India - Second Population Project

〃 · , … , ㅣ ㅣ」 「 , … ;&&1，「―’→，ㄴ·―·닒·／-,．·」」··1J1。．&.-1&,：··’」｀눼」·11.!‘…‘·르！&!，·1눕，J^/&..：논．「－．·―’낟‘【·―-.,I&1「·‘｀·떼―l떼l& p 닐 【， . ∼ 컨 CURENCY EQUIVALENT$ Currency Unit - Rupees US$1.60 = Rs. 8.60 (Appraisal Rate) WEIGHTS AND MEASURES Metric System ABBREVIATIONS ANM Auxiliary Nutse-Midwife AP Andhra Pradesh CHG Community Health Guide CHW Community Health Worker DANIDA Danish Development Agency D&E Demographic & Evaluation DEA Department of Economic Affairs GOI GoveTment of India HFWTC Health & Family,Welfare Training Centre IDA International Development Association IEC Information, Education and Communication IPP India Population Project LHV Lady Health Visitor -NCR Maternal Child Health MHS Male Health Supervisor MIES Manageme-t. Information and Evacuation System NGO Non-G& -mental Organization ODA Oversc-i'Development. Authority (UK) OED Operations Evaluation Department OP Out-pat ent ORG Operati6ns Research Group OT Operating Theatre PCR Project Completion Report PHC Primary Health Centre PHN Population, Health and Nutrition PPAR Project Performance Audit Report RFWTC Regional family Welfare Training Center SAR Staff Appraisal Report SIDA Swedish International Development Authority TBA Traditional Birth Attendant! UNFPA United Nations Population Fund UNICEF United Nitions; Children's Fund UP Uttar Pradesh FISCAL YEAR OF BORROWER .Goverment of India: April 1 to March 31 THE WORLD BANK Wstngton. D.C. 20433 U.S.A Ofe of okctr.C~eral OpetJtws avehenna June 29, 1990 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SULECTs Project Performance. Audit Report -- 1I)dia Second Popation Prolct fredWt2981-IN) Attached, for information, to a copy of a report entitled "Project Performance Audit Report - India Second Population Project (Credit 981-IN) , prepared by the Operatione Evaluation Department. Attacbment This docunmat has a saurctd distibutio and may be =sed by ecipietsa only in the pWerfamwe of their olicial dutisk Its contts may not otherwise to disclosed without WoM r nk a FOR OFFICIAL USE ONLY PROJECT PERFORMANCE AUDIT REPORT INDIA SECOND POPULATION PROJECT (CREDIT 981-IN) TABLE OF CONTENTS Pase No. PREFACE......... . ...... .. .. o.... ..... . . . ....... I BASIC DATA SEiT.................................. i1 EVALUATION SUMMARY......... o... ...................... iv PROJECT PERFORMANCE AUDIT REPORT I* BACKGROUND.*#.. ....* *........................ 1 II. THE PROJECT IN PRINCIPLE AND DESIGN........... 2 III. PROJECT EXECUTION AND RESULTS ................. 4 IV. PROJECT EXTENSION............................. 4 V. PROJECT IMPACTS AND POSSIBLE REASONS ......... 6 FOR FINDINGS A. Evidence.................. 6 B. Why no differential impact............ 7 C. Why such slow progress................ 9 VI. BANK PERFORMANCE.............................. 12 VII. SUSTAI NABILT................ 13 VIII. CONCLUSIONS AND LESSONS....................... 13 PROJECT COMPLETION REPORT............................... 19 PART I PROJECT REVIEW FROM BANK'S PERSPECTIVE ........ 20 Project Identity............ ........... 20 Overview and Summary. ................... 20 Background - The First India Populats.on....... 21 Project The Second India Population Project -......... 22 Background, Objectives and Development Project Description........................... 23 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 authoriztion. TABLE OF CONTENTS (Cont'd) Paste No. Project Implementation....***************** 24 Service Delivery........................ 24 26 Population Education.................... 27 Program Monitoring, Evaluation...,....... 7 and Research Program/Project Management.............. 28 Project Monitoring and Evaluation............. 28 Project Extension............................. 29 Project Sustainability........................ 29 Bank Performance....................... 30 Borrower Performance...... .......... ....... 30 Project Achievements......................... 31 Family Planning............................ 31 Maternal-Child Health...................... 33 tesons Learned.................4........99... 33 PART II PROJECT REVIEW FROM BORROWER'S PERSPECTIVE.... 36 PART III STATISTICAL INFORMATION.-.................. 38 Related Bank-Loans or Credits................. 38 Project Timetable.................-9.......... 40 - Credit Disbursements.......................... 41 Project Inputs....,www..................... 42 Project Costs and Financing................... 49 Project Achievements.............. ....... 51 Status of Covensats........................... 60 Use of Bank Resources... .................... 61 PROJECT PERFORMANCE AUDIT REPORT INDIA SECOND POPULATION PROJECT (CREDIT 981-IN) PREFACE This is a Project Performance Audit Report (PPAR) of the Second Population Project in India for which a Bank credit in the amount of US$46.0 million was approved in February, 1980. The last disbursement was made in December, 1988, a delay of three years after the original closing date of December 31, 1985, which was twice extended (first to March 31, 1986 and then to March 31, 1988). The remaining US$1.8 million undisbursed balance was subsequently cancelled. This volume consists of a Project Performance Audit Report (PPAR) prepared by the Operations Evaluation Department (OED) and the Project Completion Report (PCR) prepared by the Asia Regional Office (Parts I and III) and the Government of India (Part II). The PPAR is based on a review of the Staff Appraisal Report (No. 2668-IN) dated January 15, 1980, the President's Report (P-2692) of May 25, 1983, the Development Credit Agreement dated April 14, 1980, internal Bank memoranda and reports pertaining to this project, and interviews with Bank staff and Indian officials associated with this project. An ORD mission visited India in November-December, 1989, and held discussions with Government and project officials and visited a number of project sites. These interview and observations contributed substantially to the conclusions reached in the PPPa. The assistance provided by officials of the Government of India and the States of Uttar Pradesh and Andhra Pradesh is gratefully acknowledged. Part I of the PCR provides a good account of the project's background, implementation record and initial impacts. Part II provides comients by the Borrower giving its perspective. The PPAR elaborates on some of the PCRs conclusions, considers possible explanations for some of the results and raises several issues of significance for subsequent population projects. Following standard OED procedures, copies of the draft PPAR were sent to the Government for comment. No comments were received. PROJECT PERFO1WiCE AUDIT REPORT INDIA SECOND POPULATION PROJECT (CREDIT 981-IN) BASIC DATA SHEET KEY PROJECT DATA Appraisal Item Estimate Actual Total Project Cost (US$ million) 96.0 115.8 Overrrun (2) 21 Loan Amount (US$ million) 46.0 Disbursed 44.2 Cancelled 1.8 Date Physical components Completed 12131/85 0313188 No. of Months since Loan Signature 67 94 Proportion of Time Overrun (2) 402 Institutional performance Good OTHER PROCT DATA Item Original Plan Actual First Mention in Files 12176 (Identification) - Preparation - 1977 Appraisal Mission - 05179 Negotiations - Dec. 1979 Board Approval Feb. 12, 1980 Loan Agreement Date June 14, 1980 Effectiveness Date June 26, 1980 Closing Dite 12/311-1985 March31, 1988* Loan Disbursement Completion March 31, 1685 March 31, 1988 Borrower Government of India Executing Agency Ministry of Health (State of U and State of AP) * First revislon on March 81, 1986 CUSULATIVE ESTIMATED AND ACTUAL DISBURSEMENT (in I3* aiId i on) __Y 19 8 L fl_ I 1984" 1994 1"S ~ 19 88 1989Mto Appraisal .4 6.8 18.5 81.6 42.3 46.9 48.9 46.9 46.0 46.9 Estimate Actual 0.9 .8 2.8 8.9 16.5 26.6 82.8 88.9 41.8 44,2 Actual Of x ofEstisate .915 17 28 89 56 71 88 91 so USE OF SANK RESØJRCES muisna NeathNeaI t*. of Day7 Saecalsat Peform~ a IL-* Type& of Pa nn Slw us pLbløm 3 Throuah Anraisa1: October 3. 1976 7 19 .,b.e Jaar? 28. 1977 3 8 a,b.c.e .fbrua~y 20. 1978 3 21 a,.4 October 15. 1978 9 31 a.b.c.d.f, ay 2, 1979 Ø 28 Board A irvl Gotober 25. 1#79 4 6 a,b.4,4 a iwh 1, 1980 44 a,b,o., Iovember 19, 1980 5 20 a.b,c.f.i Hay 21, 1981 2 14 a.b 3 N,? Oatober 18, 1981 5 21 a.b.,d,£ 2 N Nay 2, 1982 2 15 a,b 2 K Otober 16. 1982 3 15 a,b,9 2 m Nay 13, 1983 1 17 b 2 m pbra 12. 1984 4 18 4.b,e. 2 14, 1984 6 20 a,b.c,, 2 N Apfti 30,198 2 9 b.o 2 m sove~aber 24, 1985 4 a a,4.b,e 2Ua * Prepart@o et July 2, 1986 4 - a,oeg,h -- December 1, 1986 2 - a.o 1 . nGum~ 4, 197 3 a.4 ced.s 1 & a Ppulaton Spootaltats b Ardhtøets a ~ ealth Spectalist6t d • Ie 0~st, . - Noitør" 6 uBa spLatat C SpeaalLa 8 Training SpeciaS.ast b • Populatio du-a 2 1 - problem fre* ør ~or problem* 2 - moderate problemt 3 m major problem 3N - NIamaamusu P • PolItIal F.za zz 2 2 m :m u al m ItDe Preappraisal .1 3.1 55.9' 48.8 97.1 - - - - AppriMal - - .2 - 89. 46.9 - - - 106.7 - - - - - 13.2 - - - - - - 13.2 lala- - 7.3 9.3 44.5 18.0 13,9 25.4 36.8 11.1 4. 197.7 Other - - - - - -- 1.4 - 1.4 TTAL .1 3.1 - 2 485 16.7 67.4 39.8 44.8 13.0 13.9 25.4 86.6 12.5 4.6 52.7 PROJECT PERHORMANCE AUDIT REPORT INDIA SECOND POPULATION PROJECT (CREDIT 981-IN) EVALUATION SUMMARY Objectives 1. This project is the second in a series of six population projects so far agreed between the Bank and the Government of India. The goal was to Implement the Sixth Plan norms (e.g., number of primary health centers and sub-centers per unit of population) in nine selected backward districts of two states, Uttar Pradesh and Andhra Pradesh, at twice the speed which the GOI planned to do so in other districts in order to more rapidly improve performance of the family planning (FP) and maternal and child health (MCH) programs. Construction and equipping of facilities (mainly sub-centers) was supported by training, information, education and communications (IEC) activities and program management components. lmlementation 2. Despite initial delays the project's physical goals were nearly all achieved and the rupee budget expended by March 31, 1986, three aonth -after the original closing date, a very commendable performance given the formidable problems that occurred along the way. The project was extended twice, first by three months to allow completion of some remaining elements and then by two years to utilize an undisbursed foreign exchange balance resulting from devaluation. This balance was used to continue the project's funding of incremental recurrent costs, to extend the IEC component to non-project districts and to correct deficiencies in already commissioned buildings. This extension was not well programmed or supervised. Imact 3. Using service statistics to judge project impact three years after buildings were commissioned and additional staff was in place, the conclusion must be that the project had virtually no differential impacts contraceptive prevalence rates slowly increased in non-project as well as project districts at about the same rate and most indexes of MCR performance (e.g4, use of clinics and trained professionals for delivery and immunization rates) indicated no upward trend in either set of districts. While a variety of factors contributed to this outcome (including siting problems, some shortcuts taken to complete the project within the specified period and temporary budget disruptions at the end of the project), the most important factors weres --excessive focus on infrastructure and relative neglect of other inputs such as training, especially in-service training and IEC. --failure to provide all necessary inputs at a significantly different rate--let alone anything like twica the rate--than they were being put in place elsewhere. The project districts differed from nonproject districts in that the number of sub-centers, plus staff and equipment for them, increased a little more rapidly, the proportion of constructed versus rented facilities increased, and IEC and management training inputs were somewhat greater. But there was no difference in other inputs affecting quality of service, such as medical supplies, multipurpose worker training and field supervision. --the fact that project as well as non-project districts operated under the constraints of, the overall program, some of which are more binding than lack of physical inputs, for example e-cess4ve focus on sterilisation, excessively large target population at. Aumber of tasks per worker, and continued neglect of factors that could influence demand for family planning and MCH, especially those lying outside the health field such as education and employment opportunities for women. Sustainability 4. There is no doubt about the long term general commitment of the Government to the family planning and MCH programs,, There also appears to be widespread recognition within and outside the Government of the problems these programs have run into. Some uncertainty about how the Government will respond to these problems has been introduced because. oftthe recent elections that brought to power a coalition Government whose policies are still evolving. 5. Maintenance of buildings and equipment established by the project has been a problem since the project ended. Two factors are implicateds financial resources and logistic and managerial problems at the local level. The GOI reports that the resource problem has now been resolved (see PCR, Part II). Other problems are still present in some locations. Conclusions and Lessons 6. The PCR presents a number of lessons derived primarily from the implementation of this project. This report, after commenting on and suggesting some revisions in these lessons, goes on to agree with the PC4 that they are unlikely to make a significant difference in the outcome until more fundamental problems with the Indian program are resolved. These problems include excessive "focus on sterilization at the expense of- vi - temporary contraceptive methods and MCH services, focus on the achievement of targets rather than the provision of services, the lack of appreciation *,.of IEC..., the need for strengthening and decentralization of program planning and management" and lack of appreciation and focus on structural changes that can affect demand, for example, women's education and employment opportunities. Most of these problems were recognized at the end of the first population project but were not taken up in the second and still remain to be resolved (see, however, para 5.22). 7. Two a.guments are frequently given for not seriously trying to tackle these more furdamental rroblems. One is that the Bank had no policy leverage or influence because its contribution to the family welfare program was small and because there was pressure to lend to this sector in any case. The other is that many of these problems involve general policy issues that were not appropriate to taks up in the context of this district-focused project. Two points su4mming out of the experience of this project should be made in rejoinder. 8. First, if the Bank wishes to have an influence on policy in a situation where its leverage is small, it has no choice but to z.ly on its powers of persuasion. That means more, not less, sector work.1/ In this case, up to about 1987, sector work was nil. 9. Second, although we are now told it works the other way, an Important early rationale for focusing on selected districts was the argument that the Bank could have more influence in selected districts than it could in the overall program. An important lesson to learn from these first two projects is that this is only the case if there is a clearcut agreement in advance that critical elements of the overall program can be different in the project areas. In the case of IPP2, there was such an agreement for infrastructure and equipment. But there was no such agreement for some other inputs and elements of the program; and some of these, in the end, proved to be more significant bottlenecks to progress than shortage of infrastructure. Without such an agreement there is no reason for the Bank to become involved in an area projects it would be more transparent to provide general support to the overall program. 10. A final comment should be added about implications for other area projects the Bank has funded. The premises of these first two projects, namely that the Sixth Plan norms are the appropriate targets to implement and that the principal bottleneck to progress, at least in the districts involved, is shortage of infrastructure, are not fully supported by their results, even though their design should allow these premises to be tested. The Bank has, however, continued to support actively the Indian Family Welfare Program. The design of projects subsequent to the second one has not been based as much as desired on either sector work or a formal assessment of the Sixth Plan norms. It will be important in the near future, therefore, to examine the extent to which these factors constrain those projects from having their desired impact, as they appear to have constrained the Second Population Project.. 11 See footnote to para 2.04 for suggestions about studies that might have made a difference. PROJECT PERFORUMNCE AUDIT REPORT INDIA SECOND POPULATION PROJECT (CREDIT 981-IN) I. Backaround 1.01. Th4k Indian family planning (FP) program Is administered by the Ministry of Health anu Ymily Welfare (MON), which provides funds'to state ministries for implementation. Along with maternal and child health (MO=) measures, family planning services are delivered through primary health centers (PCs) and subconters by the doctors, nurses, auxiliary nurse midwives (ANa) and multipurpose workers attached to these centers. Since the early seventies, this ministry's investment program has been guided by the long-range goal of establishing a network of these centers, subcenters and health workers at certain norms (densities per unit of population). This long-range blue-print, or model as it was eventually called, also guided requests to donors who were asked to support various pieces of the- investment program. 1.02. --The Bank's first population project in India (IPP1), signed in 1973, was billed as an experimental project, "to see whether performance would improve if the GOI pattern [the norms specified in the Fifth Five- Year Plan] was implemented and whether there were any alternatives to this pattern and the strategies then used for family,planning" (PPR, IPP1, para 1.03). This project provided an IDA credit of $21.2 million and a Swedish (SIDA) grant of $10.6 million to implement these norms in 11 districts of two states, Uttar Pradesh (UP),,and Karnataka more rapidly than funding would permit elsewhere, and t9 provide additional inputs to test alternatives. In addition, it supported the development of training, research and analysis capacities, including the establisbmnt of two Population Centers, and provided funds for technical assistance, overseas training and staff salaries for the project period. 