India - Population Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 3748 PROJECT PERFORMANCE AUDIT REPORT INDIA FIRST POPULATION PROJECT (CREDIT 312-IN) December 31, 1981 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. GLOSSARY Annual Growth Rate Rate at which a population is increasing (or decreasing) in a given year due to natural increase and net migration expressed as a percentage of the base population. Fertility Actual reproductive performance of an individual, a couple, or a population. Infant Mortality The number of deaths of infants under one year of age in a given year per 1,000 live births in that year. Mortality Total number of deaths per 1,000 popula- tion in a given year. Second Degreee Malnutrition Seventy-five to ninety percent of weight for height. Third Degree Malnutrition Sixty to seventy-four percent of weight for height. FOR OFFICIAL USE ONLY ACRONYMS AIIMS All India Institute of Medical Sciences ANM Auxiliary Nurse-Midwife ASCI Administrative Staff College of India, Hyderabad CBRI Central Building Research Institute CFTRI Central Food Technology Research Institute CFWB City Family Welfare Bureau CHW Community Health Worker CPWD Central Public Works Department DPS Development Policy Staff, IBRD (presently Development Economics Department) FCI Food Corporation of India FP Family Planning FPHA Family Planning/Maternal and Child Health GOI Government of India HFWTC Health and Family Welfare Training Center ICDS Integrated Child Development Services IDA International Development Association IEC Information, Education and Communication IIMA Indi4n Institute of Management, Ahmedabad IPP India Population Project IUD Intra-uterine Contraceptive Device LHV Lady Health Visitor MCH Maternal and Child Health MRW Multipurpose Health Worker MIES Management, Information and Evaluation System MO Medical Officer MOHFP Ministry of Health and Family Planning MPW Multipurpose Worker MSA Maternity and Sterilization Annex (District Hospitals) MSW Maternity and Sterilization Wing (Primary Health Centers) MTP Medical Termination of Pregnancy MTT Mobile Training Team NDO New Delhi Office NIN National Institute of Nutrition PC Population Center PCU Project Construction Unit PHC Primary Health Center PIU Project Implementation Unit PWD Public Works Department RFPTC Regional Family Planning and Training Center SAR Staff Appraisal Report SIDA Swedish International Development Authority UFWC Urban Family Welfare Center U.P. Uttar Pradesh EThi document has a restricted distribution and may be used by recipients only in the performance their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  PROJECT PERFORMANCE AUDIT REPORT INDXA FIRST POPULATION PROJECT (CREDIT 312-IN) TABLE OF CONTENTS Page No. Preface ..... ....... * .......................... i Basic Data Sheet ........ .............. . .... . . ...... . ... . ......... ii Highlights ........................................... .. . ........ iv PROJECT PERFORMANCE AUDIT MEMORANDUM I. S UMMARY.. .. *..........................*................. . II. FAMILY PLANNING AND MCH ................... * .............. 2 Impact of the lndia Population Project (IPP) on Performance of FP and MCH .....*....................... 2 Impact on Crude Birth Rate ........................ ...... 5 Balance of Various Methods of FP ......................... 5 Impact on Infant Mortality Rate ............00........... 6 Balance of FP and MCH ................................... 6 Demand for Services and IEC .............................. 7 II. NUTRITION COMPONENT ............ ..................... 8 Objectives and Characteristics ........................... 8 Popularity ..................................... . . . ... 8 Change in Nutritional Status of Children .........*....... 9 Change in MCH Performance and Acceptance of FP ........... 10 Nutrition Education ...................................... 10 Contents of Food Supplement .......................... 11 Weakness and Strength .................................... 11 IV. POPULATION CENTERS AND SUPPORTING INSTITUTES ............. 12 Justification .,........................................... 12 Dbjectives .................. 0.........*.... .... ....... 12 Functions ................................. o..... *.......... 13 Research .................................................. 14 MIES ..*... .......... ......... ... ........... .... *....... 15 Supporting Institutions ............. o ..................... 16 Dissemination of Knowledge ............................... 17 TABLE OF CONTENTS (Continued) Page No. V. SOCIO-CULTURAL OBSERVATIONS ........................ 18 Deliveries in Institutions ............................... 18 ANM ...................................................... 19 PHC Sub-Center Buildings ... ............. . ......... ... 20 Community Involvement ............... .............. 21 VI. CONCLUSIONS ....................... .. . ..... o.... o....... 22 Attachment: Comments from the Indian Institute of Management....... 23 PROJECT COMPLETION REPORT INTRODUCTION .............................. ..........*.... 27 I. PROJECT BACKGROUND .............. ........... * ........ .. 28 II. PROJECT MANAGEMENT AND COSTS **.************************ 33 III. IMPLEMENTATION PROCESS ................................. 39 IV. PROJECT RESULTS AND SUMMARY OF EXPERIENCE ....__......*** 61 V. COVENANTS AND THEIR FULFILLMENT .......................... 79 VI. ROLE OF THE BANK ............ ................ 80 VII. CONCLUSIONS AND RECOMMENDATIONS ......................... 81 Annex I - Charts I - II 84 Annex II - Tables 1 - 16 86 - i - PROJECT PERFORMANCE AUDIT REPORT INDIA FIRST POPULATION PROJECT (CREDIT 312-IN) I. PREFACE The First India Population Project (IPP) was an experimental demon- stration project implemented from May 17, 1973 to June 30, 1980 in selected districts of U.P. and Mysore (now Karnataka) states covering a population of some 20 million. IDA made available a credit of US$21.2 million and SIDA a grant of US$10.6 million to cover project costs. The project intended to test the efficacy of various program inputs and to evolve, through experimentation, ways and means of attaining better performance of the Indian national program to reduce the population growth rate. The national program, as formulated by the GOI, was not fully opera- tional due to shortage of necessary buildings, trained staff, equipment and other facilities. The main objective of the project was to provide all the necessary infrastructure and facilities in the selected districts. Additional inputs for an urban program, intensive rural program and supplementary nutri- tion program were provided to assess their impact on fertility decline. Population Centers in each of the two state capitals, Lucknow and Bengalore, were established. . They were supported by two management institutes--IIMA and ASCI. The Project Completion Report (PCR) prepared by the Population, Health and Nutrition (PHN) Department of the Bank provides a comprehensive account of the project Implementation process and evaluates the impact of all its inputs. This Audit Memorandum addresses only a few selected aspects of the project--those which are mostly "software" in nature. It is based on the PCR and other available literature related to the project as well as on the experience gained in an OED mission's visit to India from April 1 to April 21, 1981. The mission had discussions with a number of persons connected with the project at Delhi, Lucknow, Bangalore and Hyderabad and saw a few PHCs in project districts. On August 31, 1981 the draft report was sent to the Government, the two Management Institutes and SIDA for comments. Comments were received from the Indian Institute of Management and' are attached in Annex. No comments were received from SIDA or the Government. The assistance provided by the Government of India, the States of Uttar Pradesh and Karnataka, and the many officials and other individuals met during this mission is hereby gratefully acknowledged.  - ii - PROJECT PERFORMANCE AUDIT BASIC DATA SHEET INDIA FIRST POPULATION PROJECT (CREDIT 312-IN) KEY PROJECT DATA Appraisal Actual or Item Expectation Current Estimate Total Project Cost (US$ million) 31.8 31.8 Underrun or Overrun - 0 IDA Credit/SIDA Grant Amount (US$ million) - 31.8 Disbursed - 100% Date of Project Completion 06/30/78 03/31/80 Proportion Completed by Above Date 77% 100% Proportion of Time Overrun - 31% Cumulative Estimated and Actual Disbursements June 30 1973 1974 1975 1976 1977 1978 1979 1980 Appraisal Estimate 2.1 7.3 13.1 17.4 20.5 21.2 - - Actual - 0.6 3.7 8.2 12.7 16.3 19.5 21.2 Actual/Estimate (%) - 8.2 28.2 47.1 61.9 76.9 - - OTHER PROJECT DATA Original Acutal or Item Plan Revisions Current Estimate First Mention in Files 08/05/69 Government's Application 06/ /70 Negotiations 04/10/72 04/26/72 Board Approval 05/30/72 05/30/72 Credit Agreement Date 06/14/72 06/14/72 Effectiveness Date 10/17/72 02/01/73 05/19/73 Closing Date 06/30/78 06/30/79 05/21/80 Borrower Government of India Executing Agency State Governments of Mysore and Uttar Pradesh Fiscal Year of Borrower April 1 through March 31 Follow-on Project Name Second Population Project Credit Number, 981-IN Amount (US$ million) 46.0 Credit Agreement Date April 14, 1980 - iii - MISSION DATA Month/ No. of No. of Person Item Year Days Persons Days Reconnaissance 10/69 21 2 42 Preparation 04/70 5 1 5 Pre-Appraisal 7-8/70 39 8 255 Appraisal 7-8/71 17 6 85 Appraisal 10/71 24 a/a 168 Appraisal/Nutrition 01/72 9 5 36 Post-Appraisal 07/72 5 1 5 Supervision 11/72 55 2 10 Supervision 02/73 44 2 8 Supervision 7-8/73 7 2 14 Supervision 11/73 13 2 26 Supervision/Nutrition 1-2/74 16 1 16 Supervision 06/74 14 2 35 Supervision 06/74 13 5._a 35 Supervision 10/74 28 1 28 Supervision 01/75 3 1 3 Supervision 04/75 18 7 135 Supervision 9-10/75 13 1 13 Supervision 11/75 8 1 8 Supervision/Nutrition 01/76 8 4- 29 Supervision 04/76 19 4La 27 Supervision 08/76 4 1 4 Supervision 10/76 20 7._a 126 Supervision 07/78 3 1 3 Supervision 2-3/80 24 3_/ 72 Completion 07/80 14 3 42 COUNTRY EXCHANGE RATES Name of Currency (Abbreviation) Rupees (Rs.) Year: Exchange Rate: Appraisal Year Average (1971/72) US$1 = Rs 7.4 Intervening Years Average (1973/1980 US$1 = Rs 8.3 Completion Year Average (1979/80) US$1 = Rs 8.1 /a Plus SIDA representative. - iv - PROJECT PERFORMANCE AUDIT REPORT INDIA FIRST POPULATION PROJECT (CREDIT 312-IN) HIGHLIGHTS Concurrently with a special meeting of the Indian Consortium on the national family planning program in November 1969, the Government of India asked the bank for assistance. Concern at an annual growth rate of about 2.5% in the 1960's which took the 1971 population to 547 million, and an annual increment of about 12 million people prompted the request. In addition, there was a feeling that the performance of the national program was slowing down. One of the first Bank population missions to India in July 1970, recommended that a project be developed "to provide a framework for experi- mentation and orderly change." The resultant project documents were signed on June 14, 1972 and the project was declared effective on May 19, 1973, the delay resulting from difficulties in making senior staff appointments. The project was estimated to cost US$31.8 million and was fully financed by an IDA credit of US$21.2 million and a grant from the Swedish International Development Authority (SIDA) of US$10.6 million, for which IDA acted as executing agency. The objectives as stated in the appraisal report were to: complete the health infrastructure in six selected districts in Uttar Pradesh State and 5 selected districts in Mysore (subsequently re-named Karnataka) State, to Government of India (GOI) patterns, provide additional supplements and test alternative patterns; create two Population Centers to design a Manage- ment Information and Evaluation Systems (MIES), evaluate performance and recommend changes; and provide technical assistance. Overall, the project was well implemented, the two-year delay in the credit closing date being primarily to allow experimental projects to continue, as their implementation had coincided with a period of intensive family planning drives during the Emergency in India. Unfortunately, the project design failed to account satisfactorily for the time which would be necessary to make the physical and institutional inputs and to allow for adequate observation of the resultant performance outputs. The project foresaw that little demographic impact would be likely before 2000 but was over-optimistic on the time needed to achieve improved performance for the newly created facilities. Both Population Centers have been taken over by the respective state governments and will continue to moni- tor and evaluate family planning and maternal and child health performance in the selected districts. Even in the limited time available for observation, performance has been better in both states, by and large, than comparable - v - districts in the rest of the states, although the levels achieved have not, thus far, been significantly higher. Much of the experience of this project was incorporated in the (1980) Second India population project. The main lessons of this project are: - operational research is most valuable when closely linked with the program (PCR, paras. 4.02-4.05, and 4.06); - support to the program from outside agencies can be valuable (PCR, paras. 3.50, 3.51); - management training, per se, is not sufficient to improve manage- ment styles which must be the result of many interlocking fac- tors--administrative commitment, improved technical performance, improved facilities, as well as improved work programs (PCR, paras. 4.09-4.10); - to involve the community, considerable time is required (PCR, para. 4.11); - the use of mobile service delivery teams over wide areas (such as a project district) can lead to staffing difficulties (PCR, paras. 4.22 and 4.24); - the postpartum approach is probably best suited to an urban environment (PCR, paras. 4.16-4.17 and 4.21); - the project period is too short to allow definite evaluation of improved performance and project impact (PCR, paras. 4.44 and 4.49); - unnecessary confusion and time delays result from inadequately determined project organizational structures (PCR, paras. 2.01, 2.02 and 2.09); - inadequate phasing of complex inter-related activities leads to implementation and evaluation difficulties (PCR, paras. 1.14, 2.03, 3.01 and 3.48); - over-optimism in achieving results from a complex social project which included a substantial build-up of institutional and program infrastructure must be guarded against in project design (PCR, paras. 4.39 and 4.49); - establishment of a project organization with weak links to program administration tends to create a separate identity which could diminish project impact (PCR, para. 1.13--demand con- straints); and - inadequate local involvement in project generation can lead to implementation difficulties; PROJECT PERFORMANCE AUDIT MEMORANDUM INDIA FIRST POPULATION PROJECT (CREDIT 312-IN) I. SUMMARY1/ 1.01 Concurrently with a special meeting of the Indian Consortium on the national family planning program in November 1969, the Government of India asked the bank for assistance. Concern at an annual growth rate.of about 2.5% in the 1960's which took the 1971 population to 547 million, and an annual in- crement of about 12 million people, prompted the request. In addition, there was a feeling that the performance of the national program was slowing down. 1.02 One of the first Bank population missions to India in July 1970 recommended that a project be developed "to provide a framework for experi- mentation and orderly change." The resultant project documents were signed on June 14, 1972 and the project was declared effective on May 19, 1973, the delay resulting from difficulties in making senior staff appointments. The project was estimated to cost US$31.8 million and was fully financed by an IDA credit of US$21.2 million and a grant from the Swedish International Development Authority (SIDA) of US$10.6 million, for which IDA acted as executing agency. 1.03 The objectives as stated in the appraisal report were to: complete the health infrastructure in six selected districts in Uttar Pradesh State and five selected districts in Mysore (subsequently re-named Karnataka) State, to Government of India (GOI) patterns, provide additional supplements and test alternative patterns; create two Population Centers to design a Manage- ment Information and Evaluation System (MIES), evaluate performance and recommend changes; and provide technical assistance. The implied hypotheses to be tested in this experimental project were to see whether performance would improve if the GOI pattern was implemented and whether there were any alternatives to this pattern and the strategies then used for family planning. The project content included the provision of staff, construction of service facilities and the Population Centers, establishment of these Centers, staff training, and support for the creation of population units at two recognized management institutes. 1.04 Overall, the project was well implemented, the two-year delay in the credit closing date being primarily to allow experimental projects to continue, as their implementation had coincided with a period of intensive family planning drives during the Emergency in India. Initial delays were 1/ Adapted from PCR. -- 2 -- caused by the Government taking time to establish a satisfactory project organization which had been loosely exprssed in the appraisal report. The project documents envisaged the Population Centers and other implementation units as being apart from the ongoing program to provide objectivity. It became clear that these units could not be fully divorced from the program, but the relationships between the several project entities and betwseen them and the program took time, effort and patience to develop. 1.05 In the selected districts, staff and facilities were provided according to GOI patterns, and in urban areas and "intensive" districts, maternity facilities for a postpartum program were created. The two Popula- tion Centers were established with their own facilities and equipment, and undertook numerous monitoring and evaluation studies and surveys as well as designing a new service statistics system which included all aspects of health and not only family planning. The two management institutes provided support for the Population Centers and program administrators, developing, in particu- lar, very useful management training courses for program doctors. 1.06 Unfortunately, the project design failed to account satisfactorily for the time which would be necessary to make the physical and institutional inputs and to allow for adequate observation of the resultant performance outputs. The project foresaw that little demographic impact would be likely before 2000 but was over-optimistic on the time needed to achieve improved performance for the newly created facilities. Both Population Centers have been taken over by the respective state governments and will continue to monitor and evaluate family planning and maternal and child health performance in the selected districts. Even in the limited time available for observa- tion, performance has been better in both states, by and large, than compa- rable districts in the rest of the states, although the levels achieved have not, thus far, been significantly higher. 1.07 Much of the experience was incorporated in a recent India population project which became effective in 1980. In addition to attending to manage- ment and training, this project included an important motivation and communi- cations component; the first project had paid little attention to the demand for family planning and this was considered a major gap in its design. The second project is based on experience with the first, and is the basis for the Government's accelerated program of family planning and maternal and child health which is receiving substantial foreign assistance. II. FAMILY PLANNING AND MCH Impact of the India Population Project (IPP) on Performance of FP and MCH 2.01 The explicit objectives of IPP, as stated in the SAR, included the following three main elements: (a) completion of the health infrastructure and training facilities in the project areas in accordance with the GOI - 3 - pattern and provision of additional inputs in order to test alternatives to this pattern; (b) creation of two PCs with specific functions for improving the project performance; and (c) provision of the necessary technical assis- tance (PCR, para. 1.10). The PCR (para. 4.38) concludes that these objectives were generally fulfilled, but it (para. 1.10) correctly questions whether the evaluation of the project should be based on these formally stated objec- tives or on the following two implicit objectives: (a) to determine whether, given the facilities and staff required by the GOI pattern, improvement in performance (of FP and MCH) would result and (b) to determine whether there were any alternatives to the pattern and strategies employed at that time which would also improve performance. Although it is a bit too early to evaluate the project on the basis of its implicit objectives, a review of the relevant findings seems worthwhile. 2.02 The SAR (Annex 10) provides estimates of the expected number of acceptors of different methods of FP and of the expected number of births averted for each year from 1973 to 1999 in the project areas. These esti- mates, however, should not be used for the purpose of evaluation since they were based on some unrealistic assumptions (for example, the time schedule for completion of building facilities and recruitment of staff) and since they could not foresee the changes in the GO FP strategies during the Emer- gency and post-Emergency periods. The SAR does not provide any estimates of expected changes in the MCH performance. 2.03 The PCs did carry out a few studies which provide some data for this purpose. The following results are extracted mainly from the individual project completion reports prepared by each of the PCs. 2.04 Some estimates of equivalent sterilization rate per 1000 population, a comparable measure of performance, are available for the project and non- project districts of both U.P. and Karnataka. In U.P., although the rate was slightly lower in the project districts compared to matching non-project districts within the same division during the pre-project period of 1970-741/ the rate was consistently higher in the project districts for each year beginning from 1974-75. The difference increased gradually, and in 1979-80 the rate in the project districts was twice as high as in the non-project districts. During the 10-month period from April 1978 to January 1979, project districts (11% of state population) accounted for 17% of steriliza- tions, 19% of IUDs and 15% of other methods in the whole U.P. state--nearly 50% higher than non-project districts. 2.05 In Karnataka the equivalent sterilization rate in the project dis- tricts was virtually the same as in the whole state in 1973-74, but in sub- sequent years (up to 1979-80) the rate became higher in the project dis- tricts--although the difference remained small throughout. 1/ Although the IPP started in 1973, most of its inputs were not in position until 1974-75. 2.06 The MCH performance in U.P. has been measured by the following indices: (i) percentage of women registered for ante-natal services out of total of estimated number of pregnant women; (ii) percentage of deliveries conducted by trained staff out of total number of registered ante-natal cases; (iii) percentage of women receiving DT, iron and folic acid out of total number of currently married women aged 15-44 years; (iv) percentage of children receiving DPT, DT, vitamin A, iron and folic acid out of total number of children aged 0-4 years. The estimates of indices (i) and (ii) for the project districts of U.P. were lower than those in the matching non-project districts within the same division in 1974-75, but by 1977-78 the estimates for the project districts became more than twice as high as in the non-project districts. The Child Beneficiaries Index (iv) also increased sharply in project districts compared to non-project districts (in 1979-80 the estimate for project districts was four times higher). The Maternal Beneficiary Index (iii) was always higher in the project districts but the difference did not increase progressively, as it did for the other indices. 2.07 The MCH performance in Karnataka has been measured by a composite index called MCH Equivalent Rate (the sum of registered ante- and post-natal cases and twice the deliveries conducted by trained staff per 1000 popula- tion). These rates were estimated for 19 selected PHCs in the project dis- tricts and for 5 selected PHCs in non-project districts of Mysore Division. The rate increased in both project and non-project districts from 1972-73 to 1976-77, but, although it was higher in project districts in 1972-73, contrary to expectation, it was lower in project districts in 1976-77 (the latest year for which an estimate is available). 2.08 Despite the methodological deficiencies of the studies undertaken, and despite delays in establishing the required infrastructure (as detailed in the PCR), there is a clear indication that in terms of performance of both FP and MCH the project has had a reasonable impact in U.P. The comment made in the PCR (para. 4.45)--"Overall, the impact of the project has not been very significant in U.P. in terms of performance"--seems to be applicable to both the states and--in audit's view--applicable more to Karnataka than to U.P. One reason for the difference of project impact in the two states may be that since during the project period and even earlier the FP and health infrastructure in the whole State of Karnataka was always much better than in the U.P., the additional inputs in the project districts of Karnataka did not have as much impact as in U.P. In absolute terms the change in a few FP and MCH measures was greater in the project districts of Karnataka than in those of U.P., but it could have very well occurred without any project interven- tion. The performance in the whole State of Karnataka has always been better than in U.P. The comparative data available for the project and non-project districts in each state--whatever limitations they have--show a greater impact of the project in U.P. The results indicate that the investment in areas with relatively inferior level of infrastructure is more effective in improving the performance in FP and MCH. -5- Impact on Crude Birth Rite 2.09 Sample surveys carried out in the project districts of both U.P. and Karnataka show a decline in the crude birth rate during the duration of the IPP. The decline was much sharper in Karnataka. In the rural areas of the project districts of Karnataka the crude birth rate declined from 37 in 1975 to 28 in 1978. The decline in crude birth rate from 1974 to 1979-80 in the rural areas of ithree of the project districts in U.P. was as follows: 43 to 40 (Pratapgarh), 43 to 42 (Sultanpur) and 43 to 36 (Muzaffarnagar). 2.10 It is not possible to assess the specific contribution of the IPP to the decline of the crude birth rate due to two main reasons. Firstly, no comparable estimates of the crude birth rate are available for controlled districts. Secondly, the crude birth rate is affected considerably by factors other than acceptance of FP (for example, changes in the age at marriage which most probably occurred at a higher rate in Karnataka and which were not affected by the project inputs.) Balance of Various Methods of FP 2.11 Although theoretically the GOI advocates a cafeteria approach in its FP program, in practice sterilization has always been more emphasized than other methods. The tables in the SAR providing the expected number of births averted by different methods reflect the GOI pattern of emphasis on sterilization. They include the expected number of births to be averted by sterilization, IUD and condom but ignore oral pills and MTP. The OED mission got the impression from various sources in U.P. and Karnataka that the IPP concentrated too heavily on sterilization!/ (for example, the discus- sions in the PHC meetings were reported to be focused on the performance figures of sterilization and the merits of workers also mainly judged on the basis of these figures). The targets set for sterilization were, however, too high to be achieved, except during the Emergency period. 1/ PHN has commented that sterilization is still today an area of concen- tration, but was nuch stronger during project years, and the statement that "the IPP concentrated too heavily on sterilization" should be considered within the time perspective of the early 1970s when the IPP was prepared. This lack of historical perspective is further demon- strated by the criticism of having ignored oral contraceptives and MTPs in calculating births averted. The SAR is dated May 1972; at that time, oral contraceptives were not available to the India family planning program. The Medical termination of Pregnancy Act came into force only on April 1, 1972, and at that time no one could have foreseen which practitioners and which facilities would be licensed to perform MTPs. The audit still considers the point well-taken, since the alternatives were well-known to the Bank and in other parts of the world. - 6 - 2.12 The relatively higher performance of the MTP in the project dis- tricts of both the states compared to that in the non-project districts indicates that increasing numbers of Indian women would accept the MTP if adequate facilities were made available and information about these facilities communicated properly. The same is perhaps true for oral pills. The SAR (p. 9) mentioned that in the GOI program "pills are offered only in limited pilot projects" but the IPP, unfortunately, did not include any experimental design to test the feasibility of using pills as a major contraceptive device. Impact on Infant Mortality Rate 2.13 There are no data for Karnataka regarding the change in infant mortality rate. The available data for U.P. are too varied in nature to make any generalization. For example, during the period from 1974 to 1979-80 the infant mortality rate declined from 167 to 91 in rural Pratapgarh but, unex- pectedly, increased from 140 to 160 in rural Muzaffarnagar. The study made by the Lucknow PC does not provide adequate explanation for such a variation. 2.14 Improved ante-natal care of pregnant mothers and immunization of infants are the specific activities of the MCH component which should reduce the infant mortality rate. It has been mentioned above that in U.P. the performance in such activities improved more in project districts than in non-project districts. The percentage of pregnant women covered by ante-natal services changed from 4% in 1974-75 to 24% in 1977-78 in project districts, while the corresponding figures for the matching non-project districts in the same division were 7% and 11% respectively. The percentage of children aged 0-5 years receiving DPT immunization changed from 1% in 1974-75 to 7% in 1977-78 in project districts, while the corresponding percentages for the matching non-project districts in the same division were 1% and 5% respec- tively. The effect of DPT immunization on the infant mortality rate is not expected to be significant since even in 1977-78 only 7% of children were covered in the project districts. Moreover, according to a report (based on a sample survey in Karnataka) prepared by the ASCI at Hyderabad, 84% of the vaccines used for immunization were not potent. The improvement in the extent of ante-natal care service in the project districts--although not anything spectacular--could be expected to have some identifiable effect on infant mortality rate, particularly on the neonatal mortality rate, if the quality of the service was reasonably satisfactory. Unfortunately, however, there was no attempt by any PC to measure the change in these rates. Balance of FP and MCH 2.15 Although MCH activities constituted part of the program, it is obvious that there was a much greater emphasis on FP activities in project formulation as well as implementation. The objectives of the project--as stated in the SAR (p. ll)--included explicitly the provision of FP services and supplementary nutrition programs but did not mention anything about the MCH services. The provision of additional maternity beds in both rural and urban areas was, however, an important element of the IPP but they were - 7 - conceived primarily as facilitating the acceptance of post-partum FP. In the implementation process the MCH services were included but they were never given as much importance as the FP services. They were particularly neglected during the Emergency Period. Demand for Services and IEC 2.16 The SAR (p. 4 of Annex 3) noted that "the demand for family planning among the general population may be one of the most vital--and, presently, the most unexplored--areas for family planning action research" and that "a primary function of the PCs will be to study the demand, and to recommend pos- sible ways of increasing this demand." The PCs were expected to do research on "such topics as the motivations that determine the family size of high fertility couples; the present and potential effect of social structure (laws, customs, religious practices) on fertility, and most important, the barriers to acceptance of family planning services." The OED mission agrees with the view expressed in the PCR (para. 1.13) that "the PCs addressed these issues in some of their research work but did not, as the report anticipated, come up with plans for systematic attempts to influence the demand structure." The anticipation of the SAR was, however, somewhat unrealistic. The resources allocated to the PCs were inadequate to do extensive research on the complex economic, social and cultural issues related to fertility motivation, besides fulfilling their other action-cum-research obligations. Moreover, such research does not necessarily yield results useful for recommending practica- ble ways of increasing the demand for FP and MCH services. 