India - Family Welfare (Urban Slums) Project

Document of The World Bank FOR OMCLAL USE ONLY MICROFICHE COPY Report No. P- 5774-IN Type: (PM) CAMBRIDGE,/ X80302 / D10019/ SA2PH ReportNo. P-5774-IN MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT OF SDR 57.7 MILLION TO INDIA FOR A FAMILY WELFARE (URBAN SLUMS) PROJECT MAY 28, 1992 This document bas a resticted distribution and may be used by recipients only in the performauce of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS (as of May 26, 1992) Currency Unit - Rupee Rupee 26.2 - US$1.00 Rupee 1.00 - US$ 0.038 METRIC EQUIVALENTS 1 Meter (m) - 3.28 Feet (ft) 1 Kilometer (km) - 0.62 Miles FISCAL YEAR April I - March 31 ABBREVIATIONS AND ACRONYMS BCC - Bangalore City Corporation CMDA - Calcutta Metropolitan Development Authority CUDP III - Third IDA-Assisted Calcutta Urban Development Project GOI - Government of India GOWB - Government of West Bengal MCD - Municipal Corporation of Delhi MCH - Municipal Corporation of Hyderabad MOHFW - Ministry of Health and Family Welfare MCH - Maternal and Child Health ODA - Overseas Development Agency - Government of United Kingdom PMP - Private Medical Practitioners PVOs - Private Voluntary Organizations UNFPA - United Nations Fund for Population Activities UNICEF - United Nations Childrens Fund UIP - Universal Immunization Program URS - Urban Revamping Scheme WHO - World Health Organization  FOR OFFICIAL US OnL INDIA FAMILY WELFARE (URBAN SLUMS) PROJECT CREDIT AND PROJECT SUMMARY Borrower: India, acting by its President Beneficiaries: Governments of Andhra Pradesh, Karnataka, West Bengal; Bangalore City Corporation (BCC); Calcutta Metropolitan Development Authority (CMDA), Municipal Corporation of Delhi (MCD), New Delhi Municipal Committee (NDMC) and Municipal Corporation of Hyderabad (MCH). Amounts SDR 57.7 million (US$79.0 million equivalent). Terms: Standard with 35 years maturity. On-Lendig Terms: Government of India (GOI) to Andhra Pradesh, Karnataka, and West Bengal in accordance with standard arrangements for development assistance to States and Union Territories to be passed on by the respective States and Union Territory to BCC, CMDA, MCD, NDMC and MCH respectively. At present, central assistance for family welfare is provided on a grant basis. Financang Plan: Local Foreign Total ---------US$ Millions--------- GOI 17.60 17.60 IDA 69.90 9.10 79.00 Total 87.50 9.10 96.60 Economic Rate of Returns Not applicable. Staff Appraisal Report : Report No. 10548-IN This document has restricted distribution and may be used by recipients only in the perforfbm.-. of their official duties Its contents may not otherwise be discosed without World Bank authoriztion.  MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO INDIA FOR A FAMILY WELFARE (URBAN SLUMS) PROJECT 1. The following memorandum and recommendation on a proposed credit to India is submitted for approval. The Credit of SDR 57.7 million (US$79.0 million equivalent) would be on standard IDA terms with 35 years maturity. The credit would help finance a Family Welfare Project for Urban Slums in the cities of Bangalore in the State of Karnataka, Calcutta in the State of West Bengal, Delhi in the Union Territory of Delhi and Hyderabad in the State of Andhra Pradesh. The proceeds of the credit would be passed by the Government of India (GOI) to the States. The States would then pass the funds on to the municipalities as a budgetary allocation in the form of a grant. 2. Background: India's urban population is expected to grow from 160 million in 1981 to 320 million in 2000, or from about a quarter to a third of the total population. The Government of India (GOI) is faced with new issues in urban social development and is exploring ways to ensure that the expanding urban population has access to affordable and good quality social services. GOI's National Family Welfare Program, which includes family planning (FP) and maternal and child health (MCH) services has a predominately rural orienta- tion, but must now make better provision for urban slum populations. Vital rates for urban slum populations are substantially higher and contraceptive prevalence rates significantly lower than those for non-slum populations. Infant mortality rates in slum areas, for example, average about 80 per 1,000 live births as against about 20 for the non-slum population. The total fertility rate (TFR) for urban areas is, on average, lower at 3.9 than the 4.6 rate for rural areas; however, data available suggest higher TFRs among slum populations. 