Jamaica - Population Project

Document of The World Bank FILE COPY FOR OFFICIAL USE ONLY Report No. 2580 PROJECT PERFORMANCE AUDIT REPORT JAMAICA FIRST POPULATION PROJECT (Loan 690-JM) June 29, 1979 Operations Evaluation Department 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. ABBREVIATIONS EV - Encouragement Visitor FP - Family Planning JFPA - Jamaica Family Planning Association KSAC - Kingston - St. Andrew Corporation Area MCW - Ministry of Communications and Works NFPB - National Family Planning Board RMC - Rural Maternity Center USAID - United States Agency for International Development VJH - Victoria Jubilee Hospital MOHEC - Ministry of Health and Environmental Control FOR OFFICIAL USE ONLY Project Performance Audit Report JAMAICA FIRST POPULATION PROJECT (Loan 690-JM) Table of Contents Page No. Preface i Basic Data Sheet ii Disbursement Table iii Highlights iv PROJECT PERFORMANCE AUDIT MEMORANDUM I. Project Summary I II. Main Issues Sociological Setting and Project Design 4 Rural Maternity Centers 6 National Family Planning Board 7 Victoria Jubilee Hospital 10 Project Management and Physical Implementation 12 III. Conclusions 15 PROJECT COMPLETION REPORT I. Introduction 18 II. Project Background 18 III. Project Implementation 21 IV. Project Cost and Finance 29 V. Bank Performance 31 VI. Conclusions and Recommendations 31 Annexes: 1 - 8 34 Map 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.  Project Performance Audit Report JAMAICA FIRST POPULATION PROJECT (Loan 690-JM) Preface This is a report on an audit of performance under the First Population Project in Jamaica, for which a loan of US$2 million was approved in June, 1970. The closing date of the loan was March 31, 1977, and the final disbursement was made in May, 1977. An Operations Evaluation Department mission visited Jamaica December 14-22, 1978, and held discussions about the project with officials in the Ministries of Health and Environmental Control (MOHEC), Communication and Works (MCW), and Finance, and in the University of the West Indies, the Department of Statistics, the Victoria Jubilee Hospital, (VJH) and USAID.(United States Agency for International Development). The cooper- ation extended by all of these officials is gratefully acknowledged. In addition to the information and views gathered during the above visit, the audit is based on a review of a number of documents: the World Bank Review of the Jamaica Family Planning Program (April, 1969), the Appraisal for a Population Project (Report No. PP-2A dated June, 1970), the Loan Agreement, the Report of the First External Review of the Jamaica National Family Planning Program (July, 1972), the USAID Evaluation of the Jamaica Family Program (June 1974), the Appraisal for a Second Population Project (Report No. 1040b-JM dated May, 1976), the Report of the External Advisory Panel on Population (August, 1976), the Review of the Implemen- tation of Recommendations of the External Advisory Panel on Population dated December, 1978, the Economic Memorandum on Jamaica dated May, 1978, the Project Completion Report (PCR) prepared by the Population Projects Department dated October, 1978, and the materials in the Bank's files relating to this project. Statistical information was obtained from the Victoria Jubilee Hospital and from the Ministry of Health and the Depart- ment of Statistics in Jamaica, and a review made of eleven publications concerning the socio-economic context of reproductive behavior in Jamaica. Discussions have also been held with Bank staff associated with the project. The report consists of the Audit Memorandum and the PCR. The audit memorandum addresses a number of issues which are not fully covered in the PCR, including problems in the rationale, design, construction and eventual use of the VJH, and problems in the design and use of the rural maternity centers (RMCs); it suggests socio-economic factors, crucial to achieving continuing contraceptive use, which are relevant to project design. The audit also elaborates on the development and subsequent weakening of the National Family Planning Board (NFPB), with particular attention given to the problems posed by a single purpose institution whose functions overlap those of multi-purpose institutions. During and after the country visit, the Government's views were obtained on all the above issues and are fully reflected in the audit memorandum.  - ii PROJECT VKHFORMANCF AuDIT RKPORT 1AIC DATA SIET JAMAICA FIRST POPiP.ATION PROJECT (LOAN h90-.M) KEY PROJECT DATA Appraisal Actual or Item Expectation Current Estimate Total Project Cost (USS million) -3.3 4.6 Overrun (Z) - 1.3 Loan Amount (USS million) 2.0 2.0 Disbursed as of 05/20/1977 2.0 2.0 Date for Completion of Physical Components Rural Maternity Centers 1/15/72 10/31/73 Victoria Jubilee Hospital 3/01/73 11/30/79 OTHER PROJECT DATA Original Actual or Item Plan Revisions Current Estimate First Mention in Files 05/-/68 - Government's Application 09/-/68 - Negotiations 03/-/70 - Board Approval 06/16/70 - Loan Agreement Date 06/18/70 Effectiveness Date 11/02/70 - Closing Date 03/31/75 03/31/77 03/31/77 Borrower Government of Jamaica Executing Agency Ministry of Health & Environmental Control Fiscal Year of Borrower April 1 - March 31 Follow-on Project Name Second Population Project Loan Number 1284-JM Amount (US$ million) 6.8 Loan Agreement Date 06/17/76 MISSION DATA Month No. of No of Item Year Days Persons Staffdays Appraisal December 1969 14 4 50 Supervision I 07/70 4 1 4 Supervision II 11/70 4 2 6 Supervision III 04/71 4 2 6 Supervision IV 11-12/71 4 2 8 Supervision V 05-06/72 4 1 4 Supervision VI 06/72 4 2 6 Supervision VII 11/72 4 3 12 Supervision VIII 02/73 4 3 8 Supervision IX 03/73 2 1 2 Supervision I 05-06/73 4 1 14 Supervision I 09/73 4 1 4 Supervision XII 10/73 4 1 4 Supervision XIII 4-05/74 /1 5 A 14 Supervision XIV 07/7471 5 1 5 Supervision XV 02/75 71 4 2 8 Supervision XVI 06/75 71 5 2 10 Supervision XVII 04/76 7T I I I Supervision XVIII 08/76 71 5 2 10 Supervision IIX 02-03/7771 7 3 21 Supervision Xx 09/77 4 2 8 Supervision XXI 02/78 4 1 4 Supervision XXII 04/78 /1 4 1 4 Supervision XIX 06/78 /1 9 3 24 TOTAL 201 /2 Completion 06/78 9 2 18 COUNTRY EXCHANGE RATES Name of Currency (Abbreviation) Jamaican Dollar (J$) Tear: Appraisal Year Average Exchange Rate: US$1 -J$0.83 Intervening Years Average US$1 -J$0.87 Completion Year Average US$1 -JS.50 /1 Combined missions to supervise the First and the Second projects 7- Of which: First population project 119 Second Doulation oroiect 72  - iii - JAMAICA FIRST POPULATION PROJECT (Loan 690-JM) Disbursement Table US$000, cumulative Appraisal Actual Actual as % Period ending Estimate Disbursement of Estimated 06/30/1970 - 0 - 12/31/1970 100 0 0 06/30/1971 - 0 - 12/31/1971 600 0 0 06/30/1972 - 77 - 12/31/1972 1,150 125 10 06/30/1973 - 173 - 12/31/1973 1,700 368 22 06/30/1974 - 698 - 12/31/1974 2.000 799 40 06/30/1975 1,068 12/31/1975 1,107 06/30/1976 1,587 12/31/1976 1,704 06/30/1977/.1 2,000 /1 Last disbursement made on May 20, 1977.  - iv - Project Performni,.ce Audit Report JAMAICA FIRST POPULATION PROJECT (Loan 690-JM) Highlights The Bank loan for the First Population Project in Jamaica was signed in June 1970 for US$2 million; Bank funds supported the expansion of the Victoria Jubilee Hospital (VJH) in Kingston, the construction of 10 rural maternity centers (RMCs) in various parts of the island and technical assistance for Jamaica's National Family Planning Board (NFPB). The project was the Bank's very first lending operation in the family planning field. Much experience has been gained from this and other similar projects begun with Bank/IDA assistance in the early seventies, and the lessons learned from that early experience are, for the most part, reflected in the Bank's current population lending policies. Many of the problems encountered in the implemen- tation of this project arose from compromises between, on the one hand, the Bank's orthodox, "bricks and mortar" oriented financing methods at the time and, on the other hand, the special needs of family planning, particularly in the difficult Jamaican context. Although much was learned from this first Bank effort in the field of family planning, and although Jamaica's crude birth rate, for reasons only partly related to the project, did fall slightly during the project period, the project did not fully succeed in attaining its primary objectives of extending and improving Jamaica's national family planning program. Points of special interest are: - sociological factors needed greater attention in project design (PPAM paras. 11 to 18); - single-purpose RMCs were an inefficient use of resources and were improperly located (PPAM paras. 19 to 23; PCR paras. 3.08, 3.21 and 6.06 to -6.08); - the switch from a "vertical" family planning program to the integration of family planning with health services created many difficulties (PPAM paras. 25 to 39; PCR paras. 3.02 and 3.28); - v - the construction of a new maternity wing at the VJH represented two thirds of total project cost; although badly needed to relieve hospital over- crowding, its contribution to Jamaica's family planning program is marginal (PPAM paras. 40 to 47); and serious problems were encountered in implementation of the construction program; the Bank's wealth of experience and long-established policies and procedures in dealing with construction projects were never fully brought to bear on these problems (PPAM paras. 48 - 49; PCR paras 3.01 to 3.11 and 6.02 to 6.07). Project Performance Audit Memorandum JAMAICA FIRST POPULATION PROJECT (Loan 690-JM) I. PROJECT SUMMARY 1/ 1. The Project consisted of both construction and technical as- sistance elements designed to extend and improve the Government's national family planning program. Project funds were devoted primarily to the construction of key maternity facilities to provide expanded opportunities for educating and motivating women during their post- partum recovery period when they have high receptivity to FP information. Family planning activities in the project facilities were part of a complex set of FP activities throughout the island. The Bank's primary interest was in helping the Government develop an effective and economical national program. Therefore, the project also contained four technical assistance elements which, while small in amount, were intended to have an important impact on the success of the national program. 2. The project provided for the design, construction, and equipment of two types of facilities, both of which were to provide expanded opportunities for FP education: (a) A new 175-bed wing at the Victoria Jubilee Hospital (VJH) in Kingston and the remodeling of parts of the present old structure. This building also contains space for the hospital's midwifery school. The expanded and remodeled hospital was intended to have a capacity of 332 beds as compared with 165 at appraisal. (b) Ten Rural Maternity Centers (RMCs) at various locations across the island, each with a capacity of 4 to 8 beds. 3. The project also included the following four technical assistance elements: (a) A 3-6 month study of possibilities for rearranging some of the functions performed by doctors, nurses, auxiliary nurses, and clerks to relieve pressure on the time of the more highly-trained people, who are in short supply. (b) A study of the service-delivery system in the Kingston- St-Andrew Corporation (KSAC) to see how to make the best use of professional staff and physical facilities. 1/ Adapted from the PCR. - 2 - (c) The provision of a training advisor to help the NFPB in planning and mounting an expanded training effort. (d) An annual review by a small external team of the progress of the Program during the disbursement period. 4. The project was the Bank's first in the population sector. It was designed to extend and improve the Government's National Family Planning Program. It was aimed particularly at enlarging the post-partum program of the Ministry of Health and Environmental Control (MOHEC) by expanding its maternity facilities, as well as assisting the Government in developing an effective and economical national program. 5. Under population pressure, in 1967 the Government adopted a national policy of slowing down population growth and started offering family planning services at public hospitals. In 1968, it created the National Family Planning Board (NFPB), a semi-autonomous body responsible to the Minister of Health but with no permanent legal status. 1/. The initial target of the NFPB was to decrease the birth rate from 35 per 1,000 to 25 per 1,000 by 1975. 