1.03. Long before this first project was completed and it was possibli to determine whether the model plan did in fact make a significant difference, the Bank negotiated a secohd project (IPP2), the subject of this audit. This project also concentrated on implementation of the model plan in selected districts.- It differed from the first project in that it was based on the Sixth Plan norms which, among other things, called for one su6center per 5000 persons instead of one per 10,000, included a more s$gnificant information, education and communications (EC) component, eliminated an, unsuccessful nutrition compohent, and dropped the notion,of being experimental. Signed in 1980 after nearly five years of discussion (proonged in part by a change in Government), it provided an IDA credit of US$46.0 million to i'mplement the model program in six relatively backward districts of UP (different from those supported in the first project) and - 2 - three in Andhra Pradesh (AP) at twice the speed (five years instead of ten) which the Government planned to do so elsewhere in these states (SAR, para 4.16 and President's Report, para 52). SIDA considered participation in this project but in the end decided not to do so. At about the same time, the Government signed agreements for similar 'Area' projects in other statep- with DANIDA (Denmark), ODA (UK) and UNFPA. 1.04 Since 1980, the Bank and the GOI have proceeded with five more proje.;ts, and two additional ones are being prepared. The third, fourth and fifth credits are similar in that they continue to provide support for expansion of the health system in specific areas (the fifth differs in that it is to be implemented in two cities with the help of nongovernmental organizations). The sixth and seventh differ in that they focus on strengthening statewide training programs. The eighth, like the fifth, will provide support for the urban family welfare program, but differs in that it will be a sector operation. In general, there has been an evolution of these projects, the focus shifting from district to statewide support, from construction to IEC and training, and from concern with detailed to more general policy issues; also, the projects have consistently gotten larger. 1.05. The PCR for this project, attached to this report, provides a balanced, comprehensive description and history of this project. This PPAR will focus more on project impacts, reasons for results obtained, and selected issues, particularly those of relevance for future Bank activities in this field. II. The Project in Principle and Desian 2.01. The project was to be based on two sets of principles, those incorporated in the Government's general policy statement on Family Welfare, June, 1977, and others developed specifically for this project. The first set included the following: family planning services were to be delivered as an integral part of a family welfare program focusing on the health of mothers and children; the program would be entirely voluntary; all methods of contraception would be promoted with equal emphasis; and the focus would be on the most underserved, rural areas. The second set, initially agreed to in an Aide Memoire dated 15 November 1978 signed by representatives of the GOI, the Governments of AP and UP and the joint World Bank/SIDA mission, added that the project would be managed through the existing administrative system, perhaps enhanced by additional permanent posts, rather than through an independent implementation unit as in IPP1; that the entire spectrum of activities comprising the family welfare program would be covered; that these activities would include efforts to create community awareness and demand for the services, which would take considerable time to accomplish; and that the lessons of IPP1 would be taken into account. 2.02. Given the nature of the project, it is clear that there was another more fundamental assumption implicit in this project, that at least in UP and AP in 1980, the principal limitation to more rapid progress in acceptance of FP and MCH services was the number of supply points and staff to deliver the services and related messages. Forty eight percent of -3- project expenditures were for civil works, among other things to build or substantially upgrade and equip nearly 2000 suboenters and over 100 PHCs; an additional 27 percent went for staff salaries, to hire and train over 18,000 personnel; and 25 percent vent to purchase, operate and maintain transport equipment to enhance the mobility of this staff.2/ By component, more than 80 percent of project expenditures went for strengthening service delivery, 7 percent for training (nearly all of which was for service delivery), 8 percent for IEC and the remainder for research and evaluation, management, and innovative activities. Efforts to stimulate demand were limited to the small IEC and health education components plus whatever indirect effects might occur through the MCH program. 2.03. At the time (not long after the Emergency Period) there was considerable skepticism about the Government's willingness and ability to implement some of these principles. Was a massive building program what the program most needed, or were upgrading of staff skills and efforts to increase demand for small families of more critical importance? Despite the rhetoric, would the focus within the family welfare program remain on family planning to the neglect of MCH? Was the Government serious about promoting all contraceptive methods, or would the focus remain on sterilization, the only difference, perhaps, being that female rather than male sterilization would be promoted? It was evident that implementation of some of these principles would require some reorientation of the FP programs were plans for such a reorientation being developed; was the Government likely to face resistance to such a reorientation from the implementing agencies at the state and district level? 2.04. SIDA decided not to participate in this project, as they had done in the first, because it concluded that the risk was too high that these questions would be answered in the negative. In contrast, the Bank accepted the Government's assurances on these matters and decided to proceed without undertaking substantive investigations of its own. Indeed, no sector work was undertaken in this field before 1987 and the only policy condition attached to this project is a clause in the Credit Agreement indicating that the State Governments agreed to locate the subcenters in inhabited areas of villages and to maintain them and the equipment provided under the project. 31 2/ Expenditure percentages are from Government of India. Numbers of buildings and personnel are from Part III of the PCR. 2/ Of course, there were a large number of non-Bank studies available. While their availability meant that there was less need to focus on fact gathering, there was stl!l a need for evaluation and synthesis before these studies could be used effectively. Moreover, few existing studies focused adequately on operational issues. Examples of studies that still needed doing and might have made a difference to the design of this project includes a study of utilization rates of facilities existing prior to the project; an investigation of what would be involved in shifting the focus of the program towards a "cafeteria" approach; a careful consideration of whether male multipurpose workers were really needed and what was required to make them effective; and a study of potential utilization rates for the additional beds and,operating theaters proposed for the upgraded PHCs. -4- III. Project Execution and Results 3.01. The project faced a formidable set of implementation problemas substantial delays in getting started because of floods in UP, drought conditions in AP and uncertainties about policy directions resulting from Mrs Gandhi's reelection in 1980 and state elections that followed nine months later; difficulties in obtaining sanctions for expenditures and resistance by state ministries of finance to treating project districts differently from others; problems in obtaining suitable sites which were expected to be donated by local authorities; difficulties in finding acceptable contractors and supervising construction at the large number of remote sites required in this project; inuerference from politicians; difficulties in hiring acceptable staff; and so on. In the face of these problems, it is a tribute to the perseverance and energy of the project implementation authorities that they were able to complete nearly all project activities within three months of the original Closing Date, December 31, 1985. Section 4, Part III, of the PCR provides tables indicating the high degree of success in achieving physical targets, recruiting and training additional staff, and obtaining and deploying equipment and materials. 3.02. To accomplish all this within the allotted period, however, a number of short cuts were taken. Buildings were accepted and commissioned without adequate inspection and/or before correction of defects (PCR, Part I, par&. 14); staff were recruited that were not always of acceptable quality; some training programs were truncated (for example, that for AiMs was shortened from 18 to 12 months) and on-job indoctrination and supervision of new staff was minimal. As a result of this, plus other implementation problems, a number of buildings still do not have water and electricity connections, many buildings--20 percent in UP according to one study (PCR, para. 15 and footnotes) were improperly sited, some equipment was delivered without guidance on proper use and maintenance and has been misused or goes unused, and the services provided, particularly by subeenter staff, is considered by most observers and many potential clients, to be of quite poor quality.4/ IV. Prolect Extension 4.01. This project was extended twice, first by three months to permit completion of the construction program and then by two years, to permit expenditure of an undisbursed credit balance arising because of devaluation. The second extension is of interest because it represents a questionable change in Bank procedures and policy to accommodate Indian Government interests. 4.02. In October, 1985, the Department of Economic Affairs (DEA), MOF, requested an extension of the Closing Date from December 31, 1985 to March 31, 1987. The supervision mission that was in the field at the time was asked to investigate this request, taking into account the fact that A/ Part I of the PCR refers to some of these problems. A graphic and detailed picture based on intensive field investigations in the project districts is presented in reports of the Operations Research Group, Baroda, commissioned by the MOHFW. -5- existing guidelines permit extensions only for one year at a time and only for the purpose of completing works included in the original projectg and they prohibit expansion of works in order to utilize savings which may have arisen due to exchange rate fluctuations. After the mission reported that both state governments plus the mission agreed that all project activities could be satisfactorily completed by March 31, 1987 and it was ascertained that required expenditures under the credit would not surpass $36 million, equivalent to the original credit amount of $46 million due to devaluation of the rupee, the Bank agreed to a three month extension. 4.03. On March 12, in a meeting with representatives from MOHFW, the State of UP, and the Bank to discuss future projects, the representative from the Ministry of Finance asserted that there would be no new projects until the "undisbursed funds" under the credit were fully utilized. The argument of the MOHFW representative that the project targets were being met and rupee allocations exhausted was dismissed. After considerable delays, the MOHFW came up with proposals to utilize these funds. In September, 1986, the GOI requested a two year extension (from March 31, 1986 to March 31, 1988) that would cost $24 million, of which $11.5 million would be financed from undisbursed funds under the credit. These funds were to be used to support recurrent program costs in the original project districts, to extend the IEC and MIES components to nonproject districts in the two states and to complete some facilities handed over prematurely. Available documents provide no adequate rationale for these expenditures. Support for salaries, for example, was requested to "ensure operational staffing", a responsibility of the GOI and state governments at this point in the project. After introducing minor modifications, the Bank agreed to this request, on October 22, 1986. 4.04. Discussions with individuals who were involved with this project at the time suggest that they felt under pressure to quickly find items within the general scope of the project to use up the undisbursed balance so that they could get on with other projects. Since MOSA ruled out proposals for more construction, the bulk of the funds were spent on salary support and IEC equipment.51 Some funds, for example, went to purchase television sets (500 in UPY, many with expensive solar power components, for placement in remote villages, with no adequate plan for maintenance and repair, the rationale being that they contribute to the IEC component because they are a "powerful modernizing device". 4.05. As pointed out by the PCR (Part I, para 33), supervision during this two year extension period was minimal and superficial, focusing only on the financial disbursement record, not on what was actually done with the funds, let alone on the effects of these expenditures. This is probably explainable by noting that this period overlapped with reorganization within the Bank. 51 At about this time, the Ministry appointed an outside committee of experts to evaluate the area projects in general, many of which were coming to completion then. One of the committee's main conclusions was that too much had been spent on hardware. The Ministry felt constrained to take that point seriously in the extension. -6- V. Proiect Impacts and Possible Reasons for Findings. A. Evidence 5.01. By March 31, 1986, practically all buildings had been completed and commissioned and most staff were in place. While no significant demographic Impacts could be expected during the next three years, there should be signs of positive changes in more intermediate output measures such as contraceptive acceptance rates, percent of births occurring with professional assistance, and immunization rates. The PCR provides evidence on these measures in project and nonproject districts. Based on this material plus some additional materials that have since become available, this section derives conclusions and discusses likely reasons for the observed findings. 5.02. Two conclusions can be drawn from the evidence available on family planning. First, available indexes (contraceptive prevalence rates and percent of couples protected by various means) indicate virtually no difference between project and nonproject districts in the same state. The indexes are nearly the same at the beginning of the project and increase thereafter at roughly the same rate. In UP, a number of these indexes in project districts started one slightly higher and their rate of increase was somewhat higher, but these differences could well be within the margin of error in the data. Second, while there has been a shift towards use of temporary methods, sterilization continues to dominate. In AP, the percent of couples protected by sterilization was 97 percent in 1980 and declined to 85 percent in 1988. There is hardly any difference between project and nonproject districts. In UP, while earlier data were not available to the author, the percent of couples protected by sterilization in 1988 was 65 percent in project districts and 60 percent in nonproject districts. The difference between the two states is explained by differences in the the percent of couples protected by IUDs, averaging 2.2 percent in AP and 9.3 percent in UP in 1988. Table 1 (at the end of this PPAR) provides the evidence for the conclusions for AP.61 5.03. MCH performance indicators were also about the same in project and nonproject districts at both the beginning and the end of the project. However, in this case there is no clear upward trend as there is for FP indicators. This finding is consistent with the general observation that the Family Welfare Program is still, mainly, an FP, not an MCH, program. As can be seen from Table 2 which provides some data for a selected group of MCH indicators, there is a tendency for some indicators to rise and then to fall off when the project ended. This could be explained by disruptions related to the ending of the projects in AP, for example, without project funds, the regular budget was inadequate to pay for all the additional staff recruited during the course of the project with the consequence that some were not paid for several months and some posts (including several supervisory posts related,to MCH) were abolished. 6] Part II of the PCR indicates that IUD users have increased more rapidly in project districts. This appears not to have been the case in AP. While the percent of eligible couples protected by IUDs was higher in 1987, it started out higher in 1980, and it increased over that time at a bit slower rate. -7- 5.04. Results reported in the PPAR for IPPI are similar, the only difference being that FP and MCH performance Improved somewhat more in UP than in Karnataka. One explanation for the difference in performance between the two states, suggested at the time, is that it may be more productive to provide infrastructure in places where it is poorer (UP) than where it is better developed (Karnataka). This could have served as a rationale for concentrating on backward districts in IPP2, had this conclusion been known at the time. But the results of IPP2 do not confirm this finding (assuming backward districts were in fact thosen--see below). B. Why no differential impact? 5.05. A variety of reasons have been put forward to explain the lack of. difference in impact between project and nonproject districts. Probably all are implicated to at least some extent. The following list begins with the least important. 