China - Disease Prevention Project

Document of The World Bank Report No: 30613 IMPLEMENTATION COMPLETION REPORT (TF-25197 IDA-27940 TF-52892) ON A CREDIT IN THE AMOUNT OF US$100 MILLION TO THE PEOPLE'S REPUBLIC OF CHINA FOR A DISEASE PREVENTION PROJECT April 21, 2005 Human Development Sector Unit East Asia and Pacific Region  CURRENCY EQUIVALENTS (Exchange Rate Effective December 2004) Currency Unit = Yuan (Y) Y1.00 = US$ 0.12 US$ 1.00 = Y8.4 FISCAL YEAR January 1 December 31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immunodeficiency Syndrome AusAID Australian Agency for International Development BRFSS Behavioral Risk Factor Surveillance System CAS Country Assistance Strategy CCDC China Center for Disease Control CDC Center for Disease Control CDC Communicable Disease Center DALY Disability-Adjusted Life Years DDC Department of Disease Control EPI Expanded Program of Immunization ERR Economic Rate of Return GAVI Global Alliance for Vaccines and Immunization HEI Health Effects Institute HIV Human Immunodeficiency Virus HRD Human Resource Development IDA International Development Association IEC Information, Education and Communication IMR Infant Mortality Rate MOF Ministry of Finance MOH Ministry of Health NCD Non-communicable Diseases PIP Project Implementation Plan PSR Project Status Report QAG Quality Assurance Group RMB Renmimbi (currency of the People's Republic of China) SAR Staff Appraisal Report SARS Severe Acute Respiratory Sydrome STDs Sexually Transmitted Diseases U5MR Under-five Mortality Rate WHO World Health Organization Vice President: Jemal-ud-din Kassum, EAPVP Country Director: David Dollar, EACCF Sector Manager: Fadia M. Saadah, EASHD Task Team Leader/Task Manager: Shiyong Wang, EASHD  CHINA Disease Prevention Project CONTENTS Page No. 1. Project Data 1 2. Principal Performance Ratings 1 3. Assessment of Development Objective and Design, and of Quality at Entry 2 4. Achievement of Objective and Outputs 5 5. Major Factors Affecting Implementation and Outcome 12 6. Sustainability 13 7. Bank and Borrower Performance 15 8. Lessons Learned 17 9. Partner Comments 18 10. Additional Information 26 Annex 1. Key Performance Indicators/Log Frame Matrix 27 Annex 2. Project Costs and Financing 31 Annex 3. Economic Costs and Benefits 35 Annex 4. Bank Inputs 36 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 38 Annex 6. Ratings of Bank and Borrower Performance 39 Annex 7. List of Supporting Documents 40  Project ID: P003589 Project Name: Disease Prevention (Health 7) Team Leader: Shiyong Wang TL Unit: EASHD ICR Type: Core ICR Report Date: April 21, 2005 1. Project Data Name: Disease Prevention (Health 7) L/C/TF Number: TF-25197; IDA-27940; TF-52892 Country/Department: CHINA Region: East Asia and Pacific Region Sector/subsector: Health (98%); General public administration sector (1%); General education sector (1%) Theme: Other communicable diseases (P); Health system performance (S); Population and reproductive health (S); Participation and civic engagement (S); Gender (S) KEY DATES Original Revised/Actual PCD: 11/15/1994 Effective: 06/19/1996 06/17/1996 Appraisal: 06/07/1995 MTR: 12/31/1998 12/01/1998 Approval: 12/12/1995 Closing: 12/31/2001 06/30/2004 Borrower/Implementing Agency: PRC/MINISTRY OF HEALTH Other Partners: STAFF Current At Appraisal Vice President: Jemal-ud-din Kassum Russell Cheetam Country Director: David R. Dollar Nicholas Hope Sector Manager: Fadia Saadah Joseph R. Goldberg Team Leader at ICR: Shiyong Wang Jagdish Upadhyay ICR Primary Author: Hope C. Phillips 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: SU Bank Performance: S Borrower Performance: S QAG (if available) ICR Quality at Entry: S Project at Risk at Any Time: No  3. Assessment of Development Objective and Design, and of Quality at Entry 3.1 Original Objective: In spite of China's remarkable achievements in disease prevention programs, particularly against preventable childhood diseases, the immunization program faced several challenges during the 1980's and 1990's, including declines in resources available for preventive care as a result of economic reforms. One of the unintended victims was the immunization infrastructure, especially the cold chain, as well as the operating budgets required for the provision of syringes, needles and sterilization equipment, with the poorer provinces being more affected. The dismantling of rural cooperatives created incentives for health workers to rely on curative services for much of their income. While some provinces or local communities paid for immunization services, most charged for this service. The departure of large numbers of experienced health workers for better paying jobs, the lack of health education to increase demand for essential immunization, and the unavailability of reliable data on immunization coverage, were also identified as constraints to preventing and controlling vaccine-preventable diseases. Since 10% of the population are carriers for hepatitis B, a system to finance this vaccine was identified as particularly important. While successes had been made in vaccine-preventable diseases, China's demographics also experienced a dramatic transition: the proportion of older persons has been increasing