China - Rural Health and Medical Education Project

Dowmnen of The World Bank FOR OFICIAL USE ONLY Rqeort No. 12046 PROJECT COMPLETION REPORT CHIN RURAL HEALTH AND MDICAL EDUCATION PROJECT (CREDIT 1472-CIA) JUNE 22, 1993 MICROFICHE COPY Report No. :12046 CHA Type: (PCR) Title: RURAL HEALTH AND MEDICAL EDUCA Auzhor: pIKER, RONALD Ext. :31757 Rooo:T 9017 Dept. :OEDDI Environment, Humna Resources and Urban Development Operations Division Country Department II East Asia and Pacific Regional Office This document bas a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authoriation.  CURRENCY EQUIVALENT Currency - Renminbi (RMB) Currency Unit - Yuan (Y) Yl.0O - 100 fen At Appraisal: At Credit Closina: US$1.00 - Y 2.0 US$1.00 - Y 5.42 US$1.00 - SDR 1.06 US$1.00 - SDR 1.43 ABBREVIATIONS CNTIC - Chinese National Technical Import Corporation MCH - Maternal and Child Health MOPE - Ministry of Public Health UNICEF - United Nations Children's Fund WHO - World Health Organization FISCAL YEAR January 1 - December 31  FOR OFFICIAL USE ONLY THE WORLD BJANK Washington D.C. 0 U.SA Om" of OlOor4onerl OpMalons Ev-alu an June 22, 1993 *=!EMORA-NDUM TO. 1 EXD DIECrIORS ANDPEiDN SUBJECT: Project Completion Report on China Rural Health and Medical Educaion Project (Credit 1472CHA1 Attached is the Project Completion Report on China - Rural Health and Medical Education Project (Credit 1472-CHA) prepared by the East Asia and Pacific Regional Office. Part II was prepared by the Borrower. Tne project objecdves were to strengthen the national health planning capability, reform higher medical education, and moderize rural health services. To accomplish these objective the project supported development of 3 national health research isttutes, upgadng of facilities and teaching at 13 medical universities, and modernization of management, health facilities, technoogy, taining, and prevention progrms in 46 rural counties. Apart from underestimates of the time that implementation would take and of the recrent costs required to support the new technologies, implementation was highly satsftoy and substantial institutional development occurred. The objectives were achieved and appear to be sustainablh As this was the Bank's first loan for health in China, an audit is planned. Attachment This documt has a resrtd drbuion and may be used by rcipiets onty In the pefform of dRebJolfiW duis Its cnts may not otew be dslosed wioU World Bank authua  FOR OMCIAL USE ONLY RURAL HEALTH AID MEDICAL EDUCATION PROJECT (Credit 1472-CIA) PROJECT COMPLETION REPORT TABLE OF COUTENTS tate No. Preface ...... . , .......... l Evaluation Sumary .....,............................... ii PART I. PROJECT REVIEW nROM IDA'S PERSPECTIVE 1. Project Identity .................*.......*............ 1 2. Project Background 1 3. 'roject Objectives and Description 3 4. Project Design and Organization ................*....... 3 5* Project Implementation .... .....o.....*....*.*....... 4 6. Project Results .......s.............*........... 7 7. Project Sustainability and Replicability................ 8 S. Association Performance..r o n m a n ce...................... 9 9. Eorrower Performance .......o.. *.*..oo*. 10 10. Project Relationships ...................... oo.............. 10 11. Consulting Services ....o..*.....*........ 0...00.....0.. 10 12. Project Documentation and Data .........o.............o. 10 PART II. PROJECT REVIEW FROM BORROWER'S PERSPECTIVE 1. Comments on Part I ........................o........... 11 2. Evaluation of IDA's Performance ......,.........,...... 12 3. Evaluation of Borrower's Performance 13 4. Project Relationship ........... 14 5. Evaluation of Co-Financiers' Performance 14 6. Comments on Part III Tables ....15 PART III. STATISTICAL INFORMATION TABLES 1. Related Bank Loans and IDA Credits 16 2. Project Timetables ...... 16 3. Credit Disbursements ... 17 4a. Project mplementation in the Provinces 18 4b. Project Implementation - Universities 19 S. Project Costs and Financing ........................ 20 6. Project Results .....21 7. Status of Covenmants ........... .................... 22 8. Bank Group Staff Input ... ..............000 22 9. Bank Group Missions .............................. 23 This document has a rsticted distdbuton and may be used by rcipients only in the peormnume of their official duties Its contents may not otherwi be disclosed without Wodd Bak authorization.  