5.06. Backward districts. The original plan was to focus on backward districts; it may have been possible to bring them up to the avetage for the state but not possible to move them beyond, especially as nonproject districts were improving as well. This explanation would be more plausible if the performance indicators in project districts started out significantly below those in nonproject districts; as indicated above, they did not. Indeed, there is some question about just how backward some of the selected districts were. In AP, for example, the audit mission was told that districts selected were near the average for the state in socioeconomic development and infrastructure; and Table 3, below, indicates that the density of subcenters in project districts was actually greater than in nonproject districts in that state. 7/ 5.07. Implementation Delays and other Temporary Problems. The results can be explained by pointing to a number of problems which may have slowed down the appearance of benefits but which should not affect the longer run impact. As indicated above a number of short cuts were taken to complete the project within the time period allowed and a number of disruptions occurred when budgetary support provided by the project ceased at the end of the project. It remains to be seen whether the resolution of these problems will improve performance.8/ Given the presence of more fundamental problems, discussed below, one cannot be too hopeful on this score. 5.08. Sitina problems. If the siting problems were as frequent throughout all project districts as suggested by the ORG study for UP Z1 It might be added that if the project districts were backward in the sense that the health infcastructure was least developed there, the underlying premise of the project--that performance is positively correlated with development of infrastructure--is called into question because of the lack of difference in performance indicators at the beginning and end of the project. It is more plausible that project: districts were not especially weak so far as infrastructure is concerned. g/ It also remains to be seen whether the financial problems will soon be resolved. See discussion below on maintenance problems and sustainability. -8- (noted above), the effectiveness of the increased number of centers and subeenters could have been seriously reduced. It is plausible that this was the case. While the states committed themselves (in the credit agreement) to locate subcenters within inhabited areas of villages and detailed guidelines for siting were prepared,,/ selection was to a large extent in the hands of villagers who up to 1986 were expected to donate land for this purpose. In UP the result appears to have been that much of the land obtained in this fashion was of low economic value and therefore, more often than not, in remote locations where clients were reluctant to go and midwives (ANMs) were reluctant to live. This seems to have been much less a problem in AP (according to the ORG study) even though the same procedures were followed. A partial explanation may be that officials in UP were more reluctant to say no when land offered failed to meet guidelines and to look for more acceptable sites in other villages. Siting guidelines were also overriden in a few cases by the concerns of contractors and politicians. In an effort to solve these problems the GOI changed its policy in 1986 and began purchasing land for PHCs and subeenters. 5.09. Inadequate Provision of Inputs Other than Civil Works. The Implicit assumption behind this project, that civil works was the factor most responsible for lmiting progress, may be incorrect; other Inputs may have been more important determinants. For example, if quality of service provided was poor, clients would be discouraged from coming to the clinics no matter how conveniently there were located. There are indications that this was the case. No distinction between project and nonproject districts was made in allocating budgets for medicines and supplies; it was typically very small everywhere. More training inputs were supposed to go into the project districts; but these districts also had to hire more new recruits, and very little was spent anywhere on upgrading the skills of existing staff. Given this, plus indications from the ORG reports that quality of services in project districts was quite poor, the provision of more and better buildings and equipment may not have been sufficient to make a difference. 5.10. Lack of Sinificant Differential Progress in Provision of Infrastructure. Table 3 indicates surprising small differences between project and nonproject districts. While the number of subeenters per unit of population increased substantially in both sets of districts and the increase was greater in the project districts, the difference may have been too small to have an appreciable effect on the outcome. 5.11. While project districts had significantly larger construction budgets, a large portion of these additional funds were spent on replacing reanted quarters rather than increasing the number of centers. While this replacement generally resulted in an increase in quality of clinics and liVing quarters for staff, that improvement may not have been very productive in terms of performance. A study undertaken by the Population Center in Lucknow (PCR, footnote 2) found essentially no difference in performance between rented and nonrented centers in UP. This finding is quite plausible and consistent with the idea expressed above that other 9/ In the case of UP, the UP Town Planning Authority developed what has been described as a good and detailed set of guidelines for the project. -9- factors, for example insufficiency of supplies, constrained performance throughout the whole system. 5.12. How is it possible that the number of subcenters in nonproject districts increased nearly as fast as in project districts? This was certainly not what was planned or expected at the outset of the project. Either the Government ended up with more total resources than it anticipated or project funds allowed some reallocation of what would have been spent in these districts to the nonproject districts. While this question was not carefully explored during the audit mission, there were small signs that at least some such reallocation occurred. C. Why Such Slow Proaress? 5.13. Most observers express disappointment at the pace of decline in fertility, mortality and morbidity rates and because of that in the rate of improvement in proximate indicators of PP and MCH performance. While this is not the place for a general critique of these two programs, some of the reasons for this slow progress are relevant for the design and implementation of this project. 5.14. Excessive Focus on Infrastructure. One indication that the provision of infrastructure may be running into diminishing returns is evidence that existing facilities are underutilized. A common observation by visitors to the field, especially in UP, is the lack of utilization of beds and operating theatres, even in PHCs located close to major roads. The ORG reports for both states tend to confirm these observations. When asked why this is the case, two observations are typically given. First, people try to bypass these PHCs and go to regional hospitals whenever they can. Second, these facilities are used almost exclusively for female sterilization; when the project started, the number of beds required was based on the use of tubectomy procedures; when minilaproscopy became common, these facilities were left with excess capacity. While this change in technology could not have been anticipated, it is interesting to note that the AP Government decided to use the funds provided for expanding bed capacity in selected PHCs for other purposes on grounds that additional beds were less needed than other things. 5.15. Excessive Focus on Sterilization. Since the early 70s the Indian Family Planning program has focused on sterilization as the primary means to reduce the fertility rate. Despite rhetoric about a cafeteria approach, nothing much has changed since that time other than a shift in emphasis from male to female methods. This can be seen not only in the numbers (see Figure 1) but in the way performance targets are set and incentives used. 5.16. This focus has meant that a large fraction of the potential audience--younger couples who might be interested in spacing--are more or less ignored. In addition, however, this focus may be running into diminishing returns. Evidence from some areas of India with higher contraceptive prevalence rates indicates that the total fertility rate (TFR) is not as low as should be expected. This could result from data errors and falsification; but there is no reason to believe these problems have increased over time. The other possibility is that the demographic - 10 - impact of a given sterilization has diminished over time. It is far easier to rely on sterilizations to bring the TFR down from 7 to 5 children per women, than it is to bring it down from 5 to 3. To accomplish the latter, much more reliance must be place on temporary methods. 5.17. The PPAR for the first population project identified this excessive focus as one of the problems with the Indian program. The SAR reiterated this and indicated that the Government was planning to change its policy to provide equal emphasis to all methods. But nothing effective was done to encourage the Government in this direction. In particular, no studies (e.g., of the implications of a continued focus on sterilization or of what program changes would be necessary to change directions) were undertaken, and the loan agreement is silent on the issue. 5.18. Insufficient Focus on Promotion of Demand for Family Planning. Demand for family planning and acceptance of a small family norm can be promoted in a variety of ways, including structural and social change that decreases the value or increases the cost of large families, MCH programs to reduce child mortality rates, thereby reducing the number of births necessary to achieve a given completed family size, and IEC programs using mass media and outreach workers to deliver informational and promotional messages. The PCR and Project Performance Audit Memorandum (PPAM) for the first project called for more emphasis on such demand creation activities and the Government accepted the idea in principle. The project includes some elements of this sort--the MC component, a significantly expanded IEC component, and a small population education component--but nothing related to structural or social change. 5.19. The MCH component was ineffective. If intermediate output indicators such as those reported on in Figure 2 did not improve, there is no way that the project can have a differential effect on infant and child mortality and therefore eventually on desired family size. 5.20. The IEC component, according to the PCR, was implemented well in AP but not in UP. In neither state, however, was there a careful evaluation of the impact of these activities. There is reason to be skeptical about these impacts, or at least about the cost effectiveness of whatever impacts there were. (1) For use in family planning programs, the main value of IEC is that it creates general awareness; but surveys undertaken during the eighties indicate that awareness is already quite high. This is not the case so far as MCH issues are concerned, but IEC efforts have not focused on those issues. (2) IEC could deliver a stronger family planning message, for example, that the nation's leaders at all levels support and endorse the program. But particularly in the decade after the Emergency period, Indian leaders have been reluctant to take a strong public stand on this issue (in the last election, for example, the topic was hardly mentioned by anyone). (3) According to field staff interviewed, lack of funds andifacilities for maintenance and spare parts have limited the use to which the equipment provided under the project has been put since the project ended. (4) A large fraction of the activities under this heading involve the presentation of entertainment programs with a family planning or family welfare message. If this approach attracts new people, it may have some effect; at least, it may stimulate &ome questions and discussion about the program. But where repeat performances are made to the same audience, which is common, the "productivity" of the qtessages - 11 - delivered must be very low. A careful, detailed study of this component to determine whether these observations are generally correct and what can be done about them is long overdue. 5.21. An underlying problem is that the program has had difficulty attracting qualified IEC professionals to middle and upper-level posts. A variety of factors account for thist inadequate recognition of the importance of this component, inadequate recognition of the need for specialists in this field, partly a problem of not attaching adequate importance to this component, inability of the state governments to pay competitive salaries, and reluctance of both the center and state governments to circumvent the salary problem by contracting for these services from the private sector. Most of these issues have to be tackled at the state or national level, which place them out of reach of this project. 5.22. Of more significance, however, is the fact that the project did not include any effort to introduce structural or social changes that might affect desired family size or son preference--for example, promotion of female education and employment opportunities or changes in laws related to inheritance, age of marriage and child labor--and this despite the fact that there was agreement at the outset that such efforts were necessary. Admittedly, it would have been difficult to introduce such elements into this project. It was conceived as a project to be implemented by State ministries of health in specific districts, not as a project involving other ministries and issues that have to be tackled at the state or national level. But there is no indication that the Bank tried to introduce these elements into this project or tried to change the nature of the project to make this introduction easier.10/ 5.23. Longterm Personnel Problems. The ORG reports provide evidence, corroborated by field visits, that the quality of care provided by front- line personnel is extremely poor, so poor that many persons are discouraged from using subcenters and PHCs. ANMHs reportedly give short shrift to some important functions, for example, outreach and MCH, have extremely limited knowledge'and operate under an incentive structure that is not geared to encouraging quality performance. 5.24. The project's attempt to cope with these problems was limited to the provision of training. While nearly all training targets specified in the project were achieved, a number of factors limited the effectiveness of this component. Most of the training focused on newly employed staff rather than on in-service training and upgrading of skills of the much larger existing staff. As indicated,above, to meet training targets within the specified period and budget, some trainipg programs were significantly shortened. The content of most training courses focused on the provision of technical skills, not on what might be called work routines, for example, how to identify the target group of women, schedule adequate numbers of visits, supervise and properly motivate staff, etc. Moreover, the courses were generally considered to be insufficiently practical (eg., too little clinical work for imparting technical skills and insufficient 10/ This would have been difficult at the time since the Bank had no projects in related sectors, for example, education. - 12 - use of case studies and role playing to train managers). Here again, many of these problems were difficult to tackle within the context of this district-focused project. But it is stri.Ing that no training needs assessment or evaluation of the reorientation training for multipurpose workers was included in this project. These problems have been recognized and efforts to correct them are under way in later projects. VI. Bank Performance 6.01. With the exception of the two year extension period, Bank supervision of this project was good in the sense that it occurred regularly, frequently and had good continuity of personnel (PCR, Part I, para 33). However, the focus was to a large extent on disbursements and the meeting of physical targets (completion of buildings, number of persons hired and trained, list of equipment delivered, etc.), not on the qualitative content of various components (e.g., content of training programs, use to which IEC materials and equipment were being put, whether the project was implementing the principles its design was ostensibly based on). During the period of this project there appears to have been little dialogue with the Government on these issues and no significant sector or analytical work that would have encouraged and informed such a policy dialogue. 6.02. This picture is consistent with attitudes expressed by persons associated with the project at the state and district level. From their perspective, the Bank, as well as the central government, was mainly interested in ensuring that proper procedures were followed and funds spent in accordance with the implementation plan. Otherwise, the Bank was viewed as relatively passive, going along without seriously questioning policy decisions or lack of adherence to agreed-to principles. These people did not feel they benefited from the Bank's technical competence or experience in other parts of the world. Similar sentiments were echoed by officials in New Delhi. 