6. At the time of the Bank's program review mission in 1969, a "vertical " family planning program 2/ had already been set up by the Government, and there were tensions after the former Program Head had been replaced by a professional rival whose wife headed the private family planning program. The Minister had serious reservations about the effectiveness of the senior heaLth personnel in the Preventive and MCH side of the Ministry and of their capacity to implement the National Family Planning Program. The Bank Sector Mission (Jan-Feb. 1969) be- lieved that integration of services with the Ministry of Health would be desirable but this was resisted on the basis of the Minister's reservations and a compromise was arrived at with the then-Minister of Health in August 1969. This was to work towards such family planning service integration as a long-term goal. The pace of integration of family planning services was accelerated in subsequent years as the subject of population control surfaced as political dynamite and the "Black Power" 1/ The Bank mission recognized that the dubious legal status was not satisfactory; during preparation, it assisted with drafting of model legislation,and required in the Project that the NFPB be given per- manent legal status. This was done by the National Family Planning Act of 1970. 2/ The NFPB was to have its own separate staff of family planning workers, rather than integrating family planning activities with health services. - 3 - groups began to be critical of the program. This political setting was also reflected in attitudes to foreign advisors. The change of government in 1972 led to the loss of effectiveness of the Chairman of the Board who "in effect" was a political appointee of the former Minister; he, however, had contractual status and remained in office for several years and this led to the erosion of the effectiveness of the Board. The labor troubles, including physical attacks on Public Works staff and criminal investigations of corruption after the new government came to power all had their impact on the performance of the Public Works Department (PWD) and on physical development of the Victoria Jubilee Hospital (VJH). In fact, for a year conditions were so bad and insecure that neither the local PWD nor the consultants could supervise work at the site. The even larger financial troubles of the Government and the general climate of instability, not foreseen at project approval, affected the overall performance of the Civil Service, inclulding health and family planning staff. 7. During project generation, the Government was as much concerned with its health care system as with improving its family planning program. The Government, unlike many Third World Governments, was allocating reasonable amounts of local resources to the program and the external inputs were clearly additive to achieve improvements. Lengthy discussions within the Bank and between the Bank and the Government took into account Bank's current policies and the Government's own preference before agreement was reached on the project content. Given the potential areas to finance in population planning in 1969, it is likely that without support to a major health/MCH investment, the Bank would not have had a sizable financial involvement to make its intervention meaningful. At the same time, the project strategy was consistent with current thinking. It is also to be noted that in the late sixties, post-partum programs were considered central elements of family planning programs and their extension from urban to rural settings was actively promoted by the Population Council. Project documents and particularly the appraisal report (paras. 5.13 and 5.16) recognize the risks involved in the rural maternity centers (RMCs). 8. Originally, the project was expected to be implemented over a four and one-half year period. It was initiated in November 1970, but at present (March, 1979), it has not been fully completed. Delays were caused mainly by the absence of adequate leadership and weaknesses in project management and by the integration of the NFPB into the MOHEC and the resulting uncertainties concerning lines of authority and respon- sibility. Some of the "software" components of the project, including a study concerning the reallocation of functions of medical personnel, and the first external review, were carried out and their recommendations incorporated into NFPB policy. However, the three subsequent external reviews required in the Loan Agreement were not done, and the training advisor stayed only for a few days. 9. Construction and equipping of the RMCs was completed in 1973 and they were commissioned and staffed in 1974. All are underutilized to a greater or lesser degree, and one had to be closed down because the location was not considered appropriate. They are being converted to multi-purpose health centers. The main problems with project implemen- tation were related to the construction of the VJH new maternity wing. After two years of delays in design and awarding of contract,-the VJH construction was initiated in January 1973 but has not yet been completed. With the exception of its midwifery training school section, which began training sessions in April 1978, the VJH wing has not yet opened. 10. When construction of the VJH has been completed, the total capital cost of the project is expected to be US$4.6 million, in compar- ison to the original estimate of US$3.3 million. The 39% overrun results mainly from construction costs which have doubled.in spite of the fact that remodeling of the existing VJH building has not been done. The recurrent expenditures for the RMCs (about US$180,000 annually) are being met by the Government, but the Government may have difficulties in pro- viding the VJH recurrent expenditures (about US$1.0 million annually). II. MAIN ISSUES Sociological Setting and Project Design 11. The project was recognized by the Bank at the outset as 'extremely complex in the human factor" and not solvable by technology alone. In view of the relatively low rate of continuing use of family planning methods by acceptors (estimated at about 30% of acceptors, but attrition figures are not available) and the low percentage of women of childbearing age who are continuing users of contraception (estimated at 11% of all women 15-44 in 1974) 1/, it would seem important for the sake of improving project outcomes to address motivational factors. 12. Unlike other Bank projects, in which an assumed intended maximization of return on investment can generally be used to predict the behavior of those affected by loans, the homo economicus model cannot be applied to the reproductive behavior of individuals. 13. A large number of senior officials of the Jamaican Government indicated that the context of the Jamaican people and their society should be a crucial consideration in attempting to reduce fertility. (For example, there is a widespread belief that a woman is destined to "have her lot", a number of children determined by the number of knots in the umbilical cord of the first, or her health will ultimately suffer). 1/ Appraisal of a Second Population Project, Jamaica. World Bank, 1976 - 5 - 14. A number of factors influence reproductive behavior in Jamaica. There is a high cultural value placed on motherhood, which brings about a significant positive change in the social status of a woman or girl; this may be traceable to the matrifocal family of West African origin. It is particularly relevant to the high percentage of births to teenagers (for example, 32% of births in the VJH in 1976 and in 1977 were to those at ages 12-19). Teenagers are the least frequent users of contraception (58% had never used contraception according to one study) 1/ and least frequently involved in stable unions. 2/. 15. Other factors, concerning the social relationship between men and women, may also influence reproductive decisions. First, there is some evidence that women of all ages may wish to have one or more children to increase the stability or permanency of informal unions (common-law or visiting), which are the major form of reproductive union (approximately 70% of the births in Jamaica occur outside of formal marriage) 3/ The high proportion of informal unions has itself been well correlated with underlying economic factors; that is, the rate of marriage tends to increase with an increase in income level. 16. Secondly, there may be interference from male partners in the contraceptive efforts of women; the desire on the part of some women to conceal the use of contraceptive methods has been frequently reported. Several senior officials of the MOHEC suggested that having children may be a form of self-expression in the absence of other productive outlets for unemployed and impoverished individuals, particularly men. Fatherhood may also be equated with virility. 1/ Powell, Dorian, L. Hewitt, and P. Woo Ming: "Contraceptive Use in Jamaica: the Social, Economic, and Cultural Context", University of the West Indies, Institute of Social and Economic Research: Working Paper No.19, 1978. 2/ Roberts, G.W. Fertility and Mating in Four West Indian Populations, University of the West Indies: Institute of Social and Economic Research, 1975. 3/ Roberts, George W., and Sonja A. Sinclair, Women in Jamaica: Patterns of Reproduction and Family, New York, KTO Press, 1978. - 6 - 17. Economic constraints which limit the usefulness of planning for the future may also influence reproduction. As one senior official of the MOH told the OED mission, "there is no incentive not to have children, because they know they will live a life of poverty anyway". Conversely, married women, who may have higher incomes and who probably have a vision of a more stable future, have the highest proportion of continuing contraceptive use. 1/ 18. The above factors thus created an extremely difficult socio- logical environment for the Bank-assisted project. Even if all these factors could have been somehow taken into account in selecting and designing the Bank's first population project (they were not), it is doubtful whether a really successful project could have been devised within the Bank's and the Government's policy, experience and resource constraints. In view of the state of evolution of the Jamaican pro- gram (a service-oriented phase) in 1969, it would not have made any difference to the design of a family planning delivery system for the program. The motivational and educational approaches needed would be different and this was recognized. The need for an effective IEC 2/ strategy and program was reviewed with the Government and steps to develop local capacity to do this were started by the Board in the implementation phase of the project; the Sector Mission had discussed these issues with the Government. The Second Population Project in Jamaica supports an IEC program. Rural Maternity Centers 19. The ten RMCs have been completed since 1974, but have been under utilized to a great degree. Originally intended to have ten beds each, they have four or six beds, and these are not fully used (PCR 3.21). While the audit supports the PCR's statement that the RMCs are poorly located (3.08), this is only part of the reason for their under- utilization. 20. According to MOHEC officials, the catchment areas for some of the RMCs are insufficient; in some cases they overlap the catchment areas of other existing health facilities 3/. In addition, there has been competition from the traditional mode of delivery by untrained village nanas and from midwives associated with the Parish Councils. 1/ Powell, Dorian, et al. op. cit. 2/ Information, education and communication. 3/ The RMC sites were selected on criteria agreed to by the Bank and the Ministry of Health. These were felt to be technically sound at the time, but in the implementation it has been seen that better choices could have been made. - 7 - 21. The single purpose inpatient health facility has proved to be an inefficient use of resources. It is expensive to maintain, particularly in the provision of support services and of specialized and 24-hour staff. 22. In general, experience has shown that single purpose health facilities are used at a lower rate than multi-purpose ones. In partic- ular, the RMCs do not have the specialized and emergency services avail- able in hospitals, and many of the local women do not have faith in them. Since the RMCs lack telephones and transportation, many women prefer to give birth at home, where, in case of emergency, they may send someone to the police to telephone for transportation to a hospital. Access to a physician is also preferred over the para-medical assistance available at an RMC. 23. The audit supports the conclusions of the PCR (6.06, 6.07 and 6.08) concerning the attention which should be given in design to population density and type of services to be offered, and to the inad- visability of uni-purpose facilities. 