2.17 An assumption that a strong IEC component will result in substan- tially increasing the demand for FP is made in the Model Plan prepared by the GOI for the Area Program, currently being carried out in 46 districts of 12 Indian states. It suggests that "the approach in the future has to be through higher levels of inter-personal contacts" and also recommends communication through other agencies and media, such as opinion leaders' camps, women's cooperatives, youth clubs, traditional entertainers' movies, educational institutions, etc. The OED mission found that the assumption about the efficacy of IEC in increasing the demand for services was based more on the personal experience of state and GOI officials rather than on scientific studies. Most probably it is a valid assumption, but the identification of the appropriate strategies of IEC in different situations (as distinct from the more complex questions of fertility motivation referred to in para. 2.16) and planning for their implementation in future projects could be done on firmer grounds if PCs would do more research regarding them. They had adequate resources to do so. 2.18 In both the SAR and the PCR, the importance of IEC is recognized with reference to the demand for FP services. It should be equally important, if not more, with reference to the demand for MCH services. Undoubtedly, all mothers are inherently motivated towards better health for their children and themselves. An effective information and education program regarding available MCH services can increase substantially the proportion of women and children who would use these services. - 8 - 2.19 Existing research findings in India are not adequate to establish the extent of unmet demand for FP services and the extent by which the exist- ing demand can be increased by IEC strategies. But a high level of illiter- acy, low standard of living, economic value of children in rural areas, high infant mortality rate and such other constraints certainly limit the total effective demand for FP services. The SAR (p. 10) made only a passing refer- ence to these constraints and assumed that if the FP program is pushed, "1measured by expenditures and inputs," there is "a possibility of substantial improvements within the existing demand structure." The SAR was prepared prior to the World Population Conference at Bucharest where there was an international consensus in denouncing such an assumption. However, there were already some social science research findings on Indian population issues which seriously questioned the assumption. A recognition of these findings would perhaps have led to the inclusion of some social development strategies (for example, women's cooperatives and provision of drinking water in rural areas) in the IPP. It would have surely made the project formulation and implementation much more complex but one important lesson learnt from the project is that there is no easy way to deal with the complex population issues of India. III. NUTRITION COMPONENT Objectives and Characteristics 3.01 The inclusion of the nutrition component was made at the initiative of the GOI. The two main objectives of the component, as stated in the SAR (p. 20), were: "(a) to determine the effect that the provision of nutrition will have on the acceptance of family planning service, both directly as an incentive and indirectly as a result of the effect that a decline in infant mortality can have on the desire for fewer children; and (b) to test the means of implementing nutrition programs." No estimate of the expected change in the acceptance of family planning service within any specific period of time was provided. 3.02 The main characteristics of the program were identified as follows: (a) it would cover. one "intensive district" (one ANM stationed for every 5000 people) in Karnataka but, in view of severe administrative and personnel constraints in U.P., it would cover only one block in that state; (b) it would provide supplementary processed food for women during the last three months of pregnancy, women in the first six weeks of lactation and infants aged 6-24 months; (c) women would come to collect their weekly food supply from additional ANMs recruited for the program. Popularity 3.03 In U.P. the nutrition program became fully operational in November 1975 in Dalmau block (Rae Bareli district) and realized a high proportion of its target population very quickly. By December 1975, 72% of eligible - 9 - children and 42% of eligible women were registered as actual recipients of the food supplement. The program was, however, terminated in July 1976 because of a GOI decision to select Dalmau block for the launching of an ICDS scheme which had an in-built nutrition component. It is difficult to under- stand why this particular block had to be included in the ICDS scheme. (The OED mission gathered that it would be extremely difficult to replicate the ICDS scheme widely because of its very heavy operational costs.) 3.04 In Karnataka the nutrition program became fully operational in Thalak block (Chitradurga district) during the last quarter of 1974. The 1975 review mission of the Bank estimated that almost all eligible children and 80%-90% of eligible women in Thalak block were covered. Change in Nutritional Status of Children 3.05 In U.P. a comparison of the results obtained from a baseline survey (October/November 1974) and a repeat survey (November 1975) indicate no measurable improvement in the nutritional status of child beneficiaries as compared to the children in a control area. The absence of nutritional impact on child beneficiaries was attributed mainly to the fact that the supplementary food given in the name of a child was very commonly shared by other members of his/her household. The take-home system of food distribution was not effective in improving the nutritional status of young children. 3.06 The nutritional surveys undertaken in Karnataka (methodologically deficient due to non-use of control groups) also indicated no discernible improvement in the nutritional status of child beneficiaries. The lack of improvement was primarily attributed, as in U.P., to widespread sharing of the food supplement within the household. It was found that only 30% of eligible children and 10% of eligible women consumed the supplement regularly and exclusively. 3.07 The GOI-IDA-SIDA review mission in October 1976 observed that the program would not reduce child mortality in a short period of five years and suggested that the distribution of food supplement in Karnataka should be restricted to children of FP acceptors (thus linking the program more directly to the project's FP objectives) and to severely malnourished children and their siblings, whether or not their parents were FP acceptors. Since January 1977 the project beneficiaries covered all children of these catego- ries who belonged to the age group 6 months-5 years. The survey conducted by the NIN in 1978 could not conclusively determine the nutritional impact of the revised distribution system because of its inherent methodological deficiency. Sharing of food with older children of the household was still very widespread and it was generally accepted that the revised pattern had also proven inef- fective for the children of FP acceptors. However, a study undertaken by Bangalore PC revealed significant improvement in the nutritional status of children suffering from different degrees of protein-calorie malnutrition. Also, incidence of diarrhea and respiratory diseases among them was signifi- cantly reduced although the relapse rates were thought to be quite high, especially among the poorest. - 10 - Change in MCH Performance and Acceptance of FP 3.08 According to the subjective accounts of the project staff, the MCH performance in Dalmau block in U.P. was consistently superior to other blocks in the project area (since the ANMs in Dalmau block had more rapport with eligible women through food distribution), but the positive effect on the MCR performance did not carry over into increased acceptance of FP. The 1976 GOI/IDA/SIDA review mission concluded that no indirect effect of the nutrition program on FP acceptance would be expected, because no perceptible reduction of child mortality could occur in the short time frame of the project. The direct effect of the nutrition program on FP acceptance, through increased contacts with ANMs, could not be evaluated because the operational phase of the U.P. nutrition program coincided with the intensive family planning drive of the Emergency period. 3.09 In Karnataka also there are subjective accounts of the superior MCH performance in the two blocks where nutrition programs were implemented in the first phase, but adequate service statistics or survey data are not available to support these accounts. The provision of food supplement for children of FP acceptors at the second phase of Karnataka nutrition program was widely understood as a direct incentive for the acceptance of FP but it was never ascertained whether this approach had any incentive value. The results obtained from an attitudinal survey indicated that the potential incentive value was low. (Only 2.5% of respondents stated their willingness to undergo sterilization in order to become eligible for the food supplement.) Nutrition Education 3.10 Nutrition education constituted a small part of the U.P. nutrition program. Its effect was not formally evaluated. 3.11 In Karnataka nutrition education gained much more importance than in U.P. When even the revised pattern of supplement distribution (introduced from January 1977) failed to show any improvement in the nutritional status of the beneficiaries, the Karnataka State government proposed in January 1978 that the nutrition education program be extended to all project districts and its impact evaluated. The high cost and non-replicability of the supple- mentary feeding program were also important considerations. The evaluation studies conducted subsequently showed limited but positive effect of nutrition education activities on nutrition awareness, knowledge and dietary practices. Since January 1979 the Nutrition Education and Demonstration Teams have been working in all five project districts of Karnataka, indicating another major revision of the nutrition component's. basic design. The OED mission was informed by Karnataka Health Department officials that there were plans to gradually extend the nutrition education scheme in all districts of the state. - 11 - Contents of Food Supplement 3.12 During the preparatory phase of the nutrition program in U.P. the "Balahar" type supplement, produced by the Food Corporation of India, was used. It contained maize and soy beans which do not grow locally and had low acceptability. Moreover, it had a low shelf-life. So it was replaced by "Pushtahar," a supplement developed by the NIN. It was entirely based on wheat and other foodstuff produced in the project area and hence readily acceptable. Also, it had an adequate shelf life. 3.13 The food supplement accepted in Karnataka was identical in composi- tion with the "Pushtahar". The high popularity of the supplement led the state government to introduce it in several nutrition programs in Karnataka for supplementary feeding of vulnerable groups and to establish, under UNICEF assistance, five units for its production. Weakness and Strength 3.14 One reason why the implementation of the nutrition component did not work out as expected in the SAR is that its design was not adapted 'to the existing social and fiscal realities. When members of more than 40% of the Indian rural households are reported to survive on calories less than the required minimum, It is unrealistic to presume that the food supplement provided for young children aged 6-24 months through a take-home distribution system would be consumed exclusively by them and not shared with other chil- dren. It.was also too optimistic to expect that an improvement of nutritional status of children would reduce the infant mortality significantly enough to affect the perception and childbearing motivation of the parents within the limited duration of the project. Even if the supplementary food distribu- tion scheme worked out well, it is very doubtful whether the scheme could be widely replicated because of its heavy cost. 3.15 The main objectives of the nutrition program were exploratory in nature. Successful exploration needs adequate mechanisms for evaluation. The monitoring system of the program and the surveys undertaken for its evaluation were not satisfactory. The routine statistics generated from operation of the program could rarely be used for any evaluation purpose. The data collected from surveys were also not very useful because often they did not cover any control areas along with the experimental areas. 3.16 Despite the weakness in the design of the nutrition component and of its evaluation, a few important lessons have been learnt. One important negative lesson is that the supplementary food distribution for young children through health infrastructure, although feasible, is not effective in terms of improving the nutritional status of the target group because of social and financial constraints. At the same time, an important positive lesson is that the health infrastructure can successfully carry out the responsibil- ity of nutrition education through mobile teams and the feeding of severely malnourished children, both of which may significantly contribute towards reduction of infant mortality. - 12 - IV. POPULATION CENTERS AND SUPPORTING INSTITUTES Justification 4.01 The proposal for establishing two PCs--at Lucknow (U.P.) and Bangalore (Karnataka)--was made originally by the Bank. It went through considerable modification before being accepted by the GOI and state govern- ments. The degree of autonomy suggested by the Bank would not fit in with the existing administrative structure of the state governments. 4.02 The PCs constituted a part of the IPP and had no guarantee of their existence on its expiry. The fact that the state governments of U.P. and Karnataka have decided to absorb the PCs in their respective family welfare programs on the expiry of the IPP bears a testimony to their effective performance. The Bangalore PC has been asked by the Andhra Pradesh government to provide assistance in connection with the Second population project of the Bank. It indicates the potential value of the PCs as regional resources. No other state government in India has an agency with similar objectives and functions, none is known to have a plan for establishing one in the near future. The demographic research units affiliated with universities and other academic institutions cannot serve similar functions. 4.03 Demographic and evaluation cells exist in many state governments, but their main function is to compile routine statistical data. Serious consideration was given to the proposal for upgrading these cells instead of establishing separate PCs for the project, but the final judgment was against it. The task of upgrading the existing demographic and evaluation cells to the present level of PCs would be more difficult than establishing the new PCs. Objectives 4.04 The main objective of the PCs, was stated in the SAR (p. 1 of Annex 3 of SAR and para. 3.35 of PCR) as follows: (a) "to respond to questions posed by administrators upon which program and policy decisions depend"; (b) "to organize a management information and evaluation system (MIES) that is relevant to the needs of the GOI and the States of Mysore (Karnataka) and Uttar Pradesh."; (c) "to work within the broad framework provided by the GOI Family Planning program, and to provide information which can be used in a construc- tive way to improve the program." 4.05 The second objective is actually a means to achieve the other two. It 'is difficult to evaluate how far the PCs responded to questions posed by administrators. Since the activities of the PCs were guided by the project - 13 - Governing Boards and Research Committees whose members were mostly high-level state administrators, it can be presumed that their research programs were tuned to the needs felt by the administrators, particularly those connected with the project. Quite appropriately, the PCs concentrated their efforts on the issues related to the project itself and, hence, were severely constrained by their limited resources to fulfill the third element of the objective, that is, to work within the broad framework provided by the GOI Family Plan- ning program. They, however, did organize a MIES system which has been accepted by the GOI as suitable for use on an all-India basis. Functions 4.06 The SAR delineated four different functions of the PCs in its text (p. 24, reproduced in para. 3.35 of PCR) and six different functions in its Annex 3 (pp. 1-6). The latter are more specific and can be abstracted as follows: (a) "Establish baseline fertility levels for the project areas..."; (b) "Develop the experimental design of the project"..."the Population Center will be responsible for designing in detail, initiating and evaluating the various experimental/demonstration projects"; (c) "Develop an effective monitoring system by revising and improving the present system of recording and reporting for the project area"; (d) "Investigation of the Family Planning Demand Structure"..."A primary function of the PCs will be to study the demand, and to recommend possible ways of increasing this demand"; (e) "Establish close working relationships with program administrators and workers" through "administrative training" and "communications"; (f) "In-service Training" and "Training of Program Personnel in Data Collection, Analysis and Evaluation." 4.07 The expectation that the newly established PCs could perform all the above functions adequately during the duration of the project (initially planned for five years, later extended by two years) was unrealistic. The difficulties and delays involved in recruitment of high-level scientific personnel, construction of buildings and establishment of collaborating arrangements with other agencies (government and non-government) were under- estimated. 4.08 India is in a favorable situation compared to other developing countries regarding the availability of highly qualified demographers but there are very few who would satisfy the qualifications prescribed for the Directors of PC: "a person experienced in research, management and the methodology of evaluation" ... "has a keen awareness of problems faced by - 14 - program administrators." Most of them would like to work in autonomous institutions and in metropolitan cities. Naturally, the filling of the positions of Director in both the PCs posed a problem not only at the initial phase of the project but also subsequently. Both the PCs had highly competent Directors for some periods of time, but their performance suffered consider- ably due to lack of consistently strong leadership. It is not easy to suggest how the Director's position could be made more attractive. Perhaps a greater degree of autonomy for the PCs and better incentives in the form of opportuni- ties for participation in relevant national and international activities would help. Research 4.09 The whole project was an experimental one. Hence research and evaluation had a very important role. The limitations of human resources and time at the disposal of the PCs were serious constraints against fulfil- ling this role adequately. As expected, they concentrated on various opera- tional aspects of the project and provided information, potentially useful for implementing the project. 4.10 The project permitted experimentation with additional inputs as well as in routine program operations. The Bangalore PC conducted studies to evaluate the effect of the following five alternative strategies at the PHC level: (1) involvement of voluntary organizations in the implementation of program; (2) application of new management principles; (3) improvement of technical.competence of medical and para-medical personnel; (4) entrusting the responsibility of achieving family planning targets to village-level function- aries; and (5) introduction of non-cash incentives in the program. The designs of the above studies benefited from a workshop in which Indian experts participated but since they became affected by the intensive drive of FP during the Emergency the findings were not conclusive. Nevertheless, the studies provided some important lessons. One of them is that it is not easy to identify feasible alternative strategies which can improve the current program substantially. 4.11 The OED mission could not make a thorough review of the research program of the PCs. However, a few weaknesses and gaps which have come to its notice are mentioned below: (a) Lack of properly designed baseline studies. It is true that the recruitment of staff for the PCs took an unexpectedly long time and the service components of the project had to be started before the PCs were ready to undertake baseline studies. But there are agencies in India which could be contracted to do the job. In U.P. a baseline survey of limited scope was contracted to a state government agency, but non-inclusion of matching non-project areas as control limited its value as a tool for evaluation. This is true of the longitudinal fertility study conducted in Karnataka by the Bangalore PC in 1975 and most of the nutritional studies conducted in Karnataka by the NIN at Hyderabad. In the SAR of the Second India population project (p. 30) baseline surveys have been included as an "important project activity." - 15 - (b) Relatively less emphasis on research in MCH service delivery and .its impact. This was perhaps a reflection of the greater emphasis on FP in the project formulation and implementation. The impact of the MCH services on the health of children and mothers can be determined more easily and is detectable in a shorter period of time than the impact of FP services on fertility. As mentioned earlier, no attempt has been made to evaluate the impact of the project activities on the mortality levels of newly-born children at various ages. (c) Insufficiency of Research on IEC strategies. Both the "Model Plan" of the GOI and the SAR of the Second India population project (pp.45 to 48) recommend a variety of IEC activities for increasing the demand for family welfare services. These recommendations were not made on the basis of research findings. The studies done by the PCs on IEC were inadequate. (d) Stress on Quantity rather than Quality. Although the PCs were different from university affiliated research institutions and were expected to do research which would yield results quickly enough to be of practical use to the administrators, they would have served their objectives better by paying more attention to the quality of the research. It would have needed a more stringent selection of research topics and allocation of more resources on the selected topics. 4.12 The following suggestions are made with a view to improving the quality of research carried out by the PCs: (a) Increased use of Indian social scientists as occasional consultants. The PCs can benefit by inviting social scientists from diverse institutions to assist them in the identification of important research issues and in research design. (b) Nomination of more research experts in the Research Committees. The existing Research Committees of the PCs consist mainly of administrative personnel. A higher representation of research experts will be helpful in formulating the research programs more efficiently. (c) Advanced training and international exposure for the staff members. Very little of the fund allotted for the purpose in the IPP was used. Such training and exposure not only can increase the efficiency of the members, they also can act as incentives for bright young persons to join the PCs. MIES 4.13 According to the SAR's assessment, "the need is to establish a Management-Information and Evaluation System (MIES) which will collect rele- vant program data more efficiently, link the analysis of performance data to cost and to data from research outside the program, undertake a continuous analysis that will respond to the need of the administration, and provide the organizational and technical conditions necessary for an independent evaluation of the program." The operational implications of the above state- ment are not very clear. Both the PCs approached the establishment of MIES as - 16 - an improved service statistics collection, evaluation and monitoring system. In Karnataka, the Bangalore PC took a leading role in the development of a MIES in collaboration with the ASCI but in U.P. the IIMA took the main responsibility for it. In both the states it was found that the existing system was too time-consuming and produced little information useful to the administrators. 4.14 After each state developed its own improved system, meetings, sponsored by the GOI, were held to review both the systems and to synthesize them. The outcome was the development of a common system for rural areas which has been accepted in principle for adoption in all the districts of U.P. and Karnataka and also recommended by the GOI for all-India adoption. The new system covers all aspects of health and FP delivery services. It is simple and provides for monitoring as well as feedback. It is also reported to be much less time-consuming but no study has been done to determine the extent of time saved. In any case, development of a more efficient service statistics system was definitely a positive outcome of the IPP. 4.15 The project did not pay much attention to improving the information system regarding the supply of material resources, such as vaccines, medi- cines, equipment and stationery. The effectiveness of service offered in the PHCs and sub-centers depends considerably on efficient management regard- ing the supply of materials. One small-scale study by the ASCI in a few PHCs of Karnataka project area revealed that 84% of vaccines used in these PHCs were not potent because of difficulties in transportation, storage, etc. The situation regarding the transportation and storage of vaccines has been subsequently improved. It is reported that the supply of printed forms and stationery was sometimes so short that the ANMs had to buy them from their own salary for keeping necessary records. The existing information system regarding material resources management needs considerable improvement. A different kind of MIES should be developed for the purpose. Supporting Institutions 4.16 The pre-appraisal mission of the IPP proposed the use of short-term and long-term foreign consultants for assisting the PCs, but at the suggestion of the GOI it was finally decided that the PCs should have a continuous form of collaborative consultancy relationship ("arranged marriage") with two prominent Indian management institutes. The Lucknow PC became associated with the IIMA and the Bangalore PC with ASCI. On the whole, these associations were fruitful. The project benefited from the management expertise of the institutes and the institutes developed their own population and health expertise so that they are more useful at present to the programs in these fields. 4.17 The functions of the consulting institutes, as defined in the SAR (p. 25 and Annex 3), were too ambitious. They included assisting the PCs in the design of research, undertaking specialized studies, training personnel in management techniques and assisting the Directors of the PCs in defining - 17 - detailed functions of the PCs. The actual main contributions of the consult- ing institutes were in management training and in the development of MIES. After careful studies of organizational structures of service delivery systems the institutes designed short-term courses for management training of medical officers at different levels and gave them to a number of batches. The usefulness of these courses has been recognized by both the state governments and the GOI. The management training has been incorporated by the U.P.govern- ment in the Second India population project. The Second project, however, has made the provision for a gradual takeover of the training responsibility by the Lucknow PC from the IIMA over a period of five years. On the basis of the IPP experience, the Karnataka government realized the, need for extending management training to the whole state but, in view of the limited capacity of the Bangalore PC and the ASCI, decided to rely on printed materials to a greater extent than ber-ore (based on prototypes developed by ASCI) and to place district-level medical officers in charge of the management training of medical officers under their jurisdiction. 4.18 The collaboration between government and non-government agencies is not a common practice in India. The contribution made by the two management institutes in the government-operated IPP has set a good precedent. It may, however, be questioned whether the "arranged marriage" type of relation- ship between the institutes and the state governments was the best possible arrangement or not. In view of the limited capacity of the two institutes for fulfilling the needs of PCs and in view of the availability of the needed expertise in other Indian agencies, it would perhaps be better to give respon- sibility to the two institutes mainly for management training, MIES and related studies and to allot funds to the PCs for hiring consultants according to their felt needs. Dissemination of Knowledge 4.19 The SAR (pp. 5-6 of Annex 5) emphasized that the results of studies done by the PCs and the two supporting institutes should be disseminated properly among the operational personnel, program administrators, policymakers and researchers. It,suggested the following media of communications: monthly newsletter, quarterly and biannual periodical, biannual research seminar/con- ference and research journal. All these media were not used, neither were they necessary and practicable. The monthly newsletters published by the PCs were the most publicized medium. The newsletters along with the occa- sional study reports and monographs represent a reasonably good amount of publications coming out of the IPP. It is difficult to evaluate how effec- tively they served their purpose and how far they influenced the proposals for the Second India population project. The OED mission found that the Andhra Pradesh State government officials responsible for the Second India population project in the state were not familiar with the publications of the PCs. 4.20 The newsletters published by the PCs mostly contain research papers prepared by the staff members and are larger in size (page number) than other publications of a similar nature. Perhaps they would serve their purpose - 18 - better if they contained only the summaries of the research papers and in- cluded program-related news abstracted from publications in India and abroad. Full research papers can be presented in appropriate seminars, workshops, etc., and sent for publication in relevant national or international journals (for example, Journal of Family Welfare and Studies in Family Planning). V. SOCIO-CULTURAL OBSERVATIONS 5.01 The formulation of any project directly affecting a large number of people and its successful implementation always need an awareness of the socio-cultural characteristics of the people involved. This is especially true for a project which aims at a change in the FP behavior, which is one of the most intimate and complex aspects of human behavior. An awareness of the socio-cultural factors relevant to various aspects of the project does not necessarily mean that they can be changed in favor of successful implemen- tation of the project, but it certainly helps in adapting the project in such a way as to make it more realistic and responsive to the people concerned. 