all pregnant women and under-five children in each county, but higher coverage was encouraged. The PRF was an agreed policy initiative to be included in the project, but funded entirely by county and provincial governments, and was separate from and in addition to the IDA credit or counterpart funding. Thus, there were neither base cost estimates nor was it included in any other component budget lines, but progress in the mobilization and disbursements of funds were monitored as part of the project. Component B. Health Workers' Training (base cost US$29 million) aimed to improve the clinical, communication and management skills of village, township and county health workers involved in providing MCH care. This component drew upon existing national programs such as EPI, tetanus control, adaptations from the UNICEF- supported 300-County Project materials (i.e., MCH clinical training and training of trainers) and newly developed materials for clinical and management training. Four categories of training activities were planned: (i) short courses of in-service training, covering a range of preventive and clinical services at various levels of care; (ii) long-term courses of three to six months of placement in hospitals designated for clinical training in pediatrics and obstetrics for various levels of staff; (iii) management training courses of variable duration covering different aspects of management improvement; and (iv) training skill improvements, including training of trainers, preparation of clinical training bases, and improving skills in the development of training materials. Component C. Management Improvement (base cost US$ 40 million) aimed to develop MCH management at all levels by improving: the mechanisms and skills for better planning and coordination of MCH services; the quality and quantity of supervisory support between the levels of care; and the functioning and use of the existing management information systems (MIS) for MCH services. Component D. National Level Program (base cost US$ 2 million) undertook the major responsibility for: monitoring and project management; coordinating interactions between governmental departments and project provinces; preparing clinical protocols, training materials and the training of trainers; providing technical assistance to the project provinces; conducting national operation research studies; and disserninating the project experiences. Operational research (OR) was included under the National Level Program and in components A and C at the provincial level. The MOH organized a limited number of studies, including the study on functional coordination of MCH services. The first priority for the studies was to define and improve how the activities of the various providers of MCH services were coordinated. 3.4 Revised Components: There was no revision of the project components. -3 -  3.5 Quality at Entry. The project was not subjected to a formal Quality at Entry (QAE) review. However, based on current criteria, QAE is considered Satisfactory. The basis of the satisfactory rating derives from: (i) the consistency and agreement with the CAS (1997) (i.e., the project was focused on vulnerable groups, namely mothers and children, and the poor) and (ii) the concordance of the global goals and strategies (WHO and the World Summit for Children) for women and children with the Govemment's 2000 goals and targets for the reduction of matemal and child mortality by 50% and 30% respectively. The 1995 Law on Matemal and Infant Care defined the social context of MCH work and the responsibilities of Government at each level, inter-alia that MCH activities should focus on the whole population of women and children. The proposed project was consistent with the Bank's increasing emphasis on poor and remote areas of China. For instance, selection criteria for the participating counties were based on matemal and infant mortality ratios/rates, income, and the designation of a county as either a national or provincial poverty county. Counties already covered under the UNICEF sponsored 300-County project were excluded. 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: Achievement of both the project objectives and outputs are rated as Satisfactory. The project was approved in October 1994, became effective in January 1995 with original closing date of June 30, 2001. By mutual agreement, the project was extended through December 2001 and was closed on June 30, 2002. All project components were implemented as planned, although the pace and success of one of the components, management improvement, fell short of the original plan. The assessment of the achievement of the objectives was facilitated by the clarity of the priorities; the well-defined performance and outcome indicators; and the strong central technical and management leadership, supervision, and spirit of supportive collaboration between the central team and the Bank. Based on the Provincial Annual Reports (PAR), most provinces met the outcome targets of matemal mortality, infant mortality, under-five mortality and neonatal mortality reduction. The rapidity with which the output and outcome indicators improved in the first few years of the project are testimony to the appropriateness and continuing success of the strategies linking the first two components - improving basic health services and training. It was facilitated by the experiences of the UNICEF-supported 300 counties project, as well as the reform and reorganization of the health sector, particularly as it related to MCH services. At central, provincial and county levels of the MCH department, the primary health care structure (including the county general hospital) and HE section of EPS were combined. This strengthened the three-tiered MCH-network, expanding its coverage and integrating a reinvigorated HE strategy at all levels. The restructuring greatly improved the scope and quality of mutually supportive coordination, despite the persistence of some degree of competition for income-generating patients. The Functional Coordination Study (FCS) also provided technical and scientific support for some of the health reforms. Elements such as HE, which experienced slow initial execution, greatly accelerated its implementation later on in the project, despite resource and transport limitations. Even the most successful components of the project, however, encountered some difficulties in the course of implementation. Nearly all such problems were readily identified in the course of the biannual supervision missions and, with few exceptions, rapidly addressed. None jeopardized the ability of the project to meet its development objectives. Beneficiaries, health care providers, local and provincial leaders, Bank staff and outside consultants acknowledged that the project has been successful. However, a precise measurement of the magnitude of -4 -  that impact is hindered by two factors: a) as the original project design did not allow for a repeat of the of the baseline study at the end, the more limited ex-post external evaluation (EPEE) based on secondary data could not document the impact in a comparable pre- and post-intervention manner ; and b) the continuing weakness of the management infornation systems (MIS). On the other hand, however, EPEE greatly enhanced and provided a more in-depth understanding of many issues by relying on both qualitative and quantitative methods. To confirm the impact on MMR and IMR an assessment was made of the impact of the project on well-defined disease-specific maternal mortality ratios (e.g., postpartum hemorrhage (PPH), pregnancy induced hypertension (PIH) and infection) and cause-specific infant mortality rates (particularly neonatal asphyxia and neonatal tetanus). It was expected that each of these cause-specific mortality indicators would be lowered as a result of the application of specific clinical protocols, training, facilities and equipment introduced by the project. The significant decrease of the cause-specific mortality rates for these conditions in most provinces could be an indicator as to the positive impact of the project. 4.2 Outputs by components: Component A. Basic Health Care Delivery The elements of the basic health care delivery component involved the improvement and standardization of a series of program activities noted in section 3.3 Component A. The "hardware and software" to effect these programs included new civil works, equipment and medical vehicles, and program support. This component is rated as satisfactory, with most provinces meeting the output targets. These include the indicators of the coverage of maternal care and child care (Annex I). The major achievements are: 1) markedly improved inpatient and outpatient facilities for pregnant women and sick children at county and township levels; 2) a greatly strengthened and effective three-tiered system of MCH care, capable of identifying, appropriately referring, and treating high-rislc pregnant women and sick children, as well as the establishment of an integrated emergency care team at the county level; 3) targeted HE programs, adapted to different cultural groups and languages, and directed to families, communities and service providers; 4) increased clinical communications, including supervision and support from higher levels to county and township hospitals; 5) increased and improved space and facilities for training, management and HE activities; and 6) elimination of the differences in the rates of prenatal care, clean delivery and hospital delivery between participatory and non-participatory counties. Facilities were rehabilitated or newly constructed, and the equipment and vehicles were put in place, as planned, early in the course of the project. However, some of the equipment purchased for the project was of poor quality, requiring replacement or alternative items. Although remedial efforts and guidance were initiated soon after the issue of the poor quality of equiprnent was raised in supervisory missions and workshops, the issue continued to be mentioned and was noted in the final report. The EPEE confirmned that among the health facilities sampled, some still had the poor or non-functioning equipment originally purchased by the project. Inadequate maintenance support for some equipment also was noted. Quality control, better-defined specifications and use of the International Standards Organization criteria were introduced once the problem had been noted, but these elements did not necessarily effect the provision of suitable replacements. Health Education (HE) The HE activities can be considered successful, but with a few caveats. It is highly probable that the HE activities were a significant factor in increasing the rates of antenatal care visits, clean delivery and hospital delivery. As confirmed in the EPEE Report, the concept of "pregnancies at risk of complications" was widely understood and acted upon by both families and village midwives/doctors, as noted by the increase - 5 -  in antenatal care (ANC), hospital deliveries, and the screening and referral of PRF beneficiaries so diagnosed. Where HE has yet to make a comparable impact has been in orienting and educating families to recognize complications of delivery and to take timely action in seeking the appropriate level of care. Supporting this conclusion is the persistence of high levels (55%) of maternal deaths that take place at home or on the way to the hospital, along with the exceedingly low rate of PFR beneficiaries receiving reimbursement for delivery complications. Access to the Poorest The project succeeded in introducing financial assistance to subsidize the poor in meeting the cost of some of the most basic matemal and child health care. Information for the assessment of the PRF was derived from the consolidated final report, PAR, the EPEE, the OR studies of the PRF in the nine provinces, and a further secondary analysis of the PRF data. By 1997 most counties were able to introduce the PRF, and fewer were able to sustain it for the duration of the project. Even so, there were a small number of counties that met the coverage and reimbursement targets, kept the costs for poor families low, and achieved the reductions in maternal and child mortality. Using an indicator of "county-years" of coverage and of disbursement of PRF funds, two provinces achieved over 80% county-years recruitment target for pregnant women, one achieved 60%, five achieved from 19 to 47% county-years coverage, and one failed to report on the PRF. However, providing care and funds for the eligible women proved more difficult. In the two better perforning provinces, the county-years in which the coverage target of 5% of pregnant women was met occurred only 32% and 39% of the time. The analysis of the data for the two well performing PRF provinces suggested