24. The investment and overhead required to make the RMCs more attractive are too great relative to the potential maximum use of the RMCs. Consequently, following a suggestion made by the Bank's appraisal mission for the second project, the Ministry of Health would now like to convert them to multi-purpose outpatient health centers, with some minor structural alterations to allow for the storage, dispensary and security of medications. In the long run, the increased provision of general health services by the RMC facilities may have a positive effect on the decline in the birth rate. National Family Planning Board 25. At the time of the loan, it was recognized by the Bank that strengthening the NFPB and the development of a suitable national family planning program were necessary for the success of the project, because of the large component of the project's aims which was not solvable by technology alone. This point was stressed in the staff's presentation to the Executive Directors when the loan was approved. The "bricks and mortar" component of the project, was also intended to facilitate the development of institutions and programs; section 5.02(a) of the Loan Agreement required the Borrower to establish a National Family Planning Board (NFPB). -8- 26. In view of the institution building objectives, stressed at the time the loan was approved, it may be useful to review some of the subsequent development of the Board and its probable effect on the outcome of the proj- ect. The NFPB functioned semi-autonomously until its integration into the MOHEC in April, 1974 (PCR 3.28). This integration was intended to facilitate the resolution of a number of problems, outlined below. 27. The single purpose family planning education officers (required by section 5.04(ii) of the Loan Agreement) were being paid at a higher rate than staff of an equivalent level in the MOHEC, generating resentment among the MOHEC staff, particularly among public health nurses, who had been the original "spearhead" of family planning in Jamaica, under the JFPA. The MOHEC was already employing local community health aides in large numbers, and felt that the functions of the two types of outreach workers might be combined. 28. Similarly, integration was intended to allow the employment of an existing network of health centers, already under the authority of the MOHEC, for family planning. Public resistance to the family planning ,education officers in 1973-74, because they were thought to serve imper- ialist and racist interests, may also have led the MOHEC to wish to reduce their uni-purpose visibility. 29. According to Bank supervision reports and comments by MOHEC officials, the leadership of the NFPPB had lacked decisiveness and direction, causing the resignation of at least one member of the Board, and encouraging the MOHEC to assume its direction. Additionally, the MOHEC thought that the Board's activities were not able to maintain a high rate of continuance among acceptors of family planning, and that the integration of family planning into the provision of general health services might increase the rate of continuance. Finally, integration was intended to gain the ser- vices, as Principal Medical Officer of the MOHEC, of the individual who was the Medical Director of the NFPB. The considerations outlined above suggest that a single purpose institution, whose functions overlap those of a multi-purpose institution, may prove too expensive to maintain where there is a shortage of resources and of trained manpower. 30. On the other hand, the priorities and effectiveness of the NFPB seem to have been diminished by its incorporation into the MOHEC. As an indication, the crude birth rate, which declined by 12% (from 34.9 births per thousand population to 30.6) in 1971-74, at the height of the Board's autonomous activities, declined by 6%, or only half as much, in 1974-77, after integration. Similarly, the number of new acceptors has fallen from 25,540 in 1973 to 23,811 in 1975, and to 14,177 in 1977, the last year for which complete information is available. Partial figures for the first half of 1978 indicate a further drop to only about 68% of the same period in 1977; this would suggest an annual rate of less than 10,000 new acceptors in 1978 (40% of the pre-integration level). - 9 - Although a leveling off after a period of rapid initial progress is a common feature of many family planning programs, the change in Jamaica has been too dramatic to be merely the result of sociological factors. Moreover, the coincidence between its timing and the integration of the NFPB into the MOHEC suggests that it is at least partly the result of integration. Another factor contributing to the decrease in the number of new acceptors, however, is the successful implementation of the commercial distribution of contraceptives which, for correct and relevant reasons, siphoned a significant number of new acceptors from the MOHEC delivery system through the integrated MCH/ FP program. 31. After April 1974, the MOHEC became responsible for policy making, and the NFPB for public information, research and evaluation of family planning programs, training, and coordination with activities of other ministries. The respective roles were defined in a MOHEC policy statement on Family Planning, issued by the-new Minister. 32. A number of problems arose as a result of integration. Lines of authority and responsibility remained unclear between the MOHEC and the NFPB (e.g., PCR 3.02), and there were some disagreements over pri- orities for the allocation of funds. The lesser degree of autonomy for the NFPB and of several of its functions caused a process of demoraliz- ation in the Board, which later lost its non-MOHEC membership, e.g., from the University and the medical community. The NFPB no longer had direct contact with international agencies, and it sometimes lacked relevant information concerning their activities. In view of these considerations, the audit would qualify slightly the conclusion in the PCR (3.28) that the new NFPB "still continues as an autonomous body" within the MOHEC. 33. The NFPB's Bank-recruited training advisor, provided under the project description (Part C) and referred to in the PCR (3.22) stayed in Jamaica for only a few days, and left precipitously. The NFPB felt that they had well-qualified training officers within Jamaica, and preferred to recruit subsequently among them. 34. The integration of the 143 family planning education officers into the MOHEC resulted in their loss of seniority and promotion, and caused demoralization among them as well. Their tasks were redefined to include pre- and post- natal care, nutrition, child care, etc.,and they were unable to devote nearly as much time to family planning as previously. - 10 - 35. At the same time, the existing staff of the MOHEC were reluctant to assume family planning functions, because they felt they were being asked to take on extra work without additional remuneration for a job which had formerly been full-time and better paid than theirs. The community health aides were considerably less well trained than the family planning education officers, and there have been problems related to community confidence in them. 36. The detail of statistics-keeping on family planning (required by section 5.04(iv) of the Loan Agreement) and of trends in its use has declined since 1975. As of 1975, the MOHEC requested the integration of the family planning statistics with maternal and child health and nutrition statistics. However, the cost of integrating the two sets of statistics is estimated at $400,000 and since 1977 neither have been available. Con- sequently, it is extremely difficult to assess the impact of the family planning program, particularly since age-specific fertility rates are lacking. 37. In the recent past, the major active segment of the family planning program within the MOHEC has been the commercial distribution of contraceptives; this distribution, with total sales running about JM$40,000 a year, appears to have offset to some degree the decline in acceptors through the previously established channels. No information is available regarding the breakdown between new acceptors and continuing users, however. 38. The progressive weakening of the Board's scope of activities and of its administrative powers has caused an apparently snowballing process of demoralization within it. The OED mission heard a number of expressions of concern, from officials of the NFPB, regarding the level of interest of the MOHEC and the Government of Jamaica in family planning. Six important staff of the NFPB resigned in late 1978, and some of them may not be replaced. 39. Although the functioning of the NFPB appears to have been adversely affected by its integration with the MOHEC, it is possible that the attention given by the MOHEC to maternal and child health will itself result, in conjunction with family planning, in a long-run decrease in the birth-rate. Victoria Jubilee Hospital 40. The increased capacity resulting from the expansion and remodeling of the Victoria Jubilee Hospital (VJH), where 20% of the country's births take place, was intended to increase the typical post-partum stay beyond 24 hours, so that hospital personnel could discuss family planning with a greater number of women, and find them in a presumably more receptive state of mind (PCR 2.09). Using the post-partum period in hospitals for the introduction of methods of family planning was well accepted by family planning specialists at time of project design. - 11 - 41. However, the expansion of the VJH (even if the new wing is opened and the old wing is remodeled) may not contribute to increased post-partum acceptance as intended. The present overall occupancy rate of the VJH is approximately 118%, and this figure does not adequately represent the overcrowding in certain bottlenecks of the maternity ward, such as labor and delivery suites, and the 5-14 day recovery from abnormal delivery (about 10% of all deliveries). Use of the VJH was very high (15,809 deliveries), in 1970, due to social unrest in the Kingston area. Subsequently, the use declined somewhat, until 1975 (13,313 deliveries), when it started to rise again (approximately 13,540 deliveries in 1978). Officials of the MOHEC and VJH attribute this rise in the use of the VJH, which they expect to continue, to the rapidly increasing costs of private maternity facilities. 42. According to senior medical officials of the MOHEC and the VJH, there are frequently two or even three women in one bed, and the increase of beds in the new wing will principally serve to alleviate those problems of overcrowding most critical from a medical point of view, and not to increase the average post-partum stay. 43. In view of the information available at the time of project design concerning the high rate of use of the VJH, and the subsequent actual use, roughly predictable from the age pyramid at the time, the fact that the new wing of the VJH may mostly be used to alleviate overcrowding might have been foreseen.l/ 44. According to senior officials of the NFPB, the original idea in 1969-70 was to improve the old facilities, both in the case of the hospital and of the existing smaller health centers (the latter idea was also suggested by the Bank's 1969 Review of the Jamaica Family Planning Program). Remodeling would have been more cost effective, and would have undoubtedly produced results more quickly. At the present time, there are no funds available for the remodeling of the old wing of the VJH (specified by schedule 3 A(ii) of the Loan Agreement, and PCR 4.08). A surgical ward for tubal ligations, for which there is a large and unsatisfied demand (as well as an increased number of recovery beds to allow post-partum tubal ligations), seems to be a particularly pressing need which remodeling would alleviate. 2/ 1/ The Population Projects Department maintains that, if the plans had been followed through as envisaged in the project, including the renovations, the following would have occurred: the improvement of overcrowding, some lengthening of bed-stay in hospital, and improved facilities for abortions and sterilization. These would have improved family planning acceptance. 2/ The Population Projects Department points out that the project provided funds for the remodeling of the existing VJH maternity wing but, because of its overcrowding, remodeling work was not practicable before the completion of the new wing. In any case, it is clear that remodeling alone would not have increased the capacity of the VJH. - 12 - 45. The emphasis on new facilities, rather than the upgrading of the existing ones, in the case of both the VJH and the RMCs, seems to have resulted from two factors: (a) political considerations on the part of the Jamaican Government, concerning the visibility of new facilities, and (b) the Bank's "bricks and mortar" orientation which excluded funds for remodeling. 