3. In January 1987, India and IDA agreed on a Population Sector Strategy which would guide future collaboration in the sector. It was agreed that IDA's broad goal in the family welfare sector is to support GOI's National Family Welfare Program. Specifically, IDA support would assist in: (a) reorienting the family welfare program from its static facility-based orientation to include a larger element of outreach to the communities in which the health and family welfare facilities are located; (b) shifting the focus of the program from the sterilization of older, higher parity women to .a more balanced mix of contraceptive methods emphasizing increased use of temporary methods by younger couples; (c) increasing the attention given to the implementation of the maternal and child health elements of the program; and (d) financing priority schemes and projects which enhance service deliv- ery, training, and information, education and communications (IEC) and are concentrated in urban slums and backward high fertility States. The Urban Revamping Scheme (URS), which focuses on the provision of family welfare services to urban slum populations, is one of the major schemes which make up the National Family Welfare Program. The proposed project is the fifth since IDA and GOI agreed to the Strategy, and would support the reform, adaptation and implementation of the URS in four major urban areas. The project reflects a continuation. of the approach to cooperating with GOI to address the systemic and policy issues which retard effective implementation of the family welfare  2 program. 4. Lessons from Past IDA Ledint: The proposed project primarily takes account of lessons from service delivery models designed to meet the health needs of the urban poor. Two such models were developed in Bombay and Madras under the IDA-supported Fifth Population Project. Another model which has been used is based on the health component of the IDA-financed Calcutta Urban Development Project (CUDP III). This component was evaluated in September 1991 by the World Health Organization (WHO), and judged to be one of the most successful health service schemes in the world for urban slum areas. The proposed project would also take account of implementation experience with variants of these models, especially the ODA-assisted health projects in Calcutta and Hyderabad as well as the evaluated experiences of UNICEF, Private Voluntary Organizations (PVOs) and Private Medical Practitioners (PMPs) in the provision of health services to urban slum populations. The major lessons incorporated in project design are thats (a) family planning services can be effectively delivered by non-family planning organizations; (b) a women-to- women approach increases clients' accessibility to and acceptability of family planning in restricted societies; (c) reaching women with information and services is enhanced when field workers serve as informal support groups; (d) participatory management develops a sense of ownership among field workers and clients; (e) the effectiveness of delivering family welfare services and the demand for these services is enhanced when the outreach effort includes the involvement of community groups, volunteer women and supervisors who are recruited from the specific slum community; and (f) success is more likely when the management of the health faciliry is undertaken by local staff and the timing of operation of the facility is adjusted so that it is convenient to women who work in or outside of the home. 5. Rationale for IDA Involvemeat: First, the project would be closely linked to IDA's strategy of supporting human capital development and poverty alleviation in India. Second, it would provide IDA with the opportunity to extend rapid but targeted assistance to the most vulnerable groups, poor