that in at least one there was an impact in reducing the effect of poverty on maternal mortality. Also, in some counties the poor were protected from serious further impoverishment through the effective administration and reimbursement of the PRF and the maintenance of relatively lower costs for essential and emergency obstetric care. In addition, the OR studies noted that some counties were not strict in determining who should and should not have access to services. Therefore, some of the recipients of the services were not part of the target population. Both mobilization of funds and reimbursements declined in all provinces over time. Component B. Health Worker's Training This component is rated as satisfactory, with most provinces meeting the output targets, although there is very little data on the comprehensiveness and quality of training activities. The preparations and review of case management protocols was a prerequisite for the development of training materials and teaching aids, training of trainers and selection of training bases. While there was a strong foundation of training experience and materials developed in the 300 Counties project, some of the materials needed to be revised or new materials needed to be developed due to changes in clinical protocols and management. While this process was accomplished rapidly, the publication and dissemination of the training materials was somewhat delayed. As a consequence, several of the provinces used existing materials developed earlier with UNICEF, although some of this material did not fully reflect the norms and standards for MCH care as subsequently developed under component A. Both short-term and more long-term advanced clinical training were successfully implemented. Nearly all provinces exceeded the planned training numbers for the project due to the need: I) to update the skills of those health workers who were trained earlier, especially those who were trained before the distribution of the training materials; 2) for newer skills (such as information relating to sexually transmitted diseases (STDs)); and 3) to train additional staff to compensate for staff turnover. Training skills improvement Training bases were selected according to defined criteria from those qualified health facilities at county, prefecture and provincial level. During the project, 630 clinical bases were established at provincial (16, or - 6 -  100% of the plan), prefecture (145, or 91.8% of the plan) and county (468, or 92.8% of the plan) levels. Most of the provinces achieved or exceeded the planned training for trainers at all levels. One province fell short of its planned training of trainers at all levels by up to 30%, and one province exceeded the planned levels by at least two-fold. Over 24,000 trainers completed short-term training programs in all the provinces. In addition, overseas training and study tours were arranged for MCH staff to obtain advanced knowledge of MCH care and to become familiar with international practices in other MCH services. In some cases, overseas experts provided technical assistance on specific issues. Long-term training Long-term advanced clinical training for 3-6 months was focused on improving the skills of MCH workers at the township level through clinical practice, case discussion, practical exercises, and seminars. A total of 53,642 persons received long-term training in all the provinces, with a completion rate of 116%. Over 60% of those receiving long-term training were township or village level health workers, and 36% were county level staff. Short-term training Over 605,000 MCH staff at all levels attended the short-term training for up to one week, a completion rate of 13 1%. All provinces achieved or exceeded the planned training at county, township and village levels. Component C. Management Improvement This component is rated as unsatisfactory. The management improvement component was intended to address the shortcomings and lack of expertise necessary to improve the delivery of the MCH services. The design of this component as reflected in the SAR was well thought out and emphasized practical approaches to real problems, with approaches and methodologies appropriate to each level. However, the gap between the concept and the understanding of program management at the outset and what the project proposed was significant. There were a nurnber of issues contributing to this gap. Management training was initiated, but was slow in its development and truncated in its implementation; the development of materials for management training began slowly and initially concentrated on the production of a largely theoretical, albeit correct, presentation of broad principles and concepts of management; and the quality control procedures developed for the project, and presumably being used for MCH management, have addressed accuracy issues as related to matemal, infant and child deaths, but not the issue of under-reporting of events. Also, the sheer size, availability of time and logistics of the workshops made it difficult to apply small group, participatory and other leaming methods appropriate to the subject matter. Furthermore, participants came from widely varying technical backgrounds, with very different programmatic responsibilities, and with differing levels of knowledge of and previous training in MCH. Additionally, those involved in the formulation of management training were well qualified and highly motivated, but there was insufficient representation of the range of disciplines necessary to provide a comprehensive perspective of MCH management training as envisaged in the SAR. The SAR noted that the project would improve MCH management at all levels, with three objectives: I) to improve the mechanisms and skills for better planning and coordination of MCH services; 2) to improve the quantity and quality of supervisory support between levels; and 3) to improve the function and use of the existihg management information and surveillance systems for MCH. Each of the three was only partially achieved. The quantity and regularity of supervision was increased as a consequence of the project, but it is unclear if there was any qualitative improvement in communication skills, supervisory techniques or procedures. Finally, 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. All of these areas were to be -7 -  addressed in the specialized management training activities, but never trickled down to the county and township levels where they were intended to be applied. The Project Implementation Volume of the SAR spells out in detail a series of implicitly inter-linked activities to realize the objectives of this component at provincial and lower levels. Of the five categories of activities described, however, only the Improved Coordination of MCH Services can be considered as a success, particularly as it contributed to establishing and implementing policy change. Operational Research (OR) in relation to management needs was, on the whole, of good quality and of direct importance. However, its importance in the original project design was apparently not fully appreciated. Despite the fact that it was in the budget for the first two years of the project, it was either implemented, or the information was analyzed, late in the course of the project when the opportunities were limited for it to contribute to improving MCH management or resolving other issues among project components. Component D. National Level Program This component is rated as highly satisfactory. With few exceptions, all of the activities were implemented well and in a timely manner, thus permitting the implementation of most of the other components. The Ministry of Health and its FLO were particularly well equipped to execute this component of the project. The leadership of the former had extensive experience in implementing such collaborative efforts in the area of MCH in collaboration with UNICEF, UNFPA and other technical cooperation agencies. The latter had had extensive experience in managing and coordinating such work in other health projects with the Bank. A national lead group and a series of technical expert groups were established for the development of the content and technical strategies for the implementation of the components. Key National Level Activities included: a) project management and supervision (e.g., project management information system, supervisory visits, and the EPEE); b) intra-ministry, inter-provincial and interagency coordination; c) health workers' training program (e.g., reviewing and formulating clinical protocols, developing training materials, and developing and strengthening of training skills); d) technical support for the provinces (e.g., management improvement, HE and operations research); e) national level research (e.g., FCS); f) coordination of the project phase of preparation and appraisal (e.g., preparatory workshops and the preparation of a Project Management Manual); and g) dissemination of the project experiences. During the project phase, FLO implemented the following activities in collaboration with concerned Ministries, overseas institutions, the MOH and provincial govemments: purchase of equipment; finalizing the progress report; mid-term evaluation; managing special OR studies; and providing technical assistance to the project provinces. All aspects of the national program support to training were well executed. One of the characteristics of the success of this component was the high technical qualifications and experience of the individuals and institutions providing technical support for the central team. The good relationships and technical competence of the Bank and Central team facilitated a spirit of collaboration, open technical discussions and negotiations on different stages of the project. 4.3 Net Present Value/Economic rate of return: Economic and financial rates of return were not established at appraisal nor at the conclusion of the project. 4.4 Financial rate of return: N/A -8 -  4.5 Institutional development impact: The project is considered to have had a significant institutional impact at both national and provincial levels. At the national level, by focusing on the issues of functional coordination of the variety of services working with women and children, the FCS contributed to the technical documentation justifying the restructuring of the organization and functions of MCH services under the health reform. Another institutional outcome was the increasing collaboration among national and provincial research and training institutions in the expert technical groups in support of OR and training. At the provincial level, the establishment of the norms and the identification and support for the clinical training bases will enable the provinces and counties to address on-going human resource development issues. This will also ensure the clinical skills are maintained even in staff positions with high tumover. The systematic monitoring, recording and reporting features of an MCH management system have been successfully introduced. The application of the MIS, however, is yet to be fully applied to the planning and evaluation aspects of management at county and township levels. At the county, township and village levels, the project has strengthened the three-tiered MCH healthcare network; established a skilled, well-defined and coordinated emergency and referral system for severely sick pregnant women and children; and established and refined standardized clinical protocols for care. Among its most important institutional development (ID) impacts, the project has laid the foundation, provided the programmatic experience and accumulated the technical data essential in addressing the social and economic issues of poverty and MCH care. An in-depth analysis and review of the wealth of experience with the PRF among the 282 counties could provide the basis for addressing one of the most difficult ID challenges facing the health sector over the decade: ensuring access of the poor to health care and preventing impoverishment as a consequence of ill-health. In addition, based on the quality of the performance of the counties, further analysis will permit the identification of "county-centers of excellence" to serve as national models and field training sites for short-term and long-term training. Such centers could also serve as a MCH research and development network. 5. Major Factors Affecting Implementation and Outcome 5. 1 Factors outside the control of government or inmplementing agency: The rapid economic development and increase in the average per capita income in many counties probably had a positive impact on the project by enabling counties to mobilize counterpart funds and providing the opportunity for families to have financial access to services. On the other hand, geographic and cultural remoteness of many groups, coupled with the difficulties associated with transport for HE work and supervision in some areas may have negatively impacted project reach and therefore its coverage and effectiveness. 