46. Although at the time of project design the use of the post- partum period in hospital was part of an international policy of family planning methodology, as noted above, the rationale concerning the use of hospitals per se does not seem to have been entirely applicable in the Jamaican case. A major aspect of this rationale, according to the Population Council 1/ (which was responsible for the International Post-partum Family Planning Program, 1967-1974), is the rapidity, facility, and low expense involved in using pre-existing hospitals and hospital infrastructure for the introduction of family planning services, as well as the accessibility within the hospital of the target population. The building of a new hospital obviously does not meet either of the conditions of this rationale. 47. However, the audit considers that the Bank was severely con- strained in its choice of a suitable project by its own restrictions at the time concerning the financing of local currency costs and recurrent expenditures, as well as by its capital cost bias and its emphasis on infrastructure. Project Management and Physical Implementation 48. Although the project was the Bank's first entry in the field of population control and would.undoubtedly have been formulated, nego- tiated and implemented very differently if it were being financed today, it was by no means the first time the Bank had financed building construction. Nonetheless, the audit finds that the Bank's wealth of experience and long-established policies and procedures in dealing with construction projects were for some reason never fully or effectively brought to bear on this project. 49. One factor which probably accounts for many of the apparently unnecessary and, in retrospect, unfortunate departures from standard Bank policies and procedures in the negotiation and supervision of the project was the newness to the Bank of almost all the members of the recently established Population Projects Department at the time the project was getting underway. The architects, in particular, were un- familiar with the usual role of Bank staff in project supervision. 1/ R. Castadot, I. Sivin, et. al. "The International Post-Partum Family Planning Program: Eight Years of Experience. "Reports on Population/ Family Planning, No. 18, November, 1975. - 13 - 50. Bank supervision was complicated because: (1) most Bank letters were unanswered; (2) copies of procurement documents were forwarded to the Bank after lengthy delays; and (3) Bank recom- mendations for procurement were ignored on many occasions. Moreover, some key planning and procurement documents required to be submitted to the Bank for approval prior to inviting bids or awarding contracts were not received; others were not reviewed in detail or commented upon by Bank architects, but only by the Borrower's consultants. As a result, the Bank's position, as perceived by the Borrower, was too passive and informal, and the Bank had little influence on the Borrower's decisions, for example, in relocating the RMCs and prequalifying, selecting and dealing with the VJH contractor. The audit agrees with the conclusion of the PCR (5.02) that the Bank should have stood firm in these matters, all of which have had a major negative impact on the project. 51 In negotiating the loan agreement, the Bank abandoned its usual prudent policy of requiring the Borrower to provide adequate proj- ect management (PCR 3.01). Instead, the agreement concentrated almost exclusively on the NFPB, which was only responsible for about 10 percent of the loan disbursements, while the administrative arrangements for the other 90% were left very vague. This omission may have been the result of the Bank's approach to population lending at the time, in which it tried to enter a field of activity which is largely limited to the pro- vision of software and supplies while still sticking to its traditional policies of lending only for capital investment and foreign currency costs. 52. This approach is clearly reflected in the Board's discussion of the proposed loan on June 16, 1970, when a number of directors argued that the loan was really going to finance a hospital construction project, while the staff presenting the project de-emphasized the im- portance of the "bricks and mortar" aspect, claiming instead that the software elements, although they accounted for only 10 percent of the loan proceeds, were "large" and "vital to the success of the program". 53. In the audit's opinion, the de-emphasis of the investment aspect of the project was carried too far in the subsequent supervision of the project and is at least partly to blame for the problems now besetting the project facilities. When problems arose in the project's physical implementation, they were not accorded as much attention by the Bank's management as were problems on the software and institutional side. - 14 - 54. The PCR correctly points out (5.01) that, although 16 of the 20 Bank supervision missions included architects, this did not prevent disastrous delays in the construction of the new wing for VJH. Part of the reason for these delays may be the fact that, throughout the project's history, there was so little continuity in the architects' input. Including consultants directly employed by the Population Pro- jects Department and Bank staff borrowed temporarily from other depart- ments, no less than 10 different architects worked on the preparation, appraisal, negotiation, and supervision of this project. The population Projects Department began life without any architects of its own and was forced to borrow architects on a part-time basis from other departments. 55. The local supervising consultant's contract was drawn up at the Bank's suggestion in such a way that the consultants received almost their entire fixed fee in the first few years so that, when problems with the contractor occurred, they had largely lost interest in the job. Moreover, a firm of foreign architects was given a small contract under the project to review the work of the local architects and advise the MCW in supervising them and their subcontractors, also on a fixed fee basis which did not permit them to devote much time to the job after the first year or so. 56. The structure of architectural supervision created by this contract left the MCW at several removes from its customary role of directly supervising the contractors, and it was forced instead to deal with at least two, and sometimes three, layers of architectural and engineering consultants. The foreign consultants, moreover, who were set to watch over the local consultants, were given such a small contract that they were unable to perform any effective supervisory role beyond the design stage, although the Bank, departing from the provisions of the Loan Agreement, continued to rely on them to review and approve tender documents which should have been sent to Washington for approval by Bank staff. 57. The way described above in which the various contractual arrangements were set up in the very beginning thus created a situation in which no single set of supervising architects, including those in the Bank, felt a real sense of responsibility and commitment for the successful implementation of the project. There is no evidence ob- tainable from Bank files or from interviews, for example, that the Bank ever reviewed or commented on the Government's proposed criteria for prequalification, a procedure which should have been designed specifically to prevent the selection of undercapitalized, poorly managed contractors like the one who actually got the job. In general, the Bank files on this project reflect a cursory manner of handling procurement matters in the new department, with on the spot approvals being rendered during brief field visits by inexperienced staff or Bank consultants without reference to, or subsequent confirmation by, Headquarters managers. - 15 - 58. Because of the provisions of the loan agreement, the Bank was forced to correspond officially with NFPB on matters relating to construction, in which NFPB had little interest, while the consultants were receiving conflicting instructions from MCW and MOHEC, with neither agency able to coordinate. As one example of the result of this lack of coordination, the layout of the labor suits, as requested by the MOHEC but contrary to the recommendations of Bank staff and consulting architects, is based on the standard pattern for developed countries where each woman in labor is placed in a separate cubicle. The MOHEC admitted to the OED mission that, before the new wing can be used, they will have to tear out, at considerable expense, all the partitions sep- arating these cubicles to enable a single nurse-midwife to keep an eye on a number of patients at the same time. 59. In any event, according to senior officials of the MOHEC, it is unlikely that the new wing will be fully completed much before the end of 1979, or that, when it is at last declared ready for occupancy, the MOHEC will have the budget or staff to operate it. In September 1978, the Public Accounts Committee of the Jamaican Parliament launched an investigation of the VJH "disaster", as it is now referred to by senior government officials. The mission tried unsuccessfully to obtain a copy of the Committee's report, and recommends that the Bank pursue this matter further through official channels if a copy of the report is not received in the near future. III. CONCLUSIONS 60. There were several fundamental problems of design and implem- tation in the Jamaica First Population Project, mainly concerning Project management and supervision, the type of facilities built and their potential utilization and the development of the NFPB as an institution. 61. Although population issues are very complex in social, and not only physical, infrastructure, the Bank's own policies and biases rather stringently constrained the choice of a suitable project to the "bricks and mortar" variety. These constraints, inexperience and a desire on the part of the Bank to move ahead rapidly with its first lending operation in the population field, led to the choice of the VJH expansion, which did not meet with the conditions of the rationale for the use of hospitals in post- partum family planning, and which in any case will most probably be used mainly to alleviate overcrowding; and to the choice of the RMCs, whose single purpose and underequipped facilities did not attract enough users to justify their continuance in their intended form. - 16 - 62. The NFPB was fairly effective during its autonomous period, until 1974, but its functions duplicated or overlapped many of the functions of the MOHEC, and its single purpose staff was expensive to maintain, given the shortage of resources and of trained manpower. After integration with the MOHEC in 1974, however, its effectiveness declined considerably, and the major active segment of the family planning program at the present time is the commercial distribution of contraceptives, which is supported by USAID. 63. The history of the NFPB suggests that it may be unwise to establish or reinforce, as a condition of a Loan, a single purpose institution which serves the interest of the Loan but which creates inequalities and stresses with other existing institutions whose functions it, to some degree, duplicates. On the other hand, particularly in view of institution-building objectives such as those which were prominent in this project, it is necessary to ensure that institutions which would serve the development intent of the Loan are not submerged by other larger institutions, the very ones whose functions overlap theirs. It might be preferable to take account in project design of the probable relationship of existing multi-purpose institutions with those which more specifically are to serve project intent and to establish, in the explicit design of the project, safeguards against the overwhelming of the latter by the former. 64. Valuable experience appears to have been gained by the Population Projects Department from this project concerning the relationship of Min- istries of Health in general to family planning programs, and concerning the necessity for supervision of programs and monitoring of their impacts, as evidenced by the remarks in the Bank's current guidelines for operating staff on population projects. These guidelines also reflect an advanced degree of thinking concerning the development of social infrastructures which lower fertility, and concerning important prerequisites of institu- tional functioning, both of which are nonetheless difficult for projects to influence. 65. Due to changes in the Bank's policies, local costs and incre- mental operating costs are now eligible for Bank financing. These changes remove some of the constraints which applied to the Jamaica First Population Loan, and facilitate the flexibility of project design. 