steadily and rapidly. This has had an impact on disease patterns with non-communicable diseases (NCDs) accounting for over 75% of all deaths in China in the 1990's. Analysis from the China: Long-Term Issues and Options in the Health Transition (Report No. 7965-CHA dated June 25, 1990) indicated that the annual probability of death from infectious diseases for adult (ages 15-60) men and women in China was just over 1%, the death rate from chronic disease, injury and suicide, when compared with infectious diseases, was almost 15 times greater for men and 10 times greater for women. The most important health risk factors in modern China were identified as smoking, hypertension, unhealthy diet, overweight and obesity, and pollution. With economic freedom, changing behavior and a more mobile society, China saw a resurgence of a variety of sexually transmitted diseases (STDs), and an increase in human immunodeficiency virus (HIV). While government had developed strategies that included community-based prevention, training of general practitioners and improvements in primary health care, it was desirous of piloting health promotion interventions in a variety of settings with a view to wider replication based on experiences gained. This seventh project in support of the health sector of China had two distinct objectives: (a) prevent and control vaccine-preventable diseases to reduce morbidity, disability and mortality, especially in the poorest provinces of China, by improving the immunization services and by introducing policy measures to improve vaccine quality and ensure access of all population groups, and add new vaccines to the Expanded Program on Immunization (EPI); and (b) improve the capacity of the health sector to design and implement health promotion programs to prevent and control the rising prevalence of NCDs, STDs, HIV and injury through policy and institutional improvements, and by implementing pilot programs, including surveillance, staff training, health education, and other health promotion interventions. The objectives were clear, and the Staff Appraisal Report (SAR) noted that it was in line with the government's "8-7 Plan" which aimed to eliminate extreme poverty by the year 2000, and narrow the widening health gap between the poorer rural and richer urban areas of China. The project was important for the Bank's third objective in the Country Assistance Strategy (CAS) (Report No. 14454-CHA dated May 4, 1995), which included sustaining growth by shifting resources toward priority areas, including - 2 -  poverty reduction, human resource development, infrastructure, and environmental protection, which were under-funded. Bank support in the health sector would focus on helping the government: (a) meet the basic health needs among the rural population, particularly those living in absolute poverty; and (b) reinvigorate initiatives in disease prevention, by retaining the gains made against infectious and endemic diseases and by implementing innovative programs against non-communicable and chronic disease. Given the changes in demographics China was experiencing, the focus on prevention and control of vaccine-preventable diseases on the one hand, and increasing capacity to design and implement programs which prevent and control the rising prevalence of NCDs, STDs/HIV and injury was appropriate, and fitted in well with both the government and Bank strategies. Based on the geographic dispersion, and the number of entities involved (one component covered 10 provinces, and the other component covered 7 Cities and 1 province) the project should be considered complex, particularly because of the various levels involved in each province. On the other hand, the project was well served given institutional arrangements put in place and outlined in the Project Implementation Plan (PIP), as well as the inclusion of the Ministry of Health's (MOH) Foreign Loan Office, which had previous experience in implementing Bank-assisted health projects. 3.2 Revised Objective: The objectives were not revised. 3.3 Original Components: The Project had three components. The Immunization Component with a total cost of US$137.7 million (IDA US$86.88 million) comprised four sub-components: (i) cold chain improvement; (ii) health workers' training; (iii) management and surveillance; and (iv) information, education and communication (IEC). The objectives of the cold chain improvement sub-component, which was the responsibility of the Health Bureau of each Province, were to: (a) ensure the quality of vaccines during storage and transportation; and (b) establish a system of regular replacement of the cold chain which is sustainable beyond the project period. For the health workers' training, which fell under the Department of Disease Control (DDC) in the MOH, the objective was to improve the technical and managerial skills of all staff involved in the immunization program at all levels of the epidemic prevention network by establishing a system of regular in-service training. Implementation was the responsibility of the provinces' Health Bureau, Epidemic Prevention Station at provincial, prefecture, county and township levels and village health stations. For management and