India - Third Population Project

Docum_t of The World Bank FOR OMCLAL USE ONLY Repuru No. 12278 PROJECT COMPLETION REPORT INDIA THIRD POPULATION PROJECT (KERALA AND KkRNATAKA) (CREDIT 1426-IN) AUGUST 25, 1993 MICROGRAPHICS Report No: 12278 Type: PCR Population and Humsn Resources Operations Division Country Department II South Asia Regional Office This document hs a retricted distibution and may be Ued by nipients only in the pWformance of thik oMca duties. Its contents may not otherwise be dislosed withut World Bank authorination.  CURNC EQVS Name of Currency Indian Rupees (Re.) Appraisal Year (1983) US $1.00 = Re. 9.75 Completion Year (1992) US $1.00 - Re. 25.89 FISCAL MM OF IORROHLR April 1 to March 31  FOR OFICIAL USE ONLY THE WORLD BANK Washngt D.C. 2043M U.SA Offe of ODfeotor4oenea Operations Eveluton MEMORADUM TO THE EXECUVE DP ORS AND THPRESDENT SUBJECT: Project Completion Report on India Thrd Population Project (erala and Kamrataka Cedit 142-IN) Atached is the Project Completion Report on India - Third Population Project (Kerala and Karnataka) (Credit 1426-IN) prepared by the South Asia Regional Office. Part I was prepared by the Borrower. The report provides a satisfactory assessment of project achievements. This project continued Bank support of the Indian Government's efforts to (i) reduce fertility through icreases in contraceptive prevalence and (ii) reduce infant and maternal mortality and morbidity through improvements in quality and coverage of maternal-child health services. Its goal was to'bring two backward districts in two southern states up to state averages with respect to fertility, morbidity and mortality. Progress tards achieving this goal was satisfactory. Progress in institutional development was partiaL Sustainability of this project is considered uncertain because the PCR notes that there has been inadequate financing at both central and state levels and because of inadequate maintenance even when fumds are allocated for this purpose. This is a potentially serious problem that needs to be taken into account in planning future programs. An audit is planned in conjunction with the fourth project after the latter closes. Attachment This documet has a resticted distibution and may be used by recipients only in the peformance of their offcil dutis 1t content may not othewis be diaclosed without World Bank autiaton.  PROJECT CX9DETlON REPORT IIIDIA TE)D POPULATION PROJECT (SRAND AND) (Credit 1426-IN) TABLE OF coN PREFACE . . . . . . . . . . . . . . . . . . i EVALUATION SUMMARY . . . . . . . . . . . . . . . . . iii PART I PROJECT REVIEW FROM BANK'S PERSPECTIVE . . . . . . . . . . . . 1 1. Background. ...... ....... 1 2. Project Description . . . . . . . . . . . . . . . 4 3. Project Implementation . . . ... 5 4. Pro4ect Extension . . . . . . . . . . . . . . . . . . . . . . . 13 5. Project Finance . . . . . . . . . ... 13 6. Project Results . . . . . . . . . . . . .. . . 14 7. Project Sustainability ... .17 8. Bank Performance . . . . . . . . . . . . . . . . . . . . . . . 18 9. Borrower Performance . . . . . . . . . . . . . . . . . . . . 19 10. Issues/Lessons Learned . . . . . . . . . . . . . . . 20 PART II BORROWER'S COMMENTS ON PARTS I snd tII . . . . . . . . . . . 25 PART III STATISTICAL TABLES . . . . . . . . . . . . . . . . . . . . . 33 1. Related Bank Loans or Credits . . . . . . .333 2. Project Timetable . . . . . . . . . . . . . . . . . . . . . . . 35 3. Credit Disbursements .. .. .. ...... .. .3 6 4. Project Implementation . . . . . . . . . . . . . 37 5. Project Costs and Financing . . . . . . . . . . . . . . . . . . 45 6. Status of Covenants .4B.. ..............48 7. Use of Bank Resources . . . . . . . . . . . . . . . . . . . . . 51  PROJXCT C(OPLETION EPORT INDIA THUD POPULQTIO PROJECT (KERALA AND KARD &TAKA) (Credit 1426-IN) These A.s the Project Completion Report (PCR) for the Third Population Project for which a credit of SDR 66.3 million (US$70 million equivalent as of 1983) was approved on December 13, 1983 (Credit 1426-IN). The credit closed on March 31, 1992, 2 years behind schedule. The final disbursement was made on August 10, 1992. leaving an undisbursed balance of US$1.0 million. Parts I (Project Review from the Bank's Perspective) and III (Statistical Irformation) of this report were prepared on the basis of a PCR mission in April-May 1992. Part II comprises comments received from the Borrower (the Government of India). as vell as from the governments of the project states (Kerala and Karnataka). The preparation of the PCR was based, inter alia, on the Staff Appraisal Report, the project legal documents, other Bank documents relating to the project, supervision reports, correspondence between the Bank and the Borrower, internal Bank memoranda, and project status reports.  - iii - I;NDIA TID POPULTION PROJECT (Credit 1426-I1) VLUAMTION SUNAR Objectives and Main features i. The Third Population Project was the third in a series of Bank- supported population projects in India; the first became effectixve in 1973, the eighth has been approved by the Board on June 18, 1992, and is awaiting signing of legal documents, and a ninth project is currently under development. The project was implemented in six districts of Karnataka and four districts of Kerala as part of an effort by the Government of India to obtain external assistance to strengthen the national family velfare (family planning and maternal-child health) program in backward districts of selected states. As with the First and Second Projects, the goals of the Third Project were to achieve reductions in fertility through increases in contraceptive prevalence and reductions in infant, young child and maternal mortality and morbidity through increases in quality and coverage of maternal-child health services. Construction, equipping, furnishing and staffing of facilities to assist in expanding and strengthening service delivery were supported by training, demand generation and program management components. Im2lemfLntatioM Experience ii. The project's physical goals were essentially achieved within the project's rupee budget, which was entirely expended but not exceeded. In Kerala, civil works were completed promptly and additional works were undertaken using project savings. In Karnataka, construction was delayed and completion of planned civil works required a 2-year extension of the credit. Implementation of the training and information, education and communication (IEC) components in both states was carried out successfully, although management information system (MIS) goals were not achieved. Results iii. In the Kerala project districts, contraceptive prevalence increased from about 201 in 1984, prior to the project, to 50% in 1991, immunization of children from 202-351 to 652-901, and delivery assisted by a trained person to over 80%, more than achieving project goals and largely bridging the gap between the project districts and the rest of the state. In Karnataka, project family planning goals were not achieved, contraceptive prevalence increasing only from 26% to 40% in 1991, and the gap between the backward northern districts and the more developed southern part of the state widened over the project period. MCH goals, however, can be considered to have been more nearly reached. In neither state wac a substantial increase in the use of temporary contraceptive methods achieved.  - iv - iv. Good project results in Kerala must be attributed to both project and more general factors. Prompt achievement of project physical targets created an infrastructure in the hilly and backwara project districts that provided the basis for a substantial expansion of services. However, project success in Kerala also owed a good deal to the general situation of the state, particularly very high literacy rates and extensive demand for medical services. The northern Karnataka project districts, on the other hand, in many ways resemble parts of north India more than they do the mvwh better developed southern part of Karnataka. In these districts, it is unlikely that more rapid progress by the family welfare program can be expected and the gap between the northern and southern parts of the state bridged until basic program constraints are addressed through measures such as those included in the project's proposed service delivery strategy, which was never implemented (para. viii). Sustainability v. The difficult financial situation of the Government of India requires the Bank to be more cautious than previously regarding the sustainability of population projects. Although the family welfare program is currently a 1002 centrally supported scheme, neither continued expansion of central support for family welfare not indefinite continuation of 100X central support can be assumed under current circumstances. In addition, our cumulative experience as well as recent sector work indicate serious problems in sustaining investments ir. the family welfare and health programs due to inadequate financing at both central and state levels. It has become increasingly importatst for the Bank to ascertain that existing projects can be sustained before embarking on additional population lending. vi. The reviews of the First and Second Projects both identified maintenance of buildings constructed under the projects, which is a state responsibility, as an issue. Maintenance of large numbers of small, scattered health facilities is difficult for the states, and the record is poor even when funds are -,.located for the purpose. Unless means of ensuring state funds and securing the cooperation of the state public works departments can be developed, prospects for long-term maintenance of health facilities are poor. Iesues/Lessons Learned vii. The review of the Second Project noted the need for consistent B policies to deal with the issue of unexpended credit balances resulting from exchange rate changest. In the Third Project unexpended credit balances again emerged as an issue to which Bank, GOI and state project staff all had to devote considerable time and attention. It would seem apparent that, if unexpended credit balances in IDA projects in India are not to be cancelled, the Bank needs to develop a clear and effective alternative for dealing with this recurrent issue. If this is not done. difficulties will continue to arise across the IDA portfolio as projects near completion. viii. Like its two predecessors, the Third Project was only a small part of the larger national family welfare orotram. The project was not designed  - v - to have an impact on the underlying problems of the national program. including weak and overcentralized program planning and management and focus on sterilization at the expense of temporary contraceptive methods and maternal-child health services. An effort to address these constraints at state level through the development of a service delivery strategy that included expanded MCH services, prioritization of clients and tasks, fixed work routines for field workers, and strengthened supervision was aever implemented. If Bank projects are to have some effect on program strategy and constraints, it will be necessary to build into future projects national and state-level components specifically intended to address the basic difficulties. A beginning in this direction has been made in the recent national Child Survival and Safe Motherhood (CSSM) Project. ix. Some of the groject design and implementation issues identified in the First and Second Projects were successfully addressed in the Third Project. Project design was modified to move away from the Area Project model, which in the Second Project had limited project support to specified districts and did not permit the project to address key issues at state level. In addition, project Governing Boards empowered to take financial decisions on the part of their state governments vere constituted; adequate technical support for project IEC components was obtained; and development of systematic in-service training for program staff made considerable progress. All of these factors had a salient impact on project implementation. X. In addition, there were a number of innovative and noteworthy developments in the Third Project, particularly in the project IEC programs of both states. In -irala these included orientation of madrassa (Muslim religious school) teachers in health and family welfare subjects, which proved an effective means of reaching the Muslim community and appears to have been a factor in a substantial change in attitudes toward contraception. In Karnataks, a step-down system for in-service training utilized monthly meetings of field staff in an effective fashion. Also, an innovative set of radio dramatizations of family welfare messages with provision for audience participation via post cards broadcast in the Karnataka project area attracted excellent participation. xi. On the other hand, a program-project split which hampered project implementation and continuity was evident in the Third Project, as it had been in the two earlier projects. This problem has been resolved to a large extent in the Sixth and subsequent projects, in which there is no longer any designation of project districts. In Karnataka, failure of the project's Governing Board to meet regularly resulted in implementation bottlenecks, and quality of construction by the state Public Works Department was unsatisfactory in many instances. Difficulties in monitoring site selection for subcenters were experienced in both states. Monitoring of site selection, design of facilities and supervision of construction are also issues in other project states. If these civil works problems are to be addressed in a consistent fashion, it will be necessary for the Ministry of Health and Family Welfare and the Bank to develop a coordinated approach at both project preparation and supervision stages.  - vi - Ceneral Aeesmt xii. Overall, the project can be rated as "satisfactory." The project budget was expended, physical targets vere met without cost overruns, institutional development and impact objectives were achieved to some extent, and under present circumstances it seems possible to address sustainability concerns.  PROJECT CFeLETlON 3REP& IIDIA ThR POPmaION PROJECT (Credit 1426-I}) PART 1. PROJECT REvIEW nR@I ANK'8 ISERSPECTIVE Project Identity Project Name Third Population Project Credit No. 1426-IN Date of Credit Effectivettess May 8, 1984 Credit Closing Date March 31, 1992 Total Project Cost US$ 123.5 million Foreign E7change Component (Appr. Est.) US$ 12.3 million IDA Credit SDR 66.3 million IDA Credit. Total Disbursed SDR 65.5 million IDA Credit, Total Canceled Not yet known RVP Unit South Asia Country India Sector PHN Subsector Population Background 1. The First India PggDlation Pro1sct. The first Bank-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, 19. . It resulted from a request from the Government of India (GOI) 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 theee districts. Project inputs included the construction of health facilities, paramedical training schools, provision of equipment, furniture and vehicles, and support for incremental staff salaries, overseas training, and operation and maintenance costs. 2. The project was planaed for 5 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 vas extended by 2 years and closed on June 30. 1980. The entire IDA credit and the SIDA grant were expended.  3. 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. 4. The Project Completion Report and the PPAR identified the following lessons learned from the first project: (i) the project was set up in a way that resulted in an 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 subcenters (10,000 pcpulation), 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 coumunity participation; (vi) MCH activities needed to be accorded equa'. importance with faUily planning and the links between the two recognized and exploited. S. Second India PoDulation Proiect. The central government elected in 1977 after the Emergency period indicated that despite 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 efforts were made to obtain external assistance for accelerated program development ("Area Projects') in "backward' districts. Under the IDA-supported project, assistance was provided to six districts of Uttar Pradesh and three districts of Andhra Pradesh. At about the same time, GOI also obtained support from UNFPA, DANIDA (Denmark) and ODA (UK) for Area Projects in five other states. The primary objectives of the projects were the achievement of reductions in fertility and infant, young child and maternal mortality and morbidity. 6. The project was planned for 5 years. The credit became effective on July 26, 1980 and was scheduled to close on March 31, 1986. To utilize exchange rate savings, the credit closing date was extended for 2 years, to March 31, 1988, and project activities were extended to other districts of the two states. The Second Project reflected the expansion of subcenter coverage from 1:10,000 to 1:5,000 population under the Sixth Five-Year Plan, thus addressing one of the issues noted in the review of the First Project. Project inputs were similar to those in the First Project anad included the construction of facilities, provision of equipment furniture and vehicles, support for incremental staff salaries, training, and operation and maintenance costs. The development of management information systems, management training for medical officers, and information, education and communication components were key features. 7. The project was reviewed in a PPAR dated June 29, 1990 (No. 8896). The project completion report noted a number of difficulties/lessons learned from project implementation, including the difficulty of monitoring site selection and construction; the need to avoid having to obtain line-by-line clearance by state Finance Departments; inability to obtain maintenance andlor  repairs of equipment and vehicles; the need for systematic in-service training; the need for management of IEC components by technically competent staff and for decentralization of materials development; and the need to deal with program management problems at state rather than district level. Both the PCR and the PPAR also noted that improved project implementation is unlikely to make a significant difference in program outcomes until more fuz.damental problems with the Indian family welfare p-3gram, especially the focus on sterilization at the expense of temporary contractive methods and MCH services and the target system that drivei it, are addressed. The Third India Population Project - Background, Oblectives and Development 8. The GOI raised the possibility of a third India population project with the Bank in 1981, as part of an effort to expand external support for Area Projects. The Ministry of Health and Family Welfare (MOHFW) proposed that, using the Area Project model, a third Bank-assisted population project should be developed in the backward northern districts of Karnataka and backward and/or hilly districts of Kerala. There was no doubt that tte northern Karnatakae districts were backward compared to the more developed and progressive southern districts. And although demographic rates and social indicators in Kerala were by far the best in India, somewhat surprisingly in the hilly, substantially tribal districts of northern Kerala and the Muslim majority district of Halappuram, these indicators were even lower than they were in the northern Karnataka districts. As in the previous population projects, the primary objectives of the third project would be .he achievement of reductions in fertilitv 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 project was developed quickly. Initial project proposals were made available to a Bank supervision mission in October 1982, and a small Bank team then visited Bangalore and Trivandrum to initiate state-level *discussions. In December 1982 a project preparation workshop was held in Bangalore with participation by project officers from the Second Project states of Uttar Pradesh and Andhra Pradesh as well as GOI, state and Bank representatives. Modified project proposals were subsequently sent to the Bank and provided the basis for an appraisal mission the following April. 10. Proposed project content was generally similar to that of the Second Project. Although there was no sector work input, experience from the Second Project was thoroughly discussed at the Bangalore workshop and provided the basis for modifications in project design. It was already clear from the Second Project that because the family welfare program is managed and implemented at state level, many evident problems could only be tackled on a state basis; support limited to project districts (the Area Project model) was not an effective strategy. This lesson from the Second Project was incorporated into the design of the Third Project to some extent, although project IEC and training components were still limited to the project districts.  -4- Prolect Description 11. The Third Project was organized in terms of the family welfare norms established under the Sixth Five-Year Plan (1980-85). The system of rural primary health care was based on the primary health center (PiC), which provided curative and referral services for a population of a rural development block, or approximately 100,000 people. More specialized referral facilities were to be provided by district and medical college hospitals. The service delivery system called for: (a) a subcenter staffed by one male and one female multipurpose worker per 5,000 rural population (3,000 ;.n tribal or hilly areas); (b) one supervisor per four workers; (c) a subsidiary health center (SHC, later called a new primary health center) staffed by one medical officer and associated staff per 30,000 population; (d) a primary health center (later called an old or block-level PHC) staffed by three medical officers and associated staff per 100,000 population; (e) an upgraded PHC or community health center (CHC) staffed by two additional specialists, e.g., pediatricians and obstetricians/gynecologists. The female multipurpose worker's primary duties were to provide MCH and family planning services, while the male worker was to promote hygiene, sanitation and other public health measures as well as family planning. They were to be supported by one trained traditional birth attendant and one community health volunteer (ClV) per 1,000 rural population. The introduction of subsidiary health centers and upgraded PHCs was to be accomplished gradually. In the first stage, represented by the project, two existing dispensaries in a block were to be upgraded to subsidiary health centers, and one of every four PiCs was to be upgraded to a community health center. 12. The project had four major functional components: (i) service delivery; (ii) demand generation activities; (iii) monitoring, evaluation and operational research; and (iv) project management. With project support, the service delivery infrastructure indicated above was to be implemented in the designated project districts (para. 8). In addition, MIS and population education components were to be carried out on a state-wide basis, while project IEC and in-service training activities were to be limited to the project districts. These components were supported by the following inputs (see Part III, Section 4 for details): (a) Service Delivery - construction and refurbishing of subcent2rs, SHCs, PHCs, CHCs, and maintenance uorkshops, provision of furniture, equipment and vehicles, training and retaining of staff, incremental costs of additional staff and maintenance of equipment  - 5 - and vehicles, to extend and improve the coverage of family welfare services; (b) Demad Generationt (i) provision of community education, IEC materials, the production, pAinting and distribution of films, training and retraining of staff, incremental costs of additional staff, furniture equipment and vehicles, consultant fees and study tours to carry out the IEC component; (ii) training of lecturers, provision of population education booklets and materials, incremental costs of additional staff and payment of honoraria to lecturers, study tours, furniture, equipment and vehicles to carry out the population education component; (c) Monitoring. Evaluation and Operational Research - support for longitudinal sample surveys, introduction of a management information system, and operational research studies, including incremental costs of additional staff, printing and processing costs, furniture equipment and vehicles, to provide basic demographic, health and program information to assist program planning, monitoring and evaluation; and (d) Proiect Management - furniture, equipment and vehicles and the salaries of additional staff required to implement the project efficiently. 13. The project was planned for a 5-year implemGartation period covering the Indian financial years 1984-85 through 1988-89. Expected increases in several family planning and maternal-child health process indicators (contraceptive prevalence, delivery attendance by trained persons and immunization coverage of children) and one impact indicator (infant mortality) by the end of the project period were specified (para. 53). Project Implementation 14. In contrast to the Second Project, when substantial delays were experienced in getting project activities underway, the Third Project got off to a satisfactory start, especially in Kerala. Kerala Government Orders necessary to initiate project activity were issued in September 19"), less than 6 months after the April-May appraisal. Most preliminary activities were taken in hand; construction activities started in December 1983 and site selection and submission of architectural drawings for approval proceeded rapidly. In Karnataka, progress was slower, a contrast that was to characterize the entire project. Government Orders were not issued until January 1984, and the transfer of officers who had been associated with project preparation created additional delays. Although the initial activities carried out by the Population Center Bangalore went forward, the key construction component was not organized promptly.  - 6 - 15. In 1988, a review of project expenditures in Kerala indicated that project savings of about 80 million rupees could be expected. The savings resulted primarily from early completion of civil works together with salary savings for female field workers who were appointed between project appraisal and effectiveness and were therefore paid from regular program rather than project funds. These savings were reprogrammed, largely for additional construction but also for maintenance of facilities constructed early in the project and for additional support to project activities. In Karnataka, delays in the implementation of the civil works component resulted in increased costs, which were met from salary savings similar to those in Kerala. The entire project rupee budget was expended but not exceeded. 