66. Several other difficulties seem to have been generated by what was perceived by the Jamaicans as the inappropriate imposition of external influence. For example, the training advisor, whose brief presence was quite unsuccessful, was replaced by Jamaican training officers, and the later three external reviews were dispensed with, for reasons outlined in the PCR. The OED mission was also told that the evaluation done by USAID in 1974 was not welcomed, and that the MOHEC subsequently decided to do future evaluations on their own. - 17 - 67. Finally, the physical implementation of this project demon- strates clearly that the Bank cannot afford to abandon its normal lending policies and procedures when entering a new field for the first time. The same standards and procedures of project appraisal and supervision are needed in these "firsts" as in the more routine operations, particularly in relation to project management, contracting and procurement. If anything, even more training and guidance is needed for supervision staff working in new and uncharted areas than in the more familiar sectors of operation. - 18 - PROJECT COMPLETION REPORT JAMAICA : FIRST POPULATION PROJECT I. INTRODUCTION 1.01 In accordance with the terms of reference dated June 12, 1978, a mission comprised of Dr. K. V. Ranganathan (Medical Specialist) and Mr. B. J. Hubert (Architect) visited Jamaica from June 20-29, 1978 to carry out a project completion review of the first population project financed under Loan 690-JM. The mission's task was to collect the necessary information for the project completion report and to discuss with the Government the outcome of the project. II. PROJECT BACKGROUND A. Socio-Economic Political Setting 2.01 Jamaica is a tropical island in the Caribbean with an area of 10,962 km2. The population, which is predominantly of African descent but has Indian, Chinese and European components as well, numbers more than 2.0 million (191 people per km2). With a per capita income of about US$1,070 (1976), Jamaica compares favorably with most Latin America and Caribbean countries. In 1977, the unemployment rate was high (25%) and apparently increasing; one half of the total number unemployed was concentrated in the age group, 14-24 years. In agriculture, 2% of the farms encompass 45% of the arable land while about 145,000 farmers, with less than 2.5 hectares each, farm the hilly and less fertile areas. B. Recent Demographic Trends 2.02 During the decade 1960-70, the rate of natural increase was 3.1% (22 years' doubling time), however, emigration reduced the rate of population growth to 1.6% per annum (44 years' doubling time). Based upon this rate of growth, during 1970 Jamaica's population increased by 2.4 people per square kilometer, or, more relevantly, five people per square kilometer of agricultural land. Had emigration been nil, these increases would have been more than twice as large. 2.03 During 1960-65, the number of births per year averaged about 67,000. Since 1966, when an Island record of 71,500 births was reported, there has been a slow but steady decline to 62,000 in 1974 (the lowest figure since 1958). The crude birth rate (CBR) peaked at 42.0/1000 in 1960 and then dropped to 30.4/1000 in 1974. This decline in the CBR reflects the decrease in the total number of births, which could have been due to a sustained reduction in the number of women within the reproductive ages (sex selective emigration), or to - 19 - a decrease in age-specific fertility rates, or both. For the past decade, no tabulations of births by age of mother (the basis of age-specific fertility rates) have been made available on a yearly basis. Since the time period overlaps with the establishment of the National Family Planning Program, it would have been desirable to analyze data on age-specific movements of fertility for other than census years (the last census was in 1970). In the absence of detailed tabulations of these vital statistics (which have remained unprocessed since 1964), it is impossible to trace fertility move- ments in Jamaica effectively. 2.04 Although the CBR fell 11.5% from 1960 to 1970, census data suggest that during this period the total fertility rate and the gross reproduction rate increased slightly. In the intercensal period, age-specific fertility rates increased in female cohorts under 30 years of age and decreased in those between 30 and 49. Census data also reveals that while the number of 15-49 year old females decreased by 5.4% from 1960 to 1970 and the childbearing portion of the female population (15-44 years of age) decreased substantially from 42% to 30%, the reduction in the male cohort was less than one percent, thus reflecting a larger female emigration. Consequently, emigration between 1960 and 1970 had an appreciable effect on the age-sex structure, and the decrease in the CBR may be primarily a function of the declining proportion of women within the child-bearing age group. 2.05 The absence of data of yearly fluctuations of age-specific fertility rates, continuation rates by contraceptive method and the size of the female population protected at a given time, has led to the use of indirect estimates of program performance (e.g., crude birth rate, general fertility rate, etc.). However, the heavy influence of age-sex selective emigration on these statistics makes them inconclusive. At any rate, Jamaica's National Family Planning Program appears to have made at least a modest contribution to the decline in the birth rate over the past five-year period ending 1974. 2.06 In 1974, the Government established a CBR target of 25/1000 popu- lation for 1978 to be achieved as a result of enlisting a cohort of 100,000 family planning users (women between 15-44 years of age) by 1977.1/ Since the size of active clientele was 40,000 in 1974, achievement of the target would mean an increase of approximately 22,000 users per year. It would also correspond to a general fertility rate of 120/1000 women, 15-44 years of age by 1977. In the light of present acceptance rates (around 22,000 new acceptors per year), apparently high attrition rates and a general fertility rate of 182/1000 in 1974, it does not seem likely that those objectives will be achieved unless present trends are dramatically altered. Realistically, however, the program with the aid of the second population project, may be able to achieve a general fertility rate of 150/1000 by 1980, as a result of reaching about 100,000 family planning users in that year. 1/ In 1970, a CBR target of 25/1000 was proposed for 1975. It was then moved to 1978 as reported in Ministry Paper No. 1: "Family Planning." - 20 - 2.07 The main population trends in Jamaica are summarized by the following data: a. Natality: The CBR declined from 42.0/1000 in 1960 to 30.4/1000 in 1974. b. Mortality: The crude death rate decreased from 8.8/1000 in 1960 to 7.1/1000 in 1974; infant mortality dropped from 50.9/ 1000 live births in 1960 to 32.2/1000 in 1970, and still further to 25.3/1000 in 1974. Thus in 1974, less than half as many infants were lost in the first year of life as in 1960. c. Migration: In the ten-year period 1960-70, net emigration amounted to approximately 290,000 people. In 1974, 76% of a net migration negative balance of 12,000 people were females, mostly between 15-34 years of age. C. Project Formulation 2.08 A Bank economic mission in May 1968 tentatively identified Jamaica as a suitable country for the Bank's first project in the population field. A population mission, led by Mr. Sam Keeny of the Population Council, visited Jamaica in January 1969. The mission on return agreed that the climate for family planning Jamaica appeared favorable, and recommended that the proposed loan focus on improved administration of the family planning program, and on an expansion of family planning-related facilities. Specific facilities suggested by the mission for inclusion in the loan were the extension of the Victoria Jubilee Hospital (VJH) and the establishment of RMCs. Extensions of parish hospitals and expansion of urban health centers were suggested, but later dropped from the proposed loan mainly because the linkage to family planning was not seen to be close enough. 2.09 The Jamaican family planning program at that time relied heavily on the recruitment of women during the postpartum period. The choice of Bank support for VJH expansion and the establishment of RMCs was based on the need to increase the number of FP acceptors in order to reach the Government's target of reducing the CBR from 34 per 1,000 population in 1969 to 28 per 1,000 in 1972. The VJH was the country's largest maternity hospital, in which 20% of the country's births occurred. The VJH was chronically overcrowded, with an occupancy rate of over 100%, despite the fact that most patients were discharged less than 24 hours after giving birth. By expanding the number of beds, it was hoped that the average postpartum stay could be extended, thus allowing family planning motivators a chance to contact each postpartum patient. The same rationale applied to the RMCs, where it was hoped that the establishment of maternity facilities would, inter alia, permit the same postpartum family - 21 - planning activities. Loan Committee discussions indicate that the Bank was aware that it was considering financing health facilities, but would do so to ensure that the family planning program in Jamaica was adequately implemented. 2.10 As the Bank's first population project, there was much discussion within the Bank during 1969 regarding the type and scope of required project financing. A Loan Committee meeting held before the population mission's departure discussed the possibility of financing operating as well as capital costs, given the relatively low level of projected capital expenditures. The Loan Committee agreed that the January mission should not discuss the possible scope of Bank financing with the Jamaican authorities, but should focus on the needs of the project regardless of sources of financing. Discussions of financing within the Bank continued into the summer, and in August 1969, Mr. McNamara indicated that he would be willing to recommend Bank financing of 70% of the total project cost, independent of the estimated foreign exchange component. The Bank eventually financed the project's total foreign exchange cost of US$2.0 million, for 67% of total project cost. 2.11 There was also considerable discussion from the time of the first mission regarding the appropriate methodology for determining the cost/benefit ration of supporting family planning. Questions regarding this methodology were never satisfactorily resolved, and still continue; it was decided to present the project to the Board with a simplified economic rationale. D. Project Description 2.12 The Bank's first project in the population sector was approved in June 1970. It had an estimated total cost of US$ million and was assisted by a Bank loan of US$2 million. The project had two main components: (a) the building of a new wing at the VJH (with a capacity of 150 maternity beds, labor ward, etc., and a midwifery school to train about 20 midwives annually); and (b) the construction of 10 RMCs, each having four beds. The RMCs were a new and untested type of facility in the health system. The central strategy of the project was to expand delivery facilities to permit the postpartum recruitment of acceptors from the relatively large proportion of women (nearly 50%) who delivered in medical facilities; this was consistent with strategies then available but which have since been modified. The project also included two small operational studies, the appointment of a training consultant, the development of a home-visiting program, and a program review by an external review team. III. PROJECT IMPLEMENTATION A. Project Management 3.01 No specific reference was made to project management in the Loan Agreement, nor with regard to its physical implementation. During appraisal, it was agreed that coordination and supervision of the project would be - 22 - exercised by two groups, a policy-making project committee and an administrative team. It was also agreed that supervision of construction would be the responsibility of the consulting architects, who would be responsible to the Ministry of Communication and Work (MCW) but not to the project team. 3.02 Overall management has been a consistent problem throughout the project implementation period. Although a "senior-level committee" and a "working-level committee" (consisting of representatives of the MOH, MCW and NFPB, under the chairmanship of representatives of the MOH in each committee) were planned as described in the appraisal report, there is no evidence to indicate that these two committees were either established or ever met. The failure of the MOH to designate staff responsibility for the project resulted in very poor and periodically non-existent management of the project. The Chairman of the NFPB, in the early stages of the project, gave some attention and leadership to management of the software components, but even this was discontinued after 1972 for reasons which are not explicit. One reason often mentioned is the "weak leadership" of the then Chairman of the Board, but even after the inte- gration of the Board with the MOHEC in 1974, there was little or no improvement in project management. 