5.02 As has been mentioned above, a certain amount of demand for FP (mainly sterilization) and MCH services in the project areas was assumed without any consideration of the socio-cultural factors affecting this demand. At least the SAR provides very little evidence of such consideration. Social science input in it is minimal. Perhaps a greater participation of social scientists familiar with population issues in the pre-appraisal and appraisal missions would have,made a difference. 5.03 The studies done by the PCs provide some indications of the socio- cultural dimensions related to various aspects of the project operation. A few of them are briefly described below. Deliveries in Institutions 5.04 As a part of the "Intensive Rural Program" in two districts of U.P. and two districts of Karnataka, it was decided to provide maternity-steril- ization wings with 24 beds in each (12 for maternity and 12 for sterilization) to ten selected PHCs in each state. The main purpose was to assess the extent to which the availability of facilities for institutionalized deliv- eries and sterilizations in rural areas would improve program performance. It was expected that rural women, like their urban counterparts, would prefer to give birth in institutions attended by trained medical and para-medical personnel rather than in their homes. The social and cultural constraints regarding the use of such institutions by rural women were not fully realized. 5.05 The bed occupancy rates in these wings remained quite low even after three/four years of their opening. In a study conducted by the Bangalore PC, it was found that the percentages of total yearly bed-days utilized in ten PHC wings in Karnataka were 30%, 41% and 36% in 1977-78, 1978-79 and 1979-80 - 19 - respectively. (The OED mission visited one PHC wing in Karnataka and one in U.P. in April, 1981; their bed occupancy rates on the days of the visit were only 25% and 13% respectively.) There are several reasons for under- utilization. Rural women are not motivated to give birth and stay in an institutional environment which cannot provide the support traditionally received by them at home from relatives and midwives. The wings do not provide regular meals because of problems regarding cost, varieties of taste, ritual pollution, etc. They are located in areas where the transportation facilities are usually very inadequate; so the relatives of the patients cannot visit as often as they desire. It is true that despite these con- straints the wings will perhaps be utilized up to their full capacity in the next two decades or so, but there are surely more effective alternative ways of providing health and family planning services in rural areas. A portion of the existing wings may be used as extension of out-patients' clinic and their beds may be open to all patients instead of restricting them to maternity and sterilization cases. (.ncidentally, the Model Plan of GOI regarding area programs provides for similar wings with ten beds (gradually rising up to 30 beds) to be attached to one upgraded PHC out of every four PHCs.) It, however, recommends upgrading of those PHCs which are located in a Taluka town or in a small urban area. (the bed occupancy rates in such PHC wings are expected to be reasonably high.) ANM 5.06 For a woman to live alone in a house located in a village where she has no relatives of her own is a very uncommon experience in India. Yet this is the pattern of living for most of the ANMs recruited for the IPP as well as for the GOI family welfare program. They are the grass-root level providers of services and the success of the project or program depends mostly on the efficacy of their performance. The project succeeded in bringing up the ANM: population ratio in the project area to the optimal level of GOI program (1:10,000) and in expanding their training facilities along with improvement in training curricula. The project documents provide ample statistical account of the performance of the ANMs but provide very little information about the social and cultural factors which might have hindered or facilitated their performance. 5.07 In U.P. there was a dearth of educated women willing to serve as ANM at the beginning of the project. So a large proportion (60-70%) of the posts of ANM in the project area was filled by women of Kerala State which has always had a surplus of trained nurses. The mother-tongue of Kerala women is Malayalam--a language very different from Hindi, the common language in U.P. A large proportion (perhaps vast majority) of nurses from Kerala are Chris- tians, while most people in U.P. are Hindus and Muslims. How well could a rural population (majority illiterate) be served by ANMs with language and religion different from its own? It seems, that language and religion created very little problem for ANMs in performing their medical duties. All of them learned minimal Hindi. The Keralite ANMs have earned a good reputation in U.P. regarding their efficiency and sincerity. For various other reasons, however, the state governnent made a policy of gradually increasing the proportion of U.P. women in the ANM cadre. As a result only 10-15% of ANMs in the project area were from outside the state at the end of the project. - 20 - 5.08 Besides language and religion there are other individual character- istics of ANMs which may militate against their social acceptance in the community they serve. It is not easy for young and unmarried ANMs (majority in the project area are, however, married) to persuade older and married women about the need for family planning and talk freely with them about various possible methods of family planning. Even when they are married, their family life is often disturbed because their husbands' means of live- lihood do not allow them to live together. The social, economic and psycho- logical problems associated with living alone--and not always in,safe loca- tion--are likely to affect their job performance. A systematic study of the problems faced by the ANMs in doing their duties will yield data useful in improving their recruitment procedure, training program, job specifications and overall performance. PHC Sub-Center Buildings 5.09 The construction of a large number of PHC sub-center buildings was a major part of the construction program of the IPP and accounted for a considerable share of the project budget. Each sub-center was designed in such a way that part of it could be used as a clinic and another part as a residence of the attached ANM. The buildings are made of bricks and mortar which are too expensive for average village dwellers in India to afford. The question may be raised whether it was necessary to spend a relatively large amount of money in constructing brick-and-mortar buildings instead of con- structing low-cost buildings with locally available materials generally used for rural housing. There are at least two reasons in favor of the latter. The high cost of brick-and-mortar buildings makes it extremely difficult to replicate them in non-project areas in the foreseeable future. The buildings made of local materials like mud and thatch are usually more comfortable in hot weather. Some would also perhaps argue that such buildings would be culturally more acceptable to the people. But one strong argument in favor of the brick-and-mortar buildings is that they are easier to maintain. The buildings made of less expensive materials need a higher maintenance cost if the maintenance is done through hired labor. 5.10 Studies made by the PCs indicate that the ANMs generally like to live in the newly constructed sub-center buildings. They live more comfort- ably in these buildings than in the rented ones. It is very difficult for them to get rented accommodation in villages. The sub-centers which lie outside the inhabited areas of the villages sometimes remain unoccupied because of lack of security and inconvenience. In the Second India population project the State governments of U.P. and Andhra Pradesh have been asked to build subcenters only in the inhabited areas of the villages. 5.11 The approved design of the sub-center buildings included a closed verandah. These verandahs have been found to be very useful as waiting space for the patients on clinic days. Indian rural women, particularly those with small children, are likely to be more comfortable sitting on a floor rather than on a bench or chair. (The Bangalore PC found out that some sub-center buildings in the Karnataka project area do not have verandahs.) - 21 - Community Involvement 5.12 A view often Expressed these days is that the success of FP program in developing countries depends primarily on the active involvement of local communities in it. The examples of such involvement commonly cited are those from China and Indonesia. The social and political structures in these countries tend to encourage a strong mobilization of local communities and to involve them in the implementation of policies decided at a national level. In India since independence efforts are being made to mobilize local communities through Panchayati Raj system, but the village-level community organizations know as panchayats are still quite limited, in their activities in most of the states. The involvement of the panchayats in the GOI program of family welfare has been minimal so far. The pre-appraisal and appraisal missions of the IPP did not consider the issue of community involvement. The Bangalore PC conducted a study to evaluate the effect of a particular strategy of community involvement but its results were inconclusive because of the intensive drive in FP during the Emergency. 5.13 The project demonstrated that even when the number of ANMs was sufficiently increased in the project area so that each one had to cover an average population of 10,000 compared to a much larger average in the non- project area, the ANMs would provide service only to a part of the popula- tion, mostly living in the vicinity of the sub-center. Some of the services expected from them can be easily provided by local midwives--known as dai--if they are given minimal training. The dais have been traditionally delivering babies in Indian villages and each village has one or more dai. To many villagers dais are more acceptable than the ANMs for delivery purposes. They represent a potential community resource which can be very effectively used in Indian FP and MCH programs. The Model Plan of the GOI and the Second India population project have provision for extensive training programs for dais and for making them involved in the program. 5.14 Another mechanism which has been recently adopted on an all-India basis for involving the community is to utilize the services of Community Health Volunteers (CHV). Under the GOI-sponsored CHV scheme the volunteers are selected by the communities for rendering part-time health services after a brief training at the local PHC. They get a small remuneration of Rs.50 per month and another Rs.50 worth of medicines per month for distribution. The ideas regarding involvement of local community members in the family welfare program are not direct outcomes of the IPP but the inadequacies of the project perhaps contributed to the decision of the GOI to expedite the imple- mentation of programs based on such ideas. 5.15 The minimum educational qualification for the ANMs in U.P. was raised from first seven classes of schooling to high school certificate on the ground that sufficient numbers of candidates with high school certificates were available. The change may have a negative effect on the performance. The requirement of a higher minimum educational qualification is likely to favor the recruitment of women who do not have the community roots and the special aptitude necessary for performing ANM's job satisfactorily. - 22 - VI. CONCLUSIONS 6.01 In the Board meeting of the Bank held on 30 May 1972 which approved the IPP, the following observation was made: "If this project does nothing more than prove that certain techniques and certain elements of the present program are unproductive, it will have accomplished a lot itself." The project could not identify ways and means by which the Indian national program of family welfare can attain a significantly better performance, but it did identify certain techniques and elements in the existing progrem, particularly in its management, training, monitoring and evaluation systems, which were unproductive and needed modification. 6.02 In the implementation phase of the project various steps were taken to study and modify the above systems. The effectiveness of the modified systems has not yet been fully demonstrated but the experience gained in the process has served as a catalyst for further experimentation in the family welfare program of India. It is exemplified by the six projects formulated on the basis of guidelines provided by the Model Plan of the GOI. These are being carried out at present in collaboration with the following agencies: World Bank (Andhra Pradesh and U.P.), DANIDA (Madhya Pradesh and Tamil Nadu), UNFPA (Bihar and Rajasthan), BODA (Orissa), USAID (Gujarat, Haryana, Himachal Pradesh, Maharashtra and Punjab). 6.03 The audit is in agreement with the view of the PCR that the project was largely implemented as designed and most of its covenants were fulfilled. There were, however, weaknesses in the design and delays in the execution of some components. Some of them could have been avoided if the state and dis- trict level staff had been more involved in the formulation of the project. The perception of family planning as a controversial issue during Emergency and post-Emergency periods affected the project implementation and its accom- plishments in various ways. 6.04 The project was designed in a period when both the GOI and the Bank were overly optimistic about the demand for family planning services in India and the efficacy of these services in reducing the birth rate. It was a supply-oriented project. There was very little in it to test how the demand for FP could be increased. The Model Plan of GOI has assumed that a strong IEC component in the project design would be useful in increasing the demand for services. Perhaps it would, but only to a limited extent. The demand for family planning depends primarily on economic, social and cultural circumstan- ces. The project was too limited in scope to influence or fully identify these circumstances. 6.05 The completion of infrastructure facilities required a considerable period of time. Hence it is still too early to expect any significant impact of the project inputs on fertility and mortality or on performance levels of FP and MCH services. The impact on fertility and mortality in any case can never be accurately assessed because of the absence of properly designed baseline surveys. - 23 - 6.06 The infrastructure facilities regarding FP and MCH have always been inferior in U.P. than in Karnataka. The comparative data available for the project and non-project districts, however, indicate that in terms of performance of both FP and MCH, the project had a greater impact in U.P. than in Karnataka. The inputs related to the project did not seem to have as much impact in Karnataka as in U.P. The- results justify the investment of greater resources in relatively deprived areas. 6.07 The design of the project was too heavily biased toward the method of sterilization. This is also true for the GOI program. In hindsight, it seems that the project should have tested the acceptability of non-terminal methods (particularly oral pills) through various strategies. 6.08 There was a much greater emphasis on FP than MCH in the project. The need for the integration of FP with health services (particularly MCH services) was not fully recognized. The experience of most developing coun- tries with low fertility level testifies that it can be achieved only after infant mortality level is reduced. Improvement in MCH services is not a sufficient but necessary condition for reducing infant mortality in India. 6.09 The design of the nutrition component was not adapted to the exist- ing social and fiscal realities. The food supplement provided for young children aged 6-24 months through a take-home distribution system could not demonstrate any improvement in their nutritional status mainly because the supplement was shared by other members of the household. It is also doubtful whether the scheme could be widely replicated because of its heavy cost. 6.10 The suggestion made by the GOI-IDA-SIDA review mission in October 1976 that the distribution of food supplement in Karnataka should be re- stricted to FP acceptors could not achieve its objectives. It did not seem to act as an incentive for acceptance of family planning. Neither did it lead to an improvement in the nutritional status of children although all children of age group 6 months-5 years were allotted food supplement. However, the sug- gestion of the mission regarding distribution of food supplement to severely malnourished children and their siblings proved to be useful. Also, the nutrition education scheme initiated by the Karnataka government in January 1978 had beneficial effect. The lessons learnt from the nutrition program are mainly inconclusive. One positive lesson is that the state health infrastruc- ture can successfully carry out the responsibility of nutrition education through mobile teams and the feeding of severely malnourished children.1/ 1/ PHN has commented that the component was the first of its kind, experi- mental in nature, and India, the Bank, and the international community have profited from its lessons, which were reflected later on in the design of Bank-financed nutrition projects. - 24 - 6.11 The establishment of PCs at Lucknow and Bangalore was an innovative idea. It is an institution-building contribution of the project. The PCs have been absorbed by the respective state governments and have the potential- ity of serving as regional centers. They could not fulfill all the functions specified in the SAR but with all the constraints regarding time and human resources they performed reasonably well. There were some weaknesses and gaps in their research programs. Some of them could have been avoided if the PCs had made an increased use of Indian social scientists as occasional consultants (besides using the experts of the two supporting management institutes) and if the funds allotted for the advance training of the PC staff would be utilized effectively. 6.12 A built-in design of a collaborative arrangement between the PCs and the supporting institutes (IIMA and ASCI) had some positive and negative effects. It has established a good precedent for fruitful collaboration between govermnent and non-government agencies. Another positive effect was the development of health and population expertise in these institutes. Also, the obligatory bond of "arranged marriage" relationship prevented a possible separation of the two partners at the initial phase when both were weak and unsure of what was expected of each other. The functions defined for the supporting institutes were too ambitious. Perhaps a contractual arrange- ment with them for assisting only in management training, MIES and related studies would have been more effective. 6.13 The project aimed at a change in FP behavior which is affected directly and indirectly by a large number of social and cultural factors. The utilization of services and facilities provided in the project often depended on the social and cultural characteristics of the beneficiaries as well as of providers of service. The project provided some examples of how a consideration of these characteristics could prevent underutilization of building capacity, increase the efficiency of grass-root level workers and help in mobilization of community participation. 6.14 The IPP is regarded as a useful project by the health and family welfare officials of the GOI and State governments of U.P. and Karnataka. It provided the basic ideas of the GOI Model Plan which has set a pattern for bilateral and international assistance in the areas of population and health in India. The Bank's role as an initiator in these areas is also recognized by the national and international donor agencies currently working in India under the Area Program of the Model Plan. Attachment - 25 - (page 1) INDIAN INSTITUTE OF MANAGEMENT eam Vastrapur, Ahmedabad-380015 AHMEDABAD Gram: INDINMAN Telex: 12 351 IIMA IN Phone: 450041 Dr. 3. K. Satia November 3, 1981 Mr. Shiv S Kaour Director Operations Evaluation Deoartment The World Bank 1818H Street, N.W Washington D.C.20433 U.S.A. Dear Mr. Kapur, Re: Project Performance Audit Reoort on India First Vonulation Project (Credit 312-IN) and your letter of Augubt 31, 1981. Thank you very much for sharing with me the first draft of the oroject nerformance audit reoort on India First Population Project supnorted by Credit 312-IN of 1972. The reoort is well written and covers the important aspects of the nroiect exoerience. I have only two minor comments: 1. no.25 oara 4.12 (a) I do not think that the management institutes affiliated with the PCs were exoested to orovide the necessary technical assistance in their total research program. Management institutes were to provide assistance in management related areas. The judgement that the capacity of the management institutes in this respect is quite limited based upon this ILmited exoerience is too sweeping and unwarranted. 2. on.41 oara 6.12, 8th line The relort reads - the main negative effect was that the arrangement constrained the PCs financially and otherwise to use other institutes or individuals as consultants. The arrangement did nt .constrain the PCs in seeking such assistance. Indeed the budgets of the PCs had a provision for such assistance. 2/- Attachment (page 2) - 26 - Once again, thanks for giving me an opportunity to comment on the draft recort. Ith best regards, Yours sincerely, (3.K.SATIA) - 27 - PROJECT COMPLETION REPORT INDIA: FIRST POPULATION PROJECT (CREDIT 312-IN) INTRODUCTION 1. The legal documents did not require the Borrower to produce a project completion report. Given the experimental nature of this project, attention was, however, being paid to its evaluation before its projected completion. In March 1980, a suggestion as to the outline of a project completion or evaluation report was made by a Bank mission. The result was the preparation of reports by each of the States, Uttar Pradesh (U.P.) and Karnataka. In July 1980, a mission assisted in reviewing these drafts and suggested how they might be finalized. By November 1980, the U.P. draft had been revised, that of Karnataka had not. Considerable and commendable efforts had been made to record and evaluate the implementation processes and the impacts of the project inputs. 2. The State reports remain in draft and have not been submitted to the GOI for consideration and the preparation of a covering report. In the meantime, the attached report has been prepared from available State drafts, information in Bank files and discussions with some of those involved in project implementation. - 28 - I. PPOJECT BACKGROUND A. Context of Project Formulation 1.01 In 1951, when the first post-independence census was taken, the population of India was assessed at 361 million. From the turn of the century it had increased by 50%; in the next 20 years, to the 'census of 1971, it increased by a further 50% to a total of 547 million. In 1901, the annual increment of people was less than 1-1/2 million; in 1971 it was about 12 million. Because of a rapid fall in mortality and constant fertility, the annual growth rate rose from 1.1% in the 1920's to nearly 2.5% in the 1960's. 1.02 The first Government family planning (FP) clinic in India was opened in the old Mysore State in 1930, and India was the first country to institute a national FP program in 1952. The national program made little progress, however, until it was reorganized in 1965. In 1964, the program reached only 708,000 acceptors; by 1967-68 this figure had risen to 3 million. The Fourth Five-Year Plan (1969-74) made provision for Rs.3,300 million for family planning compared with only Rs.2.7 million in the previous plan. 1.03 In 1968, the Government of India (GOI) asked the United Nations to make a second evaluation of its national program. The mission's interim report was usad as a background document for a discussion on FP at the annual Aid India Consortium meeting in May 1969. The mission considered that steri- lization performance had peaked at 1.8 million in 1967-68 as the succeeding year's performance dropped to 1.4 million. IUD insertions had peaked at 0.9 million in 1966-67 and dropped to 0.5 million in 1968-69. Particularly amongst the international donors, there was a feeling that India's PP program was slowing down. One of the interim report-s recommendations was that "...any programme which is to reach the Indian population effectively must be even larger than the present one." B. Process of Project Formulation 1.04 Against this background, the Consortium decided to hold a special meeting to discuss the Indian FP program in Stockholm in November 1969. In the meantime, the GOI's Ministry of Health and Family Planning (MOBFP) requested Bank assistance. To prepare for the November Consortium meeting, a mission from DPS visited India in October. It was also asked to form impressions about the possible form of Bank assistance and, in this context, considerable discussion took place with the Resident Mission (NDO). The resident staff suggested that a project should be focussed on one or more of the program's "intensive districts". 1.05 After the Consortium meeting, extensive discussions were.held with Dr. Ronald Freedman (the Bank's consultant on population matters). - 29 - These were motivated by a concern for the ineffectiveness of India program management. They largely concerned the elaboration of the idea of a Manage- ment-Information-EvaLuation-Syustem (MIES) including administrative units which later came to be known as Population Centers (PCs). The Population Projects Department las established only in November 1969, when a Director was appointed and much of the early preparatory work was undertaken by staff from DPS and the India Division. Pre-Appraisal 1.06 In July/August 1970, a pre-appraisal mission visited India. It prepared a two-volume report which was submitted to the GOI in December. The report concluded that FP "performance falls short of a solution of India's population problem" and recommended that, although the mission could not determine the reasons for the downward trend in performance, a project should be developed "to provide a framework for experimentation and orderly change." The project proposal comprised three elements: a. provision of FP services in: i. an urban program; ii. an optimal GOI program; and iii. an iitensive rural program; b. two Population Centers "to be primary responsible for the management-information system and training"; and c. physical facilities and equipment. Six districts in Uttar Pradesh State (Faizabad, Sultanpur, Pratapgarh, Lucknow, Muzaffarnagar and Saharanpur) and the five districts of the Bangalore Division of Mysore State (later renamed Karnataka) were selected. Before appraisal, Rae Bareli District was substituted for Faizabad District. The urban program was to be implemented in Lucknow and Bangalore cities. GOI View of Pre-Appraisal 1.07 The GOI view of the project as described in the pre-appraisal report was that, with modifications, it could provide the basis for a suitable project. The princi'pal points raised were: a. inclusion of a supplementary nutrition program in the project districts; b. no intensive programs in U.P. because a ratio of one Auxiliary Nurse Midwife (ANM) to 8000 people was ia- possible to attain due to a shortage of ANMs; - 30 - c. the director of the PC should not be senior to the State Director of Medical Services; d. the MIES system should be developed with the support of appropriate Indian agencies ("such as the Hyderabad Staff College or one of the Institutes of Management or the Indian Statistical Institute") and not by foreigners; and e. the idea of mobile teams was not welcomed. 1.08 There was an intensive dialogue between the GOI and the Bank on three major issues: a. the status of the PCs in relation to the State adminis- tration; b. the size and nature of the GOI's proposed nutrition component; and c. the training function of the PCs which the GOI wished to curtail to evaluation training only. Project Appraisal 1.09 The project was appraised in three stages. In July 1971, a mission visited India with the particular objective of developing the MIES concept. A second appraisal mission visited India in October 1971. A representative of the Swedish International Development Authority (SIDA) joined the mission as an observer to investigate the possibilities of joint IDA-SIDA financing. In January 1972, a third mission went to India to develop the nutrition component which the GOI had requested. The preparation effort which the Bank mounted can only be described as massive. In addition to the four major missions, there was considerable assistance from the resident staff. The major issue faced in Washington was the proposal to fund 100% of project costs, a proposal eventually accepted on the grounds that the project was experimental in nature. C. The Project 1.10 As set out in the appraisal report, the project's objectives were to: a. complete the health infrastructure, training facilities and equipment to implement the GOI pattern for family planning services in all the project areas; and provide additional inputs in some areas to supplement and test alternatives to this pattern, in particular, by linking the provision of family planning service to a supplementary - 31 - nutrition program, concentrating on recently-delivered mothers, greater use of mobile teams for motivation and service, and greater concentration on training and supervision, etc.; b. create two Population Centers, one in each State to design the MIES, evaluate performance on a continuous basis, recommend changes in the project area, and ensure that recommendations that emerge are speedily implemented; and c. provide the necessary technical assistance for the whole project, and finance for incremental recurrent costs to implement the experimental aspects of the above items." It may well be relevant to question whether these are objectives as such or whether they are means by which the objectives should be attained. The real objectives of the project appear to have been to determine whether: a. given the facilities and staff as required by the GOI pattern, improvements in FP performance would result; and whether b. there were any alternatives to the pattern and the program strategies employed at that time which would also improve performance. Project Content 1.11 The project comprised the following elements: a. family planning services in: i. an urban program in Bangalore and Lucknow providing 14 maternity homes with 30 beds each to give emphasis to a postpartum program; and ii. an optimal GOI program which brought staff and facilities to a level of 1 ANM to 10,000 people, family planning training and medical facilities for sterilization--maternity and sterili- zation annexes (MSA) to all district hospitals and, in addition nine sub-district hospitals in 20 maternity and sterilization wings (MSW) with 24 beds each attached to selected Primary Health Centers (PHCs) and three mobile teams in each district, one for motivation-education, one for family planning services and one for on-the-job training; b. training of ANMs and tutors by providing five new ANM schools in Karnataka and five new and three expanded schools in U.P.; - 32 - c. a nutrition component which was to be an experimental program covering the Chitradurga intensive district in Karnataka and one block in U.P.; d. the creation of two PCs, one in Lucknow and one in Bangalore to "further elaborate the experimental design of the project and implement, with technical assistance, the Management- Information and Evaluation System"; and e. support for two management institutions to build a demographic capability and, inter alia, "monitor the development of the Population Center." 