6.03. Five possible explanations have been offered for this more or less passive role. The first is lack of adequate staff time to do much more than administer the project: apparently, there was only one full time PHN staff member working on this sector and project, and no one in the field, during most of the project period, hardly appropriate given the importance, complexity and size of this program. But why should this have been the case? The second explanation is that the Bank agreed with the overall program thrust and had confidence in Government's ability to develop and implement the project well. The SAR for this project can be interpreted as saying something like this; but the discussion of problems and issues discussed in the PCR and PPAM for the first project suggest otherwise. A third explanation, this one mentioned in the PCR, is that the Bank's contribution was only a small fraction of the total state and national expenditures on the family welfare program, too small to expect to have any significant influence on the program. But then, the Bank must rely even more heavily on its powers of persuasion and analysis, which should imply more, not less, sector and analytical work. A fourth possible explanation is that the district focus in this project limited the Bank's ability to take up issues that had to be handled at the state or national level. Why then_ did the Bank.agree to this approach? -13- 6.04. A final explanation, which in part also helps explain why sector and staff inputs were so tmited and why the Bank agreed to this approach, to that the Bank was under pressure to lend to this sector in India. This pressure appears to have come from two sources. First, PHN was under pressure to expand its population portfolio and India accounted for a large fraction of this portfolio. Second, it was agreed that India would receive a certain amount of IDA funds and that these funds would be used in the *soft sectors" plus agriculture. Given this, plus the Government9a refusal to accept program loans, there was considerable pressure to provide a large fraction of these IDA funds in the form of projects to the population and health sector. VII. Sustainability 7.01. The PCR points out that the central government has a fundamental and long-standing commitment to provide family welfare services to the population at large. While this is certainly true, the election of a new coalition government in December has Introduced some uncertainties. It is not yet clear how much priority the new government will give to this, compared to other programs, nor whether this government is prepared to implement a number of proposed changes111 believed by many to be necessary to maintain or Improve program momentu-* 7.02. The PCR also points out that atate governments are finding it difficult to maintan the many scattered buildings established by the project. Evidence of lack of maintenance and operating funds for transport and IEC equipment was also found during field interviews. This is partly a logistics problem given the widely scattered nature of this project. But it is also a problem of finances budgets allocated for maintenance are generally small and have not always made allowance for the added equipment put in place by the project. For example, an IEC officer indicated that maintenance and operating budgets became much tighter at the end of IPP2: in fiscal 88189 he,received a small but insufficient mai tenance budget from the state, but for the first 9 months of fiscal 89190 he received nothing. In its response to Part I of the PCR, the Government indicates that necessary funds for building maintenance have now been made available (PC, Part II, p. 17). VIII. Conclusions and Lessons 8.01. The PCk focuses on lessons derived primarily from the Implementation of this project and indicate that they have been taken into account in the development of subsequent Bank-assited population projects in India (PQart I, para 43). Some of these lessons warrant additional comments. III For example, to reduce the focus and targeting on sterilization, eliminat? the use of incentives and give more weight to structural factors influencing demand -14- The PCR notes that monitoring of site selection and construction is difficult and calls for more effective means of doing so. Since an important cause of this difficulty was the very large number of disbursed sites, a practical way to improve the situation is to reduce the number of sites 'hat have to be dealt within a given time period. Perhaps the iesson to learn is that future projects should be either smaller or allowed to take a longer period of time to implement. This, by the way, is a lesson that has not been incorporated in subsequent projects. New procedures to speed up clearance by state finance departments were devised in AP; the problem in UP may be less related to procedures than to resistance by that state's finance deartment to the notion that project districts should be treated differently from non-project districts. The comment about maintenance and repair problems needs to be broadened: increased care should be taken to ensure that incremental recurrent costs can and will be assumed by the central and state governments when future projects close. There,is no doubt ab6ut the need for more in-service training. But the problem with "multipurpose reorientation", in part, lies elsewhere, with the difficulty of integrating male and female multipurpose workers. The whole strategy of using male MPWs needs rethinking. 8.02. Adoption of these suggestions should improve implementation of future projects. But as paragraph 44 of Part I implies, they are unlikely igo make a significant difference in the outcome until more fundamental problems with the Indian program are resolved. These include "the focus on sterilization at the expense of temporary contraceptive methods and MCH services, the focus on the achievement of targets rather than the provision of services, the lack of appreciation.. .of IEC and the dearth of technically competent IEC managers, and the need for strengthening and decentralization of program planning and management." Lack of appreciation and focus on structural changes that can affect demand, for example, wamen's education and employment opportunities, should be added to this list. Many of these fundamental problems were recognized at the end of the first population project, but according to the PCR only issues of project management and program coverage were taken up in the second project; all the rest remain to be resolved. 0.03., If the Bank is serious about wanting a principle or a component of a project to be effectively applied and implemented, it must ensure one of two thingss either that the implementation steps are designed and accepted in advanc-: of project initiation ot that there Is good reason to believe that the borrower is both willing and able to do so later. If neither of these conditions are met, but the item' is included anyway, the Bank was probably not serious about the item and in the interest of transpfrency it should have been left out. * 15 - 8.04. Three examples can be cited from IPP2. (1) At the state level there was little interest in research and analysis, despite the development in IPP1 of two centers to conduct such work during the course of the second project. This should have been evident at the time of preparation. Indeed, the PPAM for IPPI complained about the insufficiency of research in that first project. IPP2 included a component to fund such activities, but nothing was done to spell it out or design it in advance, the predictable result being that it was neglected. (2) The PCR and PPAM for IPP1 both criticize the family welfare program for concentrating on sterilization at the expense of temporary methods and MCH, and the SAR for IPP2 indicates the borrower's intention to change this. But no practical steps to implement this intention were included in the project and the Bank undertook no investigation to determine what would be required to bring about this shift. (3) The one component that was clearly and carefully designed and which all parties--the state governments, the central government and the Bank--clearly wanted was the siseable construction component; and, making allowances for the difficult working environment, it was Implemented reasonably well. 8.05. Two arguments are given for not seriously trying to tackle more fundamental problems. One is that the Bank had no policy leverage or influence because its contribution to the family welfare program was small and because there was pressure to lend to this sector in any case. The other is that many of these problems involve general policy issues and the Bank was constrained by the nature of the project to operate in specific districts. Two points stemming out of the experience of this project should be made in rejoinder. 8.06. First, if the Bank wishes to have an influence on policy in a situation where its leverage is small, it has no choice but to rely on its powers of persuasion. That means more, not less, sector work, as was the case up to 1987. 8.07. Second, although we are now told it works the other way, an important early rationale for focusing on selected districts was the argument that the Bank could have more influence in selected districts than it could in the overall program. An important lesson to learn from these first two projects is that this is only the case if there is a clearcut agreement in advance that critical elements of the overall program can be different in the project areas. In the case of IPP2, there was such an agreement for infrastructure and equipment. But there was no such agreement for some other inputs and elements of the program; and some of these, in the end, proved to be more significant bottlenecks to progress than shortage of infrastructure. Without such an agreement there is no reason for the Bank to become involved in an area project- it would be more transparent to provide general support to the overall program. TARTY, I Couples Effectively Protected, Andhra Pradesh Percent of Eligible Couples as of 31 March, by Years -1980 1981 1982 1983 1984 1985 1986 1987 Project Areas Sterilization 25.26 25.92 25.75 27.26 27.26 28.21 29.46 30.08 kUD 0.58 0.61 0.55 0.71 1.27 1.73 2.28 2.51 C.C. Users 0.27 0.31 0.18 0.44 0.89 1.17 1.44 1.81 0.P. Users 0.02 0.03 0.04 0.11 0.43 0.57 0.63 0.54 All Methods 26.13 26.87 26.52 28.52 29.85 31.68 33.81 34.94 i. State as whole Sterilization 25.05 2532 26.33 27.53 28.60 29.70 31.24 32.75 IUD 0.32 0.33 0.34 0.40 0.73 1.02 1.53 1.73 C.C. Users 0.20 0.21 0.22 0.32 0.65 1.04 1.29 2.03 0.P. Users 0.03 0.04 0.07 0.08 0.32 0.47 0.58 0.57 All Methods 25.60 26.10 26.96 28.33 30.30 32.23 34.64 37.08 TABLE 2 HCH Performance Indicators, Andhra Pradesh Percent of Total or Target as of March 31, by Years ANCs Registered (1) Project Areas 51.17 59.27 57.14 63.08 69.66 63.27 71.73 56.39 State n.a. 48.29 46.71 45.15 51.54 66.07 n.a. n.a. PNCa Registered (1) Project Areas 42.25 47.36 36.43 48.62 49.24 49.57 54.59 14.17 State n.a. 30.69 32.52 30.11 27.52 26.26 a.a. n.a. T.T. for ANCs (1) Project Areas 62.26 95.79 60.56 104.75 89.39 88.84 74.52 52.01 State 67.07 87.92 76.44 89.40 70.51 79.21 92.81 59.75 DPT (0-2 yrs) (2) Project Areas 51.34 46.55 73.87 73.69 103.05 116.03 55.77 58.37 State 42.16 48.35 42.08 54.48 61.05 70.48 72.70 49.21 D.T. (3-8 yrs) (2) Project Areas 54.28 74.25 50.97 64.65 61.70 81.56 67.11 55.41 State 80.02 78.02 63.55 54.02 50.27 75.57 75.62 57.67 Typhoid (2) s Project Areas n.e. 25.15 38.53 82.56 96.59 54.64 57.55 40.45 State i.a. 36.65 39.58 56.33 67.60 71.49 57.55 40.45 Polio (2) Project Areas n.a. 75.74 111.88 89.56 126.90 144.25 45.71 50.38 State n.e. 93.30 106.96 82.73 66.33 72.32 .54.45 39.45 Anaemia Course Initiated (3) Women Project Areas 96.88 126.28 116.49 155.96 228.14 210.73 239.01 117.56 State 69.39 90.76 86.21 97.34 143.92 130.81 128.78 80.47 Children Project Areas 86.94 85.06 92.85 136.9 195.84 169.54 185.57 87.21 State 40.46 69.19 78.43 78.85 104.94 117.99 100.20 56.72 (1) Percent of estimated yearly pregnancies, estimated at 40 per 1000 population (2) Percent of children in relevant age brackets (3) Percent of target 18 - TAKE 3 Primary Health Care and Subcenter Coverage, 1980 and 1985/86 ------------------------------ww-----w---------m---------------w----- State Project Non-Project Districts Districts ------------------------------------ ----------------- ------------- ------ A. Andhra Pradesh 1980 (Spril) Primary Health Centers (PHCs) 420 62 358 Subeenters (SCs) 3992 638 3354 PHCa + SCS 4412 700 3712 Rural Population (10008) 40471 5767 34704 Population per Center 9173 8239 9349 1986 (April) Primary Health Centers (PRCs) 420 62 358 Subeenters (SCs) 6507 1195 5312 PRCS + SCs 6927 1257 5670 Rural Population (1000s) 44499 6371 38128 Population per Center 6424 5068 6725 ---w -----------wwee ------------------ --*-**------- **-- **----- **w-- B. Uttar Pradesh 1980 (April) Primary Health Centers (PHCs) 904 148 756 Subconters (SCs) 7597 1355 6242 PUCs + SCs 8501 1503 6998 Rural Population (1000s) 89459 15890 73569 Population per Center 10523 10572 10513 1985 (April) Primary Health Centers (PHCs)* 907 148 759 Subeenters (SCs) 15653 3130 12523 PHCs + SCa 16560 3278 13282 Rural Population (1000s) ** 97678 17350 80328 Population per Center 5898 5293 6048 ------------------------ ---------------------------------------- --------- * Estizate ** Obtained by projecting 1971-81 rural growth rate and using 1981 proporations. - 19 - 11 PROJECT COMPLETION REPORT INDIA SECOND (UTTAR PRADESH/ANDHRA PRADESH) POPULATION PROJECT (CREDIT 981-IN) JANUARY 31, 1990 Population, Human Resources, Urban and Water Operations Division Country Departnient IV Asia Regional Office I.1 - 21 - PROJECT REVIEW FROM BANK'S PERSPFCTIVE Project Identity Project Name Second Population Project Credit No. 981-IN Date of Credit Effectiveness July 26, 1980 Completion Date March 31, 1988 Closing Date March 31, 1988 Total Project Cost US$15.3 million equivalent Original Project Cost US$ 96.0 million equivalent Project Extension Cost US 19.3 million equivalent Foreign Exchange Component (Appr. Est.) US$ 16.3 million equivalent IDA Credit US$ 46.0 million IDA Credit, Total Disbursed US$ 44.2 million IDA Credit, Total Cancelled US$ 1.8 million RVP Unit Asia Country India Sector PHR Subsector Population OMrvyiew and Su=mary 1. The Second Population Project was the second of a series of Bank- supported population projects in India; the first became effective in 1973, the sixth will become effective in 1989, and additional projects are under development. The project was implemented in six districts of Uttar Pradesh and three districts of Anxdhra Pradesh as part of an effort by the Government of India to obtain external assistance to strengthen the national family welfare (family planning and maternal-child health) program in backward districts of selected states. Construction and equipping of facilities was supported by training, information, education & communication (IEC), and program management components. 2. Despite initial delays, the project's physical goals were virtually achieved and the rupee budget expended within the planned five-year period, for which the two states deserve considerable credit. Using credit savings resulting from exchange rate changes, the project was subsequently extended for two years to allow implementation of support activities in districts not originally included in the project. Project family planning goals were achieved, although those for maternal-child health were not. Particularly in Uttar Pradesh, implementation of the 2E and management information system components was not satisfactory, and in neither state were program achievements in project districts significantly different from those in non-project districts. 3. The project was only a small part of mucU~ larger state and national family welfare programs and its effects were therefore limited. of the lessons learned from the First Project, only project management and ubcenter coverage issues were successfully addressed in the Second Project. The project had little, if any, impact on underlying problems of the family - 22 - welfare program, including weak and overcentralized program planning and management, focus on sterilization at the expense of temporary contraceptive methods and maternal-child health services, and lack of adequate technical and management support for IEC. Background - The First India Population Project 4. The first IDA-assisted population project in India, supported by an IDA credit of US$21.2 million and a (Swedish) SIDA grant of US$10.6 million, became effective on May 17, 1973. It was the result of a request from the Government of India in 1969 for Bank assistance in developing a comprehensive family planning demonstration project. The project was implemented in six districts of Uttar Pradesh and five districts of Karnataka, the two states representing different levels of socio-economic development. The project provided for the completion of the health infrastructure in these districts. Urban, rural and supplementary nutrition components were included to assess their relative impacts on fertility decline. Population Centres in the two st.ce capitals, Lucknow and Bangalore, were established to refine experimental designs, develop management information and evaluation systems (MIES), evaluate performance and recommend improvements in the program. The project also supported development of health management units at the Indian Institute of Management, Ahmadabad and the Administrative Staff College, Hyderabad. Project inputs included the construction of facilities, including paramedical training schools, provision of equipment, furniture and vehicles, and support for incremental staff salaries, overseas training, and operation and maintenance costs. 5. The project was planned for five years, with the credit to close on June 30, 1978. Following project effectiveness, implementation proceeded steadily. In 1976-77, as project civil works were being completed and supporting institutes were becoming functionally effective, intensive family planning drives were launched under the Emergency (1975-77). These drives in effect negated the experimental aspects of the project, masked the results of project inputs, and made evaluation of project impact difficult. In view of Emergency disruptions, the credit was extended by two years and closed on June 30, 1980. The entire IDA credit and the SIDA grant were expended. 6. The project was reviewed in a Project Performance Audit Report (PPAR) dated January 1982 (No. 3748). The PPAR noted that because of weaknesses in baseline data and the difficulty of linking program achievements to project inputs, it was difficult to draw firm conclusions about project impact. The report concluded that in terms of family planning performance there was little significant impact. It was also not possible to identify significant improvement in the nutritional status of intended beneficiaries of nutritional supplementation, pregnant and lactating women and young children, primarily because the program was organized on a take-home basis and it became clear that a substantial share of the food was not reaching these groups. 