3.03 During project implementation, the responsibility for construction was undertaken by the MCW senior architect. Most of the time this individual made good recommendations, but did not receive adequate support from the Minister of Communications and Work who had the power of decision--as, for example, in the case of prequalification of contractors and termination of contracts for the VJH. In spite of the delays in design, awarding of contracts and site works, the construction of the RMCs was satisfactorily implemented. This has not been the case with the VJH extension. B. Physical Implementation Civil Works 3.04 Design of project buildings. Architectural programs for: (a) the VJH extension and remodeling work; and (b) ten RMCs were developed during project preparation and agreed upon between the Government and the Bank during appraisal. The program for the VJH was prepared by a foreign hospital consultant; the programs for the ten RMCs were prepared by the MCW's chief architect (Details of the schedules of accommodation are presented in Annexes 1 and 2). During appraisal, agreement was also reached on the selection of two private Jamaican architectural firms, one for the VJH and one for the RMCs. Appointment of the first was a condition of loan effectiveness, but both contracts were only signed on November 16, 1970 after lengthy discussions regarding cost estimates for the VJH and location of the sites for the RMCs. A 12-month delay occurred in designing the project buildings because of: (a) difficulties between the architectural firm and the hospital consultant for the VJH in reaching agreement on program details and construction standards; and (b) changes in the location of the RMCs. Bidding documents for the RMCs were completed in December 1971 and for the VJH in February 1972 (Annexes 3 and 4). - 23 - 3.05 The new maternity wing of the VJH is well oriented but is not very well linked with the existing medical buildings. Its architectural design is generally good and the layout of its medical and training services is functional. However, the design and specifications for the mechanical installations have caused many problems during construction. In particular, the location of the air conditioning unit, which is in the middle of the second floor just below the delivery rooms and operation theater, will result in noise and vibration in these vital areas. It is likely that the sophisticated design of the electrical and mechanical installations combined with the poor quality of construction work, will result in many maintenance problems, 3.06 The design of the RMCs is good. It was well adapted to local conditions and has proved to be functional. 3.07 Location of the project facilities. The VJH is located in the center of the old section of Kingston. At the time of appraisal, the existing 165-bed maternity wing was over-crowded for both patients and staff. As the VJH has a very good reputation, the decision was made to increase its capacity by 150 maternity beds rather than build another maternity hospital in the Kingston area. However, the site of the VJH is surrounded by narrow streets and a shortage of parking facilities already existed. The addition of a new maternity wing has aggraveted circulation of traffic and reduced the parking capacity which causes problems for emergency cases. A separate maternity hospital built in another populated part of Kingston might have been more suitable and permitted more economic construction with less elaborate mechanical installations. 3.08 The location of the RMCs was agreed upon during appraisal, but four RMCs were relocatedduring implementation. The RMC in Mountainside was relocated to Newell (St. Elizabeth) and the RMC in Friendship was relocated in Chestercastle (hanover). In both of these cases, changes were motivated by population migration. The RMC in Malton was relocated in Robins Hall (Manchester) because no suitable site was available. Robins Hall is only four miles from Malton but its road accessibility is very bad. The RMC in Green Island was relocated in Dias under political influence. Six of the RMCs are well located at road crossings in populated rural communities. The four other RMCs are either isolated or located near other maternity facilities. The RMCs in Hopeton, Robins Hall and Wood Park are located in insufficiently populated areas and served by a poor road network. Very few deliveries have taken place in the Dias RMC because of the proximity of the Lucea Hospital five miles away. 3.09 Five contractors were prequalified for the construction of the VJH extension early in 1972 but only two bids were received on June 1, 1972. The contract was awarded to the lowest bidder on January 2, 1973. The contractor was, however, requested to take steps to reinforce his managerial capabilities, particularly for mechanical service installations, and to ensure that half the mechanical sub-contractors were accepted by the MCW. - 24 - 3.10 Eight local contractors were prequalified for the construction of the ten RMCs early in 1972. For the tendering of bids, the RMCs were divided into three groups: (a) the East group, (with centers in Port Morant, Long Bay and Wood Park); (b) the Central group, (with centers in Elderslie, Robins Hall and Newell); and (c) the Western group, (with centers in Clark Town, Dias, Chester Castle and Hopeton). Al contracts were awarded to the lowest bidders, For the Eastern and Central groups, the contracts were awarded in May 1972 but late location changes for two centers in the Western group delayed awarding of that contract until November 1972. 3.11 Problems during construction. Many difficulties have occurred during the construction of the VJH maternity wing, and the remodeling of existing buildings has not yet been undertaken. Although these difficulties resulted mainly from the contractor's poor performance, other causes were partially responsible: (a) social turmoil in Kingston which led to lengthy strikes; and (b) inadequate leadership in work supervision. Very early in the construction cycle, it appeared that the contractor did not have the managerial and technical capabilities required for such a sizable contract, The situation was further aggravated by additional labor strikes resulting from delays in paying salaries. Early in 1974, the architect recommended to the Government that the contract be terminated, but his proposal was not accepted and the contractor was only requested to improve its management. Although construction progress improved temporarily, even the building framework had not been completed by October 1974. As improvement in the contractorts performance was not maintained, the guarantors (an insurance company) took over the management and control of the work early in 1975. Most of the work was completed by mid-1976, but since then little progress has been made. The midwifery school facilities, which are located in the west half of the second floor, were commissioned early in March 1978 and since then have been in operation. As the mechanical installations of the other parts of the building were not yet complete in June 1978, the Government decided to terminate the contract with the guarantors and to have all remaining work completed by the MCW. The building is not expected to be fully completed before November 1978. Since 1972, responsibility for work supervision has been shared among the MCV, the architect and the MOHEC. Although the MCW has primary responsibility for the civil works component, it has failed to ensure effective leadership. Experience has now proved that the contractor should not have been prequalified and the contract should have been terminated early in 1974. 3.12 No major difficulties were encountered in the construction of the RMCs. Some delays were, however, caused by: (a) late changes in site locations for centers in the Western group; Cb) shortages of building materials; and (c) the last-minute decision to include complementary site works. Equipment and Furniture 3.13 The equipment and furniture lists for the VJH extension and the RMCs were prepared by the MOHEC, with the assistance of the hospital consultant. The final lists and bidding documents were completed by the end - 25 - of 1972. Equipment and furniture were procured under international competitive bidding, and, with the exception of the wooden furniture, were all imported. There were only a few delays in delivery. RMC installations were made upon completion of construction in 1973 and early 1974. For the VJH, equipment and furniture were stored in MOHEC facilities prior to installation in 1977. 3.14 For the VJH, all equipment and furniture has been installed and, with the exception of some electrical and mechanical connections still to be made, are ready for commissioning. 3.15 For the RMCs, equipment and furniture are generally adequate and pronounced satisfactory by the users. However, some equipment, such as incubators, have proved to be too sophisticated and thus were never utilized, and incinerators were not installed in seven of the centers. 3.16 The new VJH facilities and equipment have been poorly maintained because of a shortage of personnel, inadequate supervision, and the sporadic presence of mechanical sub-contractors. 3.17 All RMC buildings and equipment inspected by the mission were well maintained. Day-to-day maintenance is the responsibility of the nurses in charge; they are assisted by the MOHEC country directorate and the MCW local representatives for the maintenance of medical equipment and buildings. 3.18 In 1973, the MOHEC created a maintenance unit, but performance of the unit has never been satisfactory. For the maintenance of buildings, the unit is adequately staffed with MCW personnel, but for the maintenance of medical equipment the unit is lacking the necessary specialists. The unit has an insufficient budget allocation and has foreign exchange difficulties in the procurement of imported spare parts. The MOHEC is concerned by the poor performance of the unit and has requested that the Bank and United Nations Development Programme finance a study geared toward reorganizing the unit. The study is part of the second Bank population project and was initiated early in June 1978. It is hoped that the findings of this study will contribute to the proper maintenance of facilities and equipment for the VJH extension. C. Implementation of Software Inputs Utilization of Facilities 3.19 The maternity wing of the VJH extension has not been commissioned to date. In addition to the need for attending to "mechanical" alterations and replacements, the MOHEC budget for this fiscal year has no provision for either the incremental staff or supplies required. As a result of these failures, overcrowding the existing maternity wards continues and the duration - 26 - of stay in the hospital for women has not been lengthened as anticipated during appraisal. Consequently, this incomplete project component has not contributed to any improvement in the VJH postpartum program. Nevertheless, the dedicated work of the existing staff is at least able to keep the annual number of postpartum acceptors at nearly the same level (about 35% of all women who have given birth in the hospital attend a family planning clinic) for the seven year period 1971-78. 