1.12 In the context of population work in India and elsewhere in the late sixties and early seventies, the projects concentration on FP is understandable. To a great extent the project's content reflected the GOI's perception of a FP program, but did not take cognizance of the fact that FP services were integrated (as a GOI policy) organizationally, with those providing maternal and child health (MCH) services. As implementation proceeded the links became apparent and MCH work was not, in fact, neglected. Attention to this aspect of the national program during preparation might have reinforced the integration concept much earlier than half way through implementation. In the event, both MIESs covered all aspects of health services delivery in their final designs. 1.13 The project's content makes very little reference to demand con- straints, although one of the functions of the PCs was to investigate "the family planning demand structure" and the appraisal report discussed demand constraints in some detail. There appears to have been an implicit assumption in the project-s design that the national program's mass-media effort would support the service delivery aspects. A consultant specialist in Information, Education and Communications (IEC) took part in the preappraisal mission but there is little, if any, evidence of concern for this field in the pre-appraisal report; it is not mentioned in the discussion of the FP program and the report implicitly assumed away demand problems. An annex on motivational communication seems to have been deliberately ommitted from this report, the reason for which is not apparent. The PCs addressed the demand issue in some of their research work but did not, as the appraisal report anticipated, come up with plans for systematic attempts to influence the demand structure. The project design concentrated on the physical and staff aspects of the program and virtually ignored the motivation and communication aspects of the program. Provision was made for a motivation team in each of the four intensive districts but this failed, primarily because of administrative difficulties. 1.14 The project documents do not refer to a project completion date. In the President's Report (para. 18), reference is made to a five-year proqject; in Annex 3 p. 3 of that report, reference is made to the project running from 1972-78. There is no reference to timing in the Appraisal Report itself; many of the annexes refer to a five-year period. The con- struction implementation schedule for Mysore (Annex 8) shows an implemen- - 33 - tation perio4 of five years and for U.P. of six years; there are no im- plementation schedules for other components. The estimated disbursement schedule runs from FY 1972/73 to FY 1977/78 a total of six years. The credit closing date was to be June 30, 1978. Changes in Project Content 1.15 The project architect visited India in November 1972, to super- vise "the capital project" and the department director visited Delhi in February 1973, for discussions with GOI officials on project implementation. In the course of these several exchanges with the GOI, two amendments to Schedule 1 of the Joint Financing Agreement (project description) were agreed. In Mysore six of the 70 jeeps to be procured were substituted for six cars and in U.P. 10 cars were substituted for 10 of the 43 jeeps. In view of the organizational problems being faced in the implementation of the construction component and particularly the delays in building design studies, the Associa- tion agreed that 100 aub-centers in U.P. and 96 in Mysore could be constructed in accordance with existing designs. Additional civil works, comprising water supplies, fencing, staff quarters and accommodation for patients relatives, were sanctioned in 1978. LI. PROJECT MANAGEMENT AND COSTS A. Credit Effectiveness 2.01 The credit documents were signed on June 14, 1972, but the credit did not become effective until May 19, 1973. There were six conditions of credit effectiveness. The date of effectiveness was first postponed from October 17, 1972, to February 1, 1973, because the States had difficulty in finding project nutrition officers and PC directors. The latter posts proved very difficult to fill and a second postponement of the credit closing date became necessary to May 1, 1973, and a third to July 1, 1973. The GOI, however, advised the Bank on May 2, 1973, of the two appointments to the PCs and the credit was declared effective on May 19, 1973. B. Project Management 2.02 As envisaged in the appraisal report, responsibility for project management was to be vested in a Governing Board established in each State. In U.P., the Board, chaired by the Chief Secretary, consisted of 14 members with the Project Coordinator as Secretary. The Minister of Health was chairman of the Karnataka Board which had 10 members. The appraisal report had no project organizational charts, and was somewhat vague about the lines of authority of the various units and management posts which it created. It proposed that a Project Coordinator be appointed in the Office of the Secretary - 34 - of Health "as a post of liaison and coordination for the execution of the project in each State which woula be carried out by four groups." In each state, these groups consisted of: a. Project Family Plannirig Officer in the Directorate of Health Services, responsible for the family planning program; b. Nutrition Project Officer, also referred to as the Project Director (Nutrition), to be in the State Ministry of Health "responsible for the overall planning and evaluation of the program"; c. PC responsible for management information and evaluation; and d. Project Construction Unit headed by Superintending Engineer. 2.03 Inadequate attention to phasing the various components and their relationship to each other contributed to initial implementation problems. The only implementation schedules in the project documents related to con- struction activities. Too little account was taken of the time needed to develop institutional capabilities which had to be created from scratch. Little consideration seems to have been given to the time needed to put staff and facilities in place, or to establish a project organization to get implementation moving. As one example, the project expected returns in the form of tubectomies from the various facilities as early as 1973, when they were not due for completion until half-way through the fifth year in U.P. and until the end of the third year in Karnataka according to the construction implementation schedule. One possible reason for this lack of attention to the project as a whole appears to have been the way in which components were developed in semi-watertight compartments--construction, population centers, nutrition, etc. The construction component seems to have been handled almost independantly of other project elements. In illustration, the project architect in submitting a separate Back-to-Office report after the second appraisal mission noted that he had "assisted the IBRD mission"; the nutrition godowns (conceived during the nutrition appraisal mission in which there was no architect) were never included in the architect's work programs. 2.04 There seems to have been less than full understanding of the relation- ships between the Central and State Governments and of the way in which the Indian system of administration operates. This undoubtedly led to many of the delays at the inception of the project whilst Government officials tried to sort out the administrative pattern which would provide the most correct and profitable linkages between the units and between the project and the program. It created personal tensious and was the principal reason why the construction element of the project .did not take effect as appraised. [In this respect, the project design showed considerable lack of understanding and even in- sensitivity towards Indian culture and institutions.] In part perhaps - 35 - due to the lack of experience with India of project staff in the design stage, it also appears to be the result of "over-direction" by Bank staff, possibly insufficient discussion with program staff at district level during preparation, and a mixing of the preparation and appraisal phases of the project cycle. The last is, however, a particular difficulty of projects in the social sectors where Government capabilities appear less strongly developed than other sectors. 2.05 By establishing separate project units with their own hierarchy of Governing Boards, implementation was initially divorced from those who were running the prog:cam. The stress laid on the experimental nature of the project created an impression that project and program were linked only remotely. With the appointment of senior staff to the project coordinator's posts this attitude eventually dissipated and there was very close integration of project and program in the later years. Considerable discussion took place up to and including appraisal on this issue and a Bank consensus emerged that existing institutions, such as State demographic and evaluation cells, were too weak and low in status to be used. It left critical program units in a weak state, however, and their strengthening was undertaken by the second population project. 2.06 Another source of confusion arose because agencies external to the program were involved in project implementation only through their respon- sibility to a Governing Board with vague executive powers. The PC, for example, was seen as being able to determine how the FP program was faring and make recommendations to program administrators for changes of policies, strategies and inputs. The PC director was originally intended to be respon- sible to the Governing Board of which he was to be only a member. The implementation-of the construction component involved the use of two agencies in planning and supervision which were not responsible to the State admini- stration but only to the Governing Board. In essence, attempting to create a project organization which was to have an impact on a Government program and yet not be fully responsible to its administrators created suspicion and weak organizational linkages. 2.07 In both States the Project Coordinator eventually came to assume direct responsibility, rather than just a liaison function, for project implementation. 1/ About mid-1973, the Coordinators became Special Secretaries in the Secretary of Health's Office, a senior rank which greatly facilitated implementation. In U.P., the Coordinators were all drawn from the medical cadre; in Karnataka they were officers of the Indian Administrative Service (LAS) until 1976, when a senior medical officer was appointed. The heads of the three units, including the directors of the PCs, now functioned under the administrative control of the Coordinator. In 1976, a deputy project coordinator was appointed to assist the U.P. coordinator. Administratively, this local resolution of the vagueness of linkages worked well although it had two important consequences: firstly the PC did not have the indepen- 1/ Project organizational charts are shown in Annex 1. - 36 - dence anticipated in the appraisal report, and secondly, the creation of the section in the Secretary of Health's office initially tended towards a separation of project and program. Relatively frequent changes of senior staff exacerbated this situation. 2.08 After the credit was declared effective in May 1973, there was no in-depth supervision until a full supervision mission in April 1975 when project administration was reviewed and attention drawn to a "weak project administrative structure." By this time, the modified system had*become entrenched; as it responded to the realities of the situation, neither the Bank nor the GOI seemed averse to accepting it. 2.09 Each State appointed a steering committee to deal with the routine administration of the project. In U.P., it was headed by the Secretary, Medical Health at Family Planning and had five members. The Karnataka steering committee, headed by the Health Secretary' had four members. U.P. had a Research sub-committee of the Governing Board to review experimental and innovative designs prepared by the PC; Karnataka had a Technical Advisory Committee for essentially the same purpose. Each committee provided for GOI representation and the attendance of invitees including the Population Specia- list in the New Delhi Office. Meetings were held regularly and proved useful in expediting decisions. In Karnataka, decisions taken by the Governing Board were accepted as decisions taken by the State Government but in U.P. all decisions had to be followed up in the normal way through the bureaucracy. 2.10 Detailed proposals for the management of the "physical part" of the projects are contained in Annex IV of the project working papers. There are inconsistencies between this text and the appraisal report. The former notes that "coordination of the physical and financial elements of the entire project in planning, functional studies, design, execution and evaluation will require the appointment of a firm of Consultant Architects" which would be "a firm of the highest standing in India, appointed on the recommendation of the Chief Architect of the Central Public Works Department (CPWD) and the Indian Institute of Architects". The appraisal report, however, states that the State Architects were to be given total responsibility, with the Chief Archi- tect as consultant; this was the proposal which was followed. In addition, assurances were obtained from the GOI at negotiations that "a project planning research study would be executed of the functional, anthropometric, and environmental conditions necessary to ensure the satisfactory performance of the types of buildings to be constructed under the project." This study was to be undertaken by the Central Building Research Institute (CBRI) at Roorkee in U.P. 2.11 These proposals were based on four premises. Firstly, the number of widely dispersed facilities to be constructed was too large for each State PWD to handle routinely and a separate project construction unit (PCU) would be necessary; this was correct and the proposed PCU worked well in practice. Secondly, existing facilities were considered inadequate and new facilities would need more professional attention than would be normally available; this conclusion was also correct. Thirdly, the solution to the first two premises - 37 - lay in giving architects the leading role in project planning and implementa- tion; this was of dubious validity as the architect always plays a subordinate role to the engineer in Indian government construction programs. And fourthly, as a consequence of the third premise it was decided that the Chief Architect, CPWD, was to play a key role in the project's construction component; this was also of dubious validity as he is responsible only for the architecture of centrally financed schemes and has no authority and little direct influence over State Architects. 2.12 The overall proposals for the management of the project's civil works did not work out as planned. The Chief Architect, CPWD, did not act in the proposed consultancy role. Although considerable discussion took place with the 001, and although proposals to provide staff for him to carry out his project functions were made, the Chief Architect was most reluctant to become involved and by December 1973 seems to have successfully bowed out of project implementation. This situation appears to have been due to the original misconception as to his functions and failure by the MOHFP to involve him fully in project discussions and negotiations. 2.13 The position of the CBRI was also the subject of initial confusion until an agreement between the GOI and CBRI was signed on June 23, 1973. CBRI had, however, started work before the contract was signed, but by this stage, Karnataka had involved Its State Architect and proceeded with construction planning. U.P. had no Chief Architect and had already asked CBRI to act as such with regard to the project. The slowness in doing the required research and production of type designs led to the decision to allow the States to pro- ceed with construction of some sub-centers in accordance with existing designs. 2.14 Each State established PCUs headed by superintending engineers who were responsible to their respective Project Coordinators. Staff were seconded from State Public Works Departments but initial delays were caused by the reluctance of junior engineers to leave the PWD because it was perceived as an interruption of their careers. C. Reporting 2.15 Quarterly progress reports for both States started with the October- December quarter of 1973, three months after project effectiveness. Early reports were general and descriptive, lacking statistical details in recording progress, achievements, and costs. From one report to the next, there was inconsistency and incompleteness in the quantity and quality of data recorded, making it difficult to compile a complete set of data for any component. The Appraisal Report had no indications for standardization in reporting procedures. Even though requests were repeatedly made by supervision missions for a more systematic reporting system, there were few results for its improvements. In mid-1977, a series of proformas were developed by the MOHFP, in consultation with the States and the population specialist in the NDO, for quarterly reports. Once MOHFP program data were added they provided a satisfactory, - 38 - systematic base for quantitative reporting; the problem of providing qualita- tive reports was discussed subsequently on several occasions but no satis- factory solution emerged. All reports and correspondence from the States came through the GOI to the Bank; the protocol of dispatching quarterly reports was more complex and led inevitably to long delays in their availability in Washington. D. Project Costs and Disbursements 2.16 The total project cost, including contingencies, was appraised in May 1972, at Rs 231.5 million or US$31.8 million - equivalent. The project was fully financed by an IDA credit of US$21.2 million and a SIDA grant of US$10.6 million, for which IDA was the executing agency. Due to revaluation of the US dollar and Swedish Kroner, more Rupees became available. When the credit was closed on June 30, 1980, the credit and grant had been fully disbursed and the actual project cost was Rs 272.4 million, or 18% higher than the appraisal estimate. This, however, included additional civil works sanctioned by IDA and SIDA. 2.17 As the following table shows there were marked differences between appraised and actual expenditures in several categories.. Salary costs were about 150% above appraisal estimates, due mainly to lack of provision for engineers' salaries. Civil works were about 50% higher, due to the inclusion of additional works; the appraised estimates (including contingencies) were close to actual expenditures. As the nutrition component was not fully implemented there were savings in this category. Expenditures against the technical assistance category was very low because there was no overseas training and because of over-estimates in the professional fees for civil works consultancy. 2.18 By the original credit closing date of June 30, 1978, 77% of the IDA credit and Swedish grant had been disbursed. (See Annex II, Table 1). To the date of the first postponement on June 30, 1979, 92% of the proceeds had been disbursed. - 39 - INDIA: PROJECT COST BY EXPENDITURE CATEGORY (in thousand Rupees) As % of As appraised Actual Appraised Estimate Uttar Pradesh Karnataka Uttar Pradesh Karnataka Uttar Pradesh Karnataka (%) (%) Civil Works 53,285 38,435 78,098 58,285 147 152 Salaries 13,438 20,414 45,838 1/ 48,576 2/ 341 238 Vehicles 2,920 3,365 2,494 4,211 85 125 Equipment and Furniture 15,832 12,116 12,221 12,685 77 105 Technical Assistance 10,410 9,026 510 1,364 5 15 Nutrition 1,310 13,758 1,131 6,947 86 50 Unallocated 21,531 15,638 - - - - Subtotal 118,726 112,752 140,292 132,068 118 117 TOTAL 231,498 272,360 118 1/ Includes salaries for technical assistance construction unit. 2/ Includes salaries for technical assistance construction unit plus maintenance of facilities and vehicles. Source: State Project Completion Reports, June 1980. III. IMPLEMENTATION PROCESS 3.01 The project was designed to test the hypothesis that, given adequate resources to meet its infrastructural requirements, the performance of the FP program in the selected districts would improve. Concurrently, mechanisms were to be established to determine whether there were any modifications which would lead to program improvement. Before either could be achieved, five sets of discrete but closely related activities had to be completed. They were the: a. supplementation of physical facilities by a large civil works program; - 40 - b. procurement.of furniture, equipment and vehicles; c. provision of staff for existing and proposed facilities to GOI staffing levels, and the training of those staff; d. creation of institutions to carry out the monitoring, research and evaluation work, and to provide the required management consultancy expertise; and e. establishment of activities to implement the nutrition component. Implementation of the project demanded a high degree of coordination and posed inherent problems of the synchronization of the various activities. Its design did not take into account the need for clear phasing and its failure to identify an executive locus of project management provided a source of initial confusion. Once the project administrators had estab- lished the revised management pattern, these aspects were quickly identi- fied and planning and implementation proceeded more smoothly. This process, however, took about 18 months to 2 years. A. Civil Works Construction in U.P. 3.02 The PCU in U.P. was created in December 1972, with a Director of Works at its head, two Joint Directors (one Civil, one Electrical), and seven divisions, two in Lucknow and the remainder divided among each of the remaining five project districts. According to the Appraisal Report, 800 buildings were to be constructed, 645 of which were small sub-centers to be built mainly in remote rural areas. In the event, 779 buildings were constructed as 20 had been constructed by the PWD before the project started and others were combined as units of existing buildings. Additional work sanctioned by IDA and SIDA comprised two operating theatres, 8 patients' relatives sheds, 28 tubewells with overhead tanks, 69 staff quarters, access roads, and compound walls. 3.03 U.P. decided to start work on rural sub-centers as a priority and there was a three-month slippage from appraisal estimates. By the es- timated date of completion, however, only 90 sub-centers remained to be constructed but these took a further two years to complete. Major build- ings were started, in some cases, 2-1/2 years behind appraisal estimates. Overall construction in U.P. took 6-1/4 years compared with five years as estimated at appraisal. 3.04 The final cost of construction in U.P. was Rs 78.098 million, of which Rs 5.285 million was spent on additional works. The Appraisal Report estimate was Rs 53.285 million for construction and Rs 18.45 million for price and physical contingencies, a total of Rs 71.735 million. The - 41 - comparable expenditure of appraisal work carried out was Rs 72.813 million, equivalent to a cost overrun of Rs 1.078 million or 1.5%. Construction in Karnataka 3.05 The PCU in Karnataka was formed in February 1973, with a Super- intending Engineer as director, assisted by three Executive Engineers stationed in Bangalore, Kolar and Chitradurga respectively. Difficulties were encoun- tered with the secondment of State PWD staff, and local temporary staff had to be recruited to fill posts of assistant engineers, junior engineers and even clerks. The State Architect was provided with assistance from project funds to produce drawings and site plans. By March 1974, 546 of 694 sub-center sites had been procured, by March 1975, 680, and the remaining 14 were obtained within another 12 months. No difficulties were found with sites for major buildings. The 767 buildings listed in the Appraisal Report were completed with the exception of.eight nutrition godowns; in addition, 97 staff quarters, water supplies and compound walls, were constructed. 3.06 There was a six-month slippage in the start of the construction of sub-centers, compared with appraisal estimates, and by the scheduled end of construction, only 216 had been finished; the remainder were com- pleted in the next 27 months. The PC was started and completed on schedule but work on the major buildings was delayed up to two years compared with appraisal estimates. All facilities included at the appraisal stage were completed by mid-1977, having taken four years to construct compared with an appraisal estimate of 3-1/2 years. 3.07 The final cost of construction in Karnataka was Rs 58.285 million of which Rs 16.257 million was spent on additional works. The Appraisal Report estimate was R. 38.435 million for construction and Rs 8.408 million for price and physical. contingencies, a total of Rs 46.843 million. Expen- diture on civil works included at the appraisal stage was Rs 42.028 million, 90% of the estimate. Construction Problems 3.08 Problems with the civil works program common to both States con- cerned: a. Sites - it proved difficult to obtain suitable sites for many of the sub-centers, particularly in remote areas, where there was no State-owned land in the villages. As a result some (20-30% in Karnataka) sub-centers are sited on the outskirts of villages or in even more remote locations. This inhibited use by the community and resulted in ANMs refusing to live in the quarters, which are integrated with the clinic, because of the lack of security. Lack of compound walls led to encroachments and vandalism until they were provided under the additional works program; - 42 - b. Contractors - both States had difficulty in attracting contrac- tors to build small, remote facilities; many were undercapitalized and failed to complete their contracts. In Karnataka, of the 694 sub-centers, tendered contractors abandoned work on 115 , leading to the enforcement of penalty clauses; of these, 40 were completed by force-account and the remainder re-contracted; c. Shortages - of cement, steel, bricks and tarfelt; and d. Difficulties in Recruiting Staff - because of the temporary nature of the PCU. 3.09 Facilities were, however, well constructed but the "radical" design for facilities in U.P. which used pre-fabricated channel roofing has led to serious maintenance problems, such as leaking roofs and difficul- ties in keeping buildings clean. In Karnataka, well-tried construction techniques proved more suitable to rural construction. Both States report that glass windows for rural sub-centers are not suitable because they attract vandals and are difficult to replace; traditional wooden shutters are much more suitable. Maintenace of Facilities 3.10 There are no statements in the project documents with regard to the maintenance of buildings. This was a serious omission because of the pro- jected length of time between the completion of buildings and the end of the project when the State PWDs would assume maintenance responsibility. Money was made available in U.P. only in 1980, when some of the buildings were already five years old. Despite an order issued in June 1976, in Karnataka placing responsibility for the maintenance of completed buildings on the PWD, no work took place because no funds were provided in the PWD budget. In 1978, project funds were used for maintenance and Rs 1.135 million was spent. Evaluation of Facilities 3.11 Both Population Centers published reports on the effectiveness of project buildings. The U.P. study (Population Center Newsletter, Vol. 5, No. 2, April - June 1979) related to the perceptions of only 10 ANMs who had worked in the sub-center prior to the construction of a new building. Of the 10 new centers, 7 were adjacent to the old buildings, 2 within one kilometer of the village and 1 beyond 3 kilometers. Only 4 ANMs expressed satisfaction with their new quarters, the remainder thinking them too small. Four had lived in the sub-centers and six now lived in the new sub-centers. ANMs expressed dissatisfaction with poor maintenance, lack of electricty and/or water, and poor location (in three instances). Nine of the 10 ANMs perceived that their work performance had increased because the new facility had improved the ANM's image which had attracted more women. The one dissentient lived in a nearby town, continued to live there after a new sub-center was built, and, not surprisingly, noted no improvement in performance. Eight ANMs thought that village people were pleased with the new buildings whilst two - 43 - reported that villagers thought there was no need for a standard higher than their own kacha buildings. 3.12 In Karnataka, a sub-center utilization evaluation has been com- pleted, one for the evaluation of sterilization facilities is ongoing (as of November 1980) and one for PHCs is planned. The findings of the completed study are confined to the 100 sub-centers constructed in Bangalore district; one of these sub-centers had not been occupied by the Health Department and was vacant. Of the 99 buildings, 86 were found to be in good condition. Considerable problems were being experienced with the handpumps fitted to the bore wells, 56% being out of action and delays from 6 to 24 months for repairs being experienced. Eighty ANMs were living in the quarters provided, 10 were living elsewhere and 9 posts were vacant at the time of the survey. Reasons for non-residence included husbands working elsewhere, widows without support, village non-cooperation and lack of security. Accessibility is a problem--with the expansion of services, more remote areas are being served-- and of the 99 centers, 87 were more than 5 kilometers from the parent PHC where the supervisory doctor is stationed, and, of these, 16 were more than 25 kilometers away. Only 42 had pucca (tarred) approach roads; the remainder had only mud roads. Of 60 sub-centers, of which enquiries were made, only 40 had bus facilities. The problem of accessibility was demonstrated by the fact that medical officers dlid not, as they should, hold weekly clinics in 29 of the 98 sub-centers. Handover 3.13 Many buildings appear to have been taken over by the Health Depart- ments either before they were complete or in a poorly finished state. Building defects were seldom corrected once the hand-over took place. In future projects, the Health Department should establish handover criteria and seek the assistance of a construction agency not involved in the project to inspect buildings. Delays in maintenance aggravated this problem. B. Procurement 3.14 Procurement of furniture, equipment in packages of less than US$100,000, and vehicles, was to be on the basis of local competitive bid- ding. Contracts for equipment estimated to cost more than US$100,000 were to be procured by international competitive bidding. Neither the appraisal report nor working papers contain overall lists of equipment and furniture; lists of special equipment for PCs, mobile teams and Urban Family Welfare Centers are given in the appraisal report Table 3 A of Annex 4 for U.P. and Table 3B for Karnataka. Responsibility for selecting, ordering and delivering equipment and furniture is nowhere stated. Appraisal estimates for furniture and equipment were based on a flat 15% of construction costs. In U.P., the estimate was Rs 15.832 million compared to an actual cost of Rs 12.221 million, 77% of the appraisal estimate. The respective figures for Karnataka were Rs *12.116 million estimate and Rs 12.685 million actual, - 44 - equivalent to a cost overrun of Rs 569,000 or 5%. Both sets of figures exclude the nutrition component. The reason for the over-estimate in U.P. is not known. Vehicles 3.15 All project vehicles were procured locally, ensuring compatibility and the availability of spare parts. In U.P. the appraisal estimated cost of the 88 vehicles was Rs 2.92.million and in Karnataka for 111 vehicles the estimated cost was Rs 3.365 million. Expenditures are not strictly comparable as six cars were substituted for six jeeps in Karnataka and ten cars for ten jeeps in U.P. The final figures were Rs 2.494 million in U.P. and Rs 4.211 million in Karnataka. Because of the steep rise in petroleum prices during the project period, the original allowance of Re 1.674 million for petrol and maintenance was only half the Re 3.338 million eventually expended. C. Program Staff Requirements and Training 3.16 The training objectives of the project were addressed directly to shortages of field staff and the inadequate quality of their training which the appraisal report had identified as constraints on the delivery of family planning services. Training was also seen as a means for building up administrative capabilities. Uttar Pradesh 3.17 One of the objectives of the project was to provide one subcenter staffed by an ANM for every 10,000 people. By inference, no differentiation was made in U.P. between the urban areas, where a different service pattern existed, and rural areas which are served by subcenters; all areas with the exception of Lucknow City were regarded as rural. Table 4 of Annex 3, of the appraisal report, designed to show how many sub-centers should be built, is incomprehensible, as is Table 5 which purports to show how many ANMs will be required under the project. It is not possible to determine whether staffing patterns and training loads were adequately evaluated. 