surveillance, under the oversight by MOH DDC and project offices in each Province, the objective was to improve the management and implementation of the immunization program at all levels, particularly in the areas of cold chain and logistics, service delivery, collection and utilization of immunization coverage and disease data, and supervisory support between levels. It was to be implemented by the National Expanded Program of Immunization (EPI) Center and Provincial Epidemic Prevention Stations. The objectives of the IEC sub-component were to: (a) promote public awareness and knowledge on EPI vaccine-preventable diseases; and (b) generate demand for immunization services and knowledge on EPI vaccine-preventable diseases through implementation of a communication strategy. This sub-component was also the responsibility of the DDC in MOH with support from the National Expert Technical Working - 3 -  Group. Support under the Immunization component covered two-thirds (392 out of 592) of the nationally designated poverty Counties, comprising 66% (53 million out of 80 million) of the poor population. The Health Promotion Component with a total cost of US$22.43 million (IDA US$10.88 million), included: (i) institutional development and policy reform; (ii) human resource development (HRD); (iii) surveillance; and (iv) interventions (see description below). The institutional development and policy reform sub-component objectives included: (a) developing a strategic plan for health promotion; (b) defining, strengthening, coordinating arrangements to carry out health promotion activities; (c) mobilizing inter-sectoral and community participation in health promotion; and (d) instituting policy measures which support prevention work and healthy behavior change. Responsibility for the component rested, depending on the activity, with the health bureau of each city and the Yunnan Provincial Government, or the Epidemic Prevention Station (or project office), the Non-Communicable Disease Center, STD Control Offices and HEI. For monitoring purposes, the Behavioral Risk Factor Surveillance System (BRFSS) would provide baseline and monitoring information throughout implementation. The HRD sub-component expected to: (a) improve and maintain the competence of those people who carry out health promotion and related activities, both inside and outside the health sector; (b) ensure that sufficient competent people are available to manage and conduct all project activities; (c) improve and maintain skills in project management, supervision and evaluation; and (d) increase the capacity of local institutions to provide training in health promotion subjects on a long-term basis. Responsibility for this sub-component would rest with the project office or the institution responsible for HRD overall. The surveillance sub-component would: (a) establish a system for surveillance of the behavioral risk factors for NCDs, STD/s/HIV and injury; (b) establish a system of monitoring environment factors which support a healthy lifestyle; (c) upgrade mortality reporting; and (d) improve the interpretation and use of this data to monitor health trends and to plan and evaluate health promotion activities. Responsibility for this sub-component would rest with HEI, Epidemic Prevention Station, the Non-Communicable Disease Center, or STD Control Offices. The interventions sub-component objectives were to: (a) provide experience in the design, implementation and evaluation of a range of community-based health promotion interventions; and (b) reduce risk factors and prevent or control NCDs, STDs/HIV and injury in selected settings. Implementation responsibility rested with either HEI or the Epidemic Prevention Station, with Central-level Project Office providing assistance. Specific activities were identified for interventions relating to the prevention and control of STDs and HIV. Seven cities, including two medium-sized cities from the poorer inland provinces, were selected to participate in the health promotion component. Yunnan Province, with the highest concentration of HIV/AIDS in China was also selected to participate in activities relating to the prevention and control of STDs/HIV. The National Component with a total cost of US$2.49 million (IDA US$2.25 million) would provide support to the two other components, in recognition of the complexity of the Project (i.e., the distinct components, the number of participating entities, new policy developments in immunization, and the newness of health promotion in China). The activities, split between the Immunization and Health Promotion components, included providing national policy guidance and national leadership in surveillance systems and HRD, coordinating activities across provinces and cities and across several national institutions as needed. The objectives were to: (a) provide national policy guidance; (b) provide national leadership in surveillance system and HRD; (c) coordinate activities across Provinces and Cities and across - 4 -  several national institutions as needed and to disseminate project experience; (d) provide or coordinate provision of technical assistance; and (e) ensure efficient and effective project implementation. The components were