3.20 The midwifery training wing has been completed and commissioned. Twenty midwives are under training in this school in the current year. 3.21 The final RMC was completed in 1974. Utilization of these ten maternity centers has been very uneven. The RMC at Hopeton is non-functional now and the MOHEC has tentative plans to utilize this center to train medical students. The RMCs at Rbbins Hall, Dias and Wood Park are very much underutilized (about four deliveries per month). The RMCs in Long Bay, Port Morant, Clark Town and Chester Castle are utilized to a comparatively greater extent (average of 8 to 10 deliveries per month) and the one in Elderslie is well utilized (about 20). Even though the utilization of the RMCs for deliveries is low, in at least six RMCs, the attendance of mothers for antenatal and postnatal care and family planning services has been encouraging. In other words, the RMCs, although not adequately serving the objective of institutionalized care during delivery and subsequent postpartum services for family planning (as envisaged during appraisal), are still important in providing family planning and postnatal care on an outpatient basis. In addition to the inconvenient location of four RMCs (either too far from areas of population density or physically inaccessible), another important factor contributing to non-utiliza- tion seems to be the reluctance of Jamaican mothers to attend uni-purpose centers for maternity care away from home, especially when the centers do not provide services for comprehensive medical/health care of the family as a unit. The MOHEC, recognizing this constraint, plans to convert all ten RMCs into Type II health centers providing comprehensive primary health care services including family planning. This proposal, which is a step in the right direction, will be implemented when budget resources permit. Technical Assistance 3.22 A training advisor under the project was recruited in 1972 for a short period of time, but the advisor left because of some problems. The Government decided not to recruit another training advisor. However, training programs initiated by the NFPB in the various concerned ministries and agencies through the training unit of the Board are being successfully carried out. The in-service training unit established in the MOHEC has taken over the responsibility to train all health staff (about 4,000) in maternal and child health/family planning (MCH/FP) and a master training plan is now under preparation. - 27 - 3.23 Two studies and provision for external reviews were proposed under the project: (a) a study to investigate the possibilities of reallocating certain family planning functions performed by doctors, nurses, auxiliary nurses, midwives and other trained personnel, in order to lighten the workload of professional personnel who are in short supply; (b) a study of the service delivery system in the Kingston-St. Andrew area to determine appropriate scheduling for efficient use of area health clinics and the best utilization of professional staff working in these clinics for family planning purposes; and (c) four annual reviews, the first scheduled for August 1971 and the final one about August 1974, by teams consisting of not more than three external consultants, to assess the progress and efficiency of the National Family Planning Program. 3.24 The study to investigate the reallocation of certain functions performed by medical, paramedical, and other trained personnel was carried out in 1971. Most of the recommendations of this study, e.g., upgrading of nurses to accept certain responsibilities which were formerly those of doctors; integration of family planning in the university undergraduate courses; increase in the number of family planning educators to be trained and deployed in the program; and the training of clinic clerks in family planning, were accepted and implemented during the project period. 3.25 Although the project made provision for an annual external review, it was subsequently agreed to conduct only one such review during the project period. After the first external review in 1972, the Bank and the Government agreed that Bank project supervision missions could handle further review and evaluation of the project, and thus eliminate the time-consuming and somewhat cumbersome tasks of recruitment and deployment of annual external review missions. The report produced by the 1972 review team was well received by the Government. Some of its recommendations, notably those for making greater use of the commercial sector, have been influential in the subsequent broadening of Government strategy. The commercial distribution of contraceptives is now a successful program, contributing significantly to acceptance and use of pills and condoms especially in urban areas. The report also pointed out weaknesses in the training of family planning workers, inadequacy of the single purpose (family planning) home-visiting program and the low number of acceptors. The Government has since taken action on these recommendations and the second population project is supporting such activities as a comprehensive in-service training program and the deployment of multipurpose community health aides for the delivery of community-oriented comprehensive primary health care services (including family planning). Another important by-product of the recommenda- tions of the external review team was the integration of family planning with maternal and child health services of the MOHEC which has now been accomplished. - 28 - D. Fulfillment of Special Covenants and Supplementary Conditions 3.26 Refers to Article V of Loan Agreement 690-JM: Section 5.01 (a)--The project, in spite of the absence of specific focus on management, was carried out satisfactorily as far as the construction, equipping and staffing, as well as utilization of most of the ten RMCs are concerned. In the case of two RMCs, utilization has been very poor and one of these centers is not even staffed. The VJH component is very unsatisfactory and no funds have been provided to date for either commissioning or staffing and operation of the maternity extension wing. 3.27 Section 5.01 (b), (c), (d) and (e)--The Government has fulfilled all the requirements of paras. (b), (c), (d) and (e) of Section 5.01 of the Loan Agreement. However, there were some delays in the appointment of the consulting architects and in the acquisition of land for the construction of the rural maternity centers. 3.28 Section 5.02 (a), (b) and (c)--The NFPB was established by law in 1970 and adequately staffed as required under this covenant. It carried out the functions as agreed between the Bank and the Government as per Schedule V of the Loan Agreement. Effective April 1974, the NFPB was reorganized under the Chairmaship of the Permanent Secretary of the MOHEC but still continues as an autonomous body responsible for information, education and communication activities, special projects, and overall evaluation of the National Family Planning Program. Adequate funds in the Government budget were provided and continue to be provided for the functioning of the NFPB. 3.29 Section 5.03(i)--Even though the Government did not submit proposals for administrative arrangements in time as required under this covenant (before November 1, 1970), the various supervision missions did discuss and agree upon the staffing and operation of the ten RMCs before construction was completed. Such arrangements, including the working relationship between the district midwives (operating in the communities) and the RMC staff, were implemented during the project period and continue to be in effect. 3.30 Section 5.03(ii)--Studies included in part D(l) and (2) were completed in 1971 (no significant delay) and the external review study (part D (3) was conducted in 1972. External reviews were not undertaken on an annual basis for reasons explained earlier in this report (para. 3.25). 3.31 Section 5.04(i)--The postpartum program continued to be implemented to the existing maternity ward of the VJH and could not be extended to included the maternity extension which still has not been commissioned. The program was and is continuing to be operated through nine functioning RMCs. - 29 - 3.32 Section 5.04(ii)--By 1973 (not by December 31, 1970 as required in this Section), the MOHEC had put into operation the new community health aides program in two parishes (Hanover and St. James). The program was successful and, as indicated in this section, served the same purpose as face-to-face motivation of couples with respect to acceptance and use of integrated MCH/FP services. The Bank supervision missions accepted the community health aides program as satisfying this covenant. Subsequently, by 1976-77, the program had been extended to cover the whole country (supported by the second Bank-financed project) and is currently evaluated as a successful program. 3.33 Section 5.04 (iii)--A training advisor was appointed in 1972 but stayed on the job only about three weeks (para. 3.24). 3.34 The RMCs have been well maintained since completion. The MOHEC created a maintenance unit in 1973, which will be responsible for VJH maintenance. 3.35 Section 5.06--The first Chief Executive Officer of the NFPB was appointed in 1970; his appointment was acceptable to the Bank. After the NFPB was reorganized, the Permanent Secretary of the MOHEC became the Chairman of the Board (in 1976), and even though the Bank was not formally consulted, the supervision missions were aware of this change and there was no reason to object to his appointment. IV. PROJECT COST AND FINANCING 4.01 Details of the estimated and actual expenditures for the project as of June 30, 1978 are described in Annex 5. The total capital cost of the project is expected to be US$4.6 million (when the VJH has been completed), compared to the estimate of US$3.3 million. A cost overrun of about 39% results mainly from category 2 civil works, where there has been a cost increase of 92%. Annex 6 compares forecast and actual schedules of disbursements. The three -year delay in disbursements corresponds to the two and one half-year delay in the physical implementation of the project, combined with lengthy processing of withdrawal applications. 4.02 Construction cost estimates were established by the appraisal team in collaboration with architects from the MCW. Furniture and equipment costs were based on recent quotations from suppliers for similar goods. Professional fees were agreed upon with the selected firms during appraisal as fixed percentages of the construction cost, plus allocation for traveling expenses. 4.03 Construction cost increases of about 92% resulted from unrealistic cost estimates, insufficient provision for cost escalation and dealys in design and construction. During the discussion with the consulting architects at the - 30 - beginning of project implementation, it was acknowledged that cost estimates for construction were underestimated by about 15% to 20%. The situation was aggravated by delays in design and construction; there was about an 18-month delay in design and awarding of contract. Although there was no significant increase in price escalation for the construction of the RMCs, problems and delays (more than three years) encountered during the construction of the VJH extension, and an unexpected cost escalation resulting from inflation (10-20% per year instead of 5%), resulted in a 64% increase above the initial amount of the contract. Annex 7 details the forecast and actual construction cost. 4.04 There was no delay in the procurement of furniture and equipment for the VJH and RMCs, and their total cost of US$358,000 is only 12% above appraisal estimates. 4.05 The 63% cost overrun for professional fees resulted from the increase in construction cost. The cost overrun has been compensated by the financing of the technical assistance program under a foreign aid agencies grant. 4.06 The Bank loan has financed the interest and commitment charges during implementation (US$0.3 million), but because of the cost overrun, only 75% of the foreign exchange. It has financed 50% of the expenditures for construction and professional fees, but only 22% of expenditures for furniture and equipment due to the delay in processing withdrawal applications by project management. With about US$0.35 million remaining to be paid upon completion of the VJH construction, the Government will have financed 100% of the local costs (US$2.0 million) and 25% of the foreign exchange (US$0.6 million). 4.07 Recurrent costs for operating the RMCs during the FY1978-791/ (including salaries, supplies and other operating costs), according to the Government budget were J$177,386.72, which is 0.19% of the total MOHEC budget for recurrent costs. 4.08 With regard to the VJH extension, the budget for FY1978-79 has no provision for recurrent costs. The MOHEC has been requested to take urgent action to provide recurrent costs (estimated to be about J$l million per year) for this purpose. The allocation would be for salaries for incremental staff, drugs and supplies and other operational expenditures, such as maintenance for the VJH extension. 1/ April 1 to March 31. - 31 - V. BANK PERFORMANCE 5.01 Between loan signing on June 18, 1970 and the closing date of March 31, 1977, the project was supervised by 20 Bank mission involving 107 man-days, or about 15 man-days per year. Since the closing date, the project was supervised three times together with the second project (12 man-days). The timing and staffing of the supervision missions have been coordinated with the main events of project implementation inasmuch as possible. Missions have also been complemented by visits from Government officials and members of consulting firms at Bank headquarters (Annex 8). 