16. The project's original credit closing date was March 31, 1990, by which dAte with the exception of civil works in Karnataka the project's physical targets were almost all achieved and the rupee budget expended. The credit closing date was subsequently extended by 2 years, to March 31, 1992, for reasons having to do primarily with unexpended credit balances (para. 75), although the extension also permitted the completion of civil works in Karnataka. Since implementation was largely completed, the Government of India essentially closed the project on July 1, 1990, with the exception of part of the construction unit in Karnataka and skeleton staff for end-of- project purposes. 17. Implementation of the project was by and large along the lines anticipated in the staff appraisal report (SAR) and project implementation volume (PIV). Project physical targets and achievements are summarized in Part III, Section 4. Targets for civil works, equipment, furniture and vehicles were almost completely achieved. Reflecting the circumstances of each state and the lessons of experience, implementation of the IEC and population education components differed in some respects from the project documents but retained project objectives. Pre-service training of field workers and management training of medical officers was along expected lines. It was anticipated that in-service training for all staff would be available every 2 years. This goal was not achieved, but extensive in-service training was carried out in both states and progress was made towards institutionalization of such training. In both states, the introduction of a management information system (MIS) was the weakest component: the planned state-wide implementation of MIS including simplified subcenter registers, consolidated reporting formats and feedback mechanisms was not accomplished in either state. A more detailed discussion of the implementation of each project component in the two states is given in the following paragraphs. Kerala 18. Service Delivery. The project's civil works component was carried out by the Kerala Health Research and Welfare Society (KHRWS), an autonomous organization under the Government of Kerala that has been given responsibility for construction of health facilities in the state. The work of the KHRWS proved to be generally quite satisfactory, and the construction planned under the project (Part III, Section 4) was completed well before the end of the original 5-year project period. When project savings were reprogrammed in 1988, the KHRWS obtained the services of a consultant architect, which  - 7 - generally facilitated the construction carried out under the reprogranmming and in particular resulted in an improved subcenter design that was subsequently adopted in other states. 19. The Third Project used the criteria for location of subcenters that were developed for the Second Project to avoid siting problems evident in the First Project. However, the end evaluation survey indicated that, as in Uttar Pradesh in the Second Project, difficulty was experienced in obtaining satisfactory donated land, resulting in siting of about 25 percent of subcenters that did not conform to the schedule of accommodations given in the PIV. 20. The equipment situation at subcenterg indicated by the end evaluation survey was not very satisfactory. Of 20 pieces of subcenter equipment listed in the project implementation volume, on average only half were found in a sample of subcenters. Weighing scales, hemoglobin tel-ting equipment and lOcc syringes were found to be in shortest supply, and only the supply of 2cc syringes could be called really good. The survey also assessed the availability of supplies and medicines at subcenters, although these were not supported under the project. As is typical of subcenters in India, family welfare supplies were by and large available, while standard drugs were in short to very short supply.. 21. Project staffing targets were by and large met. The additional posts indicated in the PIV were sanctioned, and the end evaluation survey found that in the project districts 80 percent to 95 percent of posts for seven of eight key positions were filled, although only 60 percent of male field supervisors were in post. However, with the exception of female field workers, turnover rates were quite high. The nurse-midwife (ANM) training schools established in the project districts recruited only local trainees, and once local ANMs were appointed to posts in their home districts turnover tended to be low. 22. Trainin. Pre-service training of planned numbers of female field workers (ANms) and male field workers was carried out as anticipated, as were promotion courses for the post of female field supervisor. 23. A skills gap survey was carried out at the beginning of the project to assess training requirements of field workers and plan in-service training accordingly. All field workers and field supervisors in the project districts subsequently received a round of in-service training. In 1988, given the large number of workers who had taken up posts since the previous survey had been conducted, a second skills gap survey followed by training was carried out. The end evaluation survey included a field assessment of the skills of female field workers, field supervisors and public health nurses attached to PHCs. The investigators concluded that the staff assessed were generally well trained and that more than 90 percent were able to carry out satisfactorily the procedures they were asked to demonstrate. No major gaps in knowledge or skills were identified. It was observed, however, that in discussing the management of high-risk pregnancies, female field workers rarely mentioned preventive care and demonstrated a clinical bias in their training.  - 8 - 24. A wide variety of other in-service training was also carried out under the project (Part III, Section 4), including specialist training for IEC staff and management training for PEC medical officers. 25. Information, Education and Comuaication (INC). The IEC component in Kerala was generally implemented as set out in the staff appraisal report. The strategy was developed with the assistance of a consultant, a Keralite on the faculty of the Indian Institute of Mass Communication in Delhi. The purpose of the component was defined as generating desard for family welfare services through creation of awareness and need. The emphasis was on taking account of the social and physical characteristics of the different project districts in designing materials and planning activities, promoting local participation to the extent possit-e, and revising strategies as required on the basis of feedback. Annual action plans emphasized different segments of the population and reflected program priorities. For instance, in the first 2 years of the project the emphasis was on involving youth and on temporary family planning methods. 26. Family Education Centers (FEC.) played a key role in the IEC strategy. Three or four PECs per subcenter, each covering about 200 families, were organized in the project districts. In localities where women's organizations (mahila samaiams) already existed, one member of the samajam became the organizer of the FEC. Where they did not exist, ANMs identified local influential women and persuaded them to organize the FEC. About two thirds of the organizers were recruited in this way. All FEC organizers were given 3 days' training. 27. FECs were involved in a variety of local informational, educational and family welfare activities including the orientation training camps (OTCs) carried out by IEC staff and the organization of immunization camps, where their assistance in bringing dropout cases was particularly useful. Their effectiveness is indicated by the finding in the second skill gaps survey that 80 percent of the ANMs used FEC. to promote family welfare services. FECs also played an essential part in the organization of periodic health festivals which included film shows, exhibitions, medical check-up camps, cultural and entertainment programs, competitions and so on. These festivals, which were relatively inexpensive and very popular, were judged to be one of the most successful of project IEC activities. 28. An IEC effort of particular interest was a training program for madrassa (Muslim religious school) teachers. Muslim-majority Malappuram district alone has about 25,000 madrassa teachers who have great influence on the social and family lives of members of the Muslim community. A half-day of training in health-related subjects was made available to these teachers, who subsequently asked for additional presentations by doctors and other specialists on maternal and child health concerns. Madrassa teachers also became active in the organization of immunization and medical check-up camps under madrassa auspices. It is worth noting that in the baseline survey 53 percent of respondents in the Malappuram reported religious objections to the use of family planning, while the corresponding figure in the end evaluation survey was 3 percent.  - 9 - 29. Per the targets in the PIV, IEC equipment was obtained and a variety of IEC materials were produced (Part III, Section 4). Problems reported appear to be typical. It was not possible to produce 35mm feature films for the program, and 16mm film projectors for use at PHCs were out of order at least half the time. Although quantities of educational materials were available in some places, in one of the project districts there was no trace of them. 30. The experience in other states of India that program managers do not appreciate the potential role of IEC was also evident in Kerala. In addition, the mass educational activities organized under the project require far more effort than do the organization of orientation training camps for limited audiences, and it was evident that district and PHC-level TEC staff tended to prefer the latter to the former strategy. In some instances, existing INC staff in the project districts did not cooperate at all with project activities and trusted that they would disappear when the project cane to an end. Efforts to have PUC medical officers monitor IEC activities at 'their facilities were not successful. When the project was closed in 1990, project IEC staff was absorbed into the state family welfare unit and all mass media project-related ESC activities in the project districts came to a halt. To what extent any of the project activities will be pursued in the project districts and expanded to other areas is not known. 31. Population Education. The population education component was carried out through the directorate of college education, which was able to reach some 200,000 students in 100 colleges in the state through a series of lectures and workshops, and through the Kerala Association for Non-Formal Education and Development (RANFED), a voluntary organization active in the areas of literacy and non-formal education. Project targets for production of materials and activities were met, although an evaluation study indicated that KANFED programs in the area of population education were not very effective. 32. Hanaement Information System (MIS). Project MIS goals were not entirely achieved. A state-wide system was designed with the assistance of a consultant from the Indian Institute of Management Ahmadabad. The objectives were systematization of recording of service data at field level, its rapid transmittal to and aggregation at higher levels of the system for use by managers, and the provision of feedback information. A consolidated reporting format from PHCs directly to state headquarters was developed first but was never completely or successfully implemented. This was followed by the introduction of a set of five simplified subcenter registers designed to link mother and child records to the family record, thus providing a comprehensive data base. A study of the maintenance of registers carried out in 1989 showed that about half of the field wor rs were maintaining their registers regularly and properly and that h additional training this proportion could be easily improved. There is no -jubt that the set of registers, which greatly facilitates recording of data by field workers, is an important improvement over the previous system. 33. Although the project MIS component covered the entire state, it ran afoul of project-program difficulties as did the IEC component. Rather than strengthen and work through the family welfare statistical unit (the  - 10 - Demographic and Evaluation Cell) and introduce the MIS as a modification of tht existing system of data collection, the project urit kept control of MIS (and the associated computer) in its own hands. It is hardly surprising that the D&E Cell, the State Vital Statistics Cell (the state health statistical unit) and state program officers who required PHC data were unwilling to be dependent on the project unit as the source of their program information. 34. In 1989 the Government of Kerala, recognizing that the state's three health and family welfare statistical units were functioning independently without coordination, ordered an amalgamation of the three units as the State Health Information Cell. In practice, however, it was clear than real intexration could not take place until the project office was finally closed. After this happens in mid-1992, it is possible that an integrated state health statistical unit may be able to use the MIS components developed under the project to establish a functioning system. 