well related to achieving the objectives, and safeguards were built into the design, including the preparation of a detailed PIP, taking into consideration the capacities of the implementing agency for coordination, administrative and financial management. Lessons from previous support to the health sector taken on board in the design included: (a) the need for well organized and adequately staffed project management offices at all levels; (b) advance planning to ensure adequate counterpart financing; and (c) a flexible project design which could respond to changing circumstances in a rapidly transforming economy. As a consequence, key staff had been designated in almost all the provinces and cities prior to effectiveness, and written confirmation from provinces and cities to provide the necessary counterpart funding was a condition for their participation in the project. Lessons from disease prevention interventions resulted in: (a) surveys designed to confirm results since there can be over-reporting because targets had been set; (b) specific targeting measures and monitoring of the same to ensure coverage of some segments of the population (particularly the poorest and those floating); and (c) an IEC subcomponent was included in response to the recognition of the importance of having an effective communication strategy. International experience informed the design of the health promotion component, given China's limited experience in raising awareness for the prevention of chronic diseases, STDs, and HIV. 3.4 Revised Components: The components were not revised. 3.5 Quality at Entry: This project was not subjected to an assessment by the Quality Assurance Group (QAG) so their rating is not available. The project, as noted above, was in line with the government's plan to narrow the widening health gap between the urban and the poorer rural populations, and the Bank's strategy of reinvigorating initiatives in disease prevention focusing on retaining gains against infectious and endemic diseases, and implementing innovative programs against NCDs. The development objective was to the point, but not overly ambitious, and the choice of instrument was appropriate. The preparation included extensive stakeholder consultations, with representatives from various government levels, and included external experts in the relevant technical fields. The appropriate mechanisms were in place for the fiduciary aspects, and a detailed PIP was in place to guide implementation. The risks identified were appropriate, and mitigation measures identified. Nonetheless, while adequate counterpart funds were made available by the project cities for the health promotion component, periodic problems were encountered with counterpart funding for the immunization component. Agreement was reached on a number of policies that each province would follow, and this also paved the way for implementation. The selection of provinces and cities to participate in the project was undertaken in a manner to ensure that the development objectives would be met. All in all, the concept, objectives, approach and design were appropriate, and the quality at entry is rated satisfactory. 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: The CAS for China (Report No. 25141, dated January 22, 2003) notes that challenges remain, notwithstanding the substantial progress that has been made in poverty reduction during the previous decade. Among other strategies, the Bank's assistance would be designed to address the needs of the poorer, disadvantaged people, and lagging regions through investment lending in the social sectors. On the basis of the current strategy, this project's development objectives remain relevant in the current context. The outcome indicators selected by the project were appropriate since they were chosen on the basis of - 5 -  being sensitive to the project interventions, and the data was being routinely collected without special surveys; data collection included: (a) infant mortality rate (IMR); (b) under-five mortality rate (U5MR); and (c) disease incidence trends for poliomyelitis, measles and neonatal tetanus. Over the life of the project, both the IMR and U5MR dropped for all provinces, with the exception of Henan Province's IMR, which rose slightly (by 1.6%) and Shaanxi's U5MR, which rose by 14.2%. Otherwise, the range of decrease for the IMR was from a low of 1.9% in Shaanxi to a high of 45.9% in Shanxi, with most provinces in the range of 20-45%. In the case of the U5MR, the range was from the largest decrease in Gansu of 54.9% to the lowest in Henan of 7.0%. Again most were in the range of a 20-45% decrease. In all cases the rates were lower than the 1996 project province data reported, and when compared with national data (from China Health Statistics Digest, 2004), by the end of the project only two provinces (Shaanxi and Guizhou) had rates above the national averages for IMR (29.20) and U5MR (34.90). Shaanxi's IMR was 34.45, and U5MR was 39.62, while Guizhou's IMR was 50.01 and U5MR was 62.59. Unfortunately it is not possible to determine how much of the decrease in IMR and U5MR was attributable to the improved immunization coverage, since there were reports of increases in some