women and children, who are at risk of falling through the social safety net during a period of severe budgetary constraints on publicly- financed social programs. Third, the project would support a revamped URS which would improve linkages between family welfare services and other appropriate health interventions, specifically clean drinking water and sewerage/sanitation facilities. Fourth, the project would be based on a mix of successful local experiences in implementing health projects among slum populations while at the same time providing for trials and the introduction of new models of service delivery. Fifth, the project would include several areas where private voluntary organizations and local communities will play a major role in service delivery. Sixth, the project would represent an opportunity for continued cooperation between IDA and UNICEF, as well as closer coordination with WHO, UNFPA, and ODA in India. This will enhance policy dialogue, and project monitoring and supervision, as well as overall program evaluation. Finally, the project represents GOI's initial attempt to integrate community participation activities systematically in its urban family welfare scheme. Without the project, it is likely that slum dwellers of these specific cities would continue to lack satisfactory access to appropriate family welfare services. 6. Prolect Obiective and Description: The major objective of the  3 proposed project would be to reduce fertility and maternal and infant mortality rates among slum populations in Bangalore, Calcutta, Delhi and Hyderabad. Project objectives would be achieved by undertaking activities in five areas: Expanding service delivers to slum populations through improvements in outreach services using volunteer female health workers recruited from slum communities, and the upgrading of existing and construc- tion of new health facilities; Imroving the quality of family welfare services provided to slum populations, by upgrading the supervisory, managerial, technical and interpersonal skills of all levels of new and existing medical and para-medical workers through pre-service, institutional in-service and on-the-job recurrent training; and increasing the availability of drugs, medicines and other appropriate health supplies; Increasing the demand for family welfare services through an expanded program of information, education and communications tIEC); increased participation of the slum community through their representatives and groups in the preparation and implementation of various project activities; and the increased participation of private voluntary organizations (PVOs) and private medical practitioners (PMPs) in the delivery of family welfare services to slum communities; Strengthening the management and administration of municipal Health Departments through appropriate upgrading of management information systems (MIS), information, education and communications (IEC), training, civil works, and audit and accounting functions, as well as integrating and/or strengthening coordination of health services with the provision of environmental sanitation and water supply services; Supporting innovative schemes which cover a range of additional services including nutrition awareness, creche programs, environmental sanitation, and the education and skill training of females, especially adolescent girls; and Preparation of future projects which would support the detailed preparation and project launch activities in another 15 designated cities. 7. The total cost of the project, net of taxes and duties is US$96.60 million. The project would be financed by an IDA Credit of SDR 57.7 million (US$79.0 million equivalent) which would cover about 84S of project cost net of taxes and duties. The GOI would finance the remaining net project costs of US$14.7 million and all taxes. To facilitate an early start to the project, retroactive financing up to SDR 0.4 million (US$0.5 million) would be provided to cover eligible expenditures after November 30, 1991 that have been incurred in implementing appraised activities. A breakdown of the costs and the financing plan is in Schedule A. Amounts and methods of procurement and the disbursement schedule are in Schedule B. A timetable of key project processing events and the status of Bank Group operations in India are in Schedules C and D, respectively. Staff Appraisal Report No. 10548-IN, dated May 26, 1992, is being distributed separately. 