5.2 Factors generally subject to government control: The following factors were noted as impacting the implementation and outcome of the project: * The Ministry of Health and FLO provided outstanding leadership and gave their full support with a good understanding of the project strategies and requirements. * The health reform and restructuring of MCH, PHC and HE was structurally and functionally coordinated, thus strengthening the three-tiered system of MCH as well as the training system. *, Previous experiences gained through collaboration of the govemment with UNICEF, UNFPA and other agencies in large-scale project implementation were fully utilized. * There was increasing national and provincial recognition of the importance of and support for -9-  cross-institutional and multidisciplinary collaboration, despite the earlier tendency of institutional territoriality. * Implementation could have been facilitated further, particularly in improving MCH program management, if better use had been made of the collaborative network established among the national and provincial research and training institutions. The experiences these institutions have in epidemiology, and information and management sciences relevant to MCH would have been a valuable asset. 5.3 Factors generally subject to implementing agency control: * Despite a relatively high level of turnover of the provincial deputy directors and county vice-governors responsible for the project, there was a continued commitment from the leadership at provincial, prefecture and county levels. * Over the seven years of the project there was good continuity of project office personnel with very low turnover of the staff at provincial and county levels. * While the establishment of project offices outside of the structure of the MCHS appealed to some provinces as a means of ensuring functional coordination of the different departments concerned, the subsequent reforms removed those structural obstacles. At that point, the separate project office - once a perceived advantage - became a liability. Furthermore, a separate project office deprived the PHC/MCH departments and leaders of the "hands on" managerial and administrative experience in operations. * While the central and provincial levels recognized the functional linkages of the training component (B) and the basic health services component (A), the critical link of these components, and the complexity of the approaches required for management improvement (component C) were not fully appreciated, particularly in terms of the project's sustainability. 5.4 Costs andfinancing: The final estimated project cost of US$ 129 million is approximately 93% of the appraised cost estimate. The discrepancy is largely explained by the decline in the exchange rates. In 1994 the SDR:USD ratio was 1: 1.45, whereas by 2002 it had decreased to 1: 1.30. As for disbursement, there was a slight delay due partly to implementation delays which resulted in a project extension of one full year. At the end, the project has disbursed fully at the end. As for the counterpart funds, while the project has reached almost 100 % of the pledged counterpart funding after considerable delays, a closer look reveals that only a few provinces have effectively been able to raise counterparts funds at all three levels. More worrisome was the practice-of relying on the health sector proper, instead of the financial bureaus, to provide the counterpart funds, often from extra-budgetary sources such as user fees or other projects. 6. Sustainability 6.1 Rationalefor sustainability rating: The project is likely to be sustainable. The commitments and priorities of both central and provincial governments remain as strong, if not stronger than, at entry. Evidence for this commitment is well documented in the development and implementation of the Health IX project, which was modeled on a critical assessment of the experiences of Health VI. The policy environment is clearly open to an examination of alternative models for the financing of health care and to ensuring the protection and support of the most vulnerable among the remote and poor populations of the country. This is evident in the promotion of flexibility in the PRF efforts within Health VI, Health IX, and other similar projects as well as the support for a range of operational research studies on health financing. - 10 -  All levels of the health system have recognized the neecls and means for maintaining and advancing clinical skills, coordination and HE - major contributors to the success of the project. The restructuring of MCH/PHC greatly facilitated the capacity of the system to build on these successes and to extend them to the areas in which weakness still remain, namely MCH program management and the MIS. The effectiveness of the strategy and the logic of the components were recognized. What is yet to be appreciated fully - and what will be critical if sustainability is to lead to further advances - is the principle of efficiency in the allocation and use of resources. This would also entail an examination of the current policies of financing and budgeting within the MCH/PH[C complex of services so as to avoid unnecessary duplication of facilities, staff and programs. A more in-depth examination of the financing and budgeting of MCH and other health services appears to be an essential step in ensuring sustainability, particularly in view of the enormous variation in the actual costs of standardized care indicators, such as essential obstetric care for risk pregnancies. Furthermore, budget allocations and staffing levels need to be reviewed, insofar as budgets may be determined by number of beds and number of staff, regardless of bed occupancy or workload. The analysis included in the FCS has already shown that there is duplication of underutilized facilities in the MCHS and CGH. It was also shown that there was a large underutilized capacity in the township hospitals. The Bank and Government's emphasis on the township health infrastructure was correct. The apparent highly successful upgrading of skills and facilities, and their wider use and greater acceptability are a testimony to the project's impact, and what appears to be, despite the difficulty in precise documentation, a very significant reduction of all mortality indicators. Since the PRF was fully successful in a few of the 282 counties, in theory the PRF could be sustained if the appropriate models could be identified and adapted to the varying circumstances of the unsuccessful counties. Communities welcomed the PRF, felt it was an appropriate social policy and offered constructive suggestions for its improvement. Operationally, its impact was variable between and within provinces. According to the OR study of the PRF in the four northern provinces, sustainability was felt to depend on a) political will and social support; b) the ability to raise funds; and c) the capacity for project management. The raising of funds was thought to be the most problematic. These three requirements can be examined in more detail and from a slightly different perspective, namely: 1) family-based perceptions and decision making in the allocation of family resources for health; 2) the structure, procedures, scope and reimbursement rates of the PRF so as to be acceptable and effective; and 3) the financing and budgeting basis of health services, as well as the PRF, so that they are both efficient in their operations and equitable in achieving the coverage targets. The project has shown that it is possible to maintain the skill levels, norms for care and referral, and the motivation of the community. The effectiveness and efficiency of sustainability would be based on an optimal mix of program inputs, technical content, numbers of staff, case load and supportive clinical and program management supervision. However, with many counties still lacking a problem-solving orientation and accompanying skills, and in the absence of the further extension of program management training, some provinces and many counties may not fully maintain the managerial and administrative momentum of the project. A large portion of the program support costs went into clinical and program supervision. Both the funds and the improvement of the technical skills for supervision will be essential if effectiveness is to be maintained and efficiency improved. l In summary, insofar as sustainability includes the continmed improvement in maternal and child health, there are conditionalities for such further improvements. These include: * fully meeting the health care needs of the poor and remote populations; - 1 1 -  * strengthening and possibly broadening the scope of a financial support system for health care for the poor, and to make it more transparent, flexible and less bureaucratic. To do that requires a better use of available resources (improving efficiency and effectiveness) through: * fostering a problem solving, performance-based management culture to the county level; * strengthening the quality and coverage of the village to township MIS; and, * monitoring and evaluating the specific health needs and the resources required and used to meet those needs. 6.2 Transition arrangement to regular operations: Repeated recommendations with regard to sustainability of project operations were made during the most recent supervision missions, especially because of the expressed concems by provinces that the burden of repayment, which began in the counties after the fifth year of operations, fell on the county health bureaus, instead of finance bureaus. This obviously hinder health bureaus' ability to continue undertaking their regular activities while paying back the credit by a considerable portion of their routine budget. From the project standpoint, however, such practices are bound to jeopardize project sustainability and will in fact penalize the very provinces and counties which, after having benefited from increased funding for many years, will find themselves seriously short of funds due to both project closure, end of counterpart funding and cessation of PAF in many instances, in addition to repayment. It is probably safe to conclude, based on the experiences and comments of provincial and central levels, that much of the training component will continue and use the materials and methods developed in the project. However, even that system with its established infrastructure, norms and standards, may be constrained by the absence of financial resources to cover the continuing, albeit somewhat lower, costs of both long-term and short-term training. Some degree of supervision is also likely to continue. However, unless the financial resources are provided or mobilized from savings by eliminating wasteful duplication, program support costs for supervision will be unmet which will lead to a decrease in frequency and quality of supervision. At a county and township level, maternal mortality alone will no longer be sufficient as an indicator for the evaluation of the effectiveness of the maternal health program activities and strategies. Alternative methodologies and indicators will be required. To introduce these methods and indicators will require further training and greatly improved ascertainment and recording of live births and neonatal deaths. The systematic use and analysis of maternal mortality audits, and possibly perinatal mortality audits, will be essential in monitoring quality of care and program effectiveness. Assuming improvement in the MIS, perinatal or neonatal mortality rates (particularly early neonatal mortality rates) will be the major indicators for comparing improvements in maternal and perinatal health care. These changes will require a continuation of the early efforts and a major reorientation and further training efforts in program management and MIS at all levels. 7. Bank and Borrower Performance Bank 7. ! Lending: During the preparation, the Bank team worked closely with the MOH and its FLO, provincial teams and expert groups. Indicators for monitoring outcome, outputs, and coverage, as well as those for guiding and monitoring the PRF were collaboratively developed. The systematic monitoring of the various indicators served as an introduction to the MIS "culture" for improving management. Coordination and collaboration with the national counterparts responsible for the UNICEF supported 300-county project also served to facilitate training materials development. - 12 -  7.2 Supervision: The supervision schedule of the Bank team was acceptable and effective. In the preparation, pre-appraisal, appraisal, the first two years and last year of implementation there were two, and in one instance three, missions a year. In the other years there was one mission a year. In the last several years of the project implementation, and with some of the same members of the Bank team, the experiences of the Health VI were incorporated into the identification, preparation, pre-appraisal and appraisal phases of the Health IX project. There was good communication between the Borrower and the Bank throughout the project. 