3.18 The project made provision for the construction of eight new ANM schools in U.P. where shortages of health personnel were particularly acute, as well as hostel accommodation for ANM field trainings at eight PRCs, near each of the ANM schools. The staffing of ANM schools was to be strengthened to GOI standards through short-term training to upgrade tutors already in position and through fellowship training for qualified nurse midwives. ANM schools to be established under the project were scheduled to function from 1974-75, but ANM training was, in fact, started in five rented buildings between March and September 1973, to advance the availability of ANMs. Of the eight ANM schools to be constructed, six became ready for occupancy in 1976, and two in 1979 (see Annex II, Table 3) The hostels for ANM field training at PHCs all became available by January 1976 (see Annex II, Table 4). Throughout - 45 - the project period, the utilisation of ANM schools was significantly above the planned annual intake of 30 trainees per school per year. The shortening of the ANM curriculum to a 1-1/2 year training course from September 1978, permitted a further increase of the schools' annual intake. This change implied, however, that PHC hostels, initially laid out for ten students, now had to accommodate 12-15 students at a time. 3.19 Due to timely sanctioning of the annual operating costs for the ANM schols, they were able to start functioning at an early stage of Ehe project. The additional tutors needed to staff the new facilities became available from the State's ongoing training program for Public Health Nurses. Additionally, 24 tutors already in post were sent for upgrading training at the College of Nursing, Delhi, or similar institutions, and returned to their posts in 1974 and 1975. From 1975 onwards, all ANM schools in the project operated on the strengthened GOI staffing pattern. Further improvements in the functioning and training programs of the ANM schools resulted from a series of annual review workshops for the administrators sud senior teaching staff, which were first introduced under the Project from 1978, and have since been adopted as a statewide practice. 3.20 From July 1975, a curriculum revision, based on a review by the Lucknow PC, was introduced in all ANM schools under the project. Family planning contents were expanded in the revised curriculum and integrated into the context of family welfare, especially antenatal and postnatal care. The PC also developed a manual on population and family planning, covering the ANMs functions in family planning. The curriculum revision was subsequently introduced into ANM training throughout the State, based on an evaluation of the revised curriculum conducted by the PC in October 1976. From September 1978 onward, U.P. introduced, statewide, the new 18-month curriculum developed for the training of female multipurpose health workers (MHWs) who replace ANMs under the GOI's MHW scheme. The new curriculum was more immediately relevant to the actual job functions of female basic health workers stationed at PHCs and sub-centers, and provided a better focus for the integration of family planning contents; the special emphasis on family planning was retained even within the shortened curriculum. Field training increased in importance under the new curriculum and was lengthened to six months, compared to three under the ANM scheme. 3.21 From FY 1973-74 to FY 1979-80, 1,657 ANMs graduated from the eight training schools unde:r the project, of which 504 were deployed in project districts for their first posting (see Annex II, Table 3). At the close of the project, ANMs in position at PR.Cs, sub-centers and other project facili- ties had increased to 1,016 in 1980 from 573 in 1973 (see Annex II, Table 5). On average, the rural population covered by an ANM stationed at a sub-center in the project area decreased to 12,295 in 1980 (1980 rural population) from about 21,000 in 1973 (1971 rural population) when the project started. As PHCs in rural areas also serve as a sub-center if one ANM from each of the 88 PHCs in the project area is included in the total of sub-center ANMs providing services to rural areas, the average rural population served by an ANM in 1980 (1980 rural population) decreases further to 11,070. The U.P. project's - 46 - target of providing one ANM per 10,000 population was, however, based on the 1971 census and using that population as a basis, the ratio would be 1:9494. Availability of trained paramedical staff did not represent a constraint for program operations since only 33% of ANMs graduated under the project were actually deployed in the project area for their first posting. 3.22 The status and professional recognition of ANMs improved considerably during the course of the project. Towards the end of the project only 10-15% of candidates for ANM training came from outside the State, whereas at the beginning of the project 60-70% of candidates had been recruited from Kerala; many of the more recent recruits are relations of ANMs already posted. Educational prequalifications were raised to High School Pass with the transi- tion to the MHW training curriculum and about one-third of all more recent candidates present themselves with a B.A. or intermediate degree. 3.23 The expanded and strengthened capacities for ANM training created in U.P. under the project have met the needs for this category of staff in project districts and have, in fact, made an even greater net contribution towards meeting requirements for ANMs in other areas of the State. With the recent adoption of an improved service standard, posting one female MHW for every 5,000 population, the training infrastructure created by the project will retain a crucial role. Equally important are the advances in the develop- ment of a more job-related curriculum, development of a family planning training manual, and reliance on internal reviews and performance evaluations to improve the ANM training program. These advances resulted from close and constructive collaboration between the PIU and the PC. 3.24 Incremental recruitment costs (salaries, student stipends, fellow- ships) for the ANM schools and hostels, reimbursable under the project are given in Annex II, Table 6. The total, Rs 7.683 million, is 2-1/2 times higher than the Appraisal estimate of Rs 3.066 million. Paramedical Training in Karnataka 3.25 According to the appraisal report, a total of 1,359 ANMs would be required for the project districts of whom 1,289 were in position in 1971. Here again, however, there appears confusion between those in post, sanctioned posts, and additional numbers required which makes evaluation difficult. The objective was generally to provide one sub-center for 10,000 people, but one for 5,000 people in two intensive districts, Chitradurga and Kolar. Due to the difficult terrain in Shimoga district a greater number of sub- centers was required there than the 1:10,000 ratio. 3.26 No additional schools were provided under the project but five existing ANM schools were provided with new buildings and with hostel facili- ties for field training practice at nearby PHCs. Handover of the ANM schools was completed by April 1977. Additional tutors were appointed to all schools to meet the GOI tutor/student ratio of 1:30. - 47 - 3.27 During the project period, 862 ANMs graduated from these schools against 1,050 expected (see Annex II, Table 7). The number cf ANMs in posi- tions at PHCs and SHCs in the project area increased from 740 in 1973 to 974 in 1980; in addition, 388 ANMs were in post in 1980 in other project facilities. For the five rural districts covered by the project, the ratio of population served by one ANM decreased on average from 1:9004 in 1973 to 1:8223 in 1980. The target coverage of one ANM per 5,000 was approximated in the two "intensive" districts, Chitradurga and Kolar, where the population covered by one ANM stood at 5,207 and 5,494 in 1980, respectively (see Annex II, Table 8). Numbers of ANMs in post continued, however, to fall short of requirements, as expressed by sanctioned posts. Against 1,604 ANM posts sanctioned for station- ing at subcenters upon completion of the project, only 974 ANMs were actually in post, either at PHCs or SHCs. In-Service Training in U.P. 3.28 In addition to ANM training, the project provided for inservice training. In U.P. a new building with hostel capacity for 48 students was built for the Regional Family Planning Training Center (RFPTC), later renamed Health and Family Welfare Training Center (HFWTC), established in 1960. The faculty was strengthened by the addition of one health educator, one extension educator and support staff. Average utilization of 206 training days annually was satisfactory. The: center continued to organize training courses for PHC medical officers, extension educators and FPHAs as well as short-term orienta- tion tfaining for other PHC staff, extension staff from other departments and private medical practitioners. With the introduction of the MHW scheme, the center became responsible for conversion-triining for designated MHWs, and for the training of community health workers (IWs), starting with educating trainers. Annex II, Table 9 provides an overview of the centers training workload for various categories of staff. A mobile training team, operated under the supervision of the HFWTC Principal, was introduced under the project in July 1974, to train PHC and sub-center staff under field conditions; it consisted of a medical officer, a health education instructor, an extension educator, and a public: health nurse. During six years of operation the team achieved more than full coverage of the family planning, paramedical and extension staff stationed at PHCs and SHCs in the project area, covering about 20 PHCs a year on average, for training periods of one week per PHC. Operat- ing costs for the HFWTC and its mobile training team are in Annex II, Table 6. The total, Rs 587,361 is approximately 2-1/3 times higher than the appraisal estimate of Rs 263,000. 3.29 The mobile training team was disbanded in March 1980, on completion of the project. An evaluation conducted after the first three years of operation showed that training remained theoretical and that the intended on-the-job training for problem solving could not be achieved in practice. PHC medical officers were not prepared to attend training sessions organized by a junior medical officer with much less field experience. Mobile team staff felt that they were not being compensated for the exceptional demands of their jobs and this resulted in high turnover. Suitable accommodation was difficult to find when touring, and travelling allowances were inadequate. - 48 - In-Service Training in Karnataka 3.30 In Karnataka, in-service training was supported by the construction of an annex, handed-over in August 1975, to the existing RFPTC in Bangalore. The annex provided additional accommodation for 20 trainees and facilitated the conduct of concurrent courses at the training center. During the project, the main function of the RFPTC was to train PHC medical officers and male and female health supervisors for their training and retraining roles resulting from the introduction of the MHW scheme. The Center also trained male basic health workers. Annex II, Table 10 provides an overview of the Center's training workload for various categories of staff. As the FP content of the ANM curriculum was limited, Karnataka decided that a mobile training team would become the principal tool to elaborate FP/MCH coverage. The mobile training team attached to the RFPTC became operational in the first year of the project to meet in-service training needs in the project districts. Priority was given to the training of ANMs, especially to ANMs posted in the two intensive districts, and to their immediate supervisors. A seven-day training course, reinforcing the technical contents of preservice training on family planning and MCH, and introducing skill training in field work and group motivation, was developed for this purpose; in Chitradurga, this was supplemented by a supplementary three-day course on nutrition, which was later extended to supervisors in the other project districts. The seven-day course was evaluated in 1979, and found to be meeting its objectives; an extension to 15 days was subsequently proposed and has been accepted in principle. For its post-project operation the mobile team was assigned to two divisions (i.e. twice the project area) and a second team was proposed to cover the rest of the State. Additional Institutional Training 3.31 In both States, additional workshops, seminars and orientation courses were organized for both State and district level staff. They were concerned with upgrading professional skills, improving the field organiza- tion, and provided a forum for field staff to exchange ideas and experiences. 3.32 The appraisal report (particularly Annex III, p. 16) makes much of training for the staff of PCs and affiliated (i.e., management) insti- tutes. The latter would need training in population dynamics but "the training requirements deemed essential to an effective performance by the senior level staff both at the PCs and the affiliated institute are basically the same." These requirements are nowhere.spelt out in detail, but there is emphasis on training abroad and "whatever the final program of training, all the senior level staff should undergo training at the same time and in one group." Travelling together for a four to six month period was envisaged. 3.33 Whatever was envisaged, never came to pass. As far as can be ascertained none of the staff of the PCs or affiliated institutes ever received formal training, either in India or abroad. The reasons for this are obscure. The proposals presupposed that staff would be appointed virtually at the same time, establish good working relationships almost immediately, and would be - 49 - free from project planning for four to six months. None of these conditions were met, and training was not perceived as a priority either by the GOI or the institutions. Recruitment problems and project management difficulties effectively precluded team training. Even when the PCs and affiliated insti- tutes had established their identity and credibility, no staff training was undertaken. This may have been atrributable to a GOI reluctance to sanction overseas training. Two overseas study tours were made by senior politicians, GOI and state staff, including representatives of the PCs and affiliated institutions. Their results are difficult to evaluate but they did provide an opportunity for senior staff to look at the national family planning programs in Indonesia, Malaysia, Thailand and Korea. D. Creation of Institutions Population Centers (PCs) 3.34 The creation of PC, one in each State, was one of the three project objectives. They were described in the appraisal report as "the most critical part of the project...which will further elaborate the experimental design of the project and implement, with technical assistance, the Management-Infor- mation and Evauation System". The genesis of the concept appears to have been in the advice given by a Bank consultant in April 1970, when he "emphasized that the Bank would need to build up a Unit to undertake studies in the project area and monitor the progress of the project". They were first referred to as PCs in the pre-appraisal report where they were given respon- sibility for developing the management-evaluation system and training. Their central function was to be a "continuous review in the broadest sense of the population trends and program of the selected districts". The PCs were to be closely linked with the Demographic and Evaluation Cells which are responsible for FP program monitoring and evaluation in each State. It was clearly conceived that the PCs would be outside Government, responsible only to a Governing Board and "have the administrative and financial control necessary to function effectively." The pre-appraisal mission's back-to-office report refers to "some reservation by the U.P. Health Ministry on the creation of any machinery which appears to duplicate existing government units in charge of similar functions. A separate evaluation cell would be acceptable, pro- vided such a cell would be concerned with research rather than with ongoing evaluation." "The Mynore Health Ministry was much more receptive to the idea of a separate population center in charge of the project areas." "Of particular importance is the reaction of the Central GO. Here the attitude of the Health Ministry was defensive...." The acceptability of the PCs of U.P. and Mysore was flagged as one of the principal issues when the pre-appraisal report was submitted (November 27, 1970). In reacting to the PC concept, the GOI made the following observations whilst accepting the concept in principle: - 50 - "the head of the Population Centers should not be of the rank of Director of Health Services [DHS] but could be a Joint Director who would be in a reporting relationship to the Director of Health Services. The Population Center will need considerable administrative back-up from the DRS and the relationship of equality is likely to hamper rather than help the working of the Population Center." 3.35 Phase I of appraisal in July 1971, was devoted mainly to the development of the PC concept discussions, but there was still a substantial divergence between the concept of the Centers as envisaged in the preappraisal report and the views of the GOI. Bank staff were convinced of the need for research which could provide a basis for program improvements. They felt that this required an organization reasonably independent of program operations, an independence which they also considered would allow recommendations for change to be implemented speedily and effectively. The PC was, therefore, to be a Chartered Body with an influential Governing Board with financial and admini- strative powers independent of Government. The GOI's initial view was that monitoring and evaluation activities should be undertaken by an augmented State Demographic and Evaluation Cell. In coming closer to the Bank's posi- tion, the.GOI still felt, however, that the PC Director should be responsible to the Health Secretary for day-to-day matters. After further discussion during the second phase of appraisal in October 1971, the GOI and the two States accepted the need for PCs as an organization based on the Bank-s views. 3.35 As described in the appraisal report, the PCs had the following objectives: a. "To respond to questions posed by administrators upon which program and policy decisions depend, and to provide information regarding changes in the supply system of demand structure which have implications for policy and program operations on a continuous basis; and b. To organize a management-information and evaluation system (MIES) that is relevant to the needs of the GOI and the States of Mysore and Uttar Pradesh. The objec- tive of the Population Center should be to work within the broad framework provided by the GOI Family Planning program, and to provide information which can be used in a constructive way to improve the program. This need not be done through a radical revision of the existing system; rather, a continuous flow of small but crucial program adjustments may be necessary -- a slight rearrangement of allocations here, a shift in personnel there, etc. Thus, the program will become a dynamic and continually developing one, responsive to the changing times, to the shifting demand structure, and to the factors which affect both supply and demand." - 51 - and functions: a. "The development of the overall experimental design in the project: area; b. The design in collaboration with those responsible for the program implementation, of a system of routine data collection and analysis with a feedback system to guide program operations and to measure its effec- tiveness in reducing fertility; c. The initiation of research, to be undertaken by the Population Center or to be subcontracted to appropriate agencies, directed primarily towards assessing existing program components and experimentation with new program elements; and d. Training of program personnel in data collection and analysis." Organizationally, the PC was to be separate from the administrative system and responsible only to the Governing Board which would "establish terms of employment and set appropriate scales of pay and allowances." The Director was not to be limited to parity of pay and allowances with FP program staff as his subordinates were. Details of staff positions, qualifications and salaries were set out in the appraisal report. Each PC was to have its own building, equipment and vehicles. 3.36 From discussions with those involved in project implementation, the relationship of-the PC and the MIES as stated in the appraisal report appears to have been misunderstood. This is in part due to the confusing way in which the subject is treated in the report. The MIES, it is said, will "collect relevant program data more efficiently, link the analysis of performance data to cost and to data from research outside the program, undertake a continuous analysis that will respond to the need of administrators, and provide the organizational and tachnical conditions necessary for an independent evalua- tion of the program." These are, however, functions which the PCs were to perform and, in the absence of discussion of its operational implications, the MIES could be viewed in three ways, either as: a. a service statistics system, gathering program and other relevant data; b. a management system; or c. a management system with a built-in capability for experimentation and the continuous adjustment of program patterns; or in any combination. The States regarded (a) as the MIES and seem not to have understood that (Q) was the original project concept. - 52-.- 3.37 It is open to question whether the basic concept of the MIES was properly understood and whether the PC concept was really accepted by the GOI and State Governments. The Indian authorities clearly had misgivings about the latter. Even if it was acceptable, were the organizational arrangements for the PCs adequate? The organizational problems result from the suspicion evinced by a bureaucracy while its performance is being monitored and evalu- ated by an external agency. Without insisting on the creation of a very high-powered, autonomous agency (such as the Demographic,and Research Center at Bombay, now the International Institute for Population Studie), would an external agency have had the necessary authority? The facts that the PC had to be established and achieve credibility and that it was seen as a temporary institution, "institutional for the life of the project, say three-five years....," also question whether the proposed authority could be achieved. Could an institution designed to develop a high degree of technical excellence do so on a short-term basis? 3.38 The PC directors became subordinate to the State project coordina- tors. Their appointment was one of the conditions of credit effectiveness which was delayed until May 1973, among other reasons, because of difficulties in making the initial appointment. These difficulties persisted throughout the life of the project. In U.P., the first director appointed never took up his post, allegedly because there were problems with his contract. A successor was appointed in July 1973, and held the post until July 1976. There was then a considerable hiatus, filled by the Project Coordinator acting as Director, until April 1978, when the last incumbent was appointed; he resigned in July 1980. In Karnataka, the first director resigned, for "family reasons", in August 1974, and a successor was not appointed until February 1975. In June 1978, he resigned to become Director of the International Institute for Population Studies in Bombay and the Project Coordinator acted as Director. One of the assistant directors was promoted director in July 1979. Inadequate definition of staff relationships and the temporary nature of the post were among the factors accounting for this disturbing situation. 3.39 In U.P. it took two years from July 1973, to staff the PC fully, and procure the necessary equipment and vehicles; the PC moved into its own building in April 1977. Staffing patterns followed the appraisal report with the addition of an Assistant Director (Communications) in 1976, and a Machine Operator. In Karnataka, the PC was established in April 1973, and the first director had laid its professional foundations before he left in August 1974. It was not until the new director assumed office in February 1975, however, that research and experimental strategies of the Karnataka project were developed. 3.40 Given the vagueness of the initial concept of the PCs and their relationship with the FP program, it is difficult to evaluate their performance in terms of their specific objectives. Clearly they did not attain the pre-eminence anticipated and play the expected role in reviewing and evaluating the program and in postulating changes. In time, they did respond to questions posed by administrators, but these were essentially within the confines of the project itself; their ability to "work within the broad framework provided by - 53 - the GOI Family Planning program, and to provide information which could be used in a constructive way to improve the program" as anticipated, was limited. The PCs certainly did "organize a MIES that is relevant to the needs of the GOI and the States of Mysore and Uttar Pradesh" in the sense of establishing an effective service statistics system. Neither of the PCs elaborated and refined "the broad experimental design of the project"; given the time taken to build up an institutional capability and lack of full understanding of the PC concept, this is understandable. 3.41 Although the PCs did not develop as anticipated, their role was, nevertheless, most important in project implementation, and, even in the form in which they developed, equally important for the program. Aside from their research work, the PCs brought to bear on program implementation within the project districts an operational evaluation aspect which had been previously weak in the program. The value of such a perspective has been accepted by both State Governments which each assumed responsibility for the PCs when the project ended, rather than allowing them to become GOI institutions. Their impact on each of the State programs is now developing, and some results are seen in the national program as well. Many of the results of the work of the PCs are reflected ir. the second population project. 3.42 Both PCs responded to the appraisal report's concern to communicate the results of studies and experimental programs. Each PC published a monthly newsletter from January 1975 (Karnataka) and March 1975 (U.P.). In addition, study reports were published with commendable promptness by both PCs. The PC in Karnataka also published two monographs in an "Occasional Papers" series. Both PCs also played a critical role in project evaluation and were responsible for editing the respective State completion report drafts. Supporting Institutes 3.43 The report of the pre-appraisal mission makes no mention of insti- tutes to provide technical assistance to the PCs; long-term and short-term (foreign) advisors were suggested as a source of expertise. The GOI-s response to this was to propose that the MIES "should be developed by an appropriate Indian agency, such as the Hyderabad Staff College (ASCI) or one of the Institutes of Managiament--Selection of one such agency as a prime consultant, so to say, should be the first step--." This proposal was reviewed by the Phase I appraisal mission which identified the ASCI and the Indian Institute of Management at Ahmedabad (IIMA) as supporting institutes, both of which needed "strengthening in the population area." 3.44 Each institute was to create a population unit with two to three staff as its nucleus, and draw on other faculty members as appropriate. Project funds were provided for this purpose and were disbursed by the GOI. Each State was provided with project funds to retain an institution--IIMA for U.P., and ASCI for Karnataka--to assist their respective PCs in carrying out the following functions: - 54 - a. Monitor the development of the Population Center and assist its Director in defining the detailed functions of that institution in the light of its objectives. This may include deputizing persons to work at the center for varying periods of time; b. Assist in the design of initial research needed as a first priority (fertility and family planning knowledge, attitude, and practice surveys in each project area); c. Undertake specialized studies for the Population Center at the request of its Director; d. Train personnel of the Population Center, as well as administrators in charge of program implementation, in management techniques through 2-3 month courses; and e. Lay the groundwork for the possible development of similar centers in other States by creating an awareness among administrators in these States of the importance of manage- ment techniques through special training courses. Agreement between the States and their respective institutions were to be signed within 60 days after credit effectiveness, after consultation with the Association. Functions and responsibilities were detailed in Schedule 3 of each of the State Agreements. After consultation, Agreements were signed between U.P. and AIIMS, and between Karnataka and ASCI in January 1974. The Bank had taken the line that the nature of the consultancy should not be the tendering of advice at one time only but a continuous form of collaborative consultancy. For this reason, Agreements were made for the duration of the project, a*form of association which came to be known as an "arranged marriage". 3.45 Each of the supporting institutes approached its obligations in a different way, attempting to solve a problem inherent in the project design of simultaneously establishing institutions which were supposed to assist other institutions being established at the same time. Neither institutions had any major previous experience with Government in the social sector and needed to build not only a new capability but also credibility with a suspicious admini- stration. Both supporting institutions took a considerable time to obtain and retain good staff; recruitment was, and still is, a major problem for their population units. In addition to the problem of adapting institutional strengths to deal with Government, was the need for newly recruited staff to settle into institutional procedures. Yet, the supporting institutes were expected to give advice and consult with their respective State immediately on the signing of the Agreements. Another questionable initial assumption was the emphasis on the need for demographic expertise in the supporting institutions as if demography was the only technology for family planning management. The advisability of the "arranged marriage" was questioned in the early years of project implementation, but it is probable that, given the initial problems, - 55 - one or other of the palcties to the Agreement would well have walked out of any less binding arrangement, and this held the collaborative consultancy idea together in the early stages. 