7. The Project Completion Report and the PPAR identified the following lessons learned from the first project: (i) project management was set up without reference to Indian administrative practice, resulting in an undesirable split between project and program management; (ii) strengthened - 23 - undesirable split between project and program management; (ii) strengthened professional supervision of civil works and establishment of strict criteria for the siting of subcenters were necessary; (iii) program planning and management were weak and needed to be decentralized; (iv) service outreach constraints included overly large service areas for subeenters (10,000 population), limited staff mobility and shortage of female medical officers; (v) more emphasis was required on demand generation activities, which needed to be based on local circumstances and community participation; (vi) MCH activities needed to be accorded equal importance with family planning and the links between the two recognized and exploited; and (vii) take-home distribution of nutritional supplements was not an effective strategy for reaching at-need women and children. The Second India Population Project - Background. Objectives and Development 8. The GOI first discussed a second population project with the Bank during the 1975-77 Emergency period. The Janata government elected in 1977 indicated that despite fundamental opposition to any element of coercion in family planning, it wished to continue support for the program on a voluntary basis. The program was renamed 'Family Welfare' to reflect the inclusion of maternal-child health services, and a strategy based on obtaining external assistance for accelerated program development ('Area Projects') in 'backward' districts of selected states, based on criteria of socio-economic development, health services infrastructure, high fertility and mortality levels and low program achievements, was developed. Under the IDA-supported project, assistance was provided to six districts of Uttar Pradesh (U.P.) and three districts of Andhra Pradesh (A.P.), and in addition, the GOI obtained support from UNFPA, DANIDA (Denmark) and ODA (UK) for Area Projects in five other states (Rajasthan, Bihar, Kadhya Pradesh, Tamil Nadu and Orissa). The primary objectives of the projects were the achievement of reductions in fertility levels through increases in contraceptive prevalence and reductions in infant, young child and maternal mortality and morbidity through improvements in the quality and coverage of MCH services. 9. The Second Project was designed by task forces established in U.P. and A.P., which prepared project proposals within the framework of the Sixth Five Year Plan (1980-85) after consideration of the experience of the First Population Project and extensive discussions with government officials, community leaders and program staff. Project design s based on five premises: (i) that increased family planning acceptance would be possible only through the development of a variety of activities promoting improvement in socio-economic conditions; (ii) that significant decreases in fertility probably could not be achieved in a five-year period; (iii) that family planning acceptance is closely linked to improvements in the health of mothers and children; (iv) that improvements in health and increased family planning acceptance would depend on improvements in the quality and utilization of health and family planning services over existing low levels; and (v) that improved infrastructure and services need to be supported by informed communities to be effective. -24.- Prolect Description 10. Under the structure set out in the Sixth Plan, the organizational base for the rural primary health care system continued to be the primary health centre (PHC), which provided curative and referral services. Mor6 specialized referral facilities were to be provided by district and medical college hospitals. The service delivery system called for: - one traditional birth attendant (a11 per 1000 rural population; - one community health worker (CHW) per 1000 rural population; - a subcenter staffed by one male and one female multipurpose worker for 5000 rural population (the multipurpose scheme); * one supervisor per four workers; - three medical officers per PHC; and - two specialists per upgraded PHC. The female multipurpose Forker's primary duties were to provide NCH and family planning services, while the male worker was to promote hygiene, sanitation and other public health measures as well as support the provision of family planning services. Referral facilities were to be strengthened through the upgrading bf 25% of the PHCs to 30 beds and the appointment of specialist - staff such as pediatricians and obstetricians/gynecologists. 11. The project had five major functional components: (i) service delivery; (ii) training; (iii) information, education and communication (IEC) activities; (iv) monitoring, evaluation and operational research/innovative studies; and (v) program and project management. These components were supported by the following inputs: a. civil works: construction of and furniture and equipment for: 1987 rural subcenters; 117 primary health centers (PRCs); improvements to 79 PHCs; 2 maternity homes in urban areas; obstetric gynecological centers attached to 7 rural women's hospitals; 5 hostels attached to training schools for female multipurpose workers; 46 training wings for PHCs; training wing/hostel for the Population lentre at Lucknow; and 1 maintenance workshop for vehicles and 1 for equipment; b. vehicles: 166 jeeps for PHCs, maintenance workshops, the Population Centre at Lucknow, project construction units and project management; 17 cars for the Population Centre, construction units, and project management; 65 ambulances for selected PHCs and the maternity homes; 15 mini buses for ANM training schools and the Population Centre; and 40 vans for IEC activities; c. IEC equipment: 36 16mm film projectors; 36 generators; 36 public address systems; 210 cassette tape recorders; 39 video sets; and offset press equipment; - 25 - d. salarics: incremental staff including 447 male and 2322 female multipurpose workers; 340 male and 628 female health supervisors; 7583 &__; 9216 CHWs; 101 PHC medical officers; 120 medical specialists in gynecology and obstetrics with supporting staff; staff for two maternity homes and 11 urban family welfare centers; IEC staff at state, divisional and district levels; and project management staff at state, divisional and district levels. d. training coSts: salaries of incremental training staff; materials; stipends for pre-service training of 9216 CHWe, 7583 do&g, 2332 multipurpose workers female, 447 multipurpose workers male; allowances for promotee training of 628 health supervisors female, 340 health supervisors male; for multipurpose scheme reorientation training of 2005 multipurpose workers female, 3130 multipurpose workers male, 480 health supervisors male; 350 PHC medical officers; for management training of 959 medical officers; for specialist training of 120 medical officers; and for training of 261 IEC staff. e. other overation and maintenance costs: purchase and/or production of IEC materials, including education kits for field work, cassette tapes, video tapes, films, filmstrips, manuals, exhibitions, press ads, hoardings, posters, books, etc.; costs of OTCs; materials/supply/operation costs in support of MIES, project evaluation, operations research, and agreed innovative activities. Project Imlementation 12. Few of the planned pre-project activities were carried out, and even after credit effectiveness in July 1980 substantial delays were experienced getting project activities underway. These delays were due to uncertainties as to the attitude of Mrs. Gandhi's newly elected government towards family planning, as well as to serious flood and drought conditions in U.P. and A.P., respectively. However, most of the initial difficulties were overcome and by the original credit closing date of December 31, 1985 virtually all of the project's physical targets, including civil works, had been completed and the project's rupee budget expended. An extension of the closing date by three months, to March 31, 1986, was agreed to permit completion of some remaining buildings as well as overhead water tanks and electrical connections for a significant number of buildings in U.P. Project implementation by component is reviewed in the following paragraphs. 13. Service Delivery. By July 1981, a year after credit effectiveness, the civil works component in both states was some 18 months behind the schedule set out in the SAR. Accelerated schedules were prepared, and with good cooperation from both states in appointing staff and making other necessary arrangements, the civil works program was virtually completed within the planned project period. -26- 14. With the completion of buildings, problems concerning their equipping and commissioning became evident in both states. It is apparent from the Operations Research Group (ORG) reports' that, particularly in U.P., because of pressures to get facilities commissioned as rapidly as possible, the Health Department allowed the Public Works Department to hand over buildings wi\hout adequate inspection and/or without insistence on correction of defects before accepting them. Neither state succeeded in coordinating procurement with the construction schedule, so that commissioning of completed facilities was frequently delayed by lack of furniture, supplies and equipment. 15. Despite explicit siting guidelines for subcenters set out in the SAR, the ORG report for UP found that roughly a fifth of the subcenters covered had been improperly sited, making it difficult, if not impossible, for security reasons for ANMs to live in such subeenters. A study2 by the Population Centre, Lucknow, based on a larger sample, reported a similar finding. 16. A three-month extension of the credit closing date to March 31, 1986, permitted provision of overhead water tanks and electrical connections to facilities in U.P., for both of which the Health Department was dependent on the assistance of other departments. The ORG reports indicate problems concerning quality of construction in both states, particularly in U.P. Non- delivery of equipment was reported in A.P. In both states unfamiliarity of multipurpose workers with new equipment provided to subcenters and its consequent non-use were reported. 17. The staffing targets set out in the SAR were largely met (Part III, Section 4). However, there were a few exceptions. First, according to the SAR (para. 4.11), 902 additional male multipurpose workers were-needed in U.P. to meet the Sixth Plan norm in the project districts. Since there was an overall surplus of male workers in the state, many of whom were from the project districts, no need to recruit additional male workers was anticipated. However, the ORG report for U.P. indicates that at project-end there was a substantial shortage of male workers in the project districts, and the anticipated in-service "promotee" training of male supervisors was not carried out. Second, recruitment and training of male multipurpose workers in A.P. was delayed because of problems concerning integration of existing separate vertical cadres into the new multipurpose cadre and was not begun until June 1985, and appointment of male supervisors was correspondingly delayed. Finally, of the 141 female supervisors required in A.P., the promotion and training of 40 was delayed until 1986 due to legal complications. 1 Operations Research Group, India Population Project-Il in Uttar Pradesh and India Population Project-II in Andhra Pradesh. Baroda, 1988. Hereafter referred to as the ORG reports. 2 Population Centre, UP, Subcentre Construction and Performance of Family Welfare and Immunization Programme in IPP-II Districts. PC/RT/57. Lucknow, September 1988. - 27 - 18. Training. Pre-service, in-service and promotee training of program staff under the project was by and large carried out as planned with the exceptions noted above. The in-service training of multipurpose workers and supervisors was limited to reorientation under the multipurpose scheme. The evidence of the ORG reports suggests that additional, systematic in- service training of all staff was badly needed. 19. Management training for medical officers in U.P. was conducted at the Indian Institute of Management, Ahmadabad, until 1984, when it was taken over by the Management Training Centre established as an adjunct of the Population Centre, Lucknow under the project. A report3 by the Population Centre, Lucknow indicates that the doctors who were trained generally felt that the discussions of practical management matters and the involvement of prorram managers in the training vere valuable to them, although questions of how to motivate staff and how to deal with political interference remained. On the basis of experience, in 1987 the Management Training Centre developed two separate management courses, an orientation course for newly recruited medical officers and a management development course for experienced officers, which are currently being provided. 20. Management training in A.P. was never satisfactorily organized. It was initially carried out at the Administrative Staff College, Hyderabad, but then transferred to the state*s Institution of Administration, which organized courses at the Health and Family Welfare Training Center in Hyderabad using guest lecturers. About 80% of the number of medical officers planned to be trained were actually trained. An evaluation of the training by the Population Centre, Bangalore indicated that the curriculum was insufficiently practical and that core staff to manage the training were not appointed. 21. IEC. On the basis of the experience of the first project, the second project called for a particular emphasis on IEC, including the appointment of IEC professionals as managers, the training/retraining of IEC staff and the supply of equipment and vehicles. Procurement of the latter was accomplished as planned, and physical targets were by and large achieved (Part III, Section 4). Block and district level IEC workers were trained as called for in the SAR, and specified materials were produced. Manuals for orientation training camps (OTCs), an interpersonal communication technique developed to reach locally influential persons, were prepared in the state languages and OTCs held as planned. The ORG reports note that in both states difficulties in getting equipment repaired were experienced. 22. In A.P., the appointment of a communications professional as IEC program officer had good results. Development and production of materials were devolved to district and block levels to the extent possible, and the ORG report confirms other reports that large quantities of materials were s Population Centre, UP, Impact and Utilization of Management Training Programme for Medical Officers under IPP-II. PC/RT/56. Lucknow, August 1988. - 28 - distributed to all facilities, including subcenters, and were generally found to be quite useful. The film and slide projectors supplied were heavily used. The Gandhigram Institute of Rural Health and Family Welfare conducted an evaluation study of the project.IEC component in A.P; the report, which was generally positive, made a number of suggestions for additional staff i-aining, organizational changes and implementation improvements but did not assess the effectiveness of IEC staff and activities in communicating information concerning family welfare topics and supporting service delivery. Nor was there any evaluation of the impact of OTCs, so that it is not possible to assess the success,of the project's communication strategies. 23. The IEC component in U.P., on the 6ther hand, never developed as envisioned, in part because of the failure to appoint a technically qualified Joint Director for IC as called for in the SAR (para. 4.56), leaving district and block level IEC staff without guidance or support and vulnerable to co- option of their time for non-IEC purposes. Production of materials was contracted out to the private sector late in the project with little, if any, local input. The ORG report records that local program managers did not have much interest in IEC activities and that IEC activities in the project districts were limited. No evaluation of any of the aspects of the 150 component was undertaken. The IIN management report (Part III, Section 6B) makes it clear that the organization, management and implementation of the IEC program in U.P. needs a complete revamping. 24. Ponulation Education. The project included a small population education component to be carried out by the Population Studies Centre of SV University, Tirupati, A.P. and directed at staff and students of so2e 111 degree and junior colleges in the A.P. project districts. Baseline surveys indicated surprising ignorance concerning family planning and population issues among faculty and students. The component was organized and carried out in a professional manner, excellent materials were prepared, and staff forming the nucleus of population education cells in all of the colleges were trained. 25. Program Monitoring. Evaluation and Research. In A.P. a management information and evaluation system (MIES), derived from the systems developed under the first project and intended to replace the existing inefficient and ineffective system for reporting of service statistics, was implemented as planned in 1982. A consolidated set of printed registers in the state language was distributed to all subcenters in the project districts and revised reporting forms to facilitate rapid consolidation, analysis and feedback of data were introduced. All staff received training in the functioning and utilization of the system, and initial house-to-house surveys were carried out to complete household and eligible couple registers. Tvo evaluations were carried out in 1982 and the findings used in refresher training courses to improve implementation of the system. An MIES manual in the state language was supplied to all staff. In U.P. the project called for the implementation of the MIES developed under the first project to be implemented in the six project districts. This was to be done with the technical assistance of the Population Centre, which was to analyze the service statistics forwarded and - 29 - prepare feedback tables. The state's Demographic & Evaluation Cell, which has state-wide responsibility for compiling program service statistics, was to take over the responsibility for MIES in the first and second project districts. In fact, a separate system for compiling service statistics in 12 project districts represented an unproductive complication for an already burdened D&E Cell, which continued to ignore MIES. Ironically, the new system, which was designed to eliminate duplication and reduce the record keeping burden on field workers, became yet another source of duplicate record keeping in the U.P. project districts. An operational research project to develop the managerial potential of MIES in selected blocks was not completed. 