7.3 Overall Bank performance: The overall Bank performance was satisfactory during the preparatory and implementation stages of the project. The Bank's team maintained a reasonable level of continuity of team membership, and the Government appreciated the systematic and well-structured approach for the project formulation, design, implementation, monitoring, supervision and evaluation. Borrower 7.4 Preparation: The Borrower's perfonnance during the preparation was Satisfactory. The central level and the participating provinces had strong supporting teams and organized a number of critical activities for the preparation process. Expert groups were organized, and, for the most part, they were highly productive. The baseline studies were a critical output during this phase. For more detail see sections 3.5 and 4.2 . 7.5 Government implementation performance: Please refer to section 5.2 on implementation factors subject to Government control. 7.6 Implementing Agency: Despite a relatively high turnover of senior political leadership at provincial and county levels, the project retained a very high level of political support and commitment from provincial and county leaders who were well briefed on the major issues and strategies by which the project was seeking to achieve its goals and objectives. There was generally a low level of tumover of project management staff at province and county levels. The provinces selected one of two different management arrangements. In one, a separate province project office was established and given responsibility for coordinating the project with the PHC/MCH Department and other entities. In the second model, the PHC/MCH Department was in charge of the whole project. Problems of coordination and clearance of activities occurred with the first model, at times affecting project activities such as technical guidance and training. For more detail also see sections 4.2 and 5.3. 7.7 Overall Borrower performance: The Borrower's overall performance was rated as Satisfactory. The Government made a strong commitment from the beginning of the project, which continued and was accompanied by a great interest in the project's progress and findings. The Government considered that one of the project's important features was the process of its development as a multilevel partnership. For the most part, the Health and Finance offices at each level made an effort to ensure the proper use of the IDA credit and the provision of the counterpart funds. Financial management of the Special Account in the Ministry of Finance was satisfactory. On rare occasions, largely because of lack of familiarity with the Bank procedures and requirements, some expenditures had to be disallowed. 8. Lessons Learned The lessons learned from this project are as follows: - 13-  * Strong central leadership and close supportive supervision at the provincial level are critical to the success of the project from a policy, technical, and resource mobilization and allocation perspective. This could have been enhanced if senior managers at central and provincial levels would have had orientation sessions given the introduction of novel approaches and/or methodologies. In the context of this project this would have involved the clinical and epidemiological aspects of MCH and management sciences applications in health systems management and development. . Identify and distinguish the inter-dependence of the proiect components in terms of their timing of the implementation, technical content, and the communications and collaboration required for those involved in the planning, development and implementation of the different components. In Health VI proper, three levels of interdependence could be identified: essential - those linkages that are absolute requirements for the success of the project; critical - those linkages that are necessary for the sustainability of the project; and supportive - those linkages that further facilitate and accelerate the meeting of the goals and objectives of the project. Basic health services and the health workers' training components were an essential linkage in realizing the project objectives; basic health services and management improvement components were a critical linkage for sustainability of the project in terms of effectiveness and efficiency; operational research and the other components represented supportive linkages. . Procurement of equipment. Procurement procedures should include an appropriately multidisciplinary and independent expert group, including bioengineers to set the technical specifications, contractual conditions and vetting procedures for health facility equipment appropriate to the level of care, skills required and anticipated caseload of the facility. * Training of health workers o At a minimum, a portion of the training infrastructure needs to be maintained, and additional distance leaming methods adapted to meeting on-going training of new staff and upgrading the knowledge and skills of health workers as new knowledge and methodologies become available. o Training reinforcement and the upgrading of knowledge and skills should be among the structured functions of supervision. o Centers/counties of excellence or "best practices" should be identified and serve as training bases in program management and MIS, as well as the PRF implementation. o All training programs should be evaluated for their relevance, validity and impact in termns of improved clinical and managerial skills. . Improving MCH program management: o In plarming, implementing and facilitating continuity in the development of the newer, and somewhat unfamiliar components of a project, a more strategic integrative approach should be used. This would involve coordinating the timing and use of national and overseas study tours, the designation of national resource institutions and expert groups, and the selection of national and intemational advisors. o New concepts. such as program management, require well-understood and contextually standardized definitions. Management training should be conducted in small, participatory groups, multidisciplinary in character and involve staff working at the same and supervisory levels, particularly county/township. There is also a need for the incorporation of the principles of translation and retranslation when drawing from technical materials originally prepared in other languages. * Poverty, health and MCH o It is possible to overcome the social and economic obstacles in access to health care among the poor, - 14-  but this will require simplifying the financial arrangements and lessening the burden imposed on the most needy communities and families. o A more flexible approach on financing of health care for the poor, including risk sharing and coverage of a wider range of conditions should be developed, drawing upon the range of experience in the project. o It is possible to protect families from the impoverishing effects of health care by giving greater attention to cost containment and providing some form of community-based insurance or subsidies. 9. Partner Comments (a) Borrower/implementing agency: The Borrower's contribution to the ICR is provided in Annex 8. (b) Cofinanciers: Not applicable. (c) Other partners (NGOs/private sector): Not applicable. 10. Additional Information N/A - 15 -  Annex 1. Key Performance Indicators/Log Frame Matrix Outcome i Impact Indicators: Indicator/Matrix Projected In last PSR Actual/Latest Estimate Matemal mortality ratio (per 100,000 live 203 8 (149.4) 69 6 births) Infant mortality rate (per 1,000 live births) 77.5 (50.7) 26.5 Neonatal mortality rate (per 1,000 live births) 56.4 (33.3) 18.4 Under-5 mortality rate (per 1,000 live births) 96 6 (65.3) 34.5 Neonatal tetanus mortality rate (per 1,000 live (1 63) 0.09 births) Notes: * Data in the "Projected in last PSR" column are from the Baseline Studies (1992-1993). The figures in parenthesis are from the 1995 Provincial Annual Reports for MCH. ** Data in the Actual/Latest Estimate column are from the 2001 Annual Reports for MCH. The baseline study data were obtained from statistically designed household cluster sample. Annual report data were collected by the routine mortality reporting of maternal and child deaths. Output Indicators: Indicator/Matrix Projected'in last PSR| Actual/Latest Estimate,. Antenatal care rate (3x) 22.0 (47.4) 84.2 Postnatal care rate (2x) 30.5 (50.2) 84.7 Hospital delivery rate 18.6 (34.0) 59.6 Clean delivery rate 22 3 (60 0) 91.8 Child immuniation rate < one year of age 87.7 (90.8) 93.1 End of project Notes: * Data in the "Projected in last PSR" column are from the Baseline Studies (1992-1993). The figures in ( ) are from the 1995 Provincial Annual Reports for MCH. ** Data in the Actual/Latest Estimate column are from the 2001 Annual Reports for MCH. The baseline study data were obtained from statistically designed household cluster sample Annual report data were collected by the routine reporting of MCH service statistics. - 16 -  Annex 2. Project Costs and Financing Proect Cost by Component (in USS million equivalent) , . - | . , Appraisal: Actual/Latest Percentage of Estimate Estimate Appraisal , | Component US$ million US$ million Basic Health Care Delivery 67.35 51.02 75.75 Health Workers' Training 29.04 29.52 101.65 Management Improvement 40.35 46.87 116.16 National Level 1.91 1.32 69.11 Total Baseline Cost 138.65 128.73 Total Project Costs 138.65 128.73 Total Financing Required 138.65 128.73 Note: Differences are due to rounding. The data of this table are calculated from financial tables and annual tables according to the exchange rate of I SDR = 1.27 USD = 8.27 RMB (June 2002). Project Costs by Procurement Arrangements (Appraisal Estimate) (US$ million equivalent) ~~. t~~Ei~erdIt C~~~tab6ury., we ifm Ttal tid j 1. Civil Works 2.27 15.00 - 17.27 (0.68) (4.50) - (5. 18) 2. Equipment and medical vehicles 8.62 15.00 5.00 - 28.62 (7.44) (12.94) (4.32) - (24.70) 3. Supervision vehicles 7 92 7.92 4. Training: Long-term _ _ 5.99 - 5 99 _ _ (5.39) - (5.39) Short-term - - 21.44 - 21.44 . __- (19.29) - (19.29) Overseas studies - 0.78 - 0.78 - - (0.78) - (0.78) 5. Technical Assistance Local Specialists - 1.91 - 1.91 _ _ (1.91) (1.91) Foreign Specialists - _-0.49 0.49 _- - (0.49) _ (0.49) 6. Operation Research . = 1.07 1.07 - - ~~~~~~ ~~(1.07) --(1.07) 7. Program Support . _ 47.98 47.98 _ _ (31.19) _ (31.19) 8. Maintenance _ _ _ 5.19 5.19 Total 8.62 . 17.27 99.66 13.11 138.67 (7.44) (13.62) (68.94) . (90.00) Notgs: I/ Figures in panenthesis are the amounts financed by IDA. 2/ Others - Includes civil works and goods to be procured through national shopping, consulting services, services of contracted staff of the project management office, training, technical assistance services, and incrernental operating costs related 0o (i) managing the project, and (ii) re-lending project funds to local govenmnent units 3/ NBF - Not Bank financed. Differences due to rounding. - 17 -  Project Costs by Procurement Arrangements (Actual/Latest Estimate) (US$ million equivalent) d ; B R-> gi2 B Wr at!go i66ui ;Mditr,f f .. 6d?.B_65 t 1. Civil Works 20.08 X 20.08 (4.69) XX (4.69) 2. Equipment and medical 18.35 5.31 0.31 23.97 vehicles (16.44) (4.49) (0.21) (21.14) 3. Supervision vehicles 2.46 2.46 4. Training: Long-term 6.32 6.32 (5.09) (5.09) Short-term 22.80 22.80 (19.20) -- (19.20) Overseas studies 0.40 0.40 (0.40) (0.40) 5. Technical Assistance Local Specialists 1.53 1.53 (1.22) (1.22) Foreign Specialists 0.02 0.02 (0.02) (0.02) 6. Operation Research 0.44 0.44 (0.44) (0.44) 7. Program Support 48.19 48.19 (28.83) (28.83) 8. Maintenance 2.52 2.52 Total 18.35 5.31 100.09 4.98 128.73 (16.44) (4.49) (60.1) (81.03) Notes: I/ Figures in parenthesis are the amounts financed by IDA. 2/ Others - Includes civil works and goods to be procured through national shopping, consulting services, serv6ices of contracted staff of the project management office, training, technical assistance services, and incremental operating costs related to (i) managing the project. and (ii) re-lending project funds to local government units. 