3.46 It is difficult to assess to what extent the relationship was collaborative. In the first year or so, few studies were really collabora- tive. Neither was the relationship strictly a consultancy as there were not the time pressures or the strict costing and timing; funds were assured and the requests for advice frequently not clearly expressed. The relationship could be described as that of supplementing rather than supporting the PCs. 3.47 The supporting institutes were originally conceived as assisting the PCs in their anticipated role of being associated closely with but not actually part of the national program. As the PCs became subordinate to the Project Coordinators, the tensions involved in this process complicated the task of the supporting institutes to establi3h rapport and credibility with them. However, this meant that the supporting institutes became more involved with program administrators than had been anticipated which was of mutual benefit. 3.48 In U.P., the IIMA devoted much time in the early part of the associa- tion to finding out what was happening in the field. IIMA has estimated that "it took at least three years for management discipline to gain credibility from the health bureaucracy". It saw its role directed at improving work technology, systems development and changes in management processes, employing three processes to do so--training, action research, and consulting. The end result was 12 research projects, managementetraining for all managerial block, district and state level staff, and the des,fgn and implementation of a MIES. 3.49 The ASCI started its relationship with Karnataka in a more formal consultative manner, producing studies covering family planning program organization at various levels, and the procurement and distribution of drugs. A member of the ASCI staff was later posted as a liaison officer at the PC which contributed to closer collaboration than was evident at the beginning of the association. ASCI deliberately focussed on the organization and implemen- tation of population programs rather than macro-level population and planning or micro-level determinants of population growth (both suggested by the appraisal report) because the latter were not likely to be of immediate interest to administrators; this judgement was correct. In Karnataka, unlike U.P., the development of the MIES was done by the PC. 3.50 Although a considerable number of very valuable objective operational research studies were produced by both institutions (Annex II, Tables 11 and 12), their main contribution was in the field of management training. Training was preceded by considerable operational research in the project districts to enable it to be specific to health and family planning systems, of immediate practical value and absolutely relevant to local situations. In U.P.; the IIMA trained 88 doctors in two batches and organized two follow-up workshops, attended by 60 of these doctors, at the PC in Lucknow in 1980. The workshops were designed to reinforce the initial training and provide IIMA staff with an evaluation of their training activities. Evaluation confirmed the need for - 56 - such training, was recognized by PHC doctors and program administrators, and incorporated in the second population project. One result was the concern of the U.P. Government to develop its own management training expertise and the second population project makes provision for a gradual assumption of this responsibility by the Lucknow PC from the IIMA over a period of five years. 3.51 In Karnataka, an extensive effort was made to train program admin- istrators in which the PC and the ASCI collaborated closely. A first series of annual short-term training courses was organized from 1975 to '1977, primar- ily to expose project Medical Officers and other PHC staff to the application of management principles to PHC administration and to MCH/FP service delivery in a rural setting. From late 1977, this was followed by a series of more intensive annual training programs in which district and state level personnel participated to a greater extent than before. Based on project experience, statewide expansion of management training was considered desirable, but the combined training capacity of the PC, Bangalore and the ASCI would not be adequate for a task of this magnitude. [Compared to a State cadre of about 4,000 medical officers (of whom 100 to 200 leave the service every year), the project had, at most, been able to train 110 medical officers in a single year.] In the last phase of the project, therefore, it was decided to decen- tralize and institutionalize management training by relying on printed mater- ials to a greater extent than before (based on prototypes developed by ASCI) and by placing district level medical officers in charge of the management training of medical officers under their jurisdiction. This has not yet been evaluated. E. The Nutrition Component 3.52 The initial GOI proposal for a nutrition component within the project was for a US$8 million operational feeding program; it is no longer documented in Bank files. Presumably, the proposal needed to be scaled down and redefined to fit in with the project's overall experimental objectives. The nutrition components were appraised separately. The research objectives of the nutrition component were: a. to determine the effect that the provision of nutrition would have on the acceptance of family planning services, both directly as an incen- tive and indirectly as a result of the effect that a decline in infant mortality can have on the desire for fewer children; and b. to test the means of implementing nutrition programs." Issues to be established or criteria to be applied during experimentation were not identified. - 57 - 3.53 In both Karnataka and U.P., the component was to have the following characteristics: a. it would provide supplementary food for women in the last trimester of pregnancy, women in the first six months of lactation and for infants aged six to 24 months; b. the food would be processed and consist of cereal and pulse with a protein content of about 20%; c. the program would provide 100 to 110 grams (equi- valent to about 400 calories) daily to women, and 50 to 55 grams to children; d. women would come to collect their weekly food supply; e. an additional ANM for every five sub-centers would be provided; and f. village level volunteers would be recruited for home visiting and the collection of evaluation data. In Karnataka only, a mobile team was to be deployed at district level for health and nutrition education. Uttar Pradesh 3.54 U.P. adopted the basic component design, given in the appraisal report, in the Dalmau block of Rae Bareli district. Implementation and monitoring was the responsibility of an Assistant Director (Nutrition) who reported to the PIU Snd was assisted by two nutritionists, two health super- visors, a health'educationist and statistical assistant. The Project Agreement required the establishment of a Nutrition Division in the PC (not later than three years after the Agreement was signed) to evaluate the nutrition component and the engagement of the All India Institute of Medical Sciences (AIIMS) to assist in planning and evaluating the component. AIIMS favoured a more elaborate component design, under which a rehabilitation program for second and third degree malnutrition would have been tested alongside with the "take home approach" of the appraisal report's proposal. The State and Central government's objections to the AIIMS design were based on the foreseeably extensive staffing and infrastructure requirements of the rehabilitation approach which had been rejected during project appraisal; negotiations on this issue with the Institute were prolonged and resulted in delaying signature of the consultancy agreement and holding up the beginning of field operations. 3.55 Agreement on the component design was reached in June 1974, and a further 16 months was required to work out logistics, develop an acceptable food supplement, and post and train field staff. The component became fully operational in November 1975, in a study area covering 67,000 of the total - 58 - population of 89,000 of Dalmau block. The remaining 22,000 people served as a control, receiving the same MCH/FP service coverage as the experimental area but no nutrition supplement. Full scale operations lasted only until July 1976 when the GOI selected Dalmau block to launch an Integrated Child Development Services scheme which had an in-built nutrition component. Project operations ceased completely in November 1976, when all the food supplies in the pipeline had been distributed. 3.56 Nutrition component activities, which included supervising food distribution, were performed by 18 ANMs in the study area in addition to their routine FP/MCH work; they were supervised by 4 LHVs. The use of volunteers was not found feasible and ANMs were assisted by a part-time worker, normally a dai from the ANM's "headquarter" village. Dais were, however, not qualified to undertake the intended volunteer responsibilities of weight surveillance, data gathering and nutrition education. However, it was found that ANMs could perform these tasks quite adequately during their domiciliary visits. 3.57 The "balahar" type supplement, produced by the Food Corporation of India (FCI), was phased out during the preparatory phase because of spoilage problems and low acceptability of maize (used as a substitute, when bulgur wheat was unavailable) and soy beans. The replacement food supplement was developed by the National Institute of Nutrition (NIN) and was entirely based on foodstuffs produced in the project area (wheat, 54.5%; bengalgram, 9.1%; defatted groundnut flour, 9.1%; sugar, 27.3%; and fortified with a vitamin/ mineral premix). This supplement had an adequate shelf-life and was readily accepted. 3.58 Storage and transport arrangements from the godown at PHC headquar- ters to 44 distribution points worked smoothly throughout the project period. A "take home" system of food distribution meant that incremental staff costs were minimal. ANMs were each required to maintain thr.ee to four distribution points, each located at a maximum distance of 3 kilometers from the sub-center, where food was distributed on a fixed day during a fixed hour. This arange- ment reduced the maximum walking distance for beneficiaries to 1.5 kilometers each way and facilitated regular collections. On a yearly average, 38 out of 52 weekly rations were collected per beneficiary. Mothers were requested to bring children to the distribution point at least once a month for a checkup on the child's health status and for inquiries about the food supplement consumption in the household. Child beneficiaries themselves were present for about every other session. Pregnant and lactating women attended with some regularity, excepting the first two months after confinement. Weaning age children, who were most likely to require food supplementation were, however, most often missed by the distribution system, because of the incon- venience to mothers in taking a nurse child for food collection and the need to use the supplement in gruel form, especially prepared for the young child. 3.59 Nutrition education was a small but significant part in the nutri- tion program. A set of essential nutrition messages was defined, e.g., food needs of small children and pregnant women, easily available sources of basic food types, preparation of solid foods for weaning children, signs of nutri- - 59 - tional deficiencies, and preparation of supplements from local food sources. Messages used the local dialect and were adapted to local customs and food habits. Flashcards and charts were developed and used by LHVs during cooking demonstrations and antenatal/postnatal clinics. Project staff considered these nutrition education efforts to be successful, but they were not formally evaluated. 3.60 Project staff developed a simple monitoring system project which could have provided useful data on regularity of food collection, levels of MCH services provided to women and child beneficiaries, correlations between participation in the food supplementation program, MCH coverage and family planning acceptance. Because the component was terminated prematurely, this data base was never fully analysed. 3.61 Against an initial cost estimate of Rs 1,310,000 for a five-year project, final projeci: expenditures for the U.P. nutrition component were Rs 1,131,000 covering preparatory activities until October 1975, eight months of full scale operations until July 1976, and the subsequent phase-down and terminal evaluation; AIIMS consultancy services were reimbursed in the amount of Rs 68,369. Total food costs accounted for Rs 686,000 equivalent to almost 61% of project expenditure. Increases of food costs accounted for a signifi- cant proportion of the increased operating costs; whilst appraisal report estimates were probably based on an assumed cost of Rs 2.0 per kilogram of supplement, the price for Pushtahar was Rs 3.0 per kilogram in 1974 and had risen to Rs 4.30 per kilogram in 1976-77. Karnataka 3.62 The basic component design was implemented in Chitradurga District, one of the "intensive, districts. The component was implemented by a nutri- tion unit, headed by an Associate Director (nutrition) reporting to the PIU. In the field, the project was technically assisted by a survey team and an information and education team who were stationed in the District and admini- stratively responsible to the MOH. Key posts in these units were filled during 1973 and 1974. The Project Agreement required the PC to establish a nutrition division to evaluate the component, and required the State to sign a contract with the National Institute of Nutrition (NIN) in Hyderabad to assist in planning and evaluation. 3.63 Within Chitradurga distict, two PHC blocks were selected to test component implementation with and without the use of volunteers. A PHC block with identical FP/MCH inputs but no food supplementation was selected in Kolar District, but dropped from the design because the consultant institute (NIN) considered the distance to the control block inconvenient and thought condi- tions not sufficiently comparable. 3.64 During implementation, the basic design was altered twice. From January 1977 onward, eligibility criteria were changed to: (a) link the feeding program more directly to the project's family planning objectives; and (b) restrict supplementation to the nutritionally most needy. Rations were - 60 - also increased to try to compensate for the widespread practice of sharing the food supplement within families. Supplementary feeding was continued in two PHC blocks until project completion; additionally a rehabilitation program for severely malnourished children was tried for 15 months in two other PRCs in Chitradurga district. From June 1978, nutrition education replaced supplemen- tation as the principal approach under the nutrition component. Nutrition education teams were introduced in all project districts in Karnataka. This change was made because the even more restrictive, revised eligibility criteria adopted from January 1977, had not solved the question of non-replicability on cost grounds. Nor had it up to then been possible to demonstrate that supple- mentation had a nutritional impact. 3.65 In Thalak block, which had a population of 89,000, 26 distribution centers were established, each under the primary responsibility of the 18 ANMs and four LHVs routinely posted in the block and the four additional ANMs posted specifically to backstop the component. The "additional" ANMs were initially exclusively responsible for overall food distribution, and food distribution by regular ANMs and LHVs at their "headquarters" locations was not integrated with their MCR and family planning functions. Dais or, ex- ceptionally, school teachers were recruited instead of volunteers to act as liaison between ANMs and the community, but they considered themselves mostly as underpaid part-time employees. At the monthly honorarium offered, only 40% of the 150 sanctioned positions were filled at any one time. After over one year of preliminary activities, the nutrition program became fully operational in Thalak block during the last quarter of 1974; implementation in the second PHC block Parashurampura was started in May 1975, but full coverage was only achieved ten months later. Compared to appraisal estimates, this represented 6 and 14 months delay respectively. 3.66 The food supplement adopted in U.P. was found to be equally acceptable in Karnataka. The Central Food and Technological Research Institute (CFTRI) at Mysore was responsible for supply and quality control. 3.67 The distribution system established for the component was found to operate efficiently. Initially, the vehicle assigned to the Nutrition Educa- tion Team was used to transport the supplement within Chitradurga district, but this practice was stopped after the 1975 review mission had commented adversely upon it. Under the Karnataka distribution system, beneficiaries had to travel a considerable distance to distribution points. Distances of up to 5 km. were, however, not found to be a deterrent for collection. However, with increasing distances mainly older children were sent to collect rations and the centers did not, therefore, function as a point of contact with mothers as envisaged. Beneficiary children were not weighed since there was no reliable portable weighing equipment which ANMs could use. The changed component design adopted from January 1977, decentralized distribution points to villages or groups of villages, so as to minimize distances, encourage contacts between mothers and ANMs, and enable child weighing. Distribution points in Thalak block were increased from 26 to 71, and in Parashurampura block from 30 to 92, and the registration of beneficiaries and checkups on malnourished children was integrated with other MCR/FP services. - 61 - 3.68 Nutrition education was conducted in the introductory stage to explain the component's objectives to the community, but was then relatively neglected in favour of logistics support for supplement distribution. When even the revised pattelcn of supplement distribution failed to demonstrate an improvement in the nut:citional status of beneficiaries (perhaps because of the failure to integrate nutrition education adequately?), nutrition education was examined more closely as a possible major element of an economically feasible, replicable strategy. A series of essential nutrition messages were selected and promoted during group talks, demonstrations and village-levelexhibits, utilizing audio-visual aids developed by nutrition staff. Evaluation studies confirmed that nutrition education activities had positive although limited effects on nutrition awareness, knowledge and dietary practices, and led to the creation of Nutrition Education and Demonstration Teams in all five project districts from January 1979. 3.69 To monitor the component, a multiplicity of individual records, return forms and follow-up cards were designed. Food distribution was recorded on individual food distribution cards, weekly attendance registers, stock forms and weekly/monthly aggregate records. The health status of individual beneficiaries and their record of examinations, immunizations, etc., were recorded on individual case history forms. Followup cards for malnourished children and individual records of children's nutritional status were de- veloped but these were theoretical in design and did not relate to field conditions. The actual data yield from the monitoring system remained, therefore, deficient, and virtually all documented results from the Karnataka experiment are based on survey findings. 3.70 Compared to the appraisal report cost estimate of Rs 13,792,140 for a five-year project, final expenditures incurred from 1973-74 to 1979-80 were Rs 6,923,000 or 50.2% of the original estimate. Rs 3,520,000 or 50.8% of the expenditure total were spent on food supplement costs. Compared to initial cost estimates of Rs 1.96 per kilogram of supplement, actual production costs had risen to Rs 3.30 per kilogram even at the time of the 1975 review mission. At the close of the project, the cost of the food supplement per kilogram delivered to the PHC godown was Rs 4.25. In addition, Rs 124,000 were spent on the construction of nutrition godowns at five PHCs in Chitradurga District. IV. PROJECT RESULTS AND SUMMARY OF EXPERIENCE 4.01 This section describes the results of: a. the work of the PCs; b. the supplementation of the national program with additional postpartum facilities and mobile teams; c. the nutrition components; and - 62 - d. the FP/MCH performance of the project districts A. Population Centers Management-Information and Evaluation System (MIES) 4.02 Each of the PCs approached the organization of a MIES in terms of an improved service statistics system, but in different ways. Common to both was a careful analysis of the existing system which was found to be over-elaborate, time-consuming, producing litttle relevant information, and ignored by managers. Each U.P. sub-center had 20 registers from which 8 returns were made to the PHC which in turn sent 14 returns to district level whence an equal number went to State level. U.P. found that this system absorbed 10-15% of the pro- gram budget and about 20% of the ANMs' time at sub-center level; many ANMs had to provide their own books and papers for the records and,returns. U.P. asked the IIMA to develop a more simple and less time-consuming system. Eventually, it covered not only family planning but all aspects of the health services. It enabled district staff to evaluate the monthly performance of PHCs in three categories, readily identifying those in need of support. The system provided feedback from State level through district to PHC level identifying problems and suggesting corrective action. It was first imple- mented in.the project districts and, in January 1978, expanded to one (Lucknow) division. The PC was responsible for the training associated with the system. 4.03 In Karnataka, the PC played the lead role in collaboration with the ASCI in developing a MIES initially concerned only with FP/MCH. This system also provided for simplicity and feedback -- an upward "appraisal report" and a downward "management control report". Records at subcenters were limited to five and fascimiles of FP/MCH client cards were sent weekly, directly to State level for analysis. Returns were made by supervisors. When the MPW scheme was introduced in Bangalore district in 1978, the system was modified to cover all health activities. A similar system was introduced in 1976 for FP/MCH facilities in Bangalore city. 4.04 After both State systems had been pretested, it was decided to examine them in detail and synthesize both systems. Meetings, sponsored by the GOI, were held to review the two systems, and a common information system for rural areas was developed and pre-tested for possible introduction through- out India. In U.P. the common system is being adopted for use in both old and new project districts first, and will eventually be extended to all districts. In Karnataka, the system will be introduced state-wide. It is also probable that all States involved in the national accelerated FP program will adopt the new system. 4.05 Annex II, Table 13, shows the number of records kept under both old and new systems and illustrates the greater simplicity in the number of records and returns required by the latter. It is comprehensive and covers all aspects of the health services delivery system. Importantly, it provides - 63 - for monitoring and feedback. If properly combined with improved managerial feedback, the new system represents a significant project achievement. Experimental Strategies 4.06 The PC Lucknow concentrated on short studies of particular opera- tional significance mainly concerned with the management of various FP service units, the effectiveness of service delivery, the involvement of community groups in the program, and communication aspects. An example was the study of the FP program in Luckaow city and the scheme for reorganization which resulted, and which was subsequently implemented. In 1976, the PC was asked to evaluate the work of Deputy CMOs who had been assigned a geographical area within a district where they were responsible for all health services rather than being given responsibility for one or more aspects of the services throughout the district. The role of the PC in studying ANM curricula has already been noted. These types of studies had immediate program relevancy and gave administrators a much needed support facility. In all, the PC carried out 64 research studies (Annex II, Table 11) and also conducted surveys to determine and monitor demographic and performance indicators in project and control districts. 4.07 In addition to undertaking similar work, the PC Bangalore developed experimental strategies to postulate and test changes in program inputs and methodology. They were presented to a distinguished group of Indian experts at a workshop in April 1975 and modified as a result of discussions. Five strategies were tried in various PHC blocks in project districts between 1976 and 1979. The intensive drives started shortly after their introduction and the attention of staff was diverted to achieving the national program's FP targets. This clearly masked the results of the strategies and led to an extension of the project to see if clear results could be obtained; it also made their evaluation more difficult. Requests to exempt project districts from target requirements were turned down. 4.08 The first strategy was to see what impact the involvement of a voluntary organization would have on performance. In one block, the running of the PHC and sub-centers were completely.handed over to the Family Planning Association of India for three years. Significant improvements in performance were noted and the approach of using integrated village development activities proved useful. Replicability was limited, however, because there are few voluntary organizations capable of doing this work. It was also clear that FP/MCH could not be isolated from other health activities under the MPW scheme. In a second block, the Rural India Health Project was made respons- ible for demand generation but the involvement of Government (service) and agency (demand) could not be properly coordinated and there was no impact on FP performance. 4.09 A second strategy assumed that with improved PHC management would come improved FP/MCH performance. The ASCI provided training and other guidance for Medical Officers (MOs) at two PHCs. Work was reorganized to involve all MOs in the block in sharing responsibility for health/FP/MCH - 64 - programs. The presence of ASCI created suspicion, however, and reorganization induced resentment. The original scepticism of the MOs was never assuaged and no improvements in performance were registered. The PC concluded that "mere training and offering suggestions will not bring about changes in the manage- ment style of the MOH"; the situation demanded "an authority responsible for translating management concepts into action for effective implementation". This disappointing conclusion was largely the result of personality problems. 4.10 That improvements in the technical competence of staff.will lead to improved performance was the hypothesis of the third strategy. This involved training MOs in MTP procedures and allowing LHVs to prescribe oral pills and insert IUDs. An improvement in the FP performance of both PHC blocks in which the strategy was implemented was very marked compared with the control PHC blocks. This was probably achieved, however, at the cost of MCR services which showed no improvements. The conclusions resulted in State measures to improve MO and LHV training and in India, generally, LHVs are now empowered to prescribe oral pills and insert IUDs. 4.11 The fourth strategy presumed that PHC staff were unfairly burdened with sole responsibility for achieving FP targets when many factors other than the provision of services were responsible for success or failure. The hypothesis tested was that village authorities would be in a better position to motivate people leaving the PRC to provide effective services. Contradic- tory results were obtained from the two PHC blocks involved, one showing no improvement at all in FP performance and the other showing some, but incon- clusive, improvement. It appeared that the involvement of village authorities would not necessarily result in immediate improvements but might play an important role over time. Basic orientation and periodic re-orientation courses were thought to be essential, as were effective linkages between the authorities and PRC staff, often broken, however, by frequent transfers. The evaluation pointed to the important coordinating role which a district admini- strator could play in bringing various departments of Government, private agencies and local authorities together to develop FP programs. 4.12 The fifth strategy was concerned with incentives. In one PHC, the MO was allowed to draw the incentive money normally alloted but use it for better food, drugs and follow-up care, keeping any amount left over for himself. The innumerable problems which this raised led to its very early abandonment. In the second PRC, there were also numerous administrative problems when cash incentives were withdrawn and "in-kind" incentives (mostly household utility articles) substituted. Despite these problems, performance did improve, many women preferring "in-kind" articles which they could use, to money which they could not keep control of. In this PHC, there was a signifi- cant improvement in performance but replicability is very limited because of the inherent administrative difficulties in providing different types of incentives. 4.13 In April 1977, three combined strategies were introduced in three PRCs; no hypotheses were set but performance was compared over a two-years period with three control PHCs. The three combinations were: - 65 - a. management, village authorities and "in-kind" incentives; b. management and village authorities; and c. management, village authorities and improved technical competency. There was no significant impact on FP performance and findings generally confirmed those of the individual strategy experiments. The PC Bangalore considered that more time was probably needed for conclusive results to emerge. 