35. Research Studies. Impetus for research studies came largely from the GOI, which circulated lists of studies done in other states or projects and requested that similar studies be carried out. The research coordination committee established under the project found it difficult to assess the capacities of private research institutions, of which there were many in Kerala, and in any event was reluctant to go to the private sector. Some 12 studies were eventually carried out (Part III, Section 4), three by the Institute of Management in Government, a public sector organization, and nine by project staff. Studies covered all major aspects of the project including training needs, service coverage, IEC effectiveness and MIS. 36. Proiect Management. In Kerala, the Director, Health Services held the post of project coordinator. This arrangement could have had unfortunate results, since such an officer is always extremely busy, and throughout the project period the turnover in the post due to retirement was very high. In fact, an officer of joint secretary rank was specially selected as state project officer early in the project and was able to provide continuity and leadership for the rest of the project period. Karnataka Service Delivers 37. Civil works in Karnataka were entrusted to the Public Works Department (PWD) of the state. From the first year of the project, the civil works component was behind schedule. Difficulties in appointing staff to the construction unit were experienced, and consequently the preparation of architectural drawings and subsequent construction were delayed. By 1988 project management considered that the PWD would not be able to complete all of the construction and turned over responsibility for some 161 works to the Karnataka Land Army Corporation, a semi-autonomous organization that undertook construction work for the state. This experiment was not a success. The Land Army proved to be even slower than the PWD, and when the credit closed in March 1992 a few buildings were still not finished, although project officers expressed satisfaction with the quality of Land Army construction.  - 11 - 38. From Bank supervision reports, project documents and project audit reports it is clear that quality of PWD construction was poor and that adequate means for monitoring construction and ensuring that defects were rectified were not available. 39. The procurement of furniture and equipment was never properly coordinated with construction activiWies, with consequent delays in the commissioning of facilities. In particular, despite special note taken by a Bank mission that the provision of furniture and equipment for the training annex and hostel being constructed in Bangalore should be provided promptly so that the facility would not lie unused, this was not done, and at the time the credit closed it was not known when it would become functional. 40. Training. In addition to the pre-service training of field workers, a substantial amount of in-service training was carried out under the project (Part III, Section 4). Management training of medical officers was initially organized by the Indian Institute of Management Bangalore but was taken over by the Population Center Bangalore. When the training annex and hostel constructed under the project in Bangalore becomes available, it will become considerably easier to carry out this and other in-service training programs planned for Bangalore. Management training for medical officers has been continued after the end of the project. 41. Of particular note is the in-service (continuing education) training for field workers and supervisors that was carried out in 1988-89 and 1989-90. The training was organized on a step-down basis, with initial training given by subject specialists at two regional training centers in the project area and subsequent training of field workers given by supervisors on the occasion of the monthly PHC staff meeting. The subject specialists also attended monthly meetings to get first-hand feedback. Ten sessions on a variety of health, family welfare and program subjects were held in each year. This form of in-service training was generally considered by both program officers and field workers to be effective, and the use of the monthly PHC meeting for training purposes has been extended to the entire state. 42. Information. Education and Communication (IEC). Initial difficulties in identifying a suitable technically qualified person to head the project's IEC component and a technical consultant were experienced. However, the local person eventually selected proved to be effective, and a variety of materials were prepared and activities carried out (Part III, Section 4). An effort to engage a consultant was not satisfactory and the matter was allowed to drop. The importance of the IEC component in the project was strengthened when district project officers, once their site selection responsibilities were completed, were asked to assume responsibility for project IEC activities in their districts. 43. In addition to community education (orientation training camps), extension education and mass communication activities, the IEC program developed a number of innovative projects. Of particular interest was a radio listening project carried out in three project districts in 1987-1988 with the cooperation of All India Radio in Dharwar. A hundred subcenters in the three districts were provided with transistor radios, and groups of women listeners  - 12 - were organized by the ANMs. A series of 24 health education lessons in dramatic form were broadcast weekly with emphasis on family planning spacing methods and immunization. At the end of each program two questions based on the program were asked, and listeners who sent in answers on post cards were eligible for prizes. The programs attracted large audiences, and the number of cards received was impressive. A subsequent evaluation indicated that retention of message content by listeners was good. 44. As in Kerala, problems were encountered in relating project IEC activities to those carried out under the state's regular mass media program. At the local level, block extension educators (BEEs) were already overburdened by claims on their time for other than IEC activities, as commonly happens at PHCs. A problem that appeared to be peculiar to Karnataka also concerned the implementation of a management information systems the PHC post of computer, responsible for the compilation of statistical information, was being filled as a clerical post. Since many, if not most, computers were unable to handle figures, the MIS burden then fell on the BEE. 45. The project IEC unit was absorbed into the state mass media unit in 1990. Because of budget restrictions, however, most of the IEC activities undertaken under the project have not been continued. 46. Population Education. The population education component was carried out through the establishment of a state Population Education Centre attached to the state's Directorate of Educational Research and Training, regional centers at colleges of education at Dharwad and G.ulbarga, and district population education centers at one teacher training college in each district. The component was carried out largely as planned. Training and orientation courses for college faculty, students, government staff and publicly active persons were held. A variety of print and audio-visual materials were prepared and distributed to health facilities. 47. ManIaemeat Information System. An MIS was developed in the project districts of the First Project but was discontinued after the end of the project. The Population Center Bangalore, which had developed the earlier system, was given the responsibility for introducing a similar system state wide under the Third Project. A system was designed and the reporting forms were introduced, but introduction of the subcenter registers was limited to some of the registers in the project districts. It was realized early in the project that the allocation for printing of registers was inadequate, and additional funds were never made available despite requests from Bank missions. It was clear that MIS was not a priority of either the program or the project. This was due partly to the identification of MIS with the Population Center rather than the program; such a system is unlikely to function effectively unless it is implemented as an integral part of the program. 48. Research Studies. The Population Center Bangalore carried out baseline and final surveys for the project as well as a number of additional surveys and studies (Part III, Section 4). To support the capacity of the Population Center to carry out such studies, a computer system was provided under the project. However, this was procured late in the project and at  - 13 - credit closing was not being utilized. As a result, the Population Center wag unable to carry out its own data analysis or to produce reports promptly. 49. Project Management. In Karnataka, the project coordinator was of the rank of Additional Director Health Services, an arrangement that works well only if the Additional Director and the Director cooperate closely, which is difficult to ensure. Although the project coordinator also held the ex- officio rank of Additional Secretary in the Secretariat, the management of the project from the Directorate rather than the Secretariat, which has been the arrangement in some other Bank-supported population projects, at times seemed to work to the disadvantage to the project. Another management problem arose in the latter part of the project when the responsibilities of the state's Department of Health and Family Welfare were divided between two secretaries. Responsibility for the project and for the family welfare program were not assigned to the same secretary, an arrangement that did not contribute to bridging the project-program gap that was one of the project's difficulties. Prolect Extension 50. By the fourth year of the project, it became evident that Karnataka would not be able to complete the civil works component by the credit closing date in March 1990, let alone within the 5-year project period that came to an end in March 1989. It Was also clear that, as in the Second Project, there were going to be very substantial exchange rate savings as the result of depreciation of the Indian rupee vis-a-vis the US dollar/SDR. As noted above (para. 16), the credit was extended for 2 years, to March 31, 1992, as a part of the restructuring of the Third, Fourth and Fifth projects. However, the project was not expanded as the Second Project had been (para. 6). Except for skeleton staff and part of the civil works unit in Karnataka, the project was closed down by HOHUW as of July 1990 with less than 2 months' notice to the states. Proiect Finance 51. The project's rupee budget was fully expended. In both states, expenditure on salaries was less than anticipated because significant numbers of auxiliary-nurse midwife (ANM) posts budgeted under the project were in fact established before the beginning of the project and supported by the central government under the regular family welfare program. Expenditures under the 'Consultant Services and Training" category in Karnataka were less than half of the amount originally allocated (Part III, Section 5) because of the reluctance of the state government to engage consultant services and the reluctance of the Government of India to spent project funds for external training. Both states spent more for civil works than was originally anticipated. 52. Due to depreciation of the Indian rupee vis-a-vis the US dollar and the SDR, implementation of the original project drew down only SDR 36.7 million of the SDR 66.3 million credit. The remainder of the credit was drawn down through a restructuring of the credit and a 2-year extension of the credit closing date (para. 75).  - 14 - Prolect Results" 53. The staff appraisal report indicated that by t4e end of the project the following levels of family planning and MCH coverage could be expected in the project districtst contraceptive prevalence, 33 percent in Kerala and 43 percent in Karnatakat delivery attendance by a trained person, 75 percent in both states; immunization coverage of children, 50 percent in both states. Infant mortality was expected to be reduced by 10 per thousand live births in both states. 54. In Kerala state as a whole, the last decade has seen the achisvement of replacement fertility and the reduction of infant mortality to below 20 per thousand births, both extraordinary accomplishments given generally low income levels in the state. Factors associated with the progress made include the very high levels of female literacy in Kerala (87 percent according to the 1991 census), the density of population, which means that health facilities are easily accessible to most people, high levels of political awareness and organization, which results in greater responsiveness on the part of the public health services than is usual in India, and a large private health sector. Replacement fertility is the combined result of high contraceptive prevalence, at least 60 percent currently, and an average age at marriage for women of over 22 years, by far the highest of any Indian state. 