CHINA RAL HAJTH AND MEDICAL EDUCATION PROJECT (Credit 1472-CIA) PROJECT COOPLETIOR REPORT PREAC$ This is the Project Completion Report for the Rural Health and Medical Education Project in China, for which Credit 1472-CIA in the amount of 8DR 80.2 million (US$85 million equivalent) approved on May 8, 1984. Appraisal took place in September 1983. The Credit closing date wvs December 31, 1991, two years behind schedule. The Credit fully disbureed and the last disbursement was on April 24, 1992. The ECR was jointly prepared by the Environment, Human Resources and Urban Developmsnt Operations Division, China and Mongolia Department of the East Asia and Pacific Region (Preface, Evaluation Summary, Parts I and III), =nd the Borrower (Part II). Preparation of this PCR was started during the Bank's final supervision missiou of the project in 1991, and is based, int2r alua, on the Staff Appraisal Report, Staff Case Studies and Technical Notes, the Development Credit and Project Agreemets, supervision reports, correspondence between the Association and the Borrower, and internal Bank Group memoranda.  - ii - RURAL KEALTn AND MKDICAL EDUCATION POJECT (Credit 1472-CBA) LVALUATIOI SUNNARX Proiect Obiectives 1. This was the first Bank Group-supported health project in China. The Project evolved from the Government's objectives to: strengthen tho national health planning capability; reform higher medical education; and modernize rural health services. The project supported: a) the development of three natio%aal health research institutions to assist in the first objective; b) upgrading of facilities and teaching at 13 leading medical universities to support the second; and c) the modernization of management, health facilities, medical technology, personnel training and preventive programs In 46 rural counties of Sichuan, Neilongjiang and Shandong Provinces and Ningsia But Autonomous Region as pilot areas in which to demonstrate practical policies for the third objective. IUwmmnieation Excerience 2. Implementation was efficient but somewhat slower than planned, particularly in the case of procurement. Utilization of foreign technical assistance by the universities presented some difficulty and rather hasty construction of rural hospital buildings affected the design and qualLty of some new facilities. The personnel training program In rural areas Lar exceeded the planned requirement. Equipment provided was generally suitable and well utilized by the universities, but rural Counties tended to over-estimate the level of sophistication necessary. All beneficiaries under-estimated the recurrent costs of supporting the new technology. 3. The project significantly Improved the planning and evaluation capabilities of the Ministry of Public Health (MOPS) by establishing the three national health planning and rosearch institutes. A good model for future rural public health services was developed which is in the process of review and replication throughout the nation. Medical education benefitted significantly from modernization of the 13 universities. S8-etaInALL11t 4. The project outcomes in terus of the planned modernization of China's health services and medical education are likely to be sustained. The new "One-third Counties Upgrading Program", Initiated by the Government, now has clearer protocols for health facility rebuilding, re- equipamet and personnel training. Initial reform of curricula and teaching metho4ologies for higher medical education has been accomplished and educational research goals and review mechanisms established.  - iii. PindinAs and Le_saoas Learned 5. The project provided the following valuable lessons to China for future health projects and to IDA for similar efforts in China and elsewhere. a) Large-scale overseas professional training and technical assistance components yield best returns and become most cost-effective only when the placement of the trainees and the follow-up activities are planed properly. b) It is important to ansure that competent hospital architectural services are available to plan technical building proposals for satisfactory functioning, durability and ease of maintenance. e) The establishment of well-organized and staffed project management offices at all operational levels made a very significant contribution to the smooth implementation of the project. Projects should always include necessary personnel training and equipment for these offices, including, vhere necessary, foreign tralinig and technical assistance. d) In the case of new and innovative project components, clear guideline, should be developed to enable proper planning of the component. In this project, counties and universities experienced difficulties in developing strategies for chronic disease prevention on their own. e) Sophisticated items of equipment should be acquired after careful reviews not only of their need but also of the availability of future recurrent expenditure, spare parts, availability of properly trained operators, and the system for monitorin, their use and maintenance. f) China urgently needs to establish a national office of medical technology assessment. g) The Project in this now sector would have benefitted froa the provision of greater assistance to develop the Borrower's procurement skills. h) The gains made in improvements and management of the universities must now be followed by advancements in financial planning and budgeting as teaching costs would inevitably rise due to the demands generated by the reforms.  