8. Areements Reached: During negotiations, the GOI and States provided assurances that they would cause the Project cities to: (a) develop by June 30, 1993, a program of measures to improve compliance with the Child Marriage Restraint Act, 1929, as amended; (b) furnish to the Association by June 30, 1993, Baseline Surveys and Beneficiary/Community Needs Assessments with format and content satisfactory to the Association; and promptly thereafter suitably adjust the hours of operation of health facilities located in slums areas to be fully responsive to the findings of the Beneficiary/ Community Needs Assessment; (c) furnish to the Association for its review and comment by January 31 of each year, commencing in 1993, annual plans for civil  4 works, training and IEC in respect of the next financial year, and an annual report on progress achieved during the previous year in basic education for females; (d) establish community-based management committees for facilities and programs developed under the project and institute no later than April 1, 1994, such measures as shall generate resources from the direct beneficiaries of said facilities and programs to support a portion of the operation and maintenance costs thereof, including medicines; Ce) prepare in accordance with terms of reference agreed with the Association and furnish to the Association for review and comment by January 31, 1994, City Health Plans covering the area under its jurisdiction, and discuss said plans with the Association, including proposed actions for implementing such plans; and (f) provide to the Association by September 30, 1995 a mid-term review of the progress of the project. As a condition of disbursement for the preparation of future projects in "designated cities," the GOI would obtain from each State of the 'designated cities" and furnish to IDA, a Letter of Undertaking satisfactory to IDA indicating the terms and conditions of their participation in the project. 9. Impact of the Project on Women: The project would provide for the participation of women at all levels of design, implementation and supervision. Women will play a significant role in motivating and providing health and family welfare services in the slums. They would be involved in identifying needs through active participation in the Beneficiary/Conmmunity Needs Assessment and designing strategies to provide services to meet those identified needs. The female volunteer link worker, the auxiliary nurse midwife (ANM) and Lady Health Visitor (LHVs) are the main implementors of the project. Women would also play a key role in generating demand mad in the administration and management of health services in the municipalities. The active participation of female-led community groups and PVOs, and the large number of female PMPs would help ensure that family welfare services reach the targeted population through training and IEC programs. Finally, all staff of the administration, the community in general, and men specifically, would be sensitized through training to the impact of gender issues on the implementation of the project. 10. Proiect Sustainabilit:s When the Project is completed in FY99, it would require a total of about USS 6.4 million of additional annual recurrent expenditure which would be distributed among the four cities and the central Ministry of Health and Family Welfare (MOHFW). Assuming no real growth in budget allocations, it is estimated that the impact of recurrent project expenditures on the family welfare budgets of the States and the Municipal Corporation of Delhi (MCD) would be negligible. Several additional factors suggest that it might be difficult to ensure the sustainability of family welfare activities at the levels to be achieved during the life of the project. However, in addition to government assurances including a reconfirmation of continued central government