55. While the backward project districts have not achieved the levels of the rest of the state, the gaps between the two at the beginning of the project have been substantially reduced. In 1983, contraceptive prevalence in the project districts was less than 20 percent; by 1991 it had zisen to about 50 percent. Of particular interest are the figures for predomina.itly Muslim Malappuram district, where contraceptive prevalence was about 15 pecent in 1983 and rose to about 38 percent by 1991.2 56. Knowledge of family planning methods except for oral contraceptives was already high in the baseline survey, and for orals improved from 50 percent and 55 percent to 80 percent and 85 percent of eligible women over the project period. However, temporary contraceptive methods are still not widely useds use of temporary contraceptive methods in the project districts increased from prevalence of 2 percent and 3 percent in 1983 to only about 6 percent by 1991. 1 The discussion for Kerala utilizes a draft of the end evaluation survey. At the time of writing, only a few preliminary figures were available from the comparable Karnataka survey, and neither state's project completion report was available. 2 According to a recent report by K.C. Zachariah (Demographic Transition in Kerala in the 1980s, Center for Development Studies, Trivandrum, (1992) prevalence rates among Muslims and non-Muslims in Malappuram are about the same, leading him to interpret low contraceptive prevalence in Malappuram as reflecting a general 'backward district effect' rather than a specifically Muslim phenomenon.  - 15 - 57. Coverage of b'oth antenatal care (ANC) and immunization in the Kerala project districts has reached high levels. The baseline survey reported immunization coverage between 20 percent and 35 percent. Immunization has been the focus of the national universal immunization program (UIP), which was begun in 1985. Figures from UIP coverage evaluation surveys indicate that in 1991 the percent of children 1 to 2 years of age who were fully immunized ranged from 40 percent to 80 percent, but low figures in some districts were the result of problems with the supply of measles vaccine; except for measles, coverage ranged from about 65 percent to over 90 percent. Less than 5 percent of these children were not immunized at all, except in Malappuram district, where the reported figure was 11 percent. It is not possible to distinguish to what extent increases in immunization coverage are attributable to project inputs or to UIP, although clearly UIP was able to build on strengthened infrastructure and expanded facility coverage in the project districts. 58. The UIP coverage surveys also reported that in the project districts coverage for ANC services except for hemoglobin testing ranged from 60 percent to 80 percent, 75 percent to 85 percent of deliveries were institutional, and more than 80 percent of deliveries were conducted by a trained person in 1991. Thus, coverage levels more than achieved project goals of 75 percent of deliveries by a trained person and 50 percent imminization coverage. 59. The expansion of ANC, trained delivery and immunization undoubtedly have contributed to the substantial decline of infant mortality. Zachariah estimates that in Palghat and Malappuram districts, infant mortality in 1980- 85 was 48 and 53, respectively, and that by 1985-89 the IMR had declined to 34 and 28, respectively. These achievements significantly exceeded the project goal of a ten per thousand decline in IMR. 60. In Karnataka, overall project results are more difficult to assess than they are in Kerala. Family planning achievement figures for pre-project, early project and later project years for project districts and the rest of the state (Part III, Section 8) have a number of interesting features. First, r'hanges in achievement figures frNm district to district and year-to-year vary greatly, for reasons that are often difficult to identify. This is characteristic of the Indian family planning program. District figures reflect both national and state trends as well as local conditions. The substantial increases for all methods in 1984-85 and 1985-86, for example, probably reflect state-wide campaigns in those years. To explain the year-to- 8 The three sources available for immunization and ANC coverage in Kerala pro3ject districts in/around 1991, i.e., UIP evaluation coverage surveys, the project end evaluation survey, and Zachariah's 1991 study, are quite inconsistent. The end evaluation survey reports very high coverage of 90 percent and over for ANC services except for Palghat district, while some of Zachariah's figures for ANC and immmnization coverage are quite low. Especially for immunization, the UIP surveys are probably preferable, since trained teams from medical colleges carry out surveys every year and the methodology is standard and well understood.  - 16 - year variations in the different districts would require detailed knowledge of local program and political circumstances.4 61. Second, increases in the early project years over the preceding years were much greater than increases in the later project years over the earlier years, the opposite of what might be expected in terms of the impact of project software components. However, this is true of the non-project districts as well, which again suggests that the factors involved were not linked to the project. Third, sterilization acceptance seems to have plateaued in both project and non-project districts. At current prevalence levels this is not unexpected and still means increases in prevalence, although at a slower rate than previously. Fourth, the only method for which project increases are consistently higher than comparable non-project increases is IUDs. In sum, there is little in the family planning achievement figures to suggest a discernable project impact. 62. In terms of prevalence, the picture is similar. At the start of the project in 1983, contraceptive prevalence in the state as a whole was about 2.5 percentage points higher than in the project districts. By 1991, the difference had grown to about 6 percentage points. Prevalence in 1991 in the project districts was about 40 percent, somewhat less than the project goal. As in Kerala, use of temporary methods remains quite limited, increasing only from about 3 points in 1983 to about 5 points in 1991. 63. A coverage evaluation survey from one of the project districts (Dharwar) for 1991 indicated improvements in ANC coverage, immunization coverage and attendance at delivery over levels reported in the baseline survey. However, there was still much room for improvement. Only about a third of the women surveyed were receiving ANC services, although almost two thirds were being immunized with tetanus toxoid. About 20 percent of deliveries were institutional, and only slightly more than half of deliveries were attended by a trained person. Immunization coverage for children one to 2 years of age ranged from about 45 percent to 65 percent, but some 22 percent of these children were not immunized at all. The project goal of 75 percent of deliveries attended by a trained person was not nearly reached, although the immunization goal of 50 percent coverage can be considered to have been 4For example, a report by the Population Center, Bangalore (Programme and Community Factors Affecting the Family Welfare Programme in Gulbarga District, 1988) lists the following among program factors contributing to poor program performance in Gulbarga district in 1987: poor PHC infrastructure, a third of medical officer posts vacant, many medical officers and field staff not resident at or near their facilities, half of the medical officers not trained to perform sterilizations, poor sterilization camp logistics, high laparoscopic sterill.zation failure rates, poor MCI services, etc. Problems of these sorts are not uncommon. In addition, the report attributes particularly high sterilization acceptance in Gulbarga district in 1985-86 to an effort by the district administration to promote family planning that included promises of official assistance to sterilization acceptors in the form of house sites, loans, and so on that could not be kept. It is hardly surprising that in the following year numbers of acceptors in the district plummeted.  - 17 - achieved. As in Kerala, the effects of the project and UIP on immunization coverage are confounded. 64. Good project results in Kerala must be attributed to both project and to more general factors as well. The ability of the Government of Kerala to issue Government Orders promptly at the start of the project, the interest and assistance of the project's Governing Board, and the availability of the KHRWS to carry out civil works combined to support prompt achievement of project physical targets. The creation of infrastructure in the hilly districts were it had previously been lacking provided the basis for a substantial expansion of services. However, the large increases in family planning and MCH coverage in the Kerala project districts also owe a good deal to the general situation of the state, with its extremely high literacy rates and extensive demand for medical services. The combination of these factors made it possible for the project to close much of the gap between the project districts and the rest of the state. 65. On the other hand, the northern districts of Karnataka in many ways resemble parts of north India more closely than they do the much more developed southern parts of the state. It is probably unrealistic to expect that the family welfare program will make more rapid progress in northern Karnataka until measures to address basic program constraints such as those included in the proposed project service delivery strategy that was never implemented (para. 69) are adopted. Project Sustainability 66. Because population ;ontinues to be a priority of the Government of India and the family welfare program is a 100 percent centrally supported scheme, the sustainability of the Bank-supported population projects has not been considered an issue over the last decade or so. The current difficult financial situation of the GOI puts the matter in a somewhat different light and suggests that the Bank now needs to be more cautious. Neither continued expansion of central support for family welfare nor indefinite continuation of 100 percent central support for existing obligations can now be assumed. In addition, our cumulative experience as well as recent sector work indicate serious problems in sustaining investments in the linked family welfare and health programs due to inadequate financing at both central and state levels. It has therefore become increasingly important for the Bank to ascertain that existing programs can be sustained before embarking on additional population lending. 67. The one sustainability issue identified in the reviews of both the First and Second Projects concerns maintenance of buildings constructed under the project, which is the responsibility of the states concerned. As noted in the review of the Second Project, providing maintenance for large numbers of small, scattered health facilities is difficult for the states, and the record is poor even when funds are allocated to the PWD for the purpose, which is not always the case. Kerala was able to use project funds for maintenance of buildings constructed early in the project (para. 15). If there is another project in Karnataka in the near future (para. 82), funds for maintenance of Third Project buildings could be included in the new project. However, unless  - 18 - means of ensuring state funds for maintenance and securing PWD cooperation can be developed, prospects for adequate long-term maintenance of health facilities by the states are poor. While bearing these cautions in mind, under present circumstances project investments can be judged by and large sustainable. Bank Perfozmance 68. In the development of the Third Project, the Bank attempted to move away from the Area Project concept, which after 2 years of implementation of the Second Project was proving ineffective, and towards a state rather than district level project design, without provoking a confrontation with the Ministry over abandonment of the official Area Project strategy. In retrospect, it seems evident that it would have been better had the training and IEC components of the project been made state wide, as was MIS, and the creation of technical posts under the project avoided. However, at the time, which was characterized by a very different relationship between the Bank and the Government of India than that which currently prevails, the project officer preferred a more gradual approach. 69. The development of a strategy to facilitate moving the family welfare program in the project states away from overemphasis on sterilization targets towards provision of quality MCH and family planning services, a key issue identified in both the First and Second Projects (paras. 