3/ NBF - Not Bank financed. Differences due to rounding. Project Financing by Component (in US$ million equivalent) | . | . | .,, | . | , | Percentage of ~Appraisal| 'Component Appraisal Estimate- I Actual/Latest Estimate l ! l _______________ _ . IBank Go%t. CoF. Bank Go%t. CoF. Bank Govt. CoF. Basic Health Care Delivery 38.13 30.31 27.51 23.51 72.1 77.6 Health Workers' Training 25.50 3.51 24.69 4.83 96.8 137.6 Management Improvement 24.79 14.52 27.97 18.90 112.8 130.2 National Level 1.59 0.32 0.86 0.46 54.1 143.8 Note: Appraisal estimates are extrapolated based on SAR estimates of related cost figures. - 18 -  Annex 3. Economic Costs and Benefits An economic rate of return was not estimated for the project at the time of appraisal, nor was it calculated after its closure. - 19 -  Annex 4. Bank Inputs (a) Missions: Stage of Project Cycle No. of Persons and Specialty Performance Rating (e.g. 2 Economists, I FMS, etc.) Implementation Development Month/Year Count Specialty Progress Objective Identification/Preparation/Pre- Appraisal 7 PH; PH; PH; OA; 00; PO Identification: 09/1992 Preparation: 11 00; PH; PH; PH; PH; PH; MD; 07/1993 PH; PH; OA; PO Pre-Appraisal: 8 00; PH;PH;PH;PH;PH;FP; 11/1993 OA Appraisal/Negotiation Appraisal 1: 9 00; PH; PH; IS; OA; PH; 02/1994 PH; PH; OA Appraisal 2: 2 IS; IS 04/1994 Negotiations: 6 00; PC; PH; DO; PH; OA 08/1994 Supervision 06/1995 4 OO; PH;PH; OA S S 11/1995 3 OO;PH;PH S S 04/1996 4 00; PH;PH;PH S S 08/1996 4 OO;PH;PH;PH S S 03/1997 2 00; PH HS HS 07/1998 3 00; PH;PH HS HS 06/1999 5 O,; PH; MC; MC; PH HS HS 05/2000 3 PH; 00; MC S HS 05/2001 3 PH; MC; MC S HS 10/2001 2 PH;PH S HS 06/2002 3 PH;PH;PH HS S ICR 08/2002 / PH HS S Notes: 1/ The objective of the second Appraisal mission was to appraise the Iodine Deficiency Disorders Control component, which was subsequently prepared as a stand alone project. Specialist Skills: DO = Disbursement Officer; EC = Economist; FA = Financial Analyst; FP = Finance and Procurement Specialist; HE = Health Economist; HS = Health Specialist; Industry Specialist = IS; MC = Maternal and Child Health Specialist; MD = Medical Doctor; OA = Operations Analyst; 00 = Operations Officer; PC = Principal Counsel; Program Officer = PO; Physician = PY; PS = Procurement Specialist; PH = Public Health Specialist. - 20 -  (b) Staff: Stage of Project Cycle Actual/Latest Estimate No. Staff weeks US$ ('000) Identification/Preparation/Pre-A n.a. 537,471 ppraisal Appraisal/Negotiation n.a. n.a. Supervision n.a. 426,686 ICR n.a. n.a Total n.a. 975,432 - 21 -  Annex 5. Ratings for Achievement of Objectives/Outputs of Components (H=High, SU=Substantial, M=Modest, NWNegligibic, NA=Not Applicable) Rating Li Macro policies O H OSUOM O N * NA M Sector Policies O H * SU O M O N O NA Z Physical O H * SU OM O N O NA LI Financial O H OSUOM O N * NA Z Institutional Development 0 H * SU 0 M 0 N 0 NA El Environmental O H G SU O M O N * NA Social X Poverty Reduction 0 H 0 SU 0 M 0 N 0 NA N Gender * H O SU O M O N O NA LI Other (Please specify) O H *SUOM O N O NA O Private sector development 0 H O SU O M 0 N 0 NA F Public sector management 0 H * SU 0 M 0 N 0 NA El Other (Please specify) 0 H O SU O M 0 N * NA - 22 -  Annex 6. Ratings of Bank and Borrower Performance (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HU=Highly Unsatisfactory) 6.1 Bank perfornmance Rating N Lending OHS*S OU OHU F Supervision *HS OS OU OHU X Overall OHS OS OU O HU 6.2 Borrowerperformance Rating X Preparation *HS OS O U O HU i Government implementation performance O HS * S O U 0 HU X Implementation agency performance O HS O S 0 U 0 HU IZ Overall OHS *S Ou O HU - 23 -  Annex 7. List of Supporting Documents World Bank 1. World Bank. Country Assistance Strategy for China (CAS 1997, Report No. 1632 1-CHA). 2. World Bank. China: Comprehensive MCH Project. Staff Appraisal Report No. 13025-CHA. September 21, 1994. 3. World Bank. China: Comprehensive MCH Project. Development Credit Agreement between People's Republic of China and International Development Association. November 8, 1994. 4. World Bank. China: Comprehensive MCH Project. First Supervision Mission Aide Memoire. July 2, 1995. 5. World Bank. China: Comprehensive MCH Project. Second Supervision Mission Aide Memoire. November 17, 1995. 6. World Bank. China: Comprehensive MCH Project. Third Supervision Mission Aide Memoire. May 1, 1996. 7. World Bank. China: Comprehensive MCH Project. Fourth Supervision Mission Aide Memoire. September 3, 1996. 8. World Bank. China: Comprehensive MCH Project. Fifth Supervision Mission Aide Memoire. March 20, 1997. 9. World Bank. China: Comprehensive MCH Project. Sixth Supervision Mission Aide Memoire. July 16, 1998. 10. World Bank. China: Comprehensive MCH Project. Seventh Supervision Mission Aide Memoire. July 2, 1999. 11. World Bank. China: Comprehensive MCH Project. Eighth Supervision Mission Aide Memoire. May 21, 2000. 12. World Bank. China: Comprehensive MCH Project. Ninth Supervision Mission Aide Memoire. May 14, 2001. 13. World Bank. China: Comprehensive MCH Project. Tenth Supervision Mission Aide Memoire. October 19, 2001. 14. World Bank. China: Comprehensive MCH Project. Eleventh Supervision Mission Aide Memoire. June 15, 2002. 15. World Bank. China: Long Term Issues and Options in the Health Transition. 1992. 16. World Bank. China: Strategies for Reducing Poverty in the 1990s. 1992. Government 1. National Plan of Action for Child Development in China" and the "National Plan of Action for Women's Development in China" in 1992. 2. Law on Maternal and Infant Health Care." 1995. Other 1. Belsey, Mark. Study on Functional Coordination. June 15, 1998. 2. Beijing Medical University. Mid-Term Evaluation Report on Comprehensive MCH Project in China. July 1998. 3. Ex-post External Evaluation Section, Ex-post External Evaluation Report on Comprehensive MCH Project in China. June 2002 - 24 -  Additional Annex 8. Borrower's Contribution China Comprehensive Maternal and Child Health Project Borrower's Contribution to the Implementation Completion Report 1. Project Background In the early 1990's, the general situation of MCH services in China had exceeded most of the developing countries, however, great variations still existed within different areas. Especially in those remote rural areas, the health status of poor and vulnerable women and children lagged far behind the average level of the whole nation. Therefore, China's Govemment proposed to implement the Comprehensive Maternal and Child Health Project as a candidate project for World Bank support and this was agreed by the Bank. The project areas were finally defined including 8 project provinces namely Guangxi, Shaanxi, Sichuan, Yunnan, Gansu, Qinghai, Jiangxi and Inner Mongolia plus Chongqing as an autonomous municipal city separated from Sichuan (hereafter referred to 9 provinces). The baseline survey was conducted from 1992 to 1994 in 282 project counties in the 9 provinces. It was showed that the maternal mortality ratio and child mortality rate in project areas were much higher than the average level of China. The quality and effectiveness of MCH services were also urgently needed to be improved through implementation of this comprehensive MCH project. 2. Project Objectives, Design and Organization Project Objectives. The goal of the project is to reduce the maternal and child mortality and morbidity rate in poorest areas of China. To achieve this goal the project would (a) improve the quality and effectiveness of MCH services, especially those providecl by the primary health care workers at village, township and referral levels; (b)improve the accessibility, affordability and utilization of the essential MCH services; and (c) improve planning, resources distribution, coordination and management of MCH services. Project Design. In accordance with the four substantive components of this project: (1) Basic Health Care Delivery; (2) Health Workers Training; (3) Management Improvement, and (4) National Level Program, the final report submitted by the central level divided the project activities into seven parts: (A) Providing essential MCH services; (B) Health education; (C) Training on MCH staff; (D) MCH management; (E) Poverty relieffundfor medical services; (F) Operational research, and (G) Equipment and civil work. The most important component was providing essential MCH services, which involved primary maternal health care, children's health care, referral and emergency care system, construction of pediatric and Obs & Gyn. departments in hospitals, case management of ARI and CDD, control of neonatal tetanus, promotion of breast feeding and proper complementary weaning food, routine childhood immunization and control of IDD. The health worker's training component included short-term training, long-term training, overseas training and receiving technical assistance. The MCH management component aimed to improve the mechanisms and skills for better planning and coordination of MCH services; strengthen project supervision and evaluation by making full use of the existing management information systems (MIS). The national level was mainly responsible for project management and monitoring; coordination between different departments concerned and project provinces; preparing training materials and TOT; providing technical assistance and guidance to project areas; conducting operational research; and disseminating the project experiences. Project Management The Foreign Loan Office (FLO) of the Ministry of Health (MOH) was - 25 -  responsible for overall project management with the guidance of the Project Leading Group of MOH chaired by the Minister. The members of Project Leading Group included Director General from the Departments of PHC/MCH, FLO, Medical Administration, Disease Control, Medical Science and Technology as well as Health Statistics Center. Under the Central Leading Group, a Project Coordinating Group was established to be responsible for implementation of this project. The Project Office at each province was also established to complete the similar tasks as central level accordingly. The Central Technical Guidance Group was composed of specialists from the Medical Universities and MCH centers major in women's health care, obstetrics, children's health care, pediatrics, health management, health economics, statistics, epidemiology, and health education. The Peking Union Medical College and the Women's and Children's Health Center of Peking University (originally named Beijing Medical University) were responsible for conducting the concrete technical work of the whole project at the first and the second stage, respectively. 3. Key Project Activities and Achievements Part A: Providing essential MCH services (I) Primary maternal health care The governments at different level in project areas formulated implementation rules and regulations on MCH and construction standards in obstetrics, so the MCH services could be provided smoothly. The cascade training was conducted by county to township level and township to village level in 9 project provinces, mainly focusing on intensified prenatal examinations, and identifying risk signs and symptoms of pregnant complications. The MCH services on prenatal care, deliveries and postnatal health care at township and village level were further standardized and improved. The established 3-tiered MCH network had been put into good effects. High-risk pregnancy was identified and particularly supervised to a full extent in project counties, so that the proportion of hospital delivery increased dramatically. (2) Child health care services A 3-tiered child health care network was gradually established and completed under the great support of Government at different level and departments concemed. The training program also improved the quality of staff, and it laid a foundation for smooth conduction of child health care. Some regulations and rules were formulated at provincial level according to local situation, which facilitated the supervision on the quality of child health care services. Regular physical checkup on children was carried out in all project areas. Therefore, the abnormal illnesses could be timely detected and intervened at an early stage. In project areas, child health care services were expanded, and the outpatient services of children contributed to a positive cycle. (3) Referral and emergency care system The emergency and referral systems for treating severely sick pregnant women and children were established and improved continuously in all project counties. The network was centered at county health institutions, and a tertiary emergency and referral groups were completed at county, township and village level. The technical training on management of sick illnesses had been intensified among health care workers. The capabilities on identifying and management of high-risk cases had also been improved. The proportion of referral facilities at village and township level increased, and cases of maternal and child deaths at home or on the way to hospital because of severe