5.02 Bank assistance has been efficient in population and family program matters, but has been less successful in improving project management, in preventing mislocation of some RMCs and in avoiding delays in the construction of the VJH extension. Despite the participation of architects in 16 of the 20 missions and their sound recommendations to the Government, the construction of the VJH extension started 22 months behind schedule in January 1973 and was not yet fully completed as of June 30, 1978. The Bank should have stood firm with regard to: (a) the suitability of the relocation of RMCs; (b) prequalifica- tion of contractors; and (c) the decision to terminate the contractor's contract when it became obvious that he would not be able to complete construction satisfactorily in 1975. VI. CONCLUSIONS AND RECOMMENDATIONS 6.01 During the project implementation period, the CBR declined significantly from 34.4 per 1,000 in 1970 to 28.3 per 1,000 in 1977 notwithstanding that: (a) more women are now entering the fertile age group; (b) out-migration is no longer increasing; and (c) teenage pregnancy is still a problem. Furthermore, the National Family Planning Program of Jamaica recruited an average of 23,000 new acceptors annually through MOHEC facilities-- a cumulative total of 240,000 new acceptors. Several factors have contributed to this achievement: (a) in the rural areas recruitment was facilitated through the RMCs; (b) the revised curricula for training of midwives (including family planning) which has had a direct impact on the quality of delivery of family planning services implemented though the project has also contributed to this achievement; and (c) the impact of the VJH will further increase the number of acceptors in the Kingston area. While it is too soon to assess the impact of the second study which is to investigate the reallocation of certain functions performed by medical and paramedical personnel, this shift in duty performance is likely to permit increasing the number of health care services delivered without additional MOHEC annual recurrent expenditures. - 32 - 6.02 The project was implemented over a period of seven years instead of four and a half as forecast at appraisal. The delays were mainly caused by weak leadership in project management. 6.03 Specific responsibility for project management within the implementing agency should be stated in the legal documents as a special covenant. The organizational structure for project management including its staffing and functions should also be a condition of the loan at some appropriate stage, but not later than start of disbursement. Particular attention should be given to the administration of the hardware components of the project. Lines of responsibility should be clearly determined for: (a) approval of design at significant stages; (b) planning of physical implementation; (c) construction of the buildings financed under the project; (d) procurement of furniture and equipment; and (e) communication with the Bank, and in particular, the processing of withdrawal applications. 6.04 For the construction of project buildings, strict adherence should be paid to the criteria for the preselection of contractors at the bidding stage. During construction, project administration should have the power of decision, and not hesitate to bring the contract covenants into application if a contractor is not fullfilling his obligation. 6.05 Project implementation has shown that during project preparation, sufficient and careful attention should be given to: (a) location of health facilities; (b) quantities and types of health care services to be delivered for each facility; and (c) design adaptation of the facilities to the capacity of the local building industry. 6.06 The selection of locations and sites for health facilities should be made very carefully. The sites should: (a) be easily accessible to the population concerned; (b) permit extension; (c) be provided with ready access for ambulances; and ( ) have sufficient parking capacity. Errors in selection of locations for RMCs, which in most cases were a result of changing locations from those agreed during appraisal (and it appears that these changes were in some cases related to political rather than program reasons), have contributed to underutilization of some of the RMCs. In the future, once locations are appraised and agreed, any changes should be carefully reviewed from the point of view of population density, as well as physical accessibility for the popula- tion to be served. 6.07 Prior to design, health services to be delivered in each facility should be carefully studied to determine type, quantity and quality. During the design period, the degree of sophistication for building and mechanical installations should be adapted to the capability of the local building industry. - 33 - 6.08 Experience has shown that unipurpose facilities such as maternities in rural areas are not effective in motivating women either for institutional deliveries or for the postpartum family planning program. On the other hand, out-patient type general purpose facilities, such as health centers which provide all aspects of health care services including family planning, are widely accepted and better utilized, (especially by women) and therefore should be given careful consideration in the future. 6.09 Community outreach activities, specifically person-to-person contact, are widely accepted and very effective in motivating women to seek MCH/FP services and should continue to be expanded. 6.10 Based on the delays experienced in the construction and commissioning of the VJH extension, it is strongly recommended that this project be supervised through the end of 1980. 1 4 - ANNEX 1 JAMAICA FIRST POPULATION PROJECT--LOAN 690-JM VICTORIA JUBILEE HOSPITAL--XATERNITY BLOCK: SCHEDULE OF ACCOMMODATION Program Design Net Gross Net Nec Sa.Ft. Circulation Sq.Ft. Sq.Ft. Circulation Sq.FC. 'ard areas 21,840 10,920 (50%) 32,760 20,952 7,725 (36%) 28,677 Delivery suite 6,350 3,810 (60%) 10,160 6,300 3,035 (48%) 9,335 Pre-macure baby unit 2,370 1,422 (60%) 3,792 2,672 994 (38%) 3,666 School of midwifery 2,940 1,029 (35%) 3,969 2,948 1,374 (46%) 4,322 Services and support facilities (kitchen, administration and medi- cal officers' facilities 5,78 2,023 (35%) 7,803 _6,04 2,091 (35%) 8,195 TOTAL 19,204 (19%) 3 1 (39%) - -ANNEX -35 - JAMAICA FIRST POPULATION PROJECT--LCAN 690-JM RURAL MATERNITY CENTERS.: SCHEDULE OF ACCOMMODATION Schedule of Accommodation Square Feet 1. Clinic Delivery room 154.00 Labor and preparation 171.00 Scrup up 36.00 Sterilizing 32.50 Sterile store 32.50 Sluice 32.50 Bathroom 35.00 Subtotal 493.50 2. Ward Ward (4 beds) 378.00 Nursery 37.50 Patient's bathroom 37.50 Subtotal 453.00 3. Public Area Reception 94.50 Interview room 72.00 Demonstration 205.00 Waiting area 215.25 Consulting office 72.50 Examination room 72.50 Lavatory 47.50 Subtotal 779.25 4. Service Unit Kitchen 80.00 Kitchen store 24.00 Nurse's change and lavatory 59.50 Lavatory 31.50 Subtotal 195.00 5. Midwife Aoartment 322.00 Subtotal 2,242.50 Circulations (33% of 1-4) 637.75 TOTAL 2,380.50 Program approximacely 3,000.00 J/_t\ICI \FRST P:,Uli.' I' P. 'CT--LOJA 690-.J1M 2CI:E¿DU.LI OF CONS'RUC7lCN: rCtEC/ST AD ACL'UAL 1970 1971 1972 1973 1974 1975 1976 l971 978 1 34 3 41 2 34 1 2 3 4 1 2 3 4 2 3 4 1 4 2 33. .. k,1to-i a J lce ne tioapltall 1:L Kngston 1. Ntw motrnity wing Forecast A A P. C 1 E E E E F E E E Actual A A A A 1D B C 1) E K E E E E E E( b. E E E E E E E E E E E E 2. menodåling of exiating Lulldings Forecatt A A B C 1 E E E Actoal A A b b C 1< E E b. Contructioii of 10 aurpi mteriity Centern 3. ,4. 5. All centera Forecaat A A f CD E E E E 3. Elatr gr.p Actual A A A 1 C D E L E E Port orjni, l.ng Ut.y and Wood Park 4. Centrol group Actual A A A B C 0 E E L E F Elderuli, Robin .all, Newell 5. We,utorn gro.p Actuil A A A B C 1 k E E. E E Clak Towa , 1Dias, Cheater Castle mnd Hlopelon A - eketc, dal gn b - detalled dea$j;o und Lunder doeurienta C - Läase of Lender docinentd 1 - award of contract E - conälru<.t <n0 period (i lglual closoig date March 31, 1975, Clouing 1<te H rcli 31, 1977. - 37 - ANNEX 4 JAMAICA FIRST POPULATION PROJECT--LOAN 690-JM PHYSICAL IMPLEMENTATION TIMETABLE Forecast Completion Date Date Victoria Jubilee HosDital 1. Bank approval of architect's sketch design 6/15/70 5/26/71 2. Bank approval of architect's detailed designs and tender documents 11/15/70 1/2/72 3. Issue of tender documents 12/1/70 2/15/72 4. Award of contract 3/1/71 1/2/73 5. Start of construction 3/15/71 1/8/73 6. New wing ready for occupancy 3/1/73 10/31/78 7. Remodeling of existing building completed 9/15/73 11/30/78 Rural Maternity Centers 1. Bank approval of architect's sketch design 6/1/70 10/15/71 2. Bank approval of architect's detailed designs and tender documents 9/1/70 12/31/71 3. Issue of tender documents E 9/15/70 2/11/72 C "t w if It 4. Award of contract E 12/1/70 5/15/72 C " 5/4/72 W. " 11/1/72 5. Start of construction E 1/15/71 5/22/72 C " 5/15/72 W " 11/15/72 6. Completion of construction E 1/15/72 7/31/73 C " 10/31/73 w " 3/31/73 E = Eastern group = Port Morant, Long Bay and Wood Park C = Central group = Elders1ie, Robin Hall, Newell W = Western group = Clark Town, Dias, Chester Castle and Hopeton J2AMICA F:RST ?CPUTION PROJEC--LOAN 690-31 C .LCÅ3IVE ??LJ1C COST SLCARY ?ER CAT7ORY OF E.7E-DI-URÆ Ap?rasa.l nal Co st Cost Over-uns Lean Es: =: es_Scedue__ _s_ en s us$ s SS J$ LSS 1USS USS . : : : 267 320 298 358 (12%) 31 (.2) 38 300 78 Vlc:orla :u::lee -s:1:3l 1,250 1,500 2,560/1 2,560/1 (105%) 1,310 (91%) 1,i60 Rural '':r-1:: l,n:,±rs 166 320 ~2' 631 (97Z) 0 (7 31 Su'r:ca. 1,516 1,620 3,386 3,491 (iC4Z) 1,570 (23%) .,671 950 1,413 IIl. DC sul::c: 1:ez-san ? :zza-:. 217 260 373 425 (72%) 156 (63%) 165 Technical ass:s:rce 33 100 - - - -83/2 - -100/2 Subco:al 300 360 373 425 73 65 180 211 1V. inieres: aýc --::rChr on the '.aa 250 300 250 298 - - - 2 300 298 V. Cont:nc es 417 500 -417 - -500 270 TOTAL 2,750 3,300 4,007 4,372 (46%) 1,257/3 (39%)1,272/3 2,000 2.000 /I Esti*ates c f3na' .::-zu: jeeodeling of ex5s3cng building. /2 Tech-ica. ass.::ze :as : v SAID. /3 Differences .cs: cverun resul: from more avorable race of exchange. - 39 - AN',"IX 6 JAMAICA FIRST POPULATION PROJECT--LOAN 690-JMi SCHEDULE OF DISBURSEMENTS: FORECAST AND ACTUAL (USSOO0) Forecast Actual Accumulated Accumulated Disbursements Disbursements Disbursements Disbursements 1970 1st semester 2nd " 100 100 1971 1st " 2nd " 500 600 1972 1st 77 77 2nd " 550 1,150 48 125 1973 1st " 48 173 2nd " 550 1,700 195 368 1974 lAt " 330 698 2nd " 300 2,000 101 799 1975 1st " 269 1,068 2nd " 39 1,107 1976 1st " 480 1,587 2nd " 117 1,704 1977 1st " 296 2,000 2nd Closing Date March 31, 1975 March 31, 1977 Last disbursement made on May 20, 1977 - 40 - AfluEx 7 JAMAICA FIRST ?OPULATICN ?ROJEC---LOA4 690-JMH CONSTRUCTION COST: FORECAST AND ACTUAL (US000 and JSO0O) Appraisal Esti*ates Contract Amount Final Cost Conzingenc4es E.xcluded ConcinSencies included US$ is USs iS USS is Uss is I. VictorIa Jub'iee 4osci:al New =atermity uing 1,336 1,113 1,503 1,336 1,741 1,451 2,360/1 2,;60/= Remodeling of exising buildines 144 120 173 144 144 120 i50/, 225.z Subtotal 1,480 1,233 1,776 1,480 1,885 1,571 3,010 2,785 II. ural atermi:v C2::cers Eascern Group: ?or: "orant, :zcg 3ay acd wood ?srk 116 156 Cen:ral Group: :lderslie, ?.obins Ball and Newell 139 137 Wes:ern Group: Clark Tour., Dias Chester Castle and -*oec,,n 177 233 Subtotal ?06 255 367 306 518 432 631 526 TOTAL _186 1488 2.133 l,8 2,403 2,003 3 3,311 /1 estimate as of June 30, 1978. /2 remodeling has noc yet been undertaken. JAlAlCA lIRST pO'ULATION PROJECT--LOAN 690-jm SCIEDUI.E OF PIIOJECT* SUPERVISION #IISSIONS No. of Daye No. of Hembers Mai-Daye H.D. Eccmonet Populatiii Architect ComuuleatIanl Febtrsary 24-27, 1978 4 4 J,.ly 2-5, 1970 4 4 November 15-10, 1970 4 .2 6 I - April 25-29, 1971 5 2 10 14uvcmbe r 29 - ILcember 2, 1971 4 2 8 Hiay 30 - Jiune 2, 1972 4 14 .iiiic 11-14, 1972 4 2 6 likvebl,er 7-10, 1972 4 3 12 eua<rti<vy 6-10, 1973 4 3 8 Hamich 26-27, 1973 2 2 tlay 2) - June 11, 1973 14 14 Septe..mber 16-20, 1973 4 4 Oetul,et,8-il, 1973 4 4 Api11 29 - May 3, 1974 5 4 *l4 i 2 Ju,ly 22-27. 1914 5 l -5 cuary 24-21, 1975 4 2 Å8 Jiun 2-7 1975 5 2 s k) Apiil 24, 1976 1 1 Al .Aug%eut 22-27, 1976 5 2 *10 1 February 27 - MIarcih 5, 1977 7 3 *21 September 26-30, 1977 4 2 *8 April 3-7, 1978 4 1 A4 Junte 20-28, 1978 9 3 *24 1 I OTA. 201 7 3 10 19 3 Ut wlicl firat populaLion project 119 m"ccood populiatin project 72 *Siice April 29, 1974 tha SPN mIentonsa have concetned the fir.t a..d second projbctø. 2Monongo Bo 3 6A 5 4 9 MoMotongu A Diopensasiesa MA 970 RIVER sfÞ7 M., Pe.,TO Old H.,rb..r PROPOSED RURAL MATERNITY CENTERS5 + Port Morant 2 Lang Boy . 3 Hopeton 4 Friendship 5 Green Island ß 6 Glorks Town 7 Mountoinside 8 Elderslie 9 Malton 10 Wood Park10 $ 0 10 20 30 40JA IC EXISTING FACILITIES (Dec. 1969) K 1 L 0 m c T E: R S a Hospitals POPULATION PROJECT 9 Health Centers 0 5 0 to 20 A Dispenscriesms MAY 1970 IBRD 2798R