funding during the Eighth Five- Year Plan period (1992-97) and an increase in the FY93 budget allocation for the National Family Welfare Program, several other factors provide positive indications of sustainability. First, additional new staff have been kept to a minimum by the redeployment of existing staff and the use of volunteer and part-time workers. Second, the increased participation of the community in the management and maintenance of services, and the expanded role of PVOs and PMPs should assist sustainability. As quality improves and demand increases, it may be possible to recover some fees from beneficiaries to use for system  5 maintenance. Finally, issues relating to the sustainability of family welfare investments are being addressed comprehensively in a Health Financing Study which is now being undertaken in close collaboration with GOI. 11. Proiect Benefits: The proposed project would assist the GOI in further developing refined operational models of its Urban Revamping Scheme for nationwide replication. It would also provide a suitable vehicle for the participation of urban slum conmunities in determining the mix of services which are most appropriate to their felt needs. Further, the project would confer direct social benefits to low-income slum dwelling families, more particularly about 2.4 million women and children, by increasing their access to and the quality of family planning and maternal and child health care services. In so doing, it would promote a decline in fertility, morbidity and mortality among mothers, infants and young children. The project would also help to improve government and community awareness and responses to the needs and impact of development on omen. 12. Risks: The major risks would be institution.al and relate to the capacity of municipalities to implement the project, particularly to develop outreach services and work collaboratively with slum populations and PVOs. To minimize these risks, Municipal Health Departments wvould be strengthened under the project. In addition, arrangements would be made to increase the cooperation between State governments, municipalities, PVOs, slum communities and PMPs. Lastly, Project Advisory and Coordinating and Implementation Committees have been established with representatives from each group to provide inputs to project design, implementation and supervision. 13. Recommendation: I am satisfied that the proposed Credit would comply with the Articles of Agreement of the Association and recommend that the Executive Directors approve the proposed Credit. Lewis T. Preston President Attachments Washington D.C. May 28, 1992  6- SCHEDULE A INDIA FAMILY EFAE (URA SLUMS) PROJICT ESTIATED COSTS AND FINANCI PLAN setimated Prolect Costas ComOnot Loc Foign Total Local Forel Total 2of SaNs IncreaSSI" ti Supply -of S,1.r 99.n 1,-04.24 800 .0 40.90 --Coa X.-roving he Quthlst, of 242.57 27.11 270.28 8.98 1.08 10.01 12.7 F.W. trvila Increasing t Demnd for 228.26 24.08 247.89 8.27 0.91 9.18 11.6 F.W. Services Improving the Managemt 70.75 14.04 94.70 2.62 0.52 8.14 4.0 o F.W. Services Innovative Scheos 126.29 14.22 2m.51 7.28 0.58 7.70 9.8 Prparation of Future 190.48 25.40 215.94 7.00 0.94 8.00 10.1 Project, 8ASE COSTS 1,987.42 195.28 2,182.65 71.76 7.24 79.00 100.0 Continwncles Physical 141.79 18.61 160.40 6.26 0.70 5.05 7.5 Price 689.01 70.60 760.41 10.49 1.16 11.65 14.7 TOTAL PROJECT COs EIEE.l P? .0II.46 87.60 TM . Tli22 Financin Plant Local Foreign Total ---------US$ Millions--------- GOI 17.60 17.60 IDA 69.90 9.10 79.00 Total 87.50 9.10 96.60  SCHEDULE B Page 1 BMIA FAMILY VELFARE (URBA SLLUS) PROJECT SMNARY OF PROPOSED RIT Procurement Method TOTAL Procurement Elements ICB LCB OTHER NIA COST 1. Works 1.1 Civil Works 10.90 7.15 18.05 (9.80) (6.40) (16.20) 1.2 Dept. Charges 2.10 2.10 2. Goods 2.1 Furniture 3.00 3.00 (2.70) (2.70) 2.2 Equipment & MCH Materials 2.00 9.00 5.90 16.90 (1.80) (8.10) (5.31) (15.21) 2.3 Vehicles 2.10 2.10 (1.90) (1.90) 2.4 Medicines 6.00 4.40 10.40 (5.50) (3.70) (9.20) 2.5 Training and IEC 0.30 0.30 Materials (0.27) (0.27) S. Consultanc.es 3.1 Local Consultants, PMPs 14.75 14.75 and PVOs (14.72) (14.72) 3.2 Foreign Consultants 0.40 0.40 (0.40) (0.40) 3.3 Local Training 2.50 2.50 (2.50) (2.50) 3.4 Foreign Training 0.40 0.40 (0.40) (0.40) 4. Miscellaneous 4.1 Salaries of Additional Staff 22.20 22.20 and Honoraria of Additional Volunteers (15.50) (15.50) 4.2 Operation and Maintenance 1.00 1.00 4.3 Land 2.50 2.50 TOTAL 2.00 31.00 17.75 45.85 96.60 IDA 1.80 28.00 15.68 33.52 79.00 GOI 0.20 3.00 2.07 12.40 17.60 NOTEs Figures in parentheses represent IDA financing.  