illnesses decreased. All emergency equipment and ambulances were well equipped in county emergency centers and health centers in project areas. The - 26 -  24 hours service is provided to guarantee the illnesses access to Green Lifeline. (4) Pediatrics in hospitals The construction of county health institutions and pediatrics in township hospitals was strengthened. Some emergency equipment was equipped in the pediatric department of county general hospitals, MCH institutions and township hospitals in project areas. The training centers were established at county general hospitals in each province, in which in-service training programs were provided for pediatricians. Those trained pediatricians played an important role in actively managing sick children and facilitating the prevention and control of "Four children's diseases". The Children's Emergency Center with ICU wards for newbom infants were also established in each project county, and all the standardized programs were implemented well in these centers. (5) Obstetric and gynecological department in hospitals During the project implementation, the obstetric and gynecological department in hospitals at different level advocated a series of activities such as hospital delivery, systematic management of high-risk pregnancy through the development of "safe motherhood" initiative and establishment of "baby friendly hospital". These activities helped obstetricians identify the severe diseases and provide emergency treatment timely. Therefore, all women in project areas could make good use of the qualified health care services, and the safety of mothers and infants could be guaranteed to a high extent. In most project areas, the supervision, evaluation and utilization of information in obstetric department were improved, and the constructions were also continually strengthened. (6) Case management of ARI Pneumonia is the first death causes among under-5 children in project provinces. According to "Prevention Plan for Management of ARI and CDD", the intensified training programs on ARI case management were conducted for those village doctors in all project counties. Each project county identified county health centers as qualified training bases, in which ARI surveillance works were carried out and case management of children's pneumonia was strengthened by consolidated clinical training and practice. Most of village MCH staff received ARI training frequently, thus they could better understand the basic knowledge and diagnosis method of pneumonia. A tertiary ARI case management network was established at county, village and township level in order to expand ARI case management techniques. All ART cases were registered and managed by village doctors, who could provide follow-up and referral services appropriately. (7) Case management of CDD CDD is another major death cause of under 5 children, which is mainly caused by severe dehydration. The intensified training programs on CDD case management were provided to those health workers in township and village health centers. The ORS therapy was highly promoted with relevant demonstrations in all health centers and clinics. A tertiary CDD case management network was established at county, township and village level in project areas. According to Case Management Plan on CDD, the flowing charts on diagnosis, treatment and referral of CDD cases were distributed to village doctors. All of the children with diarrhea were registered and followed up under surveillance. In emergency cases, referral services could be timely provided to those ill children. Meanwhile, the knowledge on health care of CDD cases in families was extensively disseminated to most of the parents in project areas. - 27 -  (8) Control of neonatal tetanus The clean delivery was highly promoted in rural areas. Relevant training programs were provided to those village midwives accordingly. The rate of clean delivery has been greatly increased in project areas, which would contribute to the control of neonatal tetanus. On the other hand, the rate of hospital delivery also increased in rural areas. The awareness of self health care among the target population has been enhanced to a high extent through health education. Most pregnant women could easily access to hospital delivery under the support of Governments at different level and Working Committees of Women and Children. (9) Promotion of breast feeding and proper complementary weaning food According to the requirements of WHO, all provinces conducted Obstetrics reform and breast-feeding programs integrating with other activities such as establishment of "baby friendly hospital", "baby friendly health centers" and "baby friendly counties". Project county or township hospitals advocated pure breast-feeding within 4-6 months in addition to its Obstetrics reform. The training materials on breast-feeding and proper complementary weaning food were distributed to pregnant women through health education programs, so as to guarantee children's nutrition and their health development. (10) Routine childhood immunization Each project province formulated "Routine childhood EPI program" at provincial level according to the requests and objectives on EPI and infectious disease control by the Ministry of Health. Cold chain truck were equipped in all project county epidemic prevention stations, and refrigerators were also provided to township health centers to facilitate the operation of cold-chain system on the regular basis. Township EPI coverage was greatly improved based on the guarantee of county EPI coverage. (11) Control of IDD Eradication of IDD is a global strategic goal at 1990' World Children's Summit, and also a major activity of this project. "Implementing rule on the eradication of IDD and its surveillance" was formulated in project areas. Special funding was provided in terms of training, health education, supervision and surveillance. Health education manuals on IDD prevention were widely distributed to the public. Iodine salt and iodine capsules were dispensed to the target population including women of childbearing age, pregnant women, junior school students and children. The urine-iodine tests were regularly given to some children in order to identify IDD in time. Part B: Health education Each project province established and improved the county health education institutions. The proportion of health education professionals was greatly increased. The organizations of health education were set up in each township and village with part time health educators. A group of key technical staff had been trained and health education institutes had been strengthened in 9 provinces. In addition, a 3-tiered health education network was formed, and many women, village doctors and teachers were trained as voluntary health educators. According to local situation of the project areas, communication strategies on interpersonal communications through mass media were made under the guidance of national and provincial technical - 28 -  group on health education. In addition, a large quantity of disseminating materials was produced for the local target population. Through this program, those target population improved their knowledge, promoted their behavior changes and strengthened their capabilities of utilizing health services. All kinds of interpersonal communication activities such as home visits, small group discussion, individual interview and consultation were conducted for rural women. Besides, all project counties made fully use of mass media including TV, broadcast and newspaper to spread health education information. Provincial health education institutions also produced a lot of printing and audio materials for target population to better understand the key health message. Part C: Training on MCH staff Training on MCH staff is an important activity of this project. This training program provided MCH personnel and managerial staff at grassroots level in 282 project counties of 9 provinces or municipalities with special training courses on skills in basic MCH care, clinical services, interpersonal communications and services management, so as to strengthen the capacity of improving MCH services and to obtain the ultimate goal of decreasing MMR and IMR in the poorest areas in China. The methods of training included short-term theoretic training, long-term clinical training, overseas training and technical assistance. The cascade training was conducted from provincial, county and township level down to the village level in line with the uniform central guidance on training programs. The participatory training was adopted in the forms of lectures, small group discussion, case study, role play, brain-storming, demonstration and practice, in conjunction of various teaching devices, models, posters and video tapes, which were actually attractive and interesting to the trainees. The teaching materials were easy understood and appropriate for the trainees. The training contents were defined according to the requirements of the central level. Besides, some other relevant training was also carried out at the provincial level in line with the local MCH situation. Through supervision on training activities, it was showed that the MCH professionals at each level had enhanced their knowledge and technique of providing proper services. In a word, the training program achieved its remarkable results and attained the expected goals in terms of the health indicators on MCH services in the project areas. Part D: MCH management A number of rules and regulations as well as corresponding Plan of Actions were formulated in all project provinces in consideration of the requirement of central government and the local situation. The supervision and directions at all levels in every provinces covered 12 components, mainly in three aspects: (I) systematic MCH care, screening and management of high risks, application of the case management guidelines, emergency treatment and referral of severe cases, and health education activities; (2) the provision of MCH services in working places; and (3) supervision on the quality of MCH related information and records. The Standards ofAnnual Evaluation on Health VI Project was formulated. At the beginning of every year, all project counties took assessment by self on the project implementation in the previous year in accordance with the evaluation standards. Provincial project offices conducted random supervision and assessment regularly to evaluate the development and current problems of the project. At average, 24 times supervisions were made by the province and prefecture to project counties. Apart from the routine supervision and regular meetings, corresponding managerial activities were also carried out in line with the local actual situation in all the provinces. - 29 -  Five-layered information network was established at provincial, prefecture, county, township and village levels to strengthen the information management with practical utilization of personnel, equipment and fund in the 9 project provinces. Special professionals were appointed to collect, analyze, summarize and report the relevant MCH information and data. In accordance with the report format at the central level, the uniform forms were compiled to collect the local original data, which ensured the reliability and validity of MCH management information. Part E: Poverty relieffundfor medical services In China, there are significant differences in health status and quality of health services in various areas, the IMR and MMR in poverty stricken areas were much higher than the national average levels. In those areas, the inefficient usage of MCH resources was one of the most important reasons for the high MMR and U5MR. A number of rural people couldn't access to the MCH services due to the low capacity of pay-for-services. In this regard, govemment subsidy is one of the effective approaches to tackle the problem. Therefore, the Health VI Project has set up special poverty relief fund for MCH services, aiming at decreasing MMR and U5MR. Basically, the poverty relief fund (PRF) was raised on the basis of an average of 0.1 Yuan per capita in the project counties in the provinces. Due to the different numbers of poverty relieved counties in the province, there were remarkable differences in the amount of fund. Also the sources of fund for every province varies as follows: -financial input for the county govemment, . co-financing by govemment and health administrative departments, -fundraising by medical personnel, health bureau and township hospitals, -department of civil affairs and Poverty Relief Office, and -social donations etc. In all project counties, the fund was managed as an independent account for specific utilization and evaluation in a bottom-up reporting approach. The principles to