vaccine-preventable diseases. The external evaluation included incidence rates by province for neonatal tetanus, poliomyelitis, measles, pertussis, cerebrospinal meningitis, Japanese B encephalitis, and hepatitis B. Data from the report indicate that the incidences of measles, pertussis, cerebrospiinal meningitis, Japanese B encephalitis, and hepatitis B all declined during the life of the project. For measles and neonatal tetanus, 7 out of 10 provinces reported a drop in incidence rates. No cases of diphtheria were reported in any of the provinces over the life of the project. The data for poliomyelitis, measles and neonatal tetanus indicate that there has been a decrease in mortality rates except for Hubei and Shanxi which reported a slight increase in mortality. Incidence rates for hepatitis B increased over the life of the project, while the average mortality remained steady. Despite these increases, it is calculated that in 2003 there were 53% fewer Disability-Adjustable Life Years (DALYs) lost due to vaccine-preventable diseases than in 1995. Under the health promotion component, all cities, except for Kunming and Luoyang reported a drop in smoking by male, female and teenagers. There were increases in blood pressure testing for those over 35 years of age, and only one city showed a drop in cholesterol testing for those over 40 years of age. Awareness of how to prevent AIDS was reported at 50% for students in Chengdu to a high of 90% for adults in Kunming (Yunan Province). Knowledge of some risk factors increased, as is evidenced by the drop in smoking. Risk factors have increased since all cities reported a drop in physical exercise, and the rate of obesity increased in all cities as well. However, the rate of increase in these project populations was less than in the non-project populations. A number of policies were introduced, including the imposition of no smoking areas in cities. Although not part of the project's original objectives, the establishment of a national centre of chronic and non-communicable disease control (NCNCD) and the creation of the health promotion network, Chinese Alliance of Health Promotion, are important achievements of the project. Overall, the project improved immunization coverage, and the safety of immunizations as a result of substantial improvements in the cold chain and in immunization procedures. There was success in introducing important health promotion concepts, training and programs, especially those paving the way for more HIV/AIDS programs. The project components were implemented largely as planned, and most achieved their objective despite funding and procurement delays encountered in the early years of the Project under the Immunization component. Overall the outcome is rated satisfactory. Immunization Objective. Although the immunization coverage has been difficult to quantify precisely, some 68,764 health workers were trained, and quality improved - as measured, for example, by the increase - 6 -  in the use of single-use syringes from 28.9% to 75.5% and the decrease in the use of sterile needles for more than one person from 39.6% to 9.8%, as well as the availability of cold chain equipment. In addition, concerted efforts were made to reach difficult to reach populations, including floating populations. Finally, there was a major expansion of hepatitis B immunization, which was added to the EPI with reduced or no fees for the poorest populations. It received further assistance through the Global Alliance for Vaccines and Immunization (GAVI) support beginning in 2002. Health Promotion Objective. The health promotion component was highly successful in introducing, for the first time, modern theory and practice of health promotion into the Chinese context. Of note under the interventions sub-component was the tobacco control activities undertaken by a number of cities which was particularly successful in raising awareness and reducing smoking in the project cities. The other subcomponents of the health promotion strategy were less successful, but nevertheless did achieve some worthwhile results with very limited funding. Again a large cadre of workers were trained in the principles and practice of health promotion. The participation of Australian Agency for International Development (AusAID) in the project was very helpful in the success of the health promotion component. Their funding supported technical assistance, which contributed significantly towards increasing high level understanding of health promotion concepts and towards improving the capacity to design and implement health promotion programs. This increase in management commitment and technical capacity not only helped in bringing about a good outcome for the project, but also helped to ensure the sustainability of the health promotion efforts. National-Level Program. While a higher level objective was not specified for the National-level component, its successful implementation was necessary for achieving the project's development objectives. This component was highly successful in achieving the objectives of coordination, technical assistance and supervision. New national policies were developed in line with the project's objectives and outcomes