27. In A.P., two innovative projects to improve acceptance of family planning, one involving R"hats (local governing bodies) and the other the educated unemployed, were undertaken; neither achieved significant results. A third child-to-child program to improve the health and nutritional status of selected older children and train them to assist in bringing services to younger children and their parents was carried out in slum areas around Tirupathi with good results. A number of useful studies, particularly on subcenter performance and the management training program in U.P., were carried out by the Population Centre, Lucknow. 28. Pro&raM/Proiect Manaaement. In U.P., the project was headed by a Special Secretary cum Project Coordinator in the Secretariat of the Health and Family Welfare Department, who had other duties in addition to project responsibilities. Day-to-day project management was in the hands of an Additional Director in the Department's Directorate. In A.P., given the smaller scale of the project, the project was headed and managed by an Additional Director in the Department's Directorate. Once the post was relieved of all non-project responsibilities, project management in A.P. improved considerably. In both states the project was essentially run from the Directorates, and coordination between project and program was substantially better than-in the First Population Project. The special project construction units set up in both states experienced delays in recruiting staff but were eventually fully staffed and successfully completed the construction program. In order to support the integrated provision of health and family welfare services, the project called for the merger of the states' Health Education Units and the Mass Education Units (SAR para. 4.56) and Demographic and Evaluation Cells and Vital Statistics Cells (SAR para. 4.59), but none of these mergers was carried out. However, in A.P. statistical staff was integrated at the district level in the project districts, and this was extended to the rest of the state's districts during the project extension (para. 31). Ptoject Sonitoring and Evaluation 29. The states' project units reported on project physical achievements in routine and satisfactory fashion. The SAR (Annex 2) lists a series of performance indicators, including changes in contraceptive prevalence, fertility and infant mortality rates, maternal and child health care coverage, immunization, and improvements in knowledge about health and family welfare services. Data on these indicators were to be obtained from baseline and follow-up surveys, service statistics and special studies and -3n surveys. Baseline and mid-term surveys were carried out by the Population Centre, Lucknow for U.P. and the Population Centre, Bangalore for A.P. There were problems about these surveys. Neither institution appears to have had the facilities or technical capacity to produce reliable data and analyses, and all of the reports were much delayed. The vital rates reported were questionable, and in a number of instances differences between baseline and mid-term estimates seemed quite unlikely. End-line surveys were conducted by the Operations Research Group, Baroda. The accompanying PHC cases studies are of generally hig quality and are quite useful. Had such case studies been carried out during the project, they might have been able to make a significant contribution to improved project implementation. 30. District.and state-level calculations of contraceptive prevalence are routinely made by the state Demographic and Evaluation Cells from service statistics. Subcenter-level rates for contraceptive prevalence and NCR services were to be available from the N4IES registers and then aggregated at higher levels. In A.P. rates were compiled at the time MIES was introduced and the registers initially filled up, but this was not followed up. In U.P. the compilation of subeenter rates was not attempted. Project Extension 31. In March 1986, just prior to the expected credit closing date, the Department of Economic Affairs (DEA) of the Finance Ministry indicated that it would reauest an extension of the project for two years in order to utilize the unexpended balance of the credit resulting from exchange rate changes. The states then prepared extension proposals, which were reviewed by the Ministry and a Bank mission in July 1986; formal notification of the extension reached the states in December 1986. Both states proposed to use the extension to support ongoing activities, complete those few civil works items still outstanding, and extend specified project activities beyond the project districts. In A.P., during the extension period the IEC and MIES components of the project were extended state-wide, and Population Education was expanded. In U.P., Populatic 1ducation was introduced in women's , colleges throughout the state ane -C and training activities were expanded. ProJect Sustainability 32. Project sustainability is not likely to be an issue. The family welfare program is funded almost entirely by the central government, which has a fundamental and long-standing commitment to the provision of family welfare services. The one question that arises concerns maintenance of buildings constructed under the project. The states of U.P. and A.P. agreed to appropriate 1.5% of capital costs annually for maintenance purposes (para. 2.98(a) of the Project Agreement and Agreed Minutes to the negotiations), and in fact such a line item has appeared regularly in the budgets of both states. However, as the SAR (para. 4.17) notes, providing maintenance for small, scattered buildings is difficult for ,the states, and the record is poor despite annual allocation of funds for the purpose. There are therefore serious questions as to whether buildings constructed under the project will be maintained adequately. - 31 - Bank Performance 33. Bank'supervision of the project for the original project period was carried out regularly and had good continuity, with both the original project officer from the Population Health and Nutrition (PHN) Department and the consultant architect involved throughout. However, under the extension the project went virtually unsupervised. The last field supervision was carried out in November 1986, before the states received official notification that the project had been extended. Supervision in 1987 was hampered by the reorganization of the Bank and, with the credit due to close in March 1988, a final meeting with state authorities and project staff from both states was held in late 1987 in Delhi rather than in the states. As a result, there is almost no Bank record of project implementation, except for disbursements, for the two-year extension period. 34. When the Government's intention to request an extension of the project (para. 31) was conveyed to senior Bank management, a decision was taken to agree to the request despite an explicit Bank policy excluding use of exchange rate savings as grounds for project extension. This undercut previous statements by Bank staff that the Bank's rules precluded an extension under the circumstances and necessitated the hasty processing of extension proposals, thus underlining the need for the Bank to formulate and implement clear and consistent guidelines concerning the use of credit savings arising from exchange rate changes. Borrower Performance 35. Transfer of funds from the Government of India to the states and processing of state disbursement applications by the GOI went smoothly. Difficulty at the central government level arose from lack of communication between DEA and the line ministry, the Ministry of Health and Family Welfare. The Ministry was unaware of DEA's wish to extend the project until less than three weeks before the credit was due to close, necessitating the preparation of extension proposals by the states and their review by the Ministry under great pressure. 36. Achievement of the project's physical targets by the states of Uttar Pradesh and Andhra Pradesh within virtually the original time-frame, despite substantial delays at the beginning of the project, is a credit to the governments of both States. Several difficulties, however, can be identified. These include: - failure to implement pre-project activities; - delays and even refusal by the Finance Departments in clearing expenditures for items and activities included in the project, a problem that was particularly severe in the earlier years of the project but never entirely disappeared; - inability to select subcenter sites satisfactorily in U.P.; - inability to supervise the quality of construction; - 32 - - failure to ensure maintenance and repair of equipment, vehicles and facilities; and * failure to recruit technically qualified management for the IEC component in U.P. and failure in either state to evaluate the impact of IEC activities. The failure of the U.P. Government to regularize Population Centre staff positions, despite a clear obligation to do so after the close of the first project, is undoubtedly responsible in large measure for the state's continuing inability to recruit a permanent director for the Centre. Project Achievements4 37. Family Planning. Figures for current contraceptive prevalence from 1980 to 1988 for project districts and the states of Uttar Pradesh and Andhra Pradesh based on service statistics are shown in the table on the following page. Increases in prevalence in the project districts more or less achieved project goals but were not substantially different from achievements in non-project districts. The table indicates that in U.P. in 1980, contraceptive prevalence in the Varanasi Division districts (Varanasi, Mirzapur, Ghazipur) was higher than the state average, while prevalence in the Corakhpur Division districts (Azamgarh, Basti, Deoria) was lower. By 1986 this was still true, but because of relatively larger increases in the Varanasi districts prevalence for the project districts as a whole was higher than average prevalence for the state. In A.P. in 1980, both Chitoor and Cuddapah districts had contraceptive prevalence higher than the state average, but by 1987 prevalence in all three districts was lower than the state average. Use of temporary contraceptive methods remained somewhat higher in the project districts than in the state as a whole, but sterilization prevalence, which was almost the same in the project districts and the state in 1980, increased less rapidly in the project districts than in the state. 38. The family planning achievement figures for the project districts given in Part III, Section 6, indicate (i) substantial fluctuations year to year, and (ii) little difference in the performance of project vs. non-project districts. It is clear that the district figures reflect both national and state trends as well as local circumstances. For instance, the substantial increases in sterilizations in U.P. in 1984-85 can be attributed to the introduction and promotion of laparoscopy camps in the state. Sterilization figures after 1985 also reflect the use of staff from departments other than Health to recruit acceptors. However, it is apparent that to explain the year-to-year variations in the various districts would require detailed knowledge of local program and political circumstances. The ORG survey reports were not yet available at the time this section was written, so that end-of-project estimates for MCH coverage in the project districts were not available. - 33 - CUftENT OTRACEP21VE PREVA1ENCE RATES Ufttar Pradesh- Azama BatL Deoria Ghasipur ~irapur VaranasIL PrJ Dista U.P. 1980 9.6 7.3 10.0 13.2 13.0 12.4 10,8 11.9 1981 8.4 7.2 9.' 12.2 11.9 12.3 10.2 11.4 1982 8.7 7.5 9.6 12.4 13.5 12.7 10.7 11.9 1983 11.5 9.8 10.4 16.4 15.5 15.8 13.3 13.9 1984 14.4 11.3 13.3 21.1 18.0 17.5 15.9 15.5 1985 15.9 13.6 15.3 23.0 22.7 23,7 19.0 17.8 1986 20.0 17.0 21.0 28.7 25.9 31.6 23.5 * 22.5 1987 27.4 1988 31.4 An~h Pr~., anatapur ChIttoon Cuddapah Proj Diats A.P. 1980 23.0 27.2 29.8 26.4 25.8 1981 23.7 28.4 30.3 27.2 26.3 1982 23.1 28.8 28.8 26.7 27.2 1983 25.0 31.4 31.0 29.0 28.7 1984 28.6 32.2 31.7 30.8 31.0 1985 31.5 33.6 33.9 32.9 33.3 1986 34.5 36.3 35.3 35.4 * 36.0 1987 33.8 36.0 34.9 34.9 37.1 1988 36.0 38.4 36.7 37.1 41.4 * Expected contraceptiv prevalce« at the end of the poject was 25X for the U.P. projet district and 36Sor th* A.P. projeoct distriots (SAR. para. 7.03). - 34 - 40. Maternal-Child Health. Program MCH achievement figures (Part III, Section 6) and the figures reported for sample PHCs in the ORG reports are similar to those for family planning in that they show (i) wide variation from facility/ district to facility/district and from year to year, and (ii) little difference between project districts and state averages. Unlike the family planning figures, it is difficult to discern any overall trends. 41. The lack of clear differences between achievements in project and non-project districts may in part result because the great majority of project facilities were commissioned only late in the project, so that their impact was not yet apparent by the end of the project. It should also be noted that the establishment of subcenters in non-project districts proceeded under the Sixth Plan, so that between project and non-project districts the difference in subcenter coverage was small. In 1986 in U.P., subcenter coverage in the project districts was approximately one per 5300 rural population, compared with approximately one per 6000 rural population in the rest of the state; the situation in A.P. was similar. The significant contrast was in terms of constructed vs. rented subcenters, since the Sixth Plan supported only limited construction and most non-project subcenters functioned in rented accommodation. By the end of the project, in the non-project districts of U.P. only about 20% of subcentres functioned in constructed facilities, while in the project districts the project goal of about 50% constructured subcenters (SAR para. 4.16) was achieved. The study, referred to in para. 12, carried out by the Population Centre, Lucknow to investigate the effect of rented vs. constructed subcenters in project districts concluded (i) that most quarters attached to constructed subcenters were occupied by the posted female multipurpose worker5, but (ii) that in terms of family planning or immunization performance there was no significant difference between rented and constructed subcenters. The finding should not be taken to indicate that that construction of subcenters is unneeded but rather that constructed facilities with resident staff are not of themselves, given the present circumstances of the program, necessarily sufficient to improve worker productivity. Lessons Learned 42. Assessment of project achievements at the present time is incomplete, since it may be too soon for the effect of many aspects of the project to be evident. It would be useful to examine subsequently the impact of project-assisted investments. It is also important to recognize that the project was a small part of the much larger family welfare program and that many of the constraints and problems identified by supervision missions and evaluation reports relate to the program rather than to the project specifically. 43. The following points, however, can be identified from the implementation of the project itself: The ORG reports also reached this conclusion. -35- * monitoring of site selection and construction is difficult and effective means to strengthen it need to be devised; - procedures for avoiding the necessity of obtaining line-by-line clearance by state Finance Departments for project expenditures need to be devised; - inability to obtain maintenance and/or repairs of project-supplied equipment and vehicles was a major bottleneck; facilities and resources need to be assessed and procedures clarified. * the multipurpose reorientation of staff carried out under the project was inadequate; the provision of systematic in-service training is essential if staff productivity is to be improved; - management of the IEC component by technically competent staff and decentralization of materials development can achieve substantial improvements in IEC activities; - it is likely that feedback of the sort obtained from the ORG case study reports after the end of the project could have made a significant contribution to project/program implementation had it been available during the project period; and - since the family welfare program is managed and implemented at the state level, many of the managerial problems evident in project districts can be dealt with only on a state, rather than a district, basis. These points have been taken into account in the development of the subsequent Bank-assisted population projects in India (Part III, Section 1). 