identify the target populations were in line with the project document that at least 5% poorest pregnant women and under-S children should be covered in the project counties. The identification methods were almost the same among all the provinces. Poor households were strictly identified according to the poverty line stipulated by the local Department of Civil Affairs. However, the results showed that almost all project provinces couldn't meet the needs of this project to cover 5% of poorest pregnant women and under-S children as PRF target population. Comparatively, the rate of coverage for pregnant women was higher than that of under-S children. Poverty relief fund for medical services are mainly used in five aspects: -matemal health care, hospital delivery for high-risk pregnancy, -obstetric complications, -outpatient treatment for child moderate and severe pneumonia and CDD, -inpatient treatment for child moderate and severe pneumonia and CDD. As for the drug management, the document on "Guideline for case management of pregnant women and illness children" was issued as standards for treatment and prescription of drug, so as to prevent from over-prescription and bacteriophage-abuse. Since the implementation of poverty-relief medical services, social and economic benefits had been achieved in all project counties in 9 provinces. By means of providing the poverty-relief medical services, poor pregnant women and children were helped with medical assistance to improve their health status. The poorest population could acquire the equity of primary health care services to a certain extent. The MMR and U5MR were decreased, and eventually the local socio-economic development was strengthened in project areas. Since the PRF activity has achieved its expected results initially, the public would extensively benefit from this project. - 30 -  Part F: Operational researches Some operational researches were conducted in accordance with the local pregnant women and child health status, valuable results had been achieved, disseminated and applied in the project and non-project areas. The titles of these researches were listed as following, as for the detailed description please see to the relevant reports. (1) The applied studies on ORT in the Health VI Project in the project counties in Guangxi Province (Guangxi Province); (2) A applied study on community intervention measures to decrease death resulted from postpartum hemorrhage in the remote and poverty-stricken mountainous areas (Guangxi Province); (3) Record manual on pregnant women in rural households (Qinghai Province); (4) Study on nutrition of the infant supplementary food produced in rural households (Qinghai Province); (5) A study on the management model to decrease the MMR and IMR in rural areas (Yunnan Province); (6) Management of malnutrition in community children (Sichuan Province); (7) The dissemination of ORT to treat under-5 children diarrhea in rural areas (Gansu Province); (8) The establishment of MCH surveillance network in Gansu (Gansu Province); (9) The application of standardized approach to treat the emergency cases of infant asphyxia in pediatric departments of township health clinics (Gansu Province). Part G: Equipment and civil work (1) Allocation and utilization of equipment To strengthen the construction of MCH institutions and enhance the capacity of MCH services, this Health VI Project allocated necessary medical and office equipment and improved the conditions of village health clinics, township health centers, county MCH hospitals, county general hospitals and county epidemic prevention stations. All of the equipment was conducive to improve the capacity of health care services and emergency treatment of the relevant institutions in the project areas and decreasing MMR and IMR. Most provinces worked out the regulations on equipment management, covering installation, testing, maintenance and counterclaims. The special persons were assigned to manage the utilization of the equipment. (2) Civil works The fund for civil work was used to expand the office building of the MCH institutions at provincial, prefecture, county and township levels, which to the most extent improved the health services conditions and brought better economic and social impacts. 100% and even more planned construction tasks were accomplished successfully in all the provinces, because most of office buildings were on too poor conditions to meet the requirements of the work. The expenditures over the budget were covered by self-raised . Central Activities (1) Project management The FLO of MOH organized domestic and overseas experts to conduct baseline survey in project provinces, as well as a series of field studies, workshops and evaluation activities. In collaboration with the concermed Ministries, overseas institutions, departments from MOH and provincial govermments, the FLO of MOH well implemented the following activities such as procurement of equipment; completion of the progress and final reports, mid-term evaluation, management of operational research and provision of technical assistance to the project provinces. - 31 -  Some other activities were conducted by the central technical guidance group as the facilitation of project implementation. For instance, development of training materials, holding training courses on TOT, assessment of training and health education effectiveness, summary and analysis of information/data on MCH services, organizing workshops and disseminating project experiences. The project officers from FLO, domestic experts and members from World Bank Mission provided the supervision and technical guidance at least twice a year during the implementation of this project. The major supervised components included the provision of essential health services, training of health personnel, conducting health education programs and making sure how to utilize project funds properly. The central level could timely identify the existed problems, provide evaluation reports including suggestion to solve those problems, and give feedback to the departments concerned. (2) Health education Health Education activities at central level mainly focused on training and guidance provision. In order to make sure its quality, experts drafted all the proposals according to the plan, and all the activities were supervised on a regular basis. Health education programs played an important role in improving the technical skills of key personnel and facilitating the project implementation. Some experts were invited to design the health education component, including baseline survey, communicating strategies and intervention activities. In addition, training plans were made in order to monitor and evaluate health education activities. The training materials on were developed by the technical guidance group and distributed to project provinces so as to help MCH workers at grass roots level better understanding health education theoretical knowledge and techniques. The training course for MCH personnel was held by central experts to enhance their capacities on carrying out health education activities. Central expert group frequently supervised and provided technical guidance on communication programs for project provinces and counties. Furthermore, internal study tours also promoted experiences sharing between project areas. At the end of this project, the experts provided guidance to each project province to formulate sustainable health education plans, which were conducted by mass media and trained MCH workers. In addition, the local health education materials were recommended from project provinces to other areas, in order to share the experience and resources. (3) Training of MCH staff Training activity was a priority component in Health VI project. Central technical group played an important role in its plan-making, developing training materials, and its implementation, supervision and evaluation. The training packages included the designation of general plans, the development of materials and teaching aids, training and technical assistance from central to provincial and/or county level, as well as conducting mid-term evaluation and making future plans. The experts from central level emphasized that the short-term training should concentrate on enhancing trainees' technical capacities by means of teaching-oriented and participatory learning skills; while long-term clinical training should mainly focus on improving the practical skills of MCH staff in township hospital. Based on the training objectives, the training contents for Health VI included: (1) Essential MCH - 32 -  services; (2) Prevention and treatment of common diseases in Obs/Gyn and pediatrics; (3) Formnulation clinical service protocol at different levels; (4) Health education and interpersonal communication skills; (5) Methods for training of trainers and clinical teaching method; and (6) MCH services and information management. According to the local MCH status in project areas, some new training materials and teaching aids were developed by the central experts. Besides, the experts at central level also provided regular and irregular supervision and evaluation in terms of clinical training bases, training effectiveness and technical services. Problems were identified and feedback was given to the departments concemed timely. (4) Poverty relief fund for medical services The main activities of Poverty Relief Fund (PRF) at central level include: (1) Management of information system; (2) Supervision and observation: to identify the target population and problems of PRF; (3) Coordination and training; (4) Project evaluation; and (5) Operational research on health services by using PRF. (5) Operational researches The titles of operational researches conducted by the central level were listed as following, as for the detailed description please see to the relevant reports. (1) Functional coordination of MCH services (Faculty of MCH, Beijing Medical University); (2) Research on the breast-feeding behavior in rural project areas (MCH Center, Beijing Medical University); (3) Analysis of influencing factors to MMR and its reduction trend (MCH Center, Beijing Medical University); (4) The promotion of children's health status through MCH services (Beijing children's health care institute); and (5) A comparative research on MCH information system in project and non-project counties (Department of Statistics, School of Public Health, Beijing Medical University). 4. Project Sustainability (1) Relevant regulations and policies ensured the sustainable development of this project. Promulgation of the Maternal and Child Health Care Law by the State formed legal basis for the MCH care to protect women and children's health. The governments of different levels also set up matching regulations and norms to enforce the Law. The People's Congress supervises and examines the implementation of the Law in the governments of different level. There was also an organizational reform among the health administrative departments. The integration of MCH and primary health care in one administrative agency will achieve more reasonable systematic planning and cooperation. The administrative framework has been finalized through the organizational reform, which is a vertical system from province to district and county level. The system can serve as a sound foundation for the development of MCH and community-based health care. (2) MCH training and standardized management will pave the way of sustainable development of this project. After 7 years' implementation of this project, the project provinces benefited a lot on their development of MCH enterprise. Standard management models and related regulations and norms were established to guide all MCH care services and work. A number of managerial staff and professionals were trained in this project with updated managerial concepts. Technical Guidance Centers and Training Centers - 33 -  were set up, in which the township level doctors were trained. With their years' working experiences, these doctors' knowledge level and working capabilities were enhanced. Their quality services met the local MCH care needs. Thus, they established trusty relationship with the local people, which paved the way of continuous and sustainable development of this project. By means of appropriate technology and health promotion, people's health awareness was raised, which was also in favorable of the sustainable development of this project. (3) The implementation of this project laid a better basis for the development of MCH enterprise at grassroots level. The project has trained numbers of medical technical and administrative staff, improved the medical equipments and environment, and enhanced the capacities and quality of services, which formed a better basis for the further