4 and 7), was poorly handled by the Bank. A paper outlining how program service delivery could be reoriented along the desired lines through expansion of MCH services, prioritization of program clients and tasks, fixed work routines for field workers, an expanded role for IEC and strengthening of supervision was included in the staff appraisal report. The approaches developed in this paper were incorporated into subsequent Bank projects as well as GOI documents. However, the original paper was written in the Bank after the appraisal mission, and no attempt was made to obtain input from the states or to discuss its implications with them. Under such circumstances, it is hardly surprising that the strategy was ignored and had no impact on program implementation under the project. An effort by the author of the strategy paper to implement the approach on an experimental basis in one district of Karnataka was not followed up by the Bank with the Ministry in Delhi, and therefore nothing came of it. 70. Bank supervision of the project suffered from poor continuity. Ten supervision missions over 7 years were carried out under four task managers; two missions were actually headed by a consultant when the nominal task manager was occupied with other work. The latter 4 years of the project were overshadowed by MOHFW's requests for extension proposals followed by the abrupt termination of the project in mid-1990 (para. 16), both of which affected supervision efforts. 71. These points aside, Bank supervision of the project was by and large adequate in terms of frequency and appropriate tecbnical expertise. Larger missions prior to 1987 (Part 1II, Section 7) reflect both greater supervision needs in the earlier parc of the project as well as the reduction of staff resources available following the reorganization of the Bank in 1987.  - 19 - The one area where greater Bank attention and technical support might have made a difference was the MIS component, where difficulties in both states become evident fairly early in the project. Borrower Performance 72. Although several missions reported that delayed allocation of funds by MOHFW to the states and by the states to the project, these problems were short term and did not significantly interfere with project implementation in the longer run. Processing of state disbursement applications by the Departmer.t of Economic Affairs went smoothly. The major problem involving the Borrower concerned the handling of exchange rate savings and the possible expansion of the project. 73. Well before the original credit closing date of March 31, 1990, it was apparent that there were going to be large exchange rate savings. The Ministry evidently assumed that, as in the case of the Second Project, some or all of these savings could be absorbed through an expansion of the project to include additional districts and enhanced project activities. The Department of Economic Affairs strongly supported such an expansion of the project. The Bank indicated to Ministry that an expansion, combined with an increase in disbursement percentages in order to draw down the credit more rapidly, would be possible. In 1988 and 1989, the states were asked on three occasions by the Hinistry/DEA to draw up proposals for a project expansion, for different amounts, on very short notice. The first two sets of proposals were reviewed informally by Bank missions and guidelines for modifications indicated. 74. For reasons that are not clearly known, no expansion proposals were ever formally submitted to the Bank, although it was indicated informally that for a combination of financial and political reasons, the Planning Commission refised to approve further investment in the project states. The inability of the three concerned branches of GOI to coordinate and communicate a consistent policy concerning expansion of the Third Project to the states and the Bank created considerable hardship for project and program officers in both Kerala and Karnataka and made it difficult for the Bank to plan the development of future population lending in India. 75. In the latter part of 1989, the Department of Economic Affairs concluded that an expansion of the Third Project would not be possible. The Department then indicated to the Bank that future population lending might be jeopardized unless the Bank could come up with a way to assist CGOI in drawing down the large credit balance that remained for the Third Project. The Bank responded by developing a restructuring of the Third, Fourth and Fifth Population Projects that included amending the project description of the Third Project to cover all of the states' districts and additional family welfare activities, increasing disbursement percentages, allowing disbursement claims retroactive to November 1988, and extending the Third Project credit closing date by 2 years. After this restructuring was approved by the Bank's Board in December 1989, at DEA's instruction Kerala and Karnataka submitted  - 20 - large "special' disbursement applications that drew down most of the remaining credit.5 76. Since the project was not to be expanded and, with the exception of civil works in Karnataka, the project's physical targets had been largely achieved, in April 1990 the Hinistry informed the states that except for part of the civil works unit in Karnataka and skeleton staff for end-of-project purposes, the project would be closed down as of July 1, 1990. This abrupt termination of the project created major difficulties for both states. The state budgets for 1990-91, which had been drawn up months previously, did not include provision for project staff and activities that would not be supported by the Ministry following the end of the project. A planned and smooth transition was therefore not possible. Issues/Lessons Learned 77. Bank. The review of the Second Project noted the need for consistent Bank policies to deal with the issue of exchange rate savings. The experience of the Third Project, where due to lack of such policies Bank, GOI and state project staff had to devote considerable time and attention to restructuring rather than project implementation, underlines the continued importance of the matter. It would seem apparent that, if exchange rate savings in IDA projects in India are not to be cancelled, the Bank needs to develop a clear and effective alternative for dealing with this recurrent issue. If this is not done, difficulties will continue to arise across the IDA portfolio as projects near completion. 78. Prostram. Like its two predecessors, the Third Project was only a part of the family welfare programs of the project states and a correspondingly much smaller part of India's national family welfare program. The project was not designed to have an impact on the underlying problems of the national family welfare program identified in the reviews of the First and Second Projects, which include weak and overcentralized program planning and management and focus on sterilization at the expense of temporary contraceptive methods and maternal-child health services. A strategy to address serv ce delivery issues at state level was developed by the Bank, but there was no state input involved and it was ignored (para. 68). If Bank projects are to have some effect on program strategy and constraints, it will be necessary to build into future projects national and state-level components rf This PCR is not an appropriate place for a complete review of the restructuring of the Third, Fourth and Fifth Population Projects in India that was carried out in February 1990 on the basis on a memorandum to the Board submitted in December 1989. While the preparation of three expansion proposals and the abrupt closing of the project in July 1990 severely inconvenienced the Health & Family Welfare Departments of Kerala and Karnataka, the effect on the actual implementation of the Third Project was limited. Of approximately $38 million paid against special disbursement claims in 1990, repayment of approximately $20 million was requested by the Bank in 1992 on the grounds that disbursements for this amount were Ineligible.  - 21 - specifically intended to address the basic difficulties. A beginning in this direction has been made in the recent national Child Survival and Safe Motherhood Project (CSSM) Project. 79. Project. Of the project design and implementation issues identified in the First and Second Projects (paras. 4 and 7), some were addressed in the Third Project, including the following: (a) It was clear from early second project experience that since the family welfare program is implemented at state level, limiting project support to specified districts (the Area Project model) did not permit the project to address key management and service delivery issues and was therefore not an effective strategy. The Third Project therefore began modification of the Area Project (backward district) concept on which the Second Project had been based. Project coverage was increased to some extent in the Third Project, was further expanded in the Fourth Project, and was extended to the entire state without any designation of project districts in the Sixth and Seventh Projects. (b) To avoid the necessity of obtaining line-by-line clearance of project expenditures by state Finance Departments that was proving to be a major bottleneck in the Second Project, in the Third Project the project Governing Boards were empowered to taken decisions on behalf of the state government that were not subject to review by individual departments. The grant of such powers to the Governing Boards significantly facilitated project implementation in both states. sc) To obtain adequate technical support for IEC, a project covenant required both states to appoint at an appropriate rank a technically qualified person to direct IEC activities. As in Andhra Pradesh in the Second Project, the results of competent technical direction of the component were positive. td) The Third Project was the first of the India population projects to deal systematically with the need for in-service training in the family welfare program, although the training component were limited to the project districts. The effectiveness of the training in improving the technical knowledge and skills of field workers was demonstrated in Kerala by an end-of-project evaluation. In-service training was subsequently expanded in the Fourth and Fifth Projects and became the major focus of the Sixth and Seventh Projects. (e) There were a number of innovative and noteworthy developments in the Third Project, particularly in the project IEC programs of both states. Of special note are the following: (f) In Kerala, orientation of madrassa teachers p.x,ved an effective means of reaching the Muslim community and appears to have been a factor in a substantial change in attitudes towards contraception  - 22 - (para. 28). Health festivals and similar mass educational activities drawing on community organizations (the family education centers) were also both inexpensive and especially effective. (g) In Karnataka, a step-down system for in-service training was able to utilize monthly PHC meetings for training purposes and also made efficient use of limited numbers of subject specialists to train large numbers of field workers (para. 41). (h) An innovative set of radio dramatizations of family welfare messages with provision for audience participation via post cards in Dharwar district of Karnataka attracted large audiences, impressive participation and good retention of message content (para. 43). 80. The following issues noted in the reviews of the First and Second Projects (paras. 4 and 7) continued to be problems in the Third Project: (a) A program-project split resulted in many instances in poor cooperation between program and project staff and difficulties in the absorption of project staff and activities into the program at the end of the project. (b) A high proportion of subcenter sites (25 percent in Karnataka), which were limited to donated land, were not located in conformity with project guidelines. (c) Reliance on the state PWD to carry out project construction in Karnataka was unsatisfactory; in particular, mechanisms for monitoring of construction were not worked out. 81. The following additional points can be noted from the Implementation experience of the project: (a) Frequent meetings of the project Governing Board and Steering Committee greatly facilitated project progress in Kerala; in Karnataka failure of the Governing Board to meet regularly resulted in implementation bottlenecks. (b) Provision for maintenance of facilities constructed early in the project in later project years should have been included in the project. (c) The review of the Second Project notes that external mid-project evaluation might have improved subsequent project implementation. However, the assignment of the mid-term review to an outside agency in Karnataka was not successful. Although a review was clearly needed, program and project staff were so alienated by the approach taken in the report that their energies went into refuting the report rather than drawing lessons from it.  - 23 - 82. At this time, a further Bank-supported population project in Karnataka is under consideration. In developing the new project, the following experience and lessons from the Implementation of the Third Project in Karnataka should be taken into accounts (a) The project should cover the entire state, although civil works support can be limited to those districts not covered under the previous Bank-supported projects. (b) Project posts should be limited to those which will be abolished at the end of the project, such as civil works and accounting posts. (c) Development of a service delivery strategy should form an integral part of project preparation. (d) Improved provision for construction and monitoring of construction is needed. (e) Funds for maintenance of buildings constructed under the First and Third Projects as well as early construction under the new project should be included. (f) The initiatives undertaken in the Third Project in the IEC and training components need to be consolidated and expanded. (g) The Department's Mass Media (family welfare) and Health Education (health) units should be consolidated. (h) Training infrastructure needs to be strengthened along the lines indicated in the Ministry's training strategy and developed in subsequent Bank-assisted population projects. The role of the Population Centre Bangalore established under the First Project should be reconsidered in view of the expansion of training infrastructure, as has been done in U.P. (i) The Department's family welfare (Demographic and Evaluation Cell) and health (SBHI) statistical units should be consolidated. (j) The statistical unit should be strengthened to implement and manage the Health and Family Welfare Department's MIS; the MIS should be reviewed in the light of the experience of other states and adequately supported under the project.  - 25 - PROJECT COQPLRTXON INDIA TEIED POPMATION PROJCT (MR&L& ) {Credit 1426-IN) PART II. oceSMeT BY T9 CRCY Cgegmta of the Governmant of Indla 1. India Population Project III vhich commenced w.e.f. 1st April, 1984, in four districts of Kerala and six districts of Karnataka, vas successfully implemented in these States. The targets set in respect of various activities under the Project were almost fully achieved by these States. The Project was by and large successful in attaining ite objectives. 2. The Endline Evaluation report of IPP-III (Kerala) submitted by the Foundation for Research in Health Systems, Ahmedabad has shown the impact of the Project in the project districts of the State as under: Baseline Survev Endline Survey Birth Rate 29/1000 pop. 25/1000 pop. Couple Protection Rate 20X 502 Immunization Coverage 11.361 63S Ante-natal Coverage N.A. 951 3. The Endline Survey of IPP-III (Karnataka) conducted by the Population Centre, Bangalore has also shown significant improvement and impact of the programme activities of IPP-III in the project districts in respect of demographic indicators which have been summed up as follows: Baseline Survey Endline Survey Sex Ratio 946.0/1000 pop. 960.0/1000 pop. Crude Birth Rate 35.3/1000 pop. 29.1/1000 pop. General Fertility Rate 164.9/1000 pop. 145.5/1000 pop. General Marital 198.9/1000 pop. 176.2/1000 pop. Fertility Rate Crude Death Rate 10.5/1000 pop. 8.5/1000 pop. I.M.R. 85.7/1000 pop. 72.4/1000 pop. Couples Practicing 25.81 39.01 Family Planning 4. Project results were definitely better in Kerala than in Karnataka. It is felt that the performance could have been better, particularly in Karnataka. Experiences and lessons learned from the project as indicated in  - 26 - Part I of the report would be utilized in designing and implementing of the next project. Some project act''ities of the States suffered set backs due to cestain constraints faced by the State governments. These have been discussed in the following paragraphs. 5. In Kerala, high land cost together with a tight time schedule posed problems for the State Government in getting satisfactory donated land for subcentres. As a result the State had to accept less than ideal sites for some subcentres, despite earnest efforts made by the State Government. There was water scarcity in some subcentres but it was only seasonal, with wells drying up in sutmmer. This problem was felt mainly in Malappuram district. Ensuring regular and adequate supply of water round the year in all str-centres scattered through the district was not possible because of the topogtAphy of the districts. However. some source of water was always located not far from the subcentres premises to meet the demand in difficult times. In Subsidiary Health Centres or other larger institutions with inpatients, a steady supply of potable water was made available. 6. Kerala had to drop the idea of production of a full length feature film on family welfare because of various reasons. One of the most important problems identified was the huge cost of production and the unpredictable response of audiences if popular cine-artists took the leading roles, either leading to a positive outcome from character identification or a negative outcome where the theme and message become unimportant and blurred by the overwhelming personal charm of the film star. Problems of distribution were also anticipated. Films Division could not take over the responsibility because of statutory limitation of exhibition time available. Private distributors had their own ways of bargaining, and hardly any takers could be expected unless the theme was handled in a very subtle manner. The above consideration outweighed the benefits of a full length feature film on family welfare. 7. In the End Evaluation survey of Kerala, an unsatisfactory equipmuent situation at subcentres has been pointed out (Paragraph 20 of Part I of the report). In fact, during the project per tod, equipments were supplied to all the 768 subcentres (568+200) constructed under the project. The sampling method of the End Evaluation Survey was such that all the subceutres irrespective of whether they were established under IPP or not had an equal chance of being selected in the sample. Only about 50 percent of the subcentres were IPP subcentres in the final sample of subcentres chosen for the survey. Therefore, the statement pertaining to the equipment position of the subcentres is not a true reflection of the project activity of supplying equipment to subcentres. 8. In paragraph 29 of Part I of the report, it has been pointed out that there was no trace of educational material in one district of Kerala. In fact, supply of educational material was made to all the districts of the State. The methodology and level of efficiency of further distribution downwards varied from district to district. Some district could effectively use the materials. Others used them less effectively and were also not quite successful in convincing others what they did. The awareuess about health practices and the acceptance role of family welfare measures were the maximum  - 27 - and growth rate was minimum in that particular district vhere no trace of educational material was found. 9. Even though most of the project-related IEC activities came to a halt after expiry of the project period, community involvement is attempted to be maintained through the continued support given to voluntary groups such as Family Education Centres by the local fema.e field workers. Subeentres committees were established in all the districts through a Government Order and these Committees are called Popular Committees. 10. In Paragraph 34 of Part I of the report, the need for integration of all the health and family welfare statistical units functioning in K.(erala was recommended. Keeping in view the need of integrating the statistical units, the State Government would take urgent action to ensure compliance of the directions given. 11. The untoward effect of conflict between programe and project staff was minimized to a certain extent in Kerala by following appropriate strategies. Strengthening the areas of reciprocal interdependence was one such method adopted frequently by the project management. 12. In Karnataka, due to certain constraints, there was delay in construction of IPP buildings by the Public Works Department of the State. Various factors such as initial delays caused in initiating the project activities under this component, together with resentment of the staff posted and scarcity of water arising out of drought conditions in the early years of the project, resulted in delays. However, in subsequent years there was improvement in the activities and with the cooperation of other state-owned construction agencies, almost all the building envisaged have been completed. 13. As regards procurement of furniture and equipment in Karnataka, although there was initial delay owing to administrative reasons, equipment and furniture have been procured and distributed to all the buildings and made functional. 14. Under Management Information System. there was a little delay in Karnataka in the printing and distribution of MIES forms and registers owing to certain administrative reasons. However, these lapses were attended to and arrangements were made to print and supply MIES forms and registers. The State Covernment has assured that in the population project proposed in future, action will be taken to implement the MIES as an integral part of the programme. 15. As regards nonsubmission of expansion proposal to the Bank as pointed out in Paragraph 60 of Part I of the report, although the States of Kerala and Rarnataka formulated expansion proposals to utilize the projected savings under the project, the expansion proposals were not approved by the Government due to resource constraints. 16. Though it is true that the States were advised to reduce the number of staff (as pointed out in Paragraph 62 of Part I of the report) as most of the project activities were completed, a minimum number of skeleton staff  - 28 - required for carrying out the project activities Was allowed to be continued until final termination of the project. As a result, it was possible for the State Governments to gradually integrate the project staff within the existing health and family welfare system.  - 29 - Comments of the Qgoernme_t of Kerala The PCR of the World Bank is in general agreement with the State Government's perception and assessment of the project implemented in Kerala. The strength and weaknesses as reported by the Bank shall certainly be borne in mind when future implementation of any such project is considered. It is felt, however, that some explanation of the circumstances is required wherever weaknesses are pointed out. The same is given below pararw;.es 1. Para. 19 of the PCI: Silt groblems for bugildig locations. The district officers had been given datelines for the completion of the exercise for obtaining donated land for subcentres. The time pressure was heavy, and getting donated land at the rate of a minimum of 10 cents for each facility was a difficult task in Kerala due to very high land cost and density of population. This resulted in the acceptance of less than ideal sites in certain situations. Water scarcity was there but it was only seasonal, with wells drying up in summer. This problem was felt mainly in Malappuram District. Ensuring a steady supply of water round the year in all subcentres scattered throughout the District was impractical because of the topography of the Districts. However, some source of water was always located not far from the subcentre premises to meet the demand in difficult times. This is not the case with subsidiary health centres or other larger institutions with inpatients, where a steady supply of potable water was made available. 2. Para. 20 PCRs SupDIy of IouMpments to Subcentres. The project supplied equipments to all the 760 subcentres (560+200) constructed under it. But there were other old subcentres already existing in the districts. The sampling method of the End Evaluation Survey was such that all the subcentres (irrespective of whether they were established under IPP or not) had equal chance of being selected in the sample. Only about 50 percent of the subcentres were IPP subcentres in the final sample of pertaining to the equipment position of the subcentre is not a true reflection of the project activity of supplying equipment to subcentres. 3. Para. 29 PCR: Production of a future film and sUrnlv of IEC materials. Production of a full length feature film was considered in its different aspects by the project authority, the Standing Committee and also by the IEC Consultant. Several problems were identified. The most important among them was the huge cost of production and the unpredictable response of audience if popular cine artists took the leading role. either leading to a positive outcome from character identification or negative outcome where the theme and the message get unimportant and blurred by the overwhelming personal charm of the film star. Problems of distribution are also anticipated. Films Division could not take over the responsibility because of statutory limitation of exhibition time available. Private distributors had their own ways of  - 30 - bargaining, and hardly any takers could be expected unless the theme was handled in a very subtle manner. The above considerations outweighed the benefits of a full length feature film on family planning and therefore, the idea was dropped. Education materials had been supplied to all the districts. The methodology and the level of efficiency of further distribution downwards varied from district to district. Some districts could effectively use the materials and show that they used them. Others used them less effectively and were not quite successful in convincing others what they did. In fact the awareness about health practices and the acceptance rate of P measures were the maximum and the growth rate was minimum in that particular district where End Evaluation Survey found no trace of education materials. 