44. Of the lessons learned from the First Project (para. 7), only the issues of project management and program coverage were successfully resolved; the rest were still issues at the end of the Second Project. These included the focus on sterilization at the expense of temporary contraceptive methods and MCH services, the focus on the achievement of targets rather than the provision of services, the lack of appreciation on the part of program managers of the potential contribution of IEC and the dearth of technically competent IEC managers, and the need for strengthening and decentralization of program planning and management. Given that the project was a small part of the much larger state and national programs, it is not realistic to expect it to have had a significant impact on underlying, program-wide difficulties, and so long as these remain unresolved, the impact of specific project inputs will inevitably be constrained. These issues have been and will continue to be addressed to the extent feasible in the development of subsequent Bank- assisted population projects. - 36 - PART II. PROJECT REVIEW FROM BORROWER'S PERSPECTIVE The Family Welfare Programme of India is being implemented as a centrally sponsored programme and the funds are being released to the State governments for the implementation of different schemes. The area projects selectively being implemented in different states are amongst the centrally sponsored schemes taken up by the Government of India to bring integrated health and family welfare services closer to the people. The additional inputs provided are intended to help the districts chosen in the selected states achieve the necessary infrastructure and trained manpower more quickly than would otherwise be possible. This project, IPP-II, implemented with World Bank assistance in selected districts of Uttar Pradesh and Andhra Pradesh, were part of the overall area project scheme. The Operations Research Group (ORG), of Baroda, which was entrusted with the final evaluation of this project,. stated in their final report that the project had done fairly well in establishing all the required health infrastructure in the project districts of these two states and what is required is the consolidation of the gains and optimal utilization of the infrastructure provided. As regards the general difficulties pointed out in the implementation of the family welfare programme, such as focus on sterilization at the expense of temporary methods, focus on achieving targets rather than the provision of services, lack of appreciation of the potential contribution of IEC, and the need for strengthening and decentralizing the programme planning and management system, it may be mentioned that these issues are constantly being given attention by the Government of India in order to facilitate the achievement of the demographic goals targetted for the year 2000. Already, increased emphasis is being given to temporary methods with the result that their acceptance rates are increasing; and the universal immunization programme is totally oriented towards undertaking of MCH services throughout the country. The need for more IEC activities and regular inservice training have been taken into account in subsequent projects to the extent possible. As regards the specific difficulties faced by the states in the design and implementation of the project that are noted in Part I of this PCR, steps have since been taken to rectify these. Some of these steps are enumerated below. Regarding the supervision of the quality of the construction in Uttar Pradesh, a separate wing, namely the Project Construction Unit, was established in which the engineering staff of the State Public Works Department (PWD) was engaged to %aintain the quality and timeliness of the construction of the buildings. Regularization of the staff including the appointment of a full-time director for the Population Centre, Lucknow, is under active consideration of the State Government. Regarding achievements in the sphere of family planning (paragraph 38 of Part I), while the project districts almost achieved the project - 7- goals, there was scope in all spheres for a better performance in comparison to the non-project districts. The extra inputs of infrastructure, service, etc., provided in the project districts were commissioned mostly in the latter half of the project. Consequently, the impact of the project activities is yet to be fully evident. It is expected that in coming years the performance of the project districts will be significantly different from the non-project districts. The shortage of male multipurpose workers (paragraph 17) experienced at the end of the project life was since been taken into account in the sixth project (IPP-VI) currently under implementation in the state. Efforts are underway to train the required number of multipurpose workers and to keep them in position in the state. As regards service delivery in Andhra Pradesh (paragraph 14 and 16), the defects noted in the construction of certain buildings under the project were brought to the attention of the concerned authorities. A special officer was appointed to go into the technical aspects of the defects, to coordinate corrective action and also to suggest further remedial measures. Also, Government sanction was accorded to the PWD to maintain the buildings constructed under the project at the normal rates adopted by the PWD. Necessary funds have also been made available as additional expenditure for maintenance of these buildings. Delays were experienced in the recruitment and training of male multipurpose workers because of legal complications and delays in obtaining clearance. However, the training was resumed in July, 1988 in which the backlog was covered. The suggestion made in the ORG report to provide systematic in-service training for all categories of staff has been incorporated into IPP-VI currently being implemented in the state. The transfer of management training from the Administrative Staff College of India, Hyderabad, to the Institute of Administration (paragr.ph 20) was done on economic grounds. As regards family planning achievements under the project (paragraph 39), the performance of the project districts was better under temporary methods, while there was no significant difference compared to non-project districts so far as permanent methods are concerned. Differences have also been noticed in MCH performance between project and non-project districts. The ANCs registered and followed in the project districts during the project period were higher than the state average. The late commissioning of the project facilities could be one reason for the not very significant difference of the family planning and MCH performance between the project and non-project districts. SECTION i PMt 1i1 - PROJEI~ DATA Page 1. Related lank Lansa ar Credita Credit No., 312-IN Lgg : Pirst Papulation Project Year of Anroval: 1972 Purose :Support of family velfare program In 5 distriots of earnataka and 6 distrlots of Uttar Pradesb. Status : Credit Closed June 30, 1980 Commenta PC 61811 PPAl 1182 Credit No. : 1426-IN gg Third (ter.1alKarnatska) Populatlon Project Year of An2o~al: 193 Pu * g Support of family VGlare program In 4 ba~k ard distrLets of Kerala and 6 baolmard dtstrita o£ Karn- -aka. S~ nder ~splem atton. Coe State-level support £or IS, IEC and population admatton. Cedkt..N. g 1623-IN x Pourth (Vest 9aenal> Populatuan Projeot Year of A roval : 1985 Puro Support of amily wlfare program in 4 distriota at vest Bengal. §- Under mplementation. State-level support for MRS, UEC and population eduoation and tralaing. CrdjitN. : 1931-IN jg Fifth (BombaylMadras> PopulatLon Projeot Tear of An~roval g 1988 Proe • Support of £amily velfare program in the cites of Sombf a and ~ adras. ~ Under iaplementatlon. Cont ~ 's and privat. medical practtioer* included in project. SECTION 1 Page 2 KjgLg : SIxth (virat national F~ly Mölfare Training and system Deveopment) Populatton Iroject Year of Anoroval : 1989 EMgfggg : Suppo of fami vlfar program in atates of Utta Pra.dsh, Andbra Pradesh and ~E.dhya Pradesh. j oard pemntation scheduled for June 1989. emm 1ocus on attangthenlng of-trang aspecta of the program on a stateide basis. lULa * Seventh (Second National Wamily Welfare Training and Systems Deveonent> Population Project EERuuaa * Support of family welfare program Sa states of Punjab, maryana, Gujarat and Bihar. Under preparations Board presentation ac~anted for 1990. ComeFocus on trenghaning of trainng aspecta of the program on a stat~vide basis. * EUghth (Second Urban) Population Project Purpose : Support of fa~ly welfare program in metropolitan areas. Status : Und preparations Board presentation scheduled for 1991. Comen Identifatiom of akties still Mur discussion. -40- SECTION 2 2. Pr t Timetable First Project Brief Auwat, 1976 Second Project Brief December, 1976 Appraisal Mission May, 1979 Credit Negotiations December, 1979 Soard Approval february 12, 1980 Credit Signing J=ne 14, 1980 Credit Effectiveness July 24, 1980 Credit Closing (original) December 31, 1985 Credit Closing (revised) March 31, 1986 Credit Closing (actual) March 31, 1988 NOTE: The preparation of this project Vas delayed by a changs of Sovernment in India in 1977, and implementation in the first year of the project was further delayed by another Ohange of Soverament in 1980. -41- SECTION 3 3. Credit Disbursements -(in US$ million)- IDA FY Quarter Ending SAR Estimate Actual Actual as % of Estimate 1980 September 1979 0.0 0.0 0 December 1979 0.0 0.0 0 March 1980 0.0 0.0 0 June 1980 0.4 0.0 0 1981 September 1980 1.3 0.0 0 December 1980 2.5 0.0 0 March 1981 4.0 0.1 3 June 1981 5.8 0.6 10 1982 September 1981 7.9 0.8 10 December 1981 10.3 0.9 8 March 1982 13.2 1.3 10 June 1982 16.5 2.8 17 1983 September 1982 20.3 3.8 19 December 1982 24.3 4.8 20 March 1983 28.1 6.5 23 June 1983 31.6 8.9 28 1984 September 1983 34.8 9.6 28 December 1983 37.7 11.4 30 March 1984 40.2 15.2 38 June 1984 42.3 16.5 39 1985 September 1984 44.2 18.4 18 December 1984 45.4 19.9 44 March 1985 46.0 22.7 49 June 1985 46.0 25.6 56 1986 September 1985 46.0 26.4 57 December 1985 46.0 28.2 61 March 1986 46.0 30.1 65 June 1986 46.0 32.8 71 1987 September 1986 46.0 - 34.6 75 December 1986 46.0 35.9 78 March 1987 46.0 36.4 79 June 1987 46.0 38.0 83 1988 September 1987 46.0 38.5 84, December 1987 46.0 39.6 86 March 1988 46.0 41.1 89 June 1988 46.0 41.8 91 1989 September 1988 46.0 43.3 94 December 1988 46.0 44.2 96 - 42 - SECTION 4 Page 1 4. Proiget Innuta Andhra Pradesh Civil Works Target Completed Deleted Remarks Sub-Centers 427 421 6 @ LV Quarters 237 232 5 @ Upgradation, a. 10 bed ward 26 26 b. OT 26 22 4* New PHCs 14 14 RFWCs 27 20 7* Training Sheds. 48 45 *2+1@ ANM Hostels 5 5 Regional Workshop 1 1 Equipment Workshop 1 1 HFWTC additions at Kurnool 1 1 Medical Officers Quarters 107 108 1 extra Class III Employeds Quarters 335 334 1 @ Class IV Employees Quarters 279 282 3 extra Jeep Garages 41 41 Ambulance Garages 26 26 OP Blocks 8 - addl.const. Abbreviations: * 8 Outpatient Blocks, 1 Medical Officer Quarter. and 3 Class-IV Employees rters were additionally constructed in lieu of 7 Rural Family Welfare centres, 4 Operation Theatres and 2 Training Sheds which were found superflous. @ - 6 subcenters, 5 LV quarters, 1 Training Shed and 1 Class-III Employees Quarter were deleted as they could not be carried out due to court stay orders on sites and due to other difficulties from contractors. PHC - Primary Health Center RFUTC - Rural Family Welfare Center ANK - Auxiliary Nurse-Midwife OT - Operating Theatre LHV - Lady Health Visitor (female supervisor) HFWTC - Health & Family Welfare Training Centre OP - Outpatient -43. SECTION 4 Andhra Pradesh STAFF RECRUITED/TRAINED No. Remarks Community Health Workers 2850 Figure differs from SAR figure but represents 100% of needed staff. Traditional Sirth Attendants 3382 (dais) Female Multipurpose Workers 927 Kale Multipurpose Workers 217 Training delayed by 001; requirement of 447 not met by end of project. Female Supervisors 101 Training delayed by 001; requirement of 141 not met by end of project. IEC-ACTIVITIES Activity Target Achievement Percent Initial Orientation Tkaining Camps 5355 ,4731 88 Follow-up Orientation Training Camps 955 905 95 Health & Family Welfare Advisory Committee 1154 1154 100 District Level Workshops/ Seminars 12 12 100 Education Visits 9 9 100 Poets meet & Astavadhanam 15 15 100 Cultural Programs 47t1 4396 92 School Competitions (Essay) 1114 961 86 -44- SECTION 4 Page 3 Andhra Pradesh IEC-AUDIO VISUAL EQUIPMENT SUPPLIED Item Target Achievement Percent Tape Recorders 62 62 100 Slide cum Film Strip Projectors 71 71 100 Generators 9 9 100 l6mm Film Projectors 9 9 100 PA System 9 9 100 8m Projectors 72 72 100 Automatic slide projectors 4 4 100 VCRs & TVs 4 4 100 Cameras 10 10 100 IEC-MATERIALS Item Target Achievement Percent Aid Making Kits 71 71 100 Display Kits 62 62 100 Cloth Flip Charts (3 types) a. MCN 200 200 100 b. Dehydration 200 200 100 c. Family Welfare 200 200 100 Prerecorded tapes 62 62 100 Hoardings 190 190 100 Wall Paintings 1308 1308 100 Metal Tables 4550 4550 100 - 45 - Page 5 Uttar Pradesh CIVIL WORKS Target Completed Percent Subcenters 925 912 99 Subcenters with LHV quarters 635 627 99 PHCs 16 16 100 RFWGs 34 33 97 PHCs with RFWCs 26 24 92 Upgraded PHCs 34 28 82 PP additions to OTs 7 7 100 OTs 26 26 100 Maternity Homes 2 1 50 Training Center, Lucknow 1 1 100 Overhead Tanks 113 55 49 Approach Roads 38 38 100 Electrical Connections for existing PHCs 37 37 100 Abbreviations: PHC - Primary Health Center RFWC - Rural Family Welfare Center PP - Post Partum OT - Operating Theatre LKV - Lady Health Visitor (female supervisor) - 46 - SECTION 4 Page 4 Andhra Pradesh IEC-PRINT/PUBLICITY AND OTHER MATERIALS PRODUCED AND SUPPLIED Item Target Achievement Percent -----------000's-------- Educational Kit Booklet on MTP 55 55 100 Booklet on KCH 55 55 100 Booklet on Nutrition 55 55 100 Booklet on Family Welfare 55 55 100 Folders 15 varieties 770 770 100 Gift covers 2 varieties 110 110 100 Su"lementary Literature Booklet on Aksharamalatho Argogyam 30 30 100 Booklet on Falasayam Amitham Santhanam Mitham 30 30 100 Folders 6 varieties 90 90 100 Printed Material Wall poster on vasectomy 100 100 100 Wall poster on daughters are equal to sons 100 100 100 Stickers in 10 varieties 1000 1000 100 Cartoons in 6 varieties 600 600 100 Handbook of talking points 5 5 100 - 47 - SECTION 4 Page 6 Uttar Pradesh STAFF RECRUITED/TRAINED Target Achievement Community Health Workers 5805 5805 Traditional Birth Attendants 2801 2801 (daIa) Female Multipurpose Workers 1775 1775 Female Supervisors 487 487 Male Supervisors 222 PHC Medical Officers 81 81 4 - SECTION 4 Page 7 Uttar Pradesh IEC-ACTIVITIES/EQUIPMENT/MATERIALS Target Achievement Orientation Training Camps - Initial 5585 5582 . Follow-up 5585 5459 - Educational Kits 223400 223900 Seminar 39 36 Advisory Committee Formed - Sub center level 1564 1564 - Block level 148 148 - District level 6 6 Education Visits 4 4 School Competitions - '616' 610 Cultural Programs * by local,talents 23840 11918 - by State Parties 2500 759 Aid Making kits 148 148 Mobile Film Units 35 35 Film Strips slide projectors 148 148 Display kits 3284 3284 Tape Recorders i148 148 Portable Kits 3284 3284 Literature for Adult Education Program - Hand outs 1 75000x5yrs 6000x2yrs - Hand outs 2 " - Post Mailing Lit. * * H&FW foldrs to be supplied for 2 years 37000 5 types one year -49'- SECTION 5 5. Proiect Costs and Financing Page 1 A. Estimatea Prolet Costs at Appraisal Local Foreign Total ----------------------------- Capital Costs Base Civil Works 20,900 9,200 30,100 Furniture 1,500 550 2,050 Equipment 1,100 650 1,750 IEC Materials 1,400 600 2,000 Vehicles 1,750 650 2,400 Subtotal Capital Costs 26,650 11,650 38,300 Operational and Maintenance Costs Salaries 18,000 - 18,000 Vehicle Operational & Maintenance 600 500 1,100 Other Operational & Maintenance 16,000 100 16,100 Subtotal Operational & Maintenance 34,600 600 35,200 Innovative Activities 1,200 300 1,500 Subtotal, Base Cost 62,450 12,550 75,000 Contingenciek Physical 1,400 600 2,000 Price 15,000 4,000 19,000 Subtotal, Contingencies 16,400 4,600 21,000 TOTAL 78,850 17,150 96,999 Virtually all foreign exchange costs were indirect. - 50 - SECTION -5 Page 2 B. Credit Financing Credit Agreement Revised Fial -----------US$0001---------------- Ependiture Categories 1. Civil Works 17,000 19,000 19,479 2. Furniture, etc 5,400 5,300 4,291 3. Staff Salaries (a) for Borrower's monitoring and evaluation systems 300 1,000 918 (b) for States' staff 8,700 12,000 11,608 4. Operation & Maintenance including studies and study tours 10,600 7,500 7,814 5. Innovative Activities 1,000 200 128 6. Unallocated ..000 .J.00 TOTAL 46,000 46,000 44,238 - 51 - Project RassuIt SECTION 6 Page i A. Project AchLevammts Anaa Pradesh - PamLP P1-=- - Ach-eveent- . STEILIUATON P2RCENT CHANGES• NON O AMANT CEIT CU0 'P RO PROJ STATE ANANT CHIT CUD PROJ PR7J STATE AUR To=R DAPAB DiSTS DISTS A.P.) APUM *M02 DAPAB DiSTS DlS CA.P.) 79-80 6256 9825 6215 22296 160092 182388 80-81 8392 13585 7447 29424 214616 244100 34.1 38.3 19.8 32.0 34.1 33.8 81-82 12506 18517 9963 40986 249448 290434 49.0 36.3 33.8 39.3 16.2 19.0 82-83 15315 23064 1255 50734 206499 357233 22.5 24.6 24.0 23.8 22.9 23.0 83-84 14572 18192 11750 44514 314233 358747 -4.9 -21.1 -4.9 -12.3 2.5 0.4 84-85 14612 18273 11775 44660 330344 375004 0.3 0.4 0.2 0.3 3.1 4.5 85-86 15673 21859 12996 50528 384186 434714 7.3 19.6 10.4 13.1 16.3 15.9 86-87 14855 19200 10416 44471 407846 452317 -5.2 -12.2 -19.9 -12.0 6.2 4.0 87-88 16075 19300 11304 46679 410810 457489 8.2 0.5 8.5 5.0 0.7 1.1 157.0 96.4 81.9 109.4 156.6 150.8 NON NON AMT CT UD PROJ STATZ AMT C9IT CUD Ml03 VROJ STATE APUM TOOR DAA DISTS DISTS (A.p.) APUR TOOR DAPAR MISTS DISTS (A.P.) 79-80 955 1596 731 3282 9891 13173 80-81 1254 1988 699' 3941 13628 17569 31.3 24.6 -4.4 20.1 37.8 33.4 81-82 1206 1163 773 3142 14914 18056 -3.8 -41.5 10.6 -20.3 9.4 2.8 82-83 2983 1812 1699 6494 18339 24833 147.3 55.8 119.8 106.1 23.0 37.5 83-84 8507 3524 3104 15135 48978 64113 185.g 94.5 82.7 133.1 167.1 156.2 84-85 7354 4681 5323 17358 60941 78299 -13.6 32.8 71.5 14.7 24.4 22.1 85-86 9939 6896 6005 22840 102762 125602 35.2 47.3 12.8 31.6 68.6 60.4 86-87 6358 6180 5227 17765 77024 94789 -36.0 -10.4 -13.0 -22.2 -25.0 -24.5 87-88 7912 7589 4984 20485 153489 173974 24.4 22.8 -4.6 15.3 99.3 83.5 728.5 375.5 581.8 524.2 1433.8 1220.7 cc NON NON ANAmT CNT CD PROJ PROJ STATE AmAmT CUIT CUDI PR0 PROJ sTATE APUR 2002 DAPAR Disig Disig (W.P.) APUR R DAPAR DIST DisTg (A.P.) i 79-80 4718 1576 1812 8105 30476 38581 80-81 3584 1594 2122 7300 34382 41682 -24.0 1.1 17.2 -9.9 12.8 8.0 81-82 2760 641 1099 4500 39950 44450 -23.0 -59.8 -48.2 -38.4 16.2 6.6 02-83 4466 2945 3892 11303 51565 62868 61.8 359.8 254.1 151.2 29.1 41.4 83-84 11690 6283 6879 24852 107807 132659 161.7 113.3 . 