4.14 The experimentation was carried out with considerable thoroughness and is well documented. For those who expected significant breakthroughs, the results are disappointing. They indicate that quick and easy solutions to the problem of improving FP/MCH performance are not easily found, that experimen- tation itself requires perhaps at least five years, and that political and administrative factors, which are not susceptible to experimental manipulation, are of considerable significance. B. Program Supplementation 4.15 The appraisal report proposed three areas of program supplementation to the standard GOI levels of staff and facilities. These were the urban areas of Lucknow (U.P.) and Bangalore (Karnataka), rural districts, and intensive rural districts. In all three, supplementation was mainly achieved by provid- ing additional facilities for deliveries, tubectomies and medical terminations of pregnancy (MTP). Urban Program 4.16 A City Family Welfare Bureau (CFWB) was created in Lucknow in 1975, to direct the FP program in the city and coordinate extension work. FP work in Lucknow has since been well coordinated, mass media activities considerably expanded, and attendances at its facilities (e.g., maternity homes) consider- ably improved. The project also provided better facilities for institutional deliveries and a postpartum approach to family planning. In Lucknow, eight maternity homes were :o be provided, each of 30 beds, with 15 for deliveries and 15 for tubectomy cases. With an occupancy rate of 80%, these facilities were estimated to handle annually 3,500 deliveries and 7,000 tubectomies. They were scheduled for completion by September 30, 1976, but were not finished until June 30, 1979. None of them became operational before the 1976-77 program year, later than the appraisal report foresaw. Not surprisingly, it took some time before women gained the confidence to use these new facilities. By 1978-79 the numbers of deliveries had risen to 4,725 and by 1979-80 to 5,055, 50% above appraisal expectations. The number of deliveries as a percentage of expected deliveries from their catchment areas rose from 8.5% - 66 - in 1976-77, to 63% in 1978-79, but fell, for inexplicable reasons, to 41% in 1979-80. The expected number of tubectomy cases was not realized because of the unfavourable climate towards FP in the State after the Emergency Drives; by 1979-80, only 9% of appraisal expectation was achieved although all eight facilities showed a steady increase in the number of tubectomies. The maternity homes also ran outpatient clinics in which a full range of contra- ceptive methods was offered and by 1979-80, 95% of the expected number of pregnant women in their designated catchment areas were registered as ante- natal cases. Of these, 30% on average annually received tetanus toxoid immunization, and 50% received iron and folic acid tablets. Coverage of children aged 0-2 years protected by DPT rose from 8.9% in 1976-77, to 16.30% in 1979-80, (comparable percentages for public innoculations being 9% and 12.2% respectively) but these are still very low. 4.17 At the time of appraisal, there was already a high proportion (70%) of institutional deliveries in Bangalore (Karnataka). The project provided for six maternity homes with 150 beds, half for deliveries and half for tubectomies, located in areas not covered by existing institutions. They were expected to provide for 2,600 deliveries and abortions and 5,300 tubectomies annually. To each of these was attached an urban family welfare center (UFWC) for outpatient and family planning counselling work. Although the maternity homes and.UFWCs are located in one building, they are not operationally integrated; proximity and good sense, however, appear to have generally ensured close coordination. Eight other UFWCs were also located at other maternity homes in the city. A 30-bed sterilization unit was added to the K.G. Hospital. Four maternity homes were commissioned in late 1976, a fifth in May 1977, and the sixth in 1978. Six of the eight separate UFWCs were handed over in May 1975, one in April 1976, and the last in January 1977. Following previous practice, six of the eight UFWCs were run successfully by private organizations; one was attached to the Government Medical College and one to the HFPTC for training purposes as well as providing services to the immediate neighborhood. The maternity homes performed better than the appraised expecta- tions in terms of deliveries; in 1977-78, they were responsible for 2,805 deliveries, in 1978-79, 4,073 and in 1979-80, 4,884 deliveries. They were below expectations for tubectomies--only 748 being performed in 1979-80. This was clearly the result of the Emergency Drives, but the percentage of FP acceptors to deliveries was 27.7% in 1979-80; this is very creditable by international standards for a postpartum program. Rural Program 4.18 The project provided for female sterilization annexes (MSAs) to all district hospitals and nine sub-district (taluk) hospitals in Karnataka. In the U.P. districts this was expected to result annually, in 9,000 additional tubectomies, doubling the 1970-71 performance. Four of the annexes, all attached to district women's hospitals, became functional in 1976-77 and the last in 1977-78. U.P. evaluation is based on a comparison between project districts with women's hospitals and their annexes, and two other closely matched districts (one within the same division and the other from another division) without such hospitals with annexes. The ratios of selected FP/MCH - 67 - indices were calculated and compared; any increase in these rates was "inter- preted as due to MSAs". This is methodologically suspect as there are likely to be many more factors involved in performance than one 30-bedded steriliza- tion annex. By 1978-79, the number of deliveries was 7,253 and in the follow- ing year 7,092. MTP cases rose from 1,049 in 1976-77 to 5,677 in 1979-80. Even tubectomies increased from 1,152 in 1976-77 to 1,694 in 1979-80 despite program set backs. Although well below the appraisal expectation, it is clear that these annexes are well utilized, attracting women for institutional deliveries and catering; to family planning needs with a wider range of methods than sterilization alone; the number of IUD insertions, for example, rose from 526 in 1976-77 to 6,729 in 1979-80. Outpatient attendance rose from 38,901 in 1977-78 to over 165,000 in 1979-80, providing opportunities for extensive MCH care as well as family planning. 4.19 In Karnataka, each of the five district hospitals was provided with 30 beds for tubectomy cases (in Bangalore city, the K.G. Hospital was regarded as a district hospital). As was the case in U.P., it was not possible to use these additional beds solely for tubectomy cases; they have been used as OBGYN annexes of a standard suitable for operations, including tubectomy and MTP. They are being extensively used for deliveries as Annex II Table 14 shows. The K.G. Hospital is responsible for almost half the total number of deliveries, attracting an urban as well as a rural clientele. The percentage of cases accepting family planning was 19.9% in 1979-80. 4.20 The project also provided for 24 bed annexes at sub-district (taluk) hospitals in Karnataka. The first of these was commissioned in January 1976 and the last in November 1977. They were responsible for 2,332 deliveries in 1979-80, of which 29% accepted family planning. Performance in 1978-79 was very uneven ranging from only 66 deliveries in Pavagada to 1,022 in Sagar. This point has not been brought out in the PCs' evaluation and would repay investigation to identify factors affecting utilization. Achievements fall considerably short of expectations as to the number of tubectomies, in part due to the post-Emergency slump in FP activities. Intensive Rural Program 4.21 In each of the States, two districts were selected for an intensi- fied family planning pirogram. In U.P., Rae Bareli and Saharanpur were chosen. In addition to greater attention to staffing and training, these districts had maternity-sterilization facilities of 24 beds each (MSWs) added to five PHCs in each district and one mobile team. Half the beds in these MSWs were for deliveries and half for tubectomies. The MSWs were expected to handle a total maximum of 3,500 deliveries annually and postpartum acceptors were estimated to increase from 15% to 20% of deliveries "during the period". Most of the MSWs became functional in 1976-77. The number of deliveries has been well below expectations; in the period 1977-78 to 1979-80, the annual average was 888 deliveries. The main reason is that it seems to take much longer for a relatively less well educated rural clientele to build up confidence in institutions of this nature than an urban clientele. In 1978-79, however, the number of deliveries was 44% of registered ante-natal cases; this compares - 68 - with 55% in district women's hospitals. The number of tubectomies was only 220 in 1979-80, but reached, in fact, the appraised expectation of 20% of deliveries. The MSWs were used for a wider range of FP/MCR activities than the appraisal report envisaged. They served as peripheral facilities for MTP which numbered 2,080 in 1978-79 and 1,438 in the following year. IUD Inser- tions rose from 413 in 1977-78 to 2,949 in the following year. Admissions rose steadily to 6,260 in 1979-80 and for the half year 1980-81 were 3,120. The PC in Lucknow evaluated performance by matching PHCS with MSWs to PHCs without MSWs in the project districts; differences in selected FP/MCH per- formance ratios have been attributed to the MSW. Here again there are methodological problems but the PCs evaluation showed: a. no significant increase in clinic attendance; b. total deliveries, by trained staff were 25% higher in PHCs with MSW's; c. 12% more deliveries from the ante-natal regis- trations were found in PHCs with MSWs; d. MTPs were 260% above those of PHCs without MSWs; e. except for nirodh distribution which was 80% higher in PHCs with MSWs, no significant differences were found in FP performance; and f. there was no significant difference in maternal bene- ficiaries but child beneficiaries were 100% higher at PHCs with MSWs. Throughout the project, it proved difficult to recruit and retain medical staff for those rural facilities. 4.22 The mobile motivation-cum-service teams were established in the intensive districts in September 1974,but disbanded in July 1976, because of difficulties in recruiting and retaining medical staff for such work. 4.23 In Karnataka, the districts of Chitradurga and Kolar were selected for the intensive program. Unlike U.P., these districts were to have one sub-center for 5,000 people, in addition to ten MSWs at selected PHCs and the provision of one IEC and one service delivery team for each district. By 1980, these districts had ratios of 1:5,207 and 1:5,494 respectively. The MSWs were responsible for 1,694 deliveries in 1979-80, but of these only 10% were directly motivated to accept family planning. They were, however, foci for block FP activities and the number of acceptors outside the post- partum program was 9,161 in 1979-80, twice the number recorded by the nine sub-divisional hospitals. In particular, they provided for the first time at block level acceptable facilities for sterilization camps and for performing MTPs. - 69 - 4.24 A Mobile Motivation-cum-Service Unit was also provided in each of. the intensive districts of Karnataka from 1975-76. Working under the District Family Welfare Bureaux, they followed up tubectomy cases, inserted IUDs, helped to organize vasectomy camps and helped to maintain records at sub- centers. The strategy followed was to identify areas in which FP performance was low and concentrate on them. They held film shows, meetings, orientation camps for village leaders and distributed literature as part of their motiva- tional work. In addition to contraceptives, common drugs ,were carried to allow medical staff to deal with common ailments. They suffered from difficulties in recruiting staff, particularly doctors, because of the long, arduous touring involved. Once the intensive infrastructure was in place, the State felt that their effective utilization was restricted as their functions overlapped with static units. They were disbanded on April 1, 1978. C. The Nutrition Components Uttar Pradesh 4.25 In U.P., evaluation was based on three successive nutrition surveys (the first of which was considered defective; monitoring data were not fully analyzed). Food consumption within households, as well as levels of infant and child mortality, were studied in 1975, but the surveys were not repeated before the component was forced to close. 4.26 The survey program indicated no measurable improvements in the nutritional status of child beneficiaries on the basis of the measurements used which were mean increments in height and weight within each age and sex subgroup. This could, in part, be accounted for methodologically: the sample of children measured in the experimental area included not only regular beneficiaries, but also children who, although eligible, participated only irregularly or not at all. Among regular child participants, lack of nutri- tional impact might also be explained by sharing of the supplement within the household. The "take-home system" of delivery posed the inherent risk that the supplement would be shared. This was supported by findings of a 1975 household survey on food supplement consumption during which 40% of respondents stated that the food supplement was consumed by others as well as the intended child beneficiary. Project staff later observed that sharing could at best be limited through follow-up motivational efforts by ANMs, but never eliminated. Lack of input might also be attributed to substitution, which is as likely to have occurred, and by the circumstance that the nutritional status of a majority of the target: population of child beneficiaries was normal, by Indian standards, to start with. On balance, these observations lend support to the conclusion that the component's approach to a "take-home system" proved ineffectual in improving the nutritional status of young children. 4.27 The short duration of the component in U.P. meant that no firm -conclusions could be drawn. MCH performance in Dalmau block was, however, consistently superior to other blocks, often by a margin of 80%. About 75% of - 70 - all pregnant women in the block received a double dose of tetanus toxoid immunization and anti-anaemia treatment, and virtually all child beneficiaries received a full series of three immunizations. It is not possible to determine whether this was due to the incentive aspects of food supplementation. Staff reported that villagers seemed apathetic towards the nutrition program and the fact that adult men and women were at work from early morning to late evening left few people, except children, to collect the food. The direct effects of the supplementation program on family planning acceptance through increased contacts with ANMs could also not be fully explored, because the operational phase of the component coincided with intensive family planning drives; food distribution could not be combined with family planning motivation without the risk that the food offtake would be affected by rumours. Karnataka 4.28 The evaluation program of the Karnataka component was, for the main part, designed and carried out by NIN; it consisted of a series of four nutrition surveys. Common topics for all surveys were investigations of the nutritional status of children under six and of pregnant and lactating women, assessed through clinical examinations, dietary intakes and vital events. Methodologically, the significance of the results was diminished by the non-use of control groups. Comparisons between beneficiaries and non- beneficaries could no longer be used to show the impact of supplementary feeding, because the selection of beneficiaries had been targeted to include malnourishd children. NIN also conducted three rather more operationally oriented surveys, which covered the distribution and utilization of the supplement, effects of food distribution on MCH delivery, and nutrition education activities. These studies were well conceived, timely, and pre- sented recommendations which were operationally relevant. No investigations of the inter-relationships between the nutrition program and family planning acceptance were made because the recommendations of the 1975 review mission were understood as discouraging such a study. Family planning, and even the investigation of demographic events, had, moreover, become sensitive during the emergency period. The possible effect of the new distribution system on family planning acceptance was only investigated in 1978; under the revised distribution system this was very narrowly conceived in terms of the potential incentive value of food distribution for family planning acceptance. 4.29 An early evaluation survey of the logistics and food offtake achieved in Thalak block indicated that nearly 65% of child beneficiaries attended for more than 80% of collection days; the 1975 review mission estimated that 80%-90% of women beneficiaries and almost all child beneficiaries in Thalak block were covered. Actual coverage data are, however, not available as monthly performance statistics available from the project indicate merely monthly totals of rations distributed, instead of number of beneficiaries covered. The first evaluation of food utilization indicated no discernible improvement in the nutritional status of children in spite of good coverage and regularity of food distribution. This was attributed primarily to wide- spread sharing of the supplement within the the household--only 30% of child beneficiaries and 10% of pregnant/lactating women had been shown to consume - 71 - the supplement regularly and exclusively. Two-thirds of all rations for child beneficiaries were shared within the household, most commonly with older siblings. On average it was thought that beneficiary children received only half or one-third of the supplement, which did not provide nearly enough supplementary food to close the narrowly calculated "calorie gap" which affected most children. NIN concluded from these findings that 90% of child and 73% of women beneficiaries were unlikely to show nutritional improvements under the initial distribution mechanism and recommend an increase of the supplement amount to cover the needs of all children in a household. 4.30 This recommendation was adopted from July 1977, when the project beneficiaries were redefined to cover all children of family planning acceptors between the ages of six months and five years, as well as all severely malnour- ished children between the ages of six months and five years along with their siblings up to age five. Rations for children over four and for malnourished children were at the same time increased to 110 grams a day. Under the new pattern, the supplement was, however, still shared in 75% of the households; sharing had simply been extended to include other children. The nutritional impact of the revised distribution system was not conclusively determined because the study group of child beneficiaries examined in final 1978 survey included the children of FP acceptors as well as diagnosed malnourished children. It was generally accepted that the revised pattern had also proven ineffective. 4.31 Dietary data collected also gave evidence of substitution of nutrient intake from other sources, especially for children aged 1-2 years. For this age group, calories available from regular food sources were shown to have declined by over 200 calories; or over 40% compared to pre-project levels. Protein intake had also declined by more than 40%. On the basis of these findings it was accepted that the take-home system as initially adopted was unlikely to be effective. 4.32 More encouraging was the comparatively better performance achieved by a parallel small-scale feeding program for severely malnourished children of preschool age, in which the nutrition status of beneficiaries was monitored regularly. Nutritional status improvements were achieved for 55% of benefi- ciaries and incidences of diarrhea and respiratory diseases were significantly reduced. Mothers were also more likely to adopt better infant and child feeding practices in response to demonstrated improvements of the health and nutrition status of beneficiary children. Relapse rates were, nevertheless, thought to be quite high, especially among the poorest. 4.33 An enquiry by NIN into the "collateral" benefits of the component indicated that supplement distribution improved the image in the community of ANMs who benefitted in. the performance of their MCH functions by being able to detect more pregnant women, perform a greater number of neonatal vaccinations and by motivating more women for family planning acceptance. These largely subjective accounts could not be supported by service statistics available at the sub-centers studied. NIN, therefore, recommended the development of a simple reporting system by which the component's impact on MCH service delivery - 72 - and family planning acceptance could have-been routinely evaluated, but this was not done because of the staff's emphasis on its nutritional aspects. 4.34 The probability of an "indirect" effect of the food supplementation program on family planning acceptance was questioned by the PC Bangalore when findings of the second nutrition survey showed no impact on the nutrition status of beneficiary children and that a decline in infant mortality was therefore unlikely to result. (Infant mortality rates recorded In the pilot study block in fact increased from 73 in 1974, to 83 in 1975, and 85 in 1978.) The intended "direct" linkage of attracting mothers for attendance at group talks on family planning motivation food distribution was likewise not practi- cal, because this might have created mistrust in the composition and long-term effects of the supplement. Under the conditions of the family planning drives which dominated most of the component's first phase of experimentation any results would have been masked by increased acceptance resulting from other motivational efforts. Under the revised design, the provision of supplemen- tary food for children of family planning acceptors (initally only for acceptors of permanent methods) was widely understood as a direct, material incentive, but its value as an inducement to undergo sterilization was found to be negligible. (In a special topic survey, only 2.5% of respondents stated their willingness to undergo sterilization in order to become eligible for the food supplements.) 4.35 Among the project-s experimental interventions, nutrition.education showed the most significant impact. Consistently positive changes in knowledge and practices related to nutrition were shown in all evaluation studies. Practical demonstrations had the most pronounced effects. Changes of knowledge and practices were only limited, but were even so considered important because they could be achieved with program efforts that were replicable on a wider scale and because they resulted in nutritional improvements that were poten- tially sustainable within the means of the communities served. Although the U.P. component was short lived, it reinforced the essential lessons learned from the Karnataka -experience. One of the original objectives, that of demonstrating that nutritional improvements in children would directly lead to a reduction in infant mortality and then indirectly to a desire for fewer children was clearly over-optimistic. The assumptions underlying this hypothesis had not then been empirically tested and, as the 1976 tri- partite review pointed out, would have needed at least 20 years' observation to test. The second objective of "testing the various means of implementing nutrition programs" was successful in an administrative sense. An acceptable food supplement was tested and introduced with some success. In both areas, ANMs were available at a relatively low ratio of 1:5,000 people, however, and the number of supervisory staff was relatively high for such a small operation. 4.36 Bias in the basic design was probably responsible for a bias during implementation towards the establishment of a food supplementation distribution system and the assessment of the nutritional impact of the supplemant. There was correspondingly less attention to the indirect effects of food supplementa- tion on FP/MCH performance. The FP policy change during the component's initial implementation contributed to this lack of emphasis on the nutrition/ - 73 - FP relationship. Nutritional impact was judged to be minimal according to the measures of growth used. In light of recent work on the evaluation of nutri- tion benefits, differing conclusions may be possible. And it is also possible that a variety of other factors such as food supply, food prices, and failure effectively to integrate food supplementation with nutrition education may- have contributed to the perceived lack of impact. The issue of replicability was not addressed at implementaton and only unsatisfactorily considered during implementation. At no stage of appraisal or implementation was any effort made to determine the 'Least cost effective means of achieving the component's objectives. Significant increases in food costs highlighted the issue but failed to stimulate study. 4.37 Many of the issues which might well have'been considered in designing a component of such a complex social nature seem to have been overlooked at appraisal and hardly considered during implementation. Was this perhaps due to lack of preparation (preparation and appraisal seem to have been carried out simultaneously), inadequate involvement of Indian counterparts (the component seems to have been developed by Bank staff and consultants), or ineffective support from Bank supervision missions (the only time it was reviewed in depth was in 1975 and again in 1976, by the tripartite review)? Was this type of experimentation, in fact, suitable for inclusion in a very complex Bank project? D. Performance Results 4.38 Thus far, project performance has been evaluated only in terms of the objectives stated in the appraisal report. The results can be summarized as follows: a. health infraitructure was completed according to the GOI pattern for FP services, and additional inputs were made in some areas to supplement and test alternatives; b. two PCs were created and they did design the MIES, evaluate performance on a continuous basis, and recommend changes (they were, however, never in a position to "ensure that the recommendations that emerge are speedily implemented"); and c. technical assistance was provided as were incre- mental recurrent costs to implement experimental aspects. Given these inputs were there any improvements in overall program performance? 4.39 As has been noted in several places, the major problem with the design of this experimental project was a failure to consider adequately the - 74 - timeframe and sequence in which multifarious activities needed to be pro- grammed. The difficulties of evaluation to which the appraisal report drew attention are compounded by the fact that the time taken to meet the input objectives allowed little time for the established pattern and projected outputs to be observed. In fact, the crucial period for observing the results of this project will be the next five years during which special attention has been withdrawn and observations of the pattern under normal conditions can be made. Both States are well aware of this and have directed the respective PCs to continue monitoring and evaluating performance in the project districts. An aberration which no-one could have foreseen was the intensive program efforts during the Emergency period and the subsequent backlash against the program. 4.40 The PCs have evaluated both FP and MCH performance recognizing that, even when the project was conceived, GOI policy was to integrate FP and MCR services. The following section summarizes the evaluation work of the PCs with respect to program performance. Uttar Pradesh 4.41 In U.P., the following comparative approaches were used: a. performance of project districts with non- project districts in the whole State; b. performance of project districts with matching control districts; c. calculations of births averted with appraised expectations; and d. changes in vital rates and knowledge, attitude and practice (KAP) of family planning. To make comparisons, indicators of various FP/MCH activities were calculated for each of the seven program years 1973-74 to 1979-80. Compared with the rest of the State, the project districts were superior in performance with the exception of IUD insertions in 1975-76 when they lagged slightly. Steriliza- tions have on average been 36%, and IUD insertions 43% greater. Although the project districts were not immune from post-Emergency problems, the drop in performance was relatively less (although still considerable) and recovery has been faster, although the difference between project and non-project districts declined in the last three years. The project districts contain 13.6% of the State population; proportion of condoms distributed has been about 16-20%. Given the special inputs in the project districts, their superior performance in the number of MTP procedures is not surprising but still significant, particularly in the three years when all facilities were operational. Per- formance in MCH has also been more marked in project districts than the rest of the State. Maternal care (TT and anti-anaemia prophylaxis) indicators are - 75 - 73% and 23% higher in the project districts in 1979-80; DPT injections are 50% higher in that year having been well below the State average in 1974-75. In the second approach, the PC has also pooled the district performances in comparing performance with each district matched with a district in the same division and one outside the division. This has been done essentially to provide an assessment of project inputs. For convenience, project districts will be labelled Group A, matching districts in the same division Group B, and matching districts outside the division Group C. Each of the indi- cators is considered separately: a. ante-natal registrations. In 1974-75 performance in Group A was well below the other Groups but picked up rapidly to 1977-78 (the latest year for which figures are available). In that year, ante- natal registrations were three times greater than Group B and four times greater than Group C. b. deliveries conducted by trained staff. Here again, Group A lagged behind the other Groups at the start of the project but showed a continuous increase to 1977-78 (latest available figures) when two to three times more deliveries were being attended by trained staff in Group A than Group B and C. c. child immunization (DPT and DT). there has been a continually improving trend in child immunizations over the six-year period in Group A with substantially better performance than in Groups B and C. d. maternal beneficiaries 1/ - Group A coverage is consistently better than Groups B and C but has fallen off since 1977-78 during which time Groups B and C have improved their coverage, probably because of increased attention to this program aspect in the state as a whole since then. e. child beneficaries 2/ - The child beneficiary rate increased steadily in Group A from 1.7 in 1974-75 to 25.8 in 1979-80, four times higher than Group B and five times higher than Group C. f. sterilization acceptance - vasectomy performance increased substantially in 1976-77 to 8.0/1000, slumped dramatically in the following year to 0.2/1000 1/ Maternal beneficiary rate was defined as Cases Receiving ANC, DI, Iron and Folic Acid Currently Married Women 15-441 2/ Child beneficiary rate was defined as Cases Receiving DPT, DT, Vita.A, Eron and Folic Acid Children aged 0-4 x 1000 - 76 - but reached 1.1/1000 by 1979-80. For the last four years, performance was better than in Groups B and C. The same pattern is shown for tubectomies where Group A's performance is somewhat better than Groups B and C. g. IUD acceptance and Conventional Contraceptives -. no significant differences in performance emerged from these comparisons. 4.42 Contraceptive acceptance was also measured in terms of the sterili- zation equivalent rate, a useful measure which provides a comparative base. Group A performance is more consistent than other groups; in 1979-80 it was higher than in any previous year (1976-77 excepted) and was twice that of both Group B and Group C. 4.43 The PC has computed the number of births-averted in the project districts and compared the results with appraisal report expectations. Over the seven-year period, it was calculated that 87.4% of the originally esti- mated number of averted births was averted (see Annex II, Table 15). This figure was inflated by the special drives of 1976-77; in no other year, did the number reach expectations. The contributions of IUDs and conventional contraceptives were under-estimated by the appraisal report and sterilization seriously over-estimated. It is possible that the estimates might have been achieved if it were not for the special drives; in 1975-76, 67% of the sterili- zation estimates was achieved but in 1977-78 only 2% and recovery is very slow. This indicator clearly shows the distorting effect of the 1976-77 special drives and their aftermath. 4.44 Comparison of the results of a baseline survey in 1974 with a final survey in 1979-80 have provided, for the rural areas of three districts and Lucknow city, some evidence of vital rates and of knowledge of, attitudes towards and information known about contraception. In all four areas, there appears to have been declines in the crude birth, crude death, and infant mortality rates but this is judged not be statistically significant. Fertility in the rural areas is very high, as are death rates and infant mortality rates. In all these rural areas the percentage of married couples practising family planning rose but even the best area, (rural Muzaffarnagar in the more prosperous western part of the State) is still, at 11% very low and slightly below the State figure. 