4. Para. 30 PGR: Sustainability of IEC Activities. Even though most of the project related IEC activities came to a halt, community involvement is attempted to be maintained through the contivued support given to voluntary groups such as Family Education Centres by the local female field workers. Subcentre cowmitteet were established in all the districts in Kerala through a Government order and these committees are called popular committees. 5. Para. 34 PCR: Integration of Statistical Units. Realizing the need for the integration of all the statistical units as pointed out by the World Bank, the Government would be taking urgent action to ensure compliance of the directions given. 6. Para. 54 PCKt Maintenance of flildings. Kerala was able to use project funds for maintenance of building constructed early in the project. The State PWD has started action in preparing maintenance estimates of all IPP buildings. The maintenance work will be done promptly by the PWD. 7. Para. s8 PC0 : Proaramme-nroject Split. It was possible to minimize the untoward effect of a certain level of conflict between programme and project staff by appropriate and timely strategies. Strengthening the areas of reciprocal interdependence was one such method adopted frequently by the project management for keeping the conflict at the most productive level. .  - 31 - Commuent of the Gover2ment of o a_nataka 1. In response to the comments made by World Bank in its Project Completion Report for India Population Project III, it could be said that the Government of Karnataka has successfully completed all the programme activities in general, and as envisaged the project objectives have been achieved almost fully. The budget allocated under the project for the various components of the programmes has been utilized in full and spent. 2. The results of the Endline Survey issued by the Populat.on Centre, Bangalore in their report "Some Salient Findings of Endline Survey of IPP-III (K)" (May 1992), have revealed that there is significant improvement and impact by the programme activities of India Population Project III in the project districts in respect of demographic indicators such as sex ratio, household size, birth rate, general fertility rate and general marital fertility rate, death rate, infant mortality rate, family planning (percentage of couples practicing family planning in IPP-III Districts) and average daily turnover of outpatients in PHCs and average monthly turnover of inpatients in PHCs, when compared to baseline survey results of IPP-III (K). 3. In view of *ertain constraints, particularly in respect of civil works, there wss delay in construction of IPP buildings by the Public Works Department owing to the delay caused in taking up of project activities by the Engineering Department. Ten months' initial delays in initiating the project activity under this component, together with resentment of the staff posted and scarcity of water due to drought conditions in the earlier years of the project, caused the building of works to lag behind schedule. However, in subsequent years the situation improved and with the cooperation of other state-owned construction agencies almost all the buildings envisaged have been completed. 4. The procurement of furniture and equipmeat, though delayed owing to certain administrative reasons, has been completed and all the buildings have been made functional. 5. The World Bank also has rightly observed and stated that despite certain initial delays, the project's physical targets in respect of civil works, furniture, equipment and vehicles were almost comfletely achieved. 6. Implementation of IEC, Population Education and training programmes have been done on the lines expected. Noteworthy innovative programmes have been developed under IEC. In-service training in the family welfare programme improved the technical knowledge and skills of field workers in the project districts. The IEC project programme was abruptly ended in June, 1990 and the unit was absorbed into the state's Mass Media Wing. Due to budget restrictions, most of the activities could not be continued. 7. The World Bank has rightly observed that the innovative undertakings in the third project in respect of the IEC and Training components need to be consolidated and expanded.  - 32 - 8. Out of these experiences and lessons learnt, the new Population Project currently being proposed particularly in respect of IEC and Training will be planned to be expanded and continued for all districts of the State. 9. Under the MIS component in the third project, there was a little delay in printing and distribution of MIES forms and registers owing to certain administrative reasons. However this lapse was attended to and arrangements were made to print and supply MIES forms and registers. In the proposed population project, action will be taken to implement the MIES as an integral part of the programme. 10. Under Project Management, for various administrative reasons the Governing Board, although it could not meet regularly once in 3 months, met 11 times during the project period, as and when required, to review progress and to give required administrative sanctions and directions for implementation of the programmes. 11. In the proposed population project, care has been taken to learn from the lessons of the first and third projects. Civil works will be provided only to those districts of the State which have not been covered under the earlier projects, as suggested in the Project Completion Report. 12. The bottlenecks experienced in implementation of IPP-I and IPP-III as noted by World Bank in its comments have been taken note of in designing the new project which is under consideration by the Bank. Reliance on PWD for construction of buildings, improved provisions for construction and monitoring, development of service delivery, funds for maintenance of buildings constracted already by previous projects, and consolidation and expansion of the initiatives undertaken in the 3rd Project in IEC and Training have all been included. The need for consolidation of the Demographic Cell and the statistical units and the deficiencies noticed under project management have also been taken note of, and it is planned to avoid these bottlenecks in the proposed new population project.  - 33 - Section 1 Page 1 of 2 PROJECT C(lTIOA REPORT DmIA THIRD POPULMITON PROJECT (KRNALA MMD KARNTATKA) (Credit 1426-IN) PART III. STATISTICAL INFOEMUIO 1. Related Bank Loans or Credits Credit No. 312-IN Title First Population Project Year of Approval 1972 Purpose To support the family welfare program in five districts of Karnataka and six districts of Uttar Pradesh Status Credit Closed June 30, 1980 Comments PCR 6/81; PPAR 1/82 Credit No. 981-IN Title Second Population Project Year of A-Pnroval 1980 Purpose I To support the family welfare program in six districts of Uttar Pradesh and three districts of Andhra Pradesh Status s Credit Closed March 31, 1988 Comments PCR 1/901 PPAR 8/90 Credit No. 1623-IN Title Fourth (West Bengal) Population Project Year of AR2roval 1985 PurDose I To support the family welfare program in four districts of West Bengal Status Under implementation Comments s State-level support for MIS, IEC and population education and training Credit No. 1931-IN Title Fifth (Bombay/Madras) Population Project Year of ADDroval 1988 Purpose To support the family welfare program in the cities of Bombay and Madras Status Under implementation Comments NGOs and private medical practitioners are included in project  - 34 - Section 1 Page 2 of 2 Credit No. 2057-IN Title Sixth (First National Family Welfare Training and Systems Development) Population Project Year of ADDroval 1989 Purpose I To support the family welfare program in the states of Uttar Pradesh, Andhra Pradeeh and Madhya Pradesh Status Under implementation Comments Focus on strengthening of training aspects of the program on a statewide basis. Credit No. 2133-IN Title Seventh (Second National Family Welfare Training and Systems Development) Population Project Year of A_Rroval 1990 PurDose s To support the family welfare program in the states of Punjab, Haryana, Gujarat and Bihar. Status Under implementation. Comments Focus on strengthening of training aspects of the program on a statewide basis. Title Family Welfare (Urban Slums) Project Pur2ose : To help the Government of India increase the supply of family welfare service in the slum populations of Andhra Pradesh, Karnataka, West Bengal and Delhi. Status : Approved by Board (June 18, 1992); Effective pending Comments : Focus on reduction of fertility and maternal and infant mortality rates among slum populations by improving the outreach of family welfare services, upgrading the quality of family welfare services through extensive and on-going personnel training, expanding the demand for health services through expanded information, education and communication activities and improving the administration and management of health care agencies.  - 35 - Section 2 Page 1 of 1 2. Proiect Timetable Identification Mission October 1982 Preparation Mission December, 1982 Appraisal Mission April, 1983 Credit Negotiations October 26, 1983 Board Approval December 13, 1983 Credit Signing February 8, 1984 Credit Effectiveness May 8, 1984 Credit Closing (original) March 31, 1990 Credit Closing (revised) March 31. 1992 Credit Closing (actual) March 31, 1992  - 36 - Section'3 Page 1 of 1 3. Credit Disbursement. - (US$ million) Actual as X IDA FY Quarter Ending SAR Estimate Actual of Estimate 1984 Sejptember 1983 0.00 0.00 0.00 December 1983 0.00 0.00 0.00 March 1984 0.00 0.00 0.00 June 1984 0.50 0.00 0.00 1985 September 1984 1.00 O.CO 0.00 December 1984 2.00 0.09 4.5P March 1985 3.50 0.09 2-- / June 1985 5.00 0.93 18.60 1986 September 1985 6.75 2.64 39.11 December 1985 8.75 3.76 42.97 March 1986 11.00 11.51 104.64 June 1986 13.75 13.30 96.76 1987 September 1986 16.50 13.30 80.61 December 1986 20.00 16.62 83.10 March 1987 23.75 18.30 77.05 June 1987 27.50 22.30 81.09 1988 September 1987 31.50 24.83 78.83 December 1987 36.00 24.83 68.97 March 1988 41.00 27.99 68.27 June 1988 46.00 30.14 65.52 1989 September 1988 51.00 30.14 59.10 December 1988 56.00 32.74 58.46 March 1989 60.00 34.48 57.47 June 1989 64.00 35.78 55.91 1990 September 1989 67.00 35.78 53.40 December 1989 69.00 38.20 55.36 March 1990 70.00 54.63 78.04 June 1990 70.00 76.51 109.30 1991 September 1990 70.00 78.35 111.93 December 1990 70.00 79.29 113.27 March 1991 70.00 80.78 115.40 June 1991 70.00 82.14 117.34 1992 September 1991 70.00 82.14 117.34 December 1991 70.00 82.14 117.34 March 1992 70.00 82.14 117.34 June 1992 70.00 82.14 117.34 1993 So',tember 1992 70.00 83.22 118.89 Note: Following the Credit Closing Date the standard grace period of 4 months for submission of final disbursement applications was allowed.  - 37 - Section 4 Page 1 of 8 4. Prolect ImDlementation Civil Works Appraisal Actual Targets Achievsemets ANM SC 642 642 LHV Qtrs 161 161 M.0. Qtrs 308 308 Modified M.0. Qtrs 18 18 Class-III Qtrs 498 498 Class-IV Qtrs 280 280 SHC 236 236 FEC 83 83 CHC 28 28 Cold Room 2 2 ANM Hostel 6 6 KHFWTC Qtrs 2 2 RHFWTC Qtrs (Gulbarga) 1 1 Dormitory 17 17 Vehicle Workshop 2 2 Equipment Workshop 2 2 subtotal: 2.286 2.286 Karnataka Land Army Corp. ANN SC 61 56 M.0. Qtrs 45 43 CHC 3 Class III Qtrs 33 27 SHC 19 19 Subtotal: 161 145 Ksrnataka State Construction CorD. Hostel I I Additional Floor I 1 Subtotal: . 2 2=Z Total 2.449 2,433 Abbreviations: CHC - Community Health Centre PHC - Primary Health Centre SC - Subcentre SHC - Subsidiary Health Center MPWFTC - Multi Purpose Worker Female Training Centre Note: All facilities supplied/to be supplied with furniture and equipment as specified.  - 38- Section 4 Page 2 of 8 Ia-Service Training Training Program Nos. Trained Management Training for Medical Officers 458 in 22 batches Functional Training in Communication for Deputy Health Education Officers & BEEs 205 in 9 batches Behavioral Training in Communication for Block Health Educators 133 in 5 batches Continuing Education (5 days) for supervisors of P#Cs 737 S. e Training of Key Personnel Communication Workshop 19 Refresher Course to Key Personnel 16 Training for Trainers' of Training Institutes in Teaching Methodology 121 in 5 batches Notes No specific targets for numbers of staff to receive in-service training were set.  - 39 - Section 4 Page 3 of 8 XIC Bquipment/Activitiee Particulars/Activities Targets Achievemets Reuarks State Level Equipment 5 22 Procurement of small equipment such as projectors, tape recorders, etc., overshot target levels. Divisional Level Equipment 27 29 Two deluxe over-head projectors were bought beyond targets. District Level Equipment 18 18 Sub-Divisional Equipment 90 90 PHC/SHC Level Equipment 1,090 1,090 Other Audio-Visual Aids & Equip. 36,935 36,935 Production of films/slides /models 3,766 6,617 Orientation Training Camps 6,496 6,024 Innovative Schemes 1,340 1,340 Intensive Campaign on Spacing Methods 6 districts Mushaira Program in Gulbarga & Bidar 2 districts Area specific strategy 2 villages in each PHC Publication of News bulletins in Bidar 10 issues IEC Workshops 10 8 workshops Involvement of Voluntary Organizations 500 500 members  - 40 - Section 4 Page 4 of 8 Studie. Title of Study Date Skill Gaps Survey 1984 Baseline Survey 1986 The Block Health Educator (BHE) Role Prescribed, Perceived and Played 1987 The Health Scheme in Belgaum and Gulbarga Districts: An Evaluation 1987 Programme and Community Factors Affecting Family Welfare Programme in the Gulbarga District 1988 Health and Family Welfare