MCH development of the rural poverty stricken areas. A great number of trained MCH workers would continually provide MCH services for the local women and children. Most purchased equipments in this project still have a long expiry period and can play an important role in the MCH services of county, township and village levels. As delivering the medical service to the local people, the medical agencies can also increase their income, which will form positive capital accumulation to enlarge their service scope and update their equipments. Along with the economic development, if the government can maintain the increased annual input on MCH, more people can benefit from health care services and the health care will be promoted. (4) The fundraising for PRF is important for guarantee the sustainable development of this project. The key to ensure medical assistance is to raise sufficient poverty relief funds. Whereas, all project provinces were short of funds for poverty alleviation. The main reasons were the local government had financial difficulties and the leaders didn't pay enough attention to this activity, which may affect the development of PRF in project areas. Therefore, in order to maintain the sustainable development of the poverty alleviation programs, it is suggested to integrate this poverty alleviation activity into the national programs, in combination with the civil affairs local financial assistance work, even add this content of medical assistance into the western development in China, as well as allocate a certain amount of funds for health poverty alleviation purposes. Meanwhile, with the cooperative health care system in rural communities, we should increase the discount off the charge from poor people seeking for health services and enlarge the coverage of poverty alleviation. (5) The methods and achievements of health education will be continually made use of and further extended in project areas. The Health VI project enhanced the health promotion in each province greatly. A great number of health education professionals had been trained, and the health education staff at grassroots level had also been stably established. More and more managers and people at the grassroots level grasped the essential health education methods and took part in many health education activities, which had improved the health consciousness of local women and children to a certain extent. Furthermore, different provinces blueprinted sustainable health promotion development programs respectively, charactering with local ethnic languages, customs etc. Some provinces formulated the plans for sustainable health education development, and produced health education materials with pictures and texts to be easily understood, in line with the local regional characteristics in languages and customs. In some provinces, the Record Manualfor Pregnant Women in Rural Families and Production of Infant Supplementary Foods in Rural Households were publicized for application to raise the public awareness of self-care and improve rural children's nutrition and maternal health status. - 34 -  5. Lessons learned (1) The attention from the leaders is the key factors to guarantee the smooth implementation of the project. The implementation of this Health VI Project was compatible to obtain the objectives of National Plan of Action in China. To ensure the smooth implementation of the project, the leaders should be motivated. The significance, objectives and contents of the project were publicized, the consensus was reached in all walks of life, and the project was attached great attention and well received by the society. Since the beginning of project implementation, a project leading group was set up in each local govemment, project office and the technical guidance group were also established in all project provinces, in order to strengthen the leadership of the project and put it onto the routine working agenda. In project counties, the govemment leaders took this project into the county economic and social development programs, organized and coordinated the project implementation, and carried out outcome-based management and regular evaluation, even the results of evaluation were included in the annual government report. Under the effective support of local leaders and the guarantee of relevant policies, the health VI project was implemented smoothly. (2) The multi-sectors coordination and cooperation was the fundamental guarantee for the success of the project. Health VI project is characterized with comprehensive MCH services management. The cooperation was both intemal and extemal. The close cooperation and specifically assigned responsibilities among the medical institutes at all levels made it possible to accomplish the tasks jointly. Therefore, during the implementation of the project, the interactive communications among the above mentioned sectors were strengthened, which were invited to participate in the relevant conferences and activities to enable them to know about the process and current problems, so as to actively join the project activities and provided great support and help to solve some difficult problems. The experiences from the project implementation showed that the multi-sectors cooperation was the fundamental factor for the success of the project. (3) The consolidation and completion of the 3-tiered MCH services network are the basis of the realization of the project objectives. Before the implementation of the project, the 3-tiered MCH services network was established in some of the project counties. Some health institutions collapsed, bankrupted or existed with no specific purposes, which mainly resulted from the unmatched rural health reform, market economy and local socioeconomic development. Hence, some active measures were taken to consolidate the 3-tiered MCH services network. In addition, the managerial system of village health centers was optimized according to their categories and types of ownership. The village health clinics were administered in conjunction with the township health institutions, with increased financial input, hence the income and some practical problems were resolved for the health professionals at township and village levels. By mean of the implementation of the project, some effective measures were taken to stabilize the health human resources, consolidate and develop the 3-tiered MCH !services network, and guarantee the realization of the 12 priorities of the project, and enlarge the scope of MCH services. (4) The allocation of the counterpart fund is the necessary for the implementation of the project. The improvement of MCH services conditions need government's attention and support from all - 35 -  walks of life. Since China is still at the stage of economic development, the financial input from government is limited, it is beyond the capacity of the govemment to invest more than 100 million Yuan a year into one province. Therefore, it is necessary to develop more MCH projects supported by foreign funds, and with great efforts to provide counterpart fund by the government, in order to improve the local MCH conditions On the other hand, it is also important to pay extensive social attention to women and children with spiritual and material support, so that the MCH enterprise would be further developed. All the project provinces tried their best to ensure the fund allocation though the local financial resources were limited. (5) Project training is an important component to improve the quality of the project. This project paid great attention to the quality of training, in order to enhance the capacities of MCH professionals to provide appropriate services with high quality. During the implementation of project, the central level organized a number of experts as the project technical guidance group. In all project provinces, the trainer's teams including Ob & Gyn and pediatric specialists from the provincial MCH institutions, general hospital and children's hospitals were also established. A number of training activities had been carried out level by level according to the requirements of this project. The clinical training bases were strictly selected, which ensured the training quality. The training at all levels of the health VI project provinces enabled MCH professionals at the grassroots level to master the appropriate techniques for MCH services and health education methods, to regulate health services techniques, and increase the capacity of identification, emergency treatment and transportation of the serious and difficult cases, so as to provide the most basic and appropriate services an hence effectively decrease the MMR and IMR and achieve excellent social benefits. On the other hand, trainers at all levels were empowered with interpersonal communications techniques and skills, also increased their capacity of training to ensure the sustainable project training in the future. (6) Supervision and inspection are the important measures to achieve better results of the project. According to the requirements of the health VI project, the periodic supervision and regular meeting systems at grassroots level were established in all the provinces. Apart from the regular meetings organized by the FLO of MOH, some regular meetings or working meetings were also held by the provincial health departments to allocate annual project work. Project managerial staff at all levels regularly supervised the implementation of the project in the process of this project, the statistic system on life records had been gradually established to accumulate rich experiences in collecting, analyzing, summarizing and utilizing data and information, which inevitably enhanced the management and utilization of relevant data to reflect the current progress and existed problems, consequently a locally feasible and intemationally standardized approach was developed to provide reference for health policy making. (7) Poverty relief fund for medical assistance was a creative work in the health VI project. The PRF for medical assistance is using the funds of govemment to support the target population making full use of MCH services. It is a creative measure when compared with the traditional ways, in which the funds of government were usually provided to the medical institutions. Although some difficulties were faced in the provision of the poverty relief medical assistance, it provided a new approach to resolve the issue of equity in medical services provision and future MCH and primary health care work. The poverty relief medical assistance was a creative measure, with great cost-effectiveness, which were worthy of publicity and adoption. It is necessary to be continually strengthened that the counterpart funds and poverty relief fund should be raised to support the PRF work, and the rational utilization of the available project resources should be enhanced by the specific fund in the special account. Therefore, the PRF for medical assistance would be further improved. - 36 -  (8) The operational research provided scientific evidence for the implementation of the project. During this project, experts at central and provincial level had conducted many operational researches focused on the local MCH problems in project areas and in the respect of MCH management, information management and poverty alleviation, etc. Through a series of activities on investigation, research, analysis, invention and evaluation, the experts put forward a lot of valuable results, conclusion and suggestion. Some of the useful results had been put into practice, and make for the improvement of MCH services and management. Undoubtedly, the scientific results of the operational researches would be benefit for the future MCH project. (9) The management of project was remarkably strengthened. All the project managerial staff at all levels got used to the operational progress of the World Bank Loans Projects, mastered the basic methods in management, monitoring, supervision and evaluation, and learnt the advanced experiences of project management from both domestic and abroad for standardized and systematic operation. With the implementation of the project, the organizational structure of the project management was gradually completed. The success of the project is subject to the capacity in organization, management, coordination, planning, supervision and direction, which are the basic requirements of health administration and implementation of the international project management. By means of continuing study and generating experiences, health administrative personnel were empowered with advanced managerial skills and transferred from experience-based to scientific evidence-based management model, which fit to the future development of the project. - 37 -    IMAGING Report No.: 25239 Type: ICR