4.45 Overall, the impact of the project has not been very significant in U.P. in terms of performance. There have been absolute improvements in both FP and MCH but performance levels are still very low. There is no statistical evidence of any difference between the two intensive project districts and the others. In tubectomy operations Lucknow district consistently outranked the other districts in the period 1970-79 with the intensive districts fluctuating in rank order at random. The U.P. draft evaluation report has no performance comparisons between project districts to evaluate performance trends and analyze reasons. A quick look at the available data shows that the more prosperous western districts of Muzaffarnagar and Saharanpur have no con- sistently better FP performance than the poorer eastern districts. The urban influence of Lucknow city is evident but the reasons for this are nowhere explained in the State evaluation report. - 77 - Karnataka 4.46 In Karnataka, program performance evaluation was on a similar basis to that of U.P., using data from surveys, service statistics, and studies, and ranking comparisons with the other divisions in the State and with central districts. An analysis of performance against targets shows a project input impact. In IUD insertions the project districts are well behind in comparison with State achievements in 1973-74, but overtake them in'the following and subsequent years as attention to the program takes hold. In a comparison of sterilization performance, this lag takes four years to make up; not until 1976-77 do the project district do better in meeting targets than the State as a whole. With the exception of 1976-77 and 1977-78, the project districts outperformed the rest of the State in the use of conventional contraceptives. Since the oral contraceptive was introduced as a method in 1975, the project districts have done better than others in the State in recruiting oral contra- ceptive acceptors. In 1979-80, the acceptance rate was almost twice that of the State as a whole. Using the equivalent sterilization rate as a means of comparison, the project division is consistently above the State average. Comparing individual divisions, the project division performed better in three of the seven years (1973-80), Mysore led three times and Gulbarga once (during the Emergency). Mysore has long had a well developed health infrastructure and the inference is that, now that the project division has a similar infra- structural level, performance has come up to Mysore standards; in 1979-80 the difference between Mysore and the project division was only 0.02/1000 in favour of Mysore. Project inputs are also reflected in the superior per- formance of the project division in conducting MTPs. This is also attributable to project-initiated training of Lady MOs in MTP procedures which was subse- quently expanded on a state-wide basis. 4.47 The Karnataka PC computed a "MCH Equivalent Rate" (the sum of ante and post natal cases anad deliveries conducted by trained staff per 1,000 population) for selected PHCs in the project districts and compared them with five PRCs from Mysore division over six years from 1972 to 1978. The PHCs in the project districts showed better performance than the Mysore PHCs up to 1976-77. PHCs from the two intensive districts performed better in 1977-78 (the latest year for which data are available) than PHCs in the remaining districts. 4.48 Comparisons were also made with the appraisal estimates of births- averted shown in Annex II, Table 16. In each year, from 1973-74 to 1978-79 "actual" births-averted exceeded the estimate, even when the "abnormal" 1976-77 year is discounted. 4.49 From results of a longitudinal sample survey, the crude birth rate is estimated to have declined from 35.8 in 1974-75 in the project districts as a whole to 26.6 in 1977-78. The decline was more prominent in the rural than the urban areas. No confidence limits are placed on the data in the State's draft completion report, although there is a caution that overestimates may hAv# been made in 1974-75 and/or underestimates in 1977-78. The conclusion that "these results again show that the additional inputs...are at work" is - 78 - open to discussion; the data trends need to be compared over time and with other available data (e.g., those of the national sample survey). 4.50 Contraception certainly increased significantly in the project districts. In 1975, 15.7% of eligible couples were currently practising contraception and this had risen to 23.1% by 1978. This was largely due, however, to the special sterilization drives of 1976-77; the percentage of couples using spacing methods actually dropped from 3.6% to 2.5% in the same period. E. Summary of Experience 4.51 Several significant conclusions may be drawn from the process of planning and implementing this project. There are lessons to be learned, by both the Bank and Government, which can be divided into those of program relevance and those of project relevance. 4.52 For the program the more important lessons were: a. -the value of operational research when closely linked with the program (para. 4.02-4.05 - the MIES system; para. 3.23 -- PC contribution to improved ANM curriculum; para. 4.06-role of deputy CMOs); b. support to the program from outside agencies can be valuable (paras. 3.50, 3.51--management training); c. management training, per se, is not sufficient to improve management styles which must be the result of many interlocking factors--administrative commit- ment, improved technical performance, improved faci- lities, as well as improved work programs (para. 4.09 management training; para. 4.10--technical improvements); d. to involve the community, considerable time is required (para.4.11-use of village authorities); e. the use of mobile service delivery teams over wide areas (such as a project district) can lead to staffing difficulties (paras. 4.22 and 4.24--mobile team experiences); f. the postpartum approach is probably best suited to an urban environment (paras. 4.16-4.17-urban maternity homes; para. 4.21--rural maternity facilities); and g. the project period was too short to allow definite evaluation of improved performance and project impact (para. 4.44 -- U.P. declines in CBR, CDR, IIMR; para. 4.49 - Karnataka declines in CBR). - 79 - 4.53 For the project process, the main conclusions are: a. unnecessary confusion and time delays result from inadequately determined project organizational structures (paras. 2.01, 2.02-- overall project organization; para. 2.09--construction management); b. inadequate phasing of complex inter-related activities leads to implementation and evaluation difficulties (para. 1.14--lack of project completion date; para. 2.03--activity phasing; paras. 3.01-- synchronization of activities; para. 3.48--time taken to build up institutional capability); c. Over-optimism in achieving results from a complex social project which included a substantial build-up of institutional and program infrastructure must be guarded against in project design (para. 4.39-little time left for observations and evaluation; para. 4.49-need for time to observe demographic implications); d. establishment of a project organization with weak links to program administration tends to create a separate identity which could diminish project impact (para. 2.05--project links with program); e. all program aspects need to be analyzed and assessed; indications for example, why demand constraints were considered to be of little or no consequence should have been given (para. 1.13--demand con- straints); and f. although there was considerable discussion between GOI officials in New Delhi and Bank staff on project compositon and organiza- tion, the evidence suggests that the project was developed mainly by Bank staff and agreed to with little commitment in several aspects by the GOI, leading to initial confusion and delays in implementation (para. 1.07--GOI view of pre-appraisal; para. 2.04-- understanding of Center-State relationships; para. 3.34--reactions to PC proposals; para. 6.01, 6.03--Bank role). V. COVENANTS AND THEIR FULFILLMENT 5.01 Each of the two State Agreements included 13 sections under Article II of similar covenants. Both States carried out the project with diligence and efficiency and, with the GOI, shared considerable concern for its successful implementation. 5.02 The Governing Boards were established as laid down. Project Coordinators were appointed in the Office of the Secretary of Health as were Family Planning Officers and nutrition officers in the department of health. - 80 - 5.03 The States established and maintained PCs which broadly under- took the functions assigned to them. As discussed earlier, it is difficult to say whether they performd an "independent evaluation of the program" as Schedule I of the Agreements reads. The Centers were staffed and organized according to the Agreement, with the exception of a nutrition division since the joint tripartite nutrition review felt this was not necessary. 5.04 The States contracted the services of the two Institutes, IIMA and ASCI, as required but the contracts were not signed until January 1974, six months later than they should have been. 5.05 Both States carried out the requirements of the Agreements with respect to staffing and training, and the provision of medical and other supplies. 5.06 The States duly acquired land and rights in land for project facilities. 5.07 As described in this report, there was little or no consultation with the Chief Architect of the PWD, but the States did establish construction units. 5.08 Agreements were signed with the AIIMS and the NIN to assist in planning and evaluating the nutrition components and a mid-term nutrition review did take place during the third year of the project as required. 5.09 All other covenants relating to procurement, insurance (nothing was imported), exclusive use of goods and services, furnishing of documents and information, and the maintenance of records were fulfilled by the States. VI. ROLE OF THE BANK 6.01 The Bank appears to have played the major role in the design and preparation of the project. Key features of the project design, such as the PCs, were ideas which emanated from and were developed by the Bank. Although the GOI requested the inclusion of a nutrition component, its. design was very largely the result of the work of Bank consultants. Bank involvement up to and including appraisal took six missions, 30 people and 591 person-days in the field, as well as considerable support from the Bank's Resident Staff in New Delhi,which, inter alia, was responsible for the collec- tion of large amounts of data. 6.02 The Bank acted on behalf of SIDA which financed one-third of project costs with a US$10.3 million grant. SIDA was represented on the second-phase appraisal mission and on the tripartite nutrition review. It participated in four of the last six supervision missions from 1976 onwards. Bank missions liaised with the SIDA office in New Delhi, when SIDA was not directly repre- sented on missions, and shared reports and information with that office. - 81 - 6.03 The project was supervised by 18 missions (including the nutrition review), nine of which were accompanied by the Department Director and seven by the Division Chief, a relatively heavy management involvement. There were two project officers, one succeeding the other in October 1974; not until April 1975, did a project officer visit India on Supervision. Much of the supervision work was done from the Delhi office where a population specialist was posted from October 1972 to May 1979; there were two incumbents. The post was carried on the regional budget and was withdrawn when the region decided it had other priorities for the number of available staff positions. There was good staff continuity in supervision. No supervision missions were under- taken from headquarters between October 1976 and July 1978 (during the period of the Emergency). (In -connection with a possible second project, a mission was sent to India in February 1978 to review the family planning situation and in so doing was in contact with project authorities. In terms of mission composition, architects were well represented. The long break in 1976-78, disrupted the "team" concept of supervision as staff were directed to other work. 6.04 Early supervision missions, often of one person only with the population specialis3t from the resident staff, concentrated on problems of declaring the project effective. They also seem to have spent considerable time in explaining to Government officials precisely what were the objectives of the project. This may reflect the dominance of the Bank's role in project preparation but on the Indian side, continuity was disrupted by frequent staff turnover at all levels and by long delays in making appointments to critical positions such as director of the PCs. The officers specifically appointed by the GOI to supervise the project were very important in problem solving and getting the project moving. To their considerable interest, enthusiasm, perseverance, and support of Bank supervision missions, considerable credit must be given. 6.05 By and large, the Bank's role in implementation was helpful and productive, and cooperation between the Bank, GOI and State Governments was mutually beneficial, leading to the preparation, appraisal and implementation of a second project based, in large, on experience gained during the first project. VII. CONCLUSIONS AND RECOMMENDATIONS 7.01 The project was ambitious, large, complex and experimental in nature. It was conceived at a time when the national FP program was searching for answers as to why more progress was not being made. The project was rightly directed towards research. In the context of population programs in the late 1960s, the preoccupation with family planning is not surprising. India's population problem was of serious concern to the GOI and shared by the Bank. The Bank's assumptions were that not enough was known about the program and that the available monitoring and evaluation capability was not adequate. Thus the project was designated experimental and considerable stress laid on - 82 - evaluation. These assumptions were correct, although more attention to Indian FP research up to this time might have influehced project design in favor of some recognition of approaches towards demand problems. 7.02 In responding to these assumptions, the project was correct in its emphasis on the need for effective operational research and effective program monitoring and evaluation. By and large, the project was implemented as designed and the reason for the two years delay in closing the credit was not primarily due to implementation slippages. The institutional objectives were realized and physical facilities and staff put in place. Program results are inconclusive as is the demographic impact, but both require more time for adequate evaluation and measurement. Whilst the project did not, within the time allotted, clearly demonstrate that improved service coverage would give better performance, it did indicate several areas -- management, training, monitoring and evaluation -- which program administrators should pay closer attention to in improving the program. 7.03 Achievements in implementation were attained despite several flaws in project design. There was initially inadequate attention to activity phasing, the time needed to develop institutional capabilities, and the time needed to put staff and facilities in place. The decision to establish project units with their own hierarchy of Governing Boards led initially to a separation of project and program. 7.04 In the later years of project implementation, there was an impact on State and GOI family planning programs. Much of the excellent methodological material for program staff in U.P. derives directly from project activities. There is now a greater awareness of and willingness to deal with program weaknesses at all levels. As project staff have graduated to take charge of State programs, acceptance of the value of managerial improvements, opera- tional evaluation, an effective service statistics system and the need con- stantly to review demand activities is being gradually transferred. From the time of acute suspicion of the involvement of non-government agencies, admini- strators are now more inclined to use outside expertise. The reorganization of the health services in Karnataka in 1977 with the help of the ASCI is an example. The project did not provide any brilliant perceptions as to how the national program could be improved, it did not even clearly demonstrate that better service coverage and utilization would lead to better performance, but it did contribute to a clearer understanding by program administrators of the mechanics of implementation. Lessons learnt were incorporated in the second project which was exclusively prepared by State officials and which reflects the importance of better management, better communication, better training and the need for decentralization. The fact that a project of this size in India could be implemented was in itself of importance. Unlike many previous small experiments, it did show the possibility of operational experimentation with the program itself on a large scale, confounding the skeptics who thought it was doomed because of its size. - 83 - 7.05 Experience with the project suggests that: a. local staff should be more involved in project preparation; b. greater concern is needed for local conditions; c. an accurate time schedule is vital in successful implementation; d. administrative arrangements should be detailed clearly; e. project components need to be carefully linked with each other; and f. early supervision after effectiveness by project staff is essen- tial to see that project concepts are followed. 7.06 Both PCs will continue to monitor and evaluate performance and should pay particular attention to: a. the cost o:E program activities, and their relationship to program budgets; b. detailed utilization of physical facilities and the establish- ment of activity "norms" for program.staff and facilities; c. the impact of "integration" on family planning performance; d. continued program evaluation to identify areas of potential managerial improvement at all levels; and e. continued monitoring of support activities such as motivation and training.  INDIA: (Cr.312-1N) FIRST POPULATION PROJECT UTTAR PRADESH--PROJECT ORGANIZATIONAL CHART Projoct Gowag Bowd Pfolect Coorknaser II Acco.usD Wing WI"I Deputy P.0*curdino (19o36l bloommSuiComndume Nhutsitio m Worl BAk 22533 - 85 - it, Ii fl1 I-0 1 ed ~. - 86 - ANNEX II Table 1 INDIA: (Cr.312-IN) FIRST POPULATION PROJECT SCHEDULE OF DISBURSEMENTS (in US$ millions) Appraisal Revised % of % of FY Quarters Estimate Estimate Actual Avoraisal Revised 1973 Sept. 0.2 Dec. 0.6 Mar. 1.2 June 2.1 1974 Sept. 3.2 0.1 3.1 Dec. 4.3 0.2 4.6 Mar. 5.8 0.2 4.6 June 7.3 0.6 8.2 1975 Sept. 8.9 1.9 21.3 Dec. 10.4 2.1 20.2 Mar. 11.8 3.1 26.3 June 13.1 3.7 28.2 1976 Sept. 14.3 5.5 38.5 Dec. 15.4 6.3 40.9 Mar. 16.4 7.8 47.6 June 17.4 8.2 47.1 1977 Sept. 18.4 9.9 53.8 Dec. 19.1. 11.8 10.9 57.1 92.4 Mar. 19.8 13.5 12.1 61.1 89.6 June 20.5 15.2 12.7 61.9 83.6 1978 Sept. 20.7 15.8 13.6 65.7 86.1 Dec. 20.9 16.4 14.2 67.9 86.6 Mar. 21.1 17.0 15.1 71.6 88.8 June 21.2 17.6 16.3 76.9 92.6 1979 Sept. 18.4 16.7 90.8 Dec. 19.3 17.3 89.6 Mar. 20.1 18.1 90.0 June 21.2 19.5 92.0 1980 Sept. 19.8 Dec. 20.0 Mar. 20.7 June 21.2 Source: World Bank. INDIA: (Cr.312-IN) FIRST POPULATION PROJECT DISBURSEMENTS BY EXPENDITURE CATEGORY (in US$ millions) Appraisal Actual Allocated % of Total 1 of Base Cost Disbursed % of Allocated 1 of Total Uttar Karnataka Uttar Karnataka Uttar Karnataka Uttar Karnataka Uttar Karnataka Uttar Karnataka Category Pradesh Pradesh Pradesh Pradesh Pradesh Pradesh Civil Works 4.88 3.52 46 35 57 41 6.03 4.51 124 128 56 44 Salaries 1.23 1.87 12 19 14 22 2.14 3.34 174 179 20 33 Vehicles 0.26 0.30 2 3 3 3 0.21 0.33 81 110 2 3 Equipment & Furniture 1.45 1.11 14 1i 17 13 0.89 0.96 61 86 8 9 Technical Assistance 0.66 0.58 6 6 8 7 1.37 0.66 208 114 13 7 Nutrition 0.12 1.26 1 12 1 14 0.08 0.45 67 36 1 4 (Base Cost) (8.6) (8.64) (81) (86) (100) (100) I Unallocated 1.98 1.44 19 14 23 17 - - - - - - Subtotal 10.58 10.08 JOO 100 123 117 10.72 10.25 101 102 100 100 - GOI Technical Asastance- 0.54 0.22 41 TOTA 21.2 21.2 100 fl Disbursed directly by 00. Source: World Bank. e INDIA: (Cv.312-tn) FIRST ?OfPUATION PWECT Ur'TA" MADEs"--Pff m~weANCE øv A&m< TRAINIIN 8saloms Date a Ade.tIo!a raduatone Fosated in Project Districta Troin.4s. astabligh- Dat r of 1973- 19- 1973-" 7! 1978- 19179- Total 1973- n 974- 975- 976- 1977- 1978- 1979- Total 1973- 1974- 1975- 1976- 1977- 1978- 1979- Total center oet Dccupancy 74 75 76 77 78 79 80 74. 75 76 77 78 79 80 74 75 76 77 78 79 80 O I-nkowu 11ral Apr.1'73 Kay 16'79 47 35 36 35 34 37 51 275 42 32 33 53 31 36 47 274 42 32 20 20 3 3 120 O S.bara~pur Apr.t'73 Apr.28'16 39 43 23 34 40 34 53 246 41 36 29 35 20 34 36 231 41 26 20 20 3 3 t13 let.abød apr.l'73 nor.16'76 41 45 29 40 46 28 54 293 20 26 29 36 26 38 45 220 20 26 10 12 2 2 72 a.* macelt gar.1173 Feb.24,76 53 34 51 48 40 39 48 313 - 24 38 28 28 47 43 208 - 24 to B 5 6 53 K.saffornsar Apr.l173 Jua.09'76 38 26 22 28 41 39 51 245 26 38 2 19 25 36 165 - 26 18 10 3 2 59 L..ckaau ~ban Sop.t'73 Kay 16'79 42 44 32 35 37 32 52 274 - - 36 36 28 29 33 162 - - 10 i 5 5 35 sult.epor J.l173 Jaly&5'76 65 46 42 42 39 32 47 313 - - 45 44 42 32 41 204 - - 10 10 2 3 25 Pratapgarb Kay 21176 Kay 2176 38 38 36 43 41 33 48 306 - - 44 41 27 44 37 193 - - 10 12 3 2 27 Alitoed, (year totale> r8 11 »fl L0 2U - - - - - - - - - . . - orad-.tod (ar total*) 103 544 192 2j94 21 283 18 65- - - - - . tosted om LJ 134 108 101 26 26 504 Proet 0iattitto (Taar Total.) oucel IFa--U.P., Ireft tvalutto. Repørt, L.,kaoo, NovI "r 1 INDIA: (Cr.312-IN) FIRST POPULATION PROJECT UTTAR PRADESH- - PERFORNANCE OF AMh TRAINING IN PiC HOSTELS Date of AH Trainees Training Center Hame of PHC Occupancy 1975-76 1976-77 1977-78 1978-79 1979-80 Total Lucknow Rural Sarojininagar Sept.15 '75 18 35 34 37 51 175 Saharanpur Derband Aug. 28 '75 12 34 40 34 53 173 Fatzabad masauda Aug. 28 '75 12 40 46 28 54 IB0 Rae Barelt purshatganj Jan. 30 '76 - 48 40 39 48 175 Huzaffarnagar Baghra Nov. 4 '75 10 28 41 39 51 169 Lucknow City Nohaulatganj Oct. 15 '75 12 35 37 32 52 168 Sultanpur Dubeypur May 12 '75 20 42 39 32 47 180 Pratapgarh Sukhpalnagar Jun 5 '75 15 45 48 33 48 189 TOTAL 99 307 325 274 404 1 Source: IPP--U.P. Draft Evaluation Report, Lucknow, November 1980. 0 e% INDIA: (Cr.312-IN) FIRST POPULATION PRIET UTTAR PRADES11--POSITIONING OF ANHe AHms in Position * Subcenter PHCa - Subcenters Other Rural Ppulatii AMI:Popu Lion Ratio 1973 1980 1973 1980 1980 1971 1980i 1971 1980 Lucknow Roral 16 16 63 79 794376 916800 11512 11605 Saharanpur 32 32 71 151 18 1572027 1925382 22141 12750 Rae Karalt 32 32 77 144 18 1459409 1654116 18953 11486 husalfarn4gar 28 80 149 3 1552474 1866234 19405 12525 sultmmpur I8 38 71 142 3 1610598 1844818 22684 12991 Praupgarls 30 30 35 130 3 1394798 1567433 39851 12057 TOTAL 176 176 397 795 45 8383682 9774783 21117 12295 Source: IPP--U.P. Draft Evaluation Report, Lucknow, Novmber 1980. 0 Ix U oh AM - 91 - ANN II Table 6 INDIA: (Cr.312-IN) FIRST POPULATION PROJECT UTTAR PRADESH--EXPENDITURES INCURRED ON ANM TRAINING (in Rupees) Facility 1973-74 1974-75 1975-76 1976-77 1977-78 1978-79 1979-80 AMTC 511,514 529,241 962,211 1,334,230 1,230,553 L,336,199 1,556,187 Hostels - - 343 38,155 56,599 60,709 67,328 Appraisal Estimate: Rs.3,066,100 Actual: Rs.7,683,269 % of Estimate: 251 HFWTC and 54,055 51,968 67,325 103,117 103,538 94,589 112,769 MTT Appraisal Estimate: Rs.263,000 Actual: Rs.587,361 7 % of Estimate: 223 Source: IPP--U.P. Draft Evaluation Report, Lucknow, November 1980. INDIA: (Cr.312-IN) VIRST POPUI.ATION PRI&ECC' KARNATAKA--WPEO~mnCE OF AN TRAININ SCitOI.S Training Year of AD mI S S 1 0 Ns G R A D I AT r O N s Center Occupaucy 1973-74 1974-75 1975-74 1976-77 1977-78 1978-79 1979-80 TOTAL 1973-74 1974-75 1975-76 1976-77 1977-78 1978-79 1979-80 TOrAL Rangalore 1975 45 - 30 - 30 30 36 171 25 30 45 - 30 - 26 156 airadursa 1975 75 - - 30 30 - 30 165 28 30 69 - - 22 24 173 Kolar 1977 45 3ü - 30 3 - 30 165 59 - 45 30 30 - 24 211 shtmga 1976 - 45 30 - 30 30 30 165 30 30 - 43 30 23 29 142 Tumkur 1975 45 - 30 - 30 30 30 165 29 30 45 - 30 - 26 160 Admitted L 20 .75 9 60 150 90 156 831 Graduated 171 120 204 1 120 45 129 162 fl Year totale. Source: IPP--Karn4taka, PCR, Population Center, Ba~glore, 1980. 1 4 INDIA: (Cr.312-IN) FIRST POPULATION PROJECT KARNATAKA: POSITIONING OF ANMa ANMs in Position Rural PH1C & Subcenter PHCa & Subcontere Other Population ANMa: Population Ratio 1973 1980 1980 1973 1980 1973 1980 Chitradurga 104 131 135 1,114,472 1,385,258 1:10,716 1:5,207 Kolar 140 164 114 1,203,459 1,527,488 1; 8,596 1:5,494 Bangalore(Rural) 135 16 28 1,599,674 1,754,773 1:11,849 1:9,235 Shimoga 202 334 56 994,205 1,243,630 1: 4,921 1:3,188 Tum1kur 123 147 27 1,426,665 1,802,000 1:11,598 1:1,356 Subtotal (Rural) 704 938 360 6,338,475 7,713,149 1:9,004 1:8,223 RanealnrA (rity) 36 36 28 Total 740 974 388 Source: IPP-Karnataka, PCR, Population Center, Bangalore, 1980. O0 H - 94 - ANNEX II Table 9 INDIA: (Cr.312-IN) FIRST POPULATION PROJECT UTTAR PRADESH--NUMBER AND TYPE OF STAFF TRAINED BY HFWTC AND MTT Staff Trainers 1974-75 1975-76 1976-77 1977-78 1978-79 1979-80 TOTAL Medical Officer 42 - - 2 - - 44 Block Extension Educator 11 8 42 21 22 15 119 Lady Health Visitor 19 16 69 41 42 33 220 Auxiliary Nurse Midwife 125 71 363 261 233 143 1198 FPHA 64 40 151 112 96 57 526 TOTAL 261 141 625 437 393 250 2109 Source: IPP--U.P., Draft Evaluation Report, Lucknow, November 1980. - 95 - ANNEX II Table 10 INDIA: (Cr.312-IN) FIRST POPULATION PROJECT KARNATAKA--NUMBER AND TYPE OF STAFF TRAINED BY RFPTC AND MTT Staff Trainers 1973-74 1974-75 1975-76 1976-77 1977-78 1978-79 1979-80 TOTAL Block Extension Educator - - 4 - - - - 4 Lady Health Visitor 7 21 76 93 59? 17 103 376 Auxiliary Nurse Midwife 143 305 276 412 380 220 136 1872 FFHA 31 37 3 - - - - 71 TOTAL 181 363 359 505 439 237 239 2323 Source: IPP--Karnataka, PCR, Population Center, Bangalor4 1980. -96 - ANNEX II Table 11 INDIA: (Cr.312-IN) FIRST POPULATION PROJECT UTTAR PRADESH--RESEARCH STUDIES CONDUCTED BY POPULATION CENTER DURING 1975-80 Area of Research 1975-76 1976-77 1977-78 1978-79 1979-80 TOTAL Studies on Operational and Managerial Aspects of the Family Welfare Service Units-- .HC, Subcentre, Urban Centres, State Family Welfare Bureau 2 4 5 3 4 18 Studies on Effectiveness of Program Services Including Different Methods 4 5 4 5 6 24 Studies on Education and Com- munication Activities in Family Welfare Program 2 2 1 2 3 10 Studies on Involvement of Diff- erent Organisations/Institutes 1 1 4 3 3 12 9 12 14 13 16 64 Source: IPP--U.P., Draft Evaluation Report, Lucknow, November 1980. - 97 -- ANNEX II Table 12 INDIA: (Cr.312-IN) FIRST POPULATION PROJECT KARNATAKA--NAMES OF SELECTED STUDIES AND PUBLICATIONS BY THE POPULATION CENTER Selected Studies 1. A Longitudinal Study of Fertility, Mortality and Family Planning. 2. A Longitudinal Study of Perinatal and Infant Mortality. 3. Levels of Job Satisfaction of PHC Personnel. 4. A Study of Family Planning in a Public Section Undertaking. 5. Social Marketing of Nirodh. 6. Dual Record System. 7. Complications Among the Vasectomy and Tubectomy Acceptors in Camps and Hospitals. 8. Involvement of Satisfied Sterilisation Acceptors in Promoting Family Planning. 9. Orientation Workshop for Family Planning Officers in Bangalore Divion. 10. Management Family Planning Program at Primary Health Centers. 11. Drugs Distribution System. 12. A Study of Budgetary System--Feasibility of Using Program and Performance Budgeting System for Improving Family Planning Performance. 13. Family Planning Stores--A Study. 14. Family Planning and Health Information System. 15. A Study of Management Strategy. 16. A Study of Vaccine Distribution System. 17. A Systems Evaluation of Experimentil Strategies. Publications 1. Newsletter (published bimonthly, including findings of various studies). 2. Occasional Papers (series) 3. Popuktion and Society (semi-annual) Source: IPP--Karnataka, PCR, Population Center, Bangalor4 1980. - 98 - ANNEX II Table 13 INDIA: (Cr.312-IN) FIRST POPULATION PROJECT NUMBER OF REGISTERS MAINTAINED UNDER EXISTING AND PROPOSED SYSTEMS Existing System Proposed System Number of Number of Number of Numbers of Registers/ Reports/ Registers/ Reports/ Records Returns Records Returns Fieldworkers ANM 22 12 FHW! 8 1 Basic Hlth.Worker 11 14 MEW Vaccinator 4 3 FP Hlth.Assistant 6 4 MPW 3 2 Supervisory Staff LHV 5 3 FHW/ 4 1 Senior Health Inspec. 5 4 MHW Block Hlth. Educator 2 3 PEC Headquarters 50 42 General 45 1 Special 5 5 Quarterly 3 Semi-annually 10 Sub-center 4 - Headquarters 1 Source: IPP--KarnaLtaka, PCR, Population Center, Bangalore, 1980. INDIA: :r.312-IN) FIRST POPULATION PROJECT K48N47454--PEFORMA88CE Of MSU* (30 BEOS) IN GISTRiCe W6PI1¶TALs Banga1ore ChI,tradurge Kcolar Shimoka Tumkr QuarterEnding j* 2* 3* 4* S* 1* 2* 3* 4* 5* 1* 2* 3* 4* 5* 8* 2* 3* 4* 5* 1* 2* 3* 4* 5* December 1 1979 1649 284 38 133 264 57 35 5 109 269 65 84 77 49 37 19 - 184 92 402 80 - 8 115 September 30. 1979 1767 434 259 - 187 288 71 25 31 104 279 69 16 80 38 5 24 - 222 152 449 92 - 5 136 June 30, 1979 1594 421 9 7 211 386 22 41 20 106 273 46 3 23 34 51 24 - 32 118 201 43 - 411 71 Year subtotal 5010 1139 306 7 511 938 150 101 102 119 821 180 103 180 821 139 67 - 438 3b2 1052 215 - 176 322 areh 31, 1979 1353 348 40 - 91 297 23 4 2 106 245 34 - 84 106 31 46 7 33 78 405 93 t6 82 December 31, 1978 1447 422 57 - 154 128 36 - 122 173 252 7 30 59 35 - - - - - 367 88 k2 2 816 September 31, 1978 1609 410 119 - 210 292 43 30 til 82 314 7 9 35 33 43 51 - 27 147 497 82 162 - 98 June 30, 1978 1575 119 88 - 69 295 16 7 28 72 315 21 163 - 72 686 61 82 41 197 409 79 I49 - 70 Year Subtorat 98 _299 -5241118 63 33 826 69 202 78 246 60 58 9 0 22 8678 342 39 March 31, 1978 1511 417 273 - 94 244 26 13 115 61 280 109 46 2 62 562 102 91 48 251 433 131 198 - 76 December 31, 1977 1563 423 136 - 303 232 30 16 85 79 238 35 50 - 50 595 110 147 93 216 403 88 197 - 93 September 31 1977 - - - - - - - - - - - - - - - - June 30. 197) - - - - - - - - - - Year "ubtotal 3074 840 09 - 97 476 26 9 200 140 16 44 6 1 812 7 12 238 848 467 836 9 38 - 69 March 31, 1977 - . . - - - - - - - - - 544 42 141 121 268 381 65 126 50 127 December 30, 1976 384 53 51 - 261 37 186 124 247 236 10 154 - 176 484 35 172 415 296 404 106 116 42 82 September 30, 1976 286 40 139 286 254 40 2031 - 257 271 50 - 13979 93 628 20 142 337 219 282 til 178 104 118 June 30, 1976 1244 342 264 - 246 82 10 35 389 92 204 40 - 557 77 193 14 14 66 65 376 1)4 43 25 90 Year Subtotal [914 41% 264 190 2 _ 97 7 2252 583 596 Li 0 854 L536 36 9 Il 469 939 i48 8443 38h 463 228 47 TOTAL 15955 3713 U83 197 t984 3023 1 4 5 17 892 400 1274 * Numbera I to 3 repreøent caeg of: I - Deliverteg 2 - HTP and 8pontaneou Abortion 3 - Direct Family Plannifg 4 - Indtrect Family Plamnitag 5 - "ubeetømes Source: Stat Quarterly Rparte. INIJIA: Cr.i IS2-IN) MIM. PIIllrATiIN ItoJErT MYAR PRADEi11--ESTIfMATMJ AN AlTkAI. 1IT1S AVEWTKI Sterilmaion i0 .. rureptIve Util:rl v4__ ____a Staff Appraal Acual Staff Appraisal Acagdi Statt Appralal Aýt:tui Sutt ApraIl YFAR Report Etimate - Actual a of Report Eatimate Actudi g t o1. Reori. kbtimJLC AcLual tb it l. port- lutIal, ACt4.Il ål % of Estimte Es-[mate Eti mate Est imat. 1973-74 13642 4089 30.0 1260 5569 442.0 326 1955 599.7 15228 11613 76.1 1974-b5 27283 9906 36.3 2520 9062 359.6 652 2033 311.8 '3tI$5 21001 69.10 1975-76 36377 24485 67.3 3360 10036 298.7 870 4712 541.6 40607 3,#233 96.6 1976-77 54566 143755 263.5 5040 13105 260.0 1305 4020 308.0 111911 16880 264.1 1977-78 56355 i22u 2.2U 34 . 34 43! 336.6 6294! I512 24.l 1978-79 57522 4646 8.1 5313 3756 70.7 1375 6433 467.9 64210 14b35 23.1 1979-8(1 58658 9535 16.3 5418 19521 360.3 1402 5304 37B.3 o5478 34360 52.5 IL. 304433 197616 64.9 28119 70433 250.5 7278 28995 398.4 19830 24/044 ti/A Soerce; iPli.P., braft Evaluation Repart, .ucknow, Novewber 1980. O- - 101 ANNEX II Table 16 INDIA: (Cr.312-IN) FIRST POPULATION PROJECT KARNATAKA--ESTIMATED AND ACTUAL BIRTHS AVERTED Actual Births Births Estimated Actual Averted To Be Averted As % of Year Based on Performance As Per ApDraisal ReDort Estimate 1973-74 44,933 20,711 217 1974-75 43,010 41,421 104 1975-76 83,738 55,225 152 1976-77 380,284 82,844 459 1977-78 91,043 86,180 106 1978-79 89,611 88,461 101 TOTAL 732,619 374,842 195 Source: IPP--Karnataka, PCR, Population Center, Bangalore, 1980.