76.7 119.9 109.1 111.0 84-83 17252 6301 9204 32757 183504 216261 47.6 0.3 33.8 31.8 70.2 63.0 ' 85-86 22278 8856 9598 40732 175529 216261 29.1 40.6 4.3 24.3 -4.3 0.0 86-87 15402 3615 6419 25436 179393 204829 -30.9 -59.2 -33.1 -37.6 2.2 -5.3 87-88 26221 12128 13067 51416 372277 423693 70.2 2353.5 103.6 102.1 107.5 106.9 455.7 669.8 621.3 534.3 1121.5 998.2 -52- SECTION 6 Page 2 å~ANT CUT CU mRm3 ~ROJ STAU ANANT CMIT CUD PROJ PROJw STATE APU~ i00= DAPA DST8 DISTS (A.P.) AMUR TOR DAAR DISU DISTS (A.P.) 79-80 84 50 126 260 2379 2640 80-81 134 78 *00 412 3881 4293 59.9 55.7 58.4 58.4 63.1 62.6 81-82 147 159 156 442 5980 6442 9.5 104.0 -21.9 12.1 54.1 50.1 82-83 398 294 685 1377 7324 8701 170.9 85.3 337.9 198.0 22.5 35.1 83-84 2237 1629 1994 5861 26839 32700 462.2 453.9 191.2 325.6 266.4 275.8 84-85 3394 1944 2685 8022 40800 48822 51.7 19.3 34.6 36.9 52.0 49.3 85-86 4534 2390 2067 8992 55540 64532 33.6 23.0 -23.0 12.1 36.1 32.2 86-87 3555 1424 2469 7448 52597 60045 -21.6 -40.4 19.4 -17.2 -5.3 -7.0 87-88 5277 2843 3262 11402 97185 10~587 48.4 101.1 32.1 53.1 84.8 80.8 6187.9 5626.0 2481.0 4280.2 3984.3 4013.5 TEORAY 7ET800B ømN Nom . åA~AN CI? CUD 1~PR STT AåANT CHIT CUD PROJ PROJ STATE AM 00 DAPAB D IST - «XmTS (A.P.) AMUR 1001 DMAA DIUTS DISTS (A.P.) 79-80 5757 3222 2669 11648 42747 54394 80-81 4973 $659 3022 11654 51891 63544 -13.6 13.6 13.2 0.1 21.4 16.8 81-82 4113 1962 2029 8104 60845 68948 -17.3 -46.4 -32.9 -30.5 17.3 8.5 82-43 »847 5051 6276 19174 77228 96402 90.8 157.4 209.4 136.6 26.9 39.8 83-84 22434 11437 11977 45848 183624 229471 185.9 126.4 90.8 139.1 137.8 138.0 84-85 28000 12925 17212 58137 285245 343382 24.8 13.0 43.7 26.8 55.3 49.6 85-86 36752 18143 17670 72564 333831 406396 31.3 40.4 2.7 24.8 17.0 18.4 86-87 25315 11219 14115 5049 309014 359663 -31.1 -38.2 -20.1 -30.2 -7.4 -11.5 87-88 39410 22580 21313 83303 622951 706254 55.7 101.3 51.0 64.5 101.6 96.4 584.5 600.9 698.6 615.2 1357.3 1198.4 - 53 - SECTION 6 adhg Pradesh - NB Aab1vemnePage 3 DPT (0-2188) PECEN CRA=tES ANA~T CO2 CUD PROJ PROJ STAT AuANT CF=T CUD RoJ pOJi STAT APU T0 DAR DIS (A.P.) APUR T~0R DAPAS DISTS DIST8 (A.P.> 79-80 65969 43582 2183* 131363 513398 644761 80-81 33120 28978 17892 81990 543707 615697 -46.8 -33.5 -18.0 -37.6 5.9 -3.0 81-82 31414 37064 36842 105320 686750 792070 -10.6 27.9 105.9 28.5 26.3 26.8 82-83 54237 37872 57627 149736 642334 792070 72.7 2.2 56.4 42.2 -6.5 0.0 83-84 76052 83621 53706 213379 720237 935616 40.2 120.8 -6.8 42.5 12.1 17.9 84-85 73578 115024 51641 240243 837659 1077902 -3.3 37.6 -3.8 12.6 16.3 15.5 85-86 110214 61965 67294 239473 786834 1026307 49.8 -46.1 30.3 -0.3 -6.1 -4.8 86-87 55125 46777 25134 127036 625510 752546 -50.0 -24.5 -62.7 -47.0 -20.5 -26.7 87-88 57501 68709 16905 14311 1076006 1219121 4.3 46.9 -32.7 12.7 72.0 62.0 -12.8 57.7 -22.6 8.9 109.6 89.1 D? (3-5 TRS) ANA~T CRIT CUD PROJ PROJ STATE ANAT CBIT CUD a?03 PR STAT AMU1 I001 DAPAR DIMT DMSTS PA.P.) APUR 200 DAPAR DISTS DIMTS (A.P.) 79-80 102031 69262 45869 217162 1194891 1412053 2031 80-81 54249 75810 48228 176287 1198629 1376916 -46.8 9.5 5.1 -17.9 0.3 -2.5 81-82 53331 32978 42873 129182 1067109 1196291 -1.7 -56.5 -11.1 -27.5 -11.0 -13.1 t2-83 25658 37380 58224 121262 641312 762574 -51.9 15.3 35.8 -6.1 -39.9 -36.3 83-84 48641 28864 38636 116141 534449 650590 89.6 -22.8 -33.6 -4.2 -16.7 -14.7 84-85 77741 26829 48949 153519 824328 977847 59.8 -7.1 26.7 32.2 54.2 50.3 85-86 37133 26014 14061 77208 723506 800714 -52.2 -3.0 -71.3 -49.7 -12.2 -18.1 86-87 39633 54411 18810 112854 701346 814200 6.7 109.2 33.8 46.2 -3.1 1.7 87-88 62868 63905 21433 148206 974045 1122251 58.6 17.4 13.9 31.3 38.9 37.8 -38.4 -7.7 -53.3 -31.8 -18.5 -20.5 i TT <P8EG. (PMEN) ANANT CT CUD P PROJ rATX ANA~T CIT CUD PROJ PROJ STAT APUR TOOR ~AAR DISTS DIST6 (A.P.) APUR TO0 DAPAR DIST8 DISTn (A.P.) 79-80 29184 35736 16616 81536 562293 643829 80-81 40595 39588 24032 104215 599139 703334 39.1 10.8 44.6 27.8 6.6 9.2 81-82 22567 24008 26828 73403 614591 687994 -44.4 -39.4 11.6 -29.6 2.6 -2.2 82-83 38997 53346 39671 132214 717065 849279 72.8 123.0 47.9 80.1 16.7 23.4 83-84 6094 49094 37840 143028 632547 775575 43.8 -8.3 -4.6 8.2 -11.8 -8.7 84-85 64775 37883 39486 142144 729172 871316 15.5 -22.8 4.3 -0.6 15.3 12.3 85-86 69898 46561 43762 160227 799858 960085 7.9 22.9 10.8 12.7 9.7 10.2 8687 52344 46367 32151 131062 735301 866363 -25.1 0.0 -26.5 -18.2 -8.1 -9.8 87-88 70048 62864 30668 163580 1077932 1241512 33.8 35.0 -4.6 24.8 46.6 43.3 140.0 75.9 84,6 100.6 91.7 92.8 -54- SECTION 6 PaSe 4 .» MMM sun AAI CHIT CDm PROJ7 PROJ STATE ANN CHIT CUO 1ROJ »ROJ 8TATS APU 100 DAPAD DI8T8 DIST8 A.Pwp.) AUR 12 DAWAR DISM Dim (.P. 79-80 63867 80311 325M5 176513 794971 971484 80-81 94832 97310 65595 2$7737 1103456 1361393 48.5 21.2 102.9 46.0 38.8 40.1 81-82 74115 92543 65477 234135 1058999 1293134 -19.7 -4.9 -0.2 -9.2 -4.0 -5.0 82-83 114316 12S10 66078 305904 1154164 1460010 50.2 35.6 0.9 30.7 9.0 12.9 83-84 141471 141745 155355 458571 1700240 2158811 41.2 12.9 135.1 49.9 47.3 47.9 84-85 191967 108901 122697 423565 1538653 1962218 18.9 -23.2 -21.0 -7.6 -9.5 -9.1 $5-86 149269 148986 104285 402540 1593594 1996134 -22.2 36.8 -15.0 -5.0 3.6 1.7 86-87 123511 106852 84648 315011 1374880 1689891 -17.3 -28.3 -18,8 -21.7 -13.7 -13.3 87-88 85341 77125 48548 211014 1391905 1602919 -30.9 -27.8 -42.6 -33.0 1.2 -3.1 33.6 -4.0 50.1 19.5 75.1 65.0 P ToEAn (canLD A~ANT Can? raD v10 m PROJ STATU A~ANT Can C mD 1RO3 1103 uTATm APM 100 MAB DuTs DIT8 (A.P.) AUR ~0 DAPAB DISM Drs (A.P. 79-80 75423 62886 20091 158400 408005 564405 80-81 68246 71390 33963 173599 8U82 1037781 -9.5 13.5 69.0 9.6 111.8 83.2 81-82 63255 69633 53743 186631 989858 1176489 -7-3 -2.5 58.2 7.5 14.5 13.4 82-83 91305 104163 73049 268517 91414 1182681 44.3 49.6 35.9 43.9 ~7.4 0.5 83-84 147066 137905 108671 393642 1180474 1574116 61,1 32.4 48.8 46.6 29.1 33.1 84-85 163014 96234 81525 340773 1429085 1769858 10.8 -30.2 -25.0 -13.4 21.1 12.4 85-86 134405 118591 59331 312527 1240588 1533115 -*7.4 23.2 -27.2 -8.3 -13.2 -12.2 86-87 99199 89086 45415 233700 957495 1191195 -26.3 -24.9 -23.5 -23.2 -22.8 -23.3 87-88 76624 46889 71077 194390 1184602 13791b2 -22.8 -47.4 56.5 -16.7 23. 15.8 1.6 -25.4 253.8 22.8 190.3 143.3 -55 SeCTIOl 6 Uttua Pa8duh - Family Plantog Achieveuuts pa8* 5 STERILIMATIMIS PER~ENT CAIES NoM ml PRFW PRU STATE pmN PROJ STATE Ala OAMTI DEORiA =II1 HXRZA VM 011 DISTS I..) AM fAST1 0ERA 6DEBRI S IA 9 S 01815 DISTS tU.P. 79-80 1287 872 1573 1223 1994 3891 10840 456% 56530 80-81 1887 970 1558 2605 2221 5806 5047 63391 78438 46.6 11.2 -1.0 113.0 11.4 49.2 38.8 38.7 38.8 81-82 3919 3803 4144 4114 3887 7773 27100 130919 158619 107.7 292.1 166.0 60.2 75.0 33.9 84.1 106.5 102.2 12-83 1748. 8232 133% 12014 9584 21027 82061 348108 430169 355.4 116.5 222.3 187.8 1.4 170.5 196.2 165.9 171.2 83-84 12585 %21 14504 300 11588 17394 73992 304337 3178329 -29.5 14.9 8.6 -30.9 20.9 -17.3 -9.8 -12.6 -12.1 84-85 841 6304 11219 1346 8284 15491 5705 263581 32V64 -32.8 -34.5 -22.6 -12.0 -28.5 -10.9 -22.9 -13.4 -15.2 85-86 11685 11597 19776 11077 11063 21133 86331 454269 54600 38.1 84.0 76.3 51.6 33.5 36.4 51.3 72.3 6.6 86-87 21679 22848 289% 13334 13M66 25217 125140 617810 742950 85.5 97.0 46.6 20.4 18.1 19.3 45.0 36.0 37.4 87-88 21679 22368 31188 13770 13469 24236 126711 623389 750100 0.0 -2.1 7.6 3.3 3.1 -3.9 1.3 0.9 1.0 1584.5 2465.1 1882.7 1025.9 575.5 522.9 108.9 1264 1227 1UmS NmN fg PRM PR1 STATE 8N p8ml STATE ALM OIASI A ~ GNALI MIRIA VARM DISTS 8ISTS WJ.P.J Ala BASIl DEORIA om] KIRllIA 9MMI 08185 e1sys tU.P.i 79-80 5209 6840 3435 7164 3051 6303 32002 192257 224259 80-81 4149 3892 2741 2259 2059 5263 20363 152634 172997 -20.3 -43.1 -20.2 -68.5 -32.5 -16.5 -36.4 -20.6 -22.9 81-82 6920 5498 3952 3199 3147 7457 30173 194700 224873 66.8 41.3 44.2 41.6 52.8 41.7 48.2 27.6 30.0 02-83 6945 7375 2705 8664 4199 7964 3I52 236115 273967 0.4 34.1 -31.6 170.8 33.4 6.8 25.4 21.3 21.8 83-84 11883 10452 3567 894 5747 5772 4385 252657 29042 71.1 41.7 31.9 3.5 36.9 -27.5 22.5 7.0 9.2 84-85 17399 161% 966 13701 9772 20573 81321 378803 46124 46.4 54.9 171.5 52.8 70.0 256.4 88.3 49.9 55.9 85-86 235% 2369 18890 21147 15787 31058 134167 717893 852~0 35.6 4&.3 95.0 54.3 61.6 51.0 53.6 89.5 82.8 8-87 24928 26088 32544 17331 17333 28315 146599 936405 1083000 5.6 10.1 72.3 -18.0 9.8 -.6 9.3 30.4 27.1 87-88 34587 34268 44867 21053 19746 2999 184517 1012063 11M580 38.7 31.4 37.9 21.5 13.9 5.7 25.9 8.1 10.5 563.97 400.98 1206.1 193.86 547.19 375.92 476.58 426.41 433.57 CC m01 EN pm3 pmN STATE PRU3 K8W3 STATE AAlm DMTI 0E1R1A 8DEM 11 ~ IRIA V 01819 0818 (.P.J AZAN Bail DEORIA guAll KIRIA VARM ISTS 01STS ku.P.> 79-80 9833 7517 6412 6593 5660 7855 43870 273258 317128 80-81 9448 9534 7318 5356 3208 7988 42852 268757 3109 -5.9 26.8 14.1 -18.8 -43.3 1.7 -2.3 -1.6 -1.7 81-82 12130 13729 10298 954 7044 12804 65551 364551 430,'2 28.4 44.0 40.7 78.2 119.6 ö0.3 53.0 35.ö 38.v 82-83 14988 20455 10130 10578 9314 16339 81804 400149 481953 23.6 49.9 -1.6 I9.8 42.2 27.6 24.8 9.8 12.1 83-84 14334 11187 3094 11146 7563 13796 71120 419027 490147 -4.4 -45.3 29.3 5.4 -18.8 -15.6 -13.1 4.7 1.7 84-85 16109 21049 11989 9131 12970 38587 I9835 486581 596416 12.4 98.2 -8.4 -18.1 11.5 179.7 54.4 16.1 21.7 85-86 29810 24374 24022 14084 11328 5963 162982 64248 805230 b5.1 15.8 100.4 54.2 -12.i 53.8 48.4 32.0 35.0 8-87 23044 19852 28254 16540 9000 30432 127121 815359 942480 -22.1 -18.6 17.6 1.4 -20.* -48.1 -22.0 27.0 17.0 87-88 27889 32522 42578 19250 13341 22278 15858 848143 1006000 21.9 . ö3.8 50.7 16.4 484 -16.9 24.2 4.0 &.7 183.6u 332.64 564.04 191.97 135.J0 183.61 259.83 210.38 217.22 - 56 - page 6 mu NON B PROJ PR8W STATE PROJ PRO4 81ATE AST iRS1 DEORIA SMI l NIRZA VARA# DISIS 0118 1.P. 1 lA il E8411 DERIA WAIl 1R2A VARM 01s DISTS W.P. 80 m 3b, 93 328 184 353 15% 13500 150% 8-b1 17 603 89 258 138 406 1669 11281 12950 -36.6 66.6 -4.3 -21.3 -25.0 15.0 4.6 -16.4 -14.2 81-82 259 788 5% 317 251 456 2673 13049 15722 48.0 30.7 569.7 22.9 86,2 12.3 60.2 15.7 21.4 84-83 749 1826 567 535 458 510 445 16913 21558 189.2 131.7 -4.9 68,8 78.2 11.8 73.8 29.6 37.1 83-84 235t 2525 2856 1100 911 1377 11125 46661 57786 214.6 38.3 403.7 105.6 98.9 170.0 139.5 175.9 168.0 84-85 2i11 2839 2983 2066 1783 5132 17514 70628 88142 15.1 12.4 4.4 87.9 95.7 272.7 57.4 51.4 52.5 85-86 3150 3103 3865 1870 2152 4191 18331 03369 101700 16.2 9.3 29.6 -9.5 20.7 -18.3 4.7 18.0 15.4 86-87 2535 3181 4492 2394 1705 2880 V7186 107734 124920 -19.5 2.5 16.2 28.0 -20.8 -31.3 -6.2 29.2 22.8 8&7-B 4917 4431 6418 250 1535 3643 24474 135007 159480 94.0 39.3 42.9 5.1 48.7 26.5 42.4 25.3 27.7 1681.5 1123.9 6801.2 671.34 1277.5 931.89 1433.4 900.04 956.43 TEPORARY HETRODS NOMN MI PROJ PROJ STATE PRO3 PMlS 811 AZAN AST) 1E01A 8AII IRIA VARM DISTS DISTS .P.) AIO BASTI DEGRIA 8HAZ1 HIRA VARm DISig DISTS u.P.) 79-80 153i8 14719 9940 14085 8895 14511 77448 479015 55643 80-81 13772 14029 10148 7873 5405 13457 64884 432672 497556 -10.1 -4.7 2.1 -44.1 -39.2 -5.9 -16.2 -9.7 -10.6 81-82 19309 20015 1484 13062 10448 20717 98397 572300 670697 40.2 42.7 46.3 65.9 93.3 51.7 51.7 32.3 34.8 82-83 22682 29656 13402 19777 13971 24813 124301 653177 777478 17.5 48.2 -9.7 51.4 33.7 19.8 26.3 14.1 15.9 83-84 28573 24164 19517 21210, 14221 20945 128630 718345 84975 26.0 -19.5 45.6 7.2 1.8 -15.6 3.5 10.0 8.9 84-85 36219 40078 24458 24898 24525 64292 214670 936012 1150682 26.8 65.9 .26.3 17.4 72.5 207.0 46.9 30.3 35.9 85-86 56556 51167 46777 37102 2926) 9412 315480 1443510 1758990 56.1 27.7 89.7 49.0 19.3 47.2 47.0 54.2 52.9 86-9? 50506 49129 65290 36265 28038 61687 290905 1859494 2150400 -10.7 -4.0 39.6 -2.3 -4.2 -34.8 -7.8 28.8 22.3 87-88 67392 71221 93863 42833 35621 '55918 36848 1995212 2362M0 33.4 45.0 43.8 18.1 27.0 -9.4 26.1 7.3 9.8 339.95 383.86 844.29 204.10 300.46 285.34 373.54 316.52 324.46 -57- SECTION 6 Uttar Pradeslh - NCH Achievecents Page 7 DPI (0-2 VRO) PERCENT CHANES NON NoN PROJ PROJ STATE PROJ PROJ STATE AZAN BASil DEORIA WIAZI NIRZA VARAN DISTS DISTS lU.P. AZAN BASTI DEORIA WWI 1IRA VARAN DISTS DISTS thP. 79-90 18380 16848 5527 7487 8313 14469 71024 457976 529000 80-81 17097 20895 2628 12844 5567 13%4 72995 434005 507000 -7.0 24.0 -52.5 71.6 -33.0 -1.5 2.8 -5.2 -4. 81-82 25891 34170 11726 20964 12022 23182 127955 655045 783000 51.4 63.5 346.2 63.2 116.0 66.0 75.3 50.9 54.4 82-83 37538 .42775 22934 38851 17606 36979 196683 863317 10000 45.0 25.2 95.6 85.3 46.4 59.5 537 31.8 35.4 83-84 30356 33902 22691 32395 34017 36143 189504 998496 1188000 -19.1 -20.7 -1.1 -16.6 93.2 -2.3 -3.7 15.7 12.1 84-85 38605 60050 45350 35211 28863 64128 270207 1279793 1550000 27.2 77.1 99.9 8.7 -15.2 71.9 42.6 28.2 30.5 85-96 91308 90424 117208 59520 63800 144109 566369 1941131 2507500 136.5 50.6 158.5 69.0 121.0 132.0 109.6 51.7 61. 86-87 95616 78165 161400 69420 47357 99550 540508 2181992 2722500 4.7 -13.6 37.7 16.6 -25.8 -38.6 -4.6 12.4 8.6 87-89 105732 108270 115938 8-34% 29240 152744 595420 2888410 3485830 10.6 38.5 -28.2 20.3 -38.3 72.5 10.2 32.4 28.v 475.3 542.6 1997.7 1015.2 251.7 '955.7 738.3 530.7 558.6 DT 43-5 YRS) PROJ PROJ STATE PRDJ PROJ STATE AZM UAST1 DEOR1A effil NIRZA VRAN DISTS DISTS (0.P.i AZO BASI DE1RA G8WAI1 N1RZ VARAN DISTS DISTS (U.P. 79-80 31591 30326 8873 13753 13471 16213 114227 615773 730000 80-81 25678 27080 8125 4733 13888 20504 100008 40692 657000 -18.7 -10.7 -8.4 -65.6 3.1 26.5 -12.4 -33.9 -10.0 81-82 33801 40107 18620 31643 15720 22228 162119 620881 989000 31.6 48.1 129.2 568.6 13.2 8.4 62.1 52.6 50.5 82-83 34267 37640 34419 50583 18584 26615 202108 857892 11000 1.4 -6.2 84.8 59.9 19.2 19.7 24.7 38.2 20.3 83-84 22592 31255 12930 31100 25055 25865 148797 1039203 1211000 -34.1 -17.0 -62.4 -39.5 34.8 -2.8 -2t.4 21.1 1.8 84-85 30977 48480 44*15 19221 30152 42868 216313 1333687 1505000 37.1 55.1 245.1 -38.2 20.3 c5.7 45.4 29.3 24.3 85-86 35040 57024 32486 42490 26364 160234 353638 2153962 1812000 13.1 17.6 -27.2 121.1 -12.6 273.8 63.5 61.5 20.4 86-97 37076 '62176 78195 42438 25550 62172 307607 2414893 2050000 5.8 9.0 140.7 -0.1 -3.1 -61.2 -13.0 12.1 13.1 87-88 31500 70080 56420 30975 27288 67254 283517 3200313 2150000 -15.0 12.7 -27.8 -27.0 6.8 8.2 -7.8 32.5 4.% -0.3 131.1 535.9 125.2 102.6 314.8 148.2 419.7 194.t TT tPREG. #MEMN NON NON PROJ PROJ STATE PROJ PROJ STATE MlAN BAST1 DEGRIA 8AZ1 HIRZA VARAN DISTS DISTS tU.P.i AZAN T511 DEORIA SH41 M1RIA VARAN DISTS DISTS k0.P. 79-80 9932 17805 7089 10191 9850 14905 68772 386228 455000 80-81 14ö15 19713 10284 15020 6378 17696 83764 344234 428000 47.8 1(.7 45.1 47.4 -27.9 18. 21.8 -10.9 -5.4 81-82 17570 .36748 11309 19994 13159 19558 118238 455762 57400 19.7 9o.4 10.0 32.5 116.3 10.5 41.2 32.4 ;4. 82-83 22782 32901 24735 30836 11379 2759 150228 752772 W3000 29.1 -1,.5 118.7 55.u -13.5 41.1 27.i 65. 57.3 83-84 32794 18101 23972 22262 16125 39169 152423 732571 885eUQ 43.i -45.0 -3.1 -27.8 41.7 41.Q 1.5 -2.7 -2.9 84-5 45191 50053 43835 28817 2756 54457 250'v9 100991 1291000 37.8 170.5 di.4 29.4 ?2.1 39.0 64.J 42.1 45 85-86 45292 5191 66På 34200 35552 83352 317193 119280 151004 1 . 3.7 52.6 18.7 28.1 53.1 26.8 14.6 17.0 86-87 48285 44815 131328 35580 31239 49910 346157 1429843 177000 6.6 -4.9 Q .3 4.Q -12.1 -40.1 9.1 14.4 '.6 87-88 55083 59830 14044 42438 57132 85324 440255 1233625 161880 14.1 20.1 6.9 I9.3 el.9 11. - ?.2 -13. -5. 454.t 2J.Ov 1881.2 316.4 545.A 4;2.5 54.2 219.4 -67.4 - 58s- SECTION 6 Page 8 PROJ PRG STATt , POI PRW STATI Alm 9ST1 N DI IiA KI8IA 9mRM oisiS D16S 1U.P.i AZ 8 11 E01A m §smil fniA1 v~ 1818 119 U.P.: 79-80 29375 7459 16368 1325 7202 20140 93369 45%31 553000 80-81 77933 29759 21134 17875 10920 13344 170865 628135 79%00 174.7 299.0 29.1 29.3 50.2 -33.7 83.0 36.7 -23. 81-92 33165 37143 12975 14139 15390 1604 129496 481504 611000 -57.4 24.8 -38.6 -17.5 42.2 20.5 -24.2 -23.3 10.: 82-83 32814 535$ 21177 26728 22934 29729 189757 850243 1044000 -0.9 51.6 63.2 81.3 49.0 84.8 46.5 76.6 32.1 83-4 35992 3695 4067 31766 24818 4629 217137 115~3 1374080 9.5 -34.5 93.5 41.3 8.5 36.7 14.4 36.1 -7. 84-85 530 42499 37479 16368 30171 36062 21t039 1058 1 127500 48.5 15.2 -8.5 -56.7 21.3 -11.2 -0.5 -8.5 2.1 85-86 40755 29889 22480 25432 1O700 4905 179161 1122139 130130 -23.8 -29.7 -40.0 55.4 -64.5 3.4 -12.1 6.0 28. 96-87 27963 3664 100795 26818 27175 57936 277341 1390659 1668000 -31.4 22.6 348.4 5.4 154.0 16.1 54.8 -23.9 42.ý 87-f8 70866 10952 114170 42500 49764 80883 466135 1909865 2376000 153.4 194.5 13.3 58.5 Ø3. 39.6 68.1 37.3 42.4 149.7 1347.3 597.5 207.4 591.0 301.6 399.2 315.5 329. FE T8ElIPY (CHILDEN ON8 88l PG3 PRO3 STMIE PRO3 mU 1A11 AZM SASTI 01RI 8MZ1 K12A VAM DISTS ISTS t#.P.) AZA# A E81 A 811*21 O1M2 GW4HIRA 9 818 IS TS DI U.P. 79-80 12032 13283 17226 4918 6023 21236 74718 583282 436000 80-81 64754 30152 22148 14322 8132 13405 153513 786487 658000 438.2 131.5 28.6 191.2 35.0 -36.9 105.5 34.8 50. 81-82 2923 41331 19992 2115 17160 25666 155257 784743 94000 -54.1 34.4 -9.7 52.1 111.0 91.5 1.1 -4.2 42. 82-83 27091 50975 76255 18587 17064 33912 223984 745116 969000 -7.6 23.3 281.4 -14.7 -0.6 32.1 44.2 -5.0 3. 83-84 20479 58546 39615 17045 17009 30303 182997 828003 1#010 -24.4 14.9 -48.0 -8.3 -0.3 -10.6 -18.3 11.1 4. 84-5 35260 46853 23939 27677 30152 M279 204160 115980 13o4000 72.2 -20.0 -39.6 62.4 77.3 32.9 11.6 40.1 34. 85-86 2746 29864 42680 20658 29375 1134% 262523 1308277 157800 -22.1 -38.4 78.3 -25.4 -2.6 181.8 28.6 12.8 15. 86-87 33852 32982 92720 19382 22925 55182 25643 1322657 1579500 23.3 13.9 117.2 -6.2 -22.3 -51.4 -2.2 1.1 0. 87-88 62090 86970 8/424 33300 18120 65934 354038 1704712 2058150 83.4 164.5 -6.1 71.8 -18.0 19.5 37.8 28.9 30. 416.0 554.7 405.2 577.1 210.8 210.5 373.8 192.3 212. - 5 SECTION 6 Page 9 B. SWA The project did not call for any studies. However, in 1985, the U.P. Dept. of Health and Family Welfare, with the concurrence of the Bank and the Government of India, contracted with the Indian Institute of Management, Ahmadabad to carry out a management review of the family welfare program in U.P. This was done to assist in identifying program constraints and in anticipation of a follow-on Bank-assisted population project in the state. The findings of the study, while they did not reveal anything not already generally known, were useful in that they presented in systematic fashion a sumary of important points. The study proved useful in the subsequent development of the Sixth Population Project. -60- SECTION 7 7. Status of Covenants PROJECT AGREENET STATUS DESCRIPTION OF COVANT ComENTS 2.06 01 Primary health sub-centers States report that sites to be sited within inhabited cotrectly locateds evaluation area of village as specified. reports indicate significant wabers of Incorrect sitings in U.? 2.07 0 States to furnish IDA with All designs preliminary designs for all approved. facilities to be built. 2.08(a) OK states to make appropriate Appropriate allocations allocations for building Included in the budgets maintenance for PHCa of both statesa use for and aubcenters in the maintenance purposes project areas. uncertain. 2.08(b) OR States to make appropriate Done in both states. allocations for operation and maAitenance of vehioles used for health/family welfare in the project area. 2.09 01 States to undertake Completed in both states. mid-tes reviews of project activities Including health/family welfare data collection systems. S.02 OK A"dit AccountV4port due Audit status satisfactory. to IDA no later than ftne months after end of each fiscal year. at - Covenant complied with. /r