SCHEDULE B Page 2 Catego Amount S of Expenditure (US$ million) to be disbursed For Components other than the Preparation of Future Prolects Civil Works 15.60 90% of expenditures Furniture, Equipmeat, Vehicles, 23.00 1001 of foreign expeuditures, Medicines and IEC and NCO Materials 1002 of local ex-factory costs or 80X of other local costs Consultants, Training and 11.00 100t of expenditures Services of Private Medical Practitioners and Private Voluntary Organizations Salaries of Incremental Staff and 15.30 901 until March 31, 1995 and Honoraria for Additional Volunteers 652 thereafter For Preparation of future Projects Consultant Services 4.80 1002 of expenditures Equipment. Vehicles, 3.30 100X of foreign expenditures, and Furniture 1002 of local ex-factory costs or 80S of other local costs Unallocated 6.00 TOTAL 79.00 Estated DisbUrseMnts IDA FY FY93 F4 FY95 FY96 FY97 FY98 FY99 FY2000 Annual 8.00 9.40 12.80 12.50 12.40 11.00 10.70 2.20 Cumulative 8.00 17.40 30.20 42.70 55.10 66.10 76.80 79.00  SCHEDULE C FAMIY VfU CURIA SLMS) PROJECT TIMETABLE OP RKY PROJECT PROCESSING EVENTS (a) TTime taken to prepare the projects 3 years (b) Prepared by: The Ministry of Health and Family Welfare with assistance from the National Institute of Health and Family Welfare tc) First IDA mission: November 1988 (d) Appraisal mission departures February 21, 1992 (e) Negotiations: May 11, 1992 (f) Planned date of effectiveness: September 1992 Ig) List of relevant PCRs and PPARss Indias PCR on First Population Project (Credit 312-IN), May 19, 1981 Project Performance Audit Report No. 3748, December 31, 1981. India: PCR on Second Population Project (Credit 9PI-IN), June 20, 1989 Project Performance Audit Report No. 8896, June 29, 1990. India: PCR on Tamil Nadu Integrated Nutrition Project (Credit 1003-IN). November 26, 1989.  SCHEDULE 0 - 10 - PAGE I ol 6 THE STATUS OF BANK GROUP OPERATIONS IN NDIA A. STATEMENT OF BANK LOANS AND IDA CREDITS (As of March 81, 1992) USM IllI ton (not of cancellations) LoUn or Fiscal Year ------------------------------- Credit No. of Approval Purposo IRD IDA 1/ Undisburowd 2 90 Loans/ 6629.1 167 Credits fully disbursed/cancolled - 10949.9 1172-IN 1092 Korbo Therm l Power YI - 888.7 6.7 2076-IN 10o2 Ramgundam Therml Power It 280.0 - 6.89 1280-IN 1198 Gujarat Watoer Supply - 69.6 9.13 1819-IN 1998 Haryana Irrigation II 1388. 0.42 1866-IN 1088 Upper Indravati Hydro Power 170.0 30.42 1869-IN 198* Calcutta Urban Development III - 91.5 9.62 2288-IN 1906 Central Power Transmission 200 7 71.96 2296-IN 1983 H4ealoyan Watershed Monageent 80.2 - 6.06 1424-IN 1984 Rainted Areas Watershed Dev. - 2.6 18.89 1428-IN 1084 Populstion III 70.0 2.07 1482-IN 1984 Karnetaka Social Forestry - 24.7 1.25 2387-IN 1084 Nhava Sheva Port 260.0 - 20.81 2898-tN 1984 Dudhichua Coal 109.0 - 17.54 2408-IN 1084 Cemay Beasin Petroleum 218.5 - 29.41 2416-IN 1084 Madhya Pradesh Fortiller 172.6 6.44 1464-IN 1984 Tamil Nadu Water Supply - 88.5 19.66 SF-12-IN 1984 Tamil Nadu Water Supply - 86.6 30.51 SF-16-IN 1084 Poeryar Vaigal II Irrigation - 17.6 11.42 1488-IN 1984 Upper Canga Irrigation - 105.4 45.04 1498-IN 1984 OuJorat Medium Irrigt Ion - 166.8 47.48 2416-IN 1984 Indira Sarovar Hydroelectric 17.4 - 11.07 SF-20-IN 1984 Indira Sarovar Hydroelectric - 18.8 17.07 s181-IN 1086 Indira Surovar Hydroelectrtc - 18.2 16.90 2417-IN 1984 Railways Electrification 279.2 - 19.86 2442-IN 1984 Farokka 1I Thermal Poer 278.8 - 69.69 2462-IN 1984 Fourth Trombay Thermal Power 185.4 - 9.70 1602-XN 1084 National Cooperative Development Corporation III - 180.6 12.48 1514-IN 1086 Kerala Social Forestry - 2?.1 4.48 1628-IN 1085 National Agric. Extension I 82 9 12.44 1644-IN 1986 Bombay Urban Devolopment - 100.9 88.71 2407-IN 1085 Nuardb