CHINA RURAL HEALTH AMD MEDICAL EDUCATION PROJECT (Credit 1472-CHA) PROJECT COMPLETION REPORT PART I: PROJECT REVIEW FROM IDA'S PERSPECTIVE 1. Proiect Identity Project Name: Rural Health and Medical Education Credit number: 1472 CHA RVP unit: East Aunia and Pacific Region Country: Chins Sector: Health 2. Proiect Beekaround 2.1 In three decades since its inception in 1949, the People's Republic of China had improved the health status of its population to levels wvll beyond those of most developing countries, doubling the average expectation of life from its previous low level of 34 years. However, a substantial proportion of the poorer rural population (roughly 201) failed to benefit from the general improvement. By the early 1980'., large investments were needed to modernize the mostly outdated rural health facilities and to alleviate a severe shortage of adequately trained health manpower. This was largely the result of ten years of isolation from world progress in medieal elucation after the Cultural Revolution, which left medical colleges in substantisal need of educational reform. Furthermore, a shortage of village health workers was an unintended result of the introduction of the responsibility system in agriculture in 1980, when many village 'barefoot doctors' gave up health work to parsue more profitable farming or other small scale rural enterprises, leaving village clinics understaffed. In the meantime, the pattern of illness also changed to increased prevalence of chronic diseases due to changes in demography and lifestyle. This, in turn, czeated demands for more sophisticated health facilities, better trained health staff and effective preventive measures against newer leading causes of death. 2.2. In response, the Government declared high priorities to: a) rebuild the rural health care network; b) improve the quality of training of higher level health personnel; c) develop research institutions capable of elucidating the epidemiological transition facing the country; d) retrain village doctors to a three-year professional level; and e) improve Lealth management. 2.3. In the rural health area, in 1980, the Ministry of Public Health (MOPE)o in association with provincial and local governments, began to upgrade health care in the nation's 2,100 counties in three stages, each of 5-years duration. National and provincial governments jointly contributed about half of the capital needed while county governments, health bureaux and end-user institutions made up the remainder. Early results were  disappointing due to funding, planning and implementation weaknesses. Wealthy counties benefitted most while poorer ones, usually those with the worst facilities and least trained staff, could rarely approach the standards set by the Ministry. 2.4. For improvements in medical education, MOPE designated 13 leading medical universities, including two specialized in traditional Chinese medicine, as 'key' institutions to restore standards of scholarship and research after the Cultural Revolution and to speed up the flow of high level graduates into the health services. They were provided with modest increases in budget, and permitted to reinstate older professional staff displaced by the Cultural Revolution. The rights to send teachers overseas for training and to invite foreign visiting faculty were restored and undergraduate medical curricula were lengthened to a minimum of five years. These reforms required the colleges to recruit or train teaching faculty who would be aware of international progress in medical education and were able to develop aud introduce new curricula and teaching methods. Modern facility planning skills and large civil works outlays ware also needed to update or rebuild libraries, laboratories and teaching hospitals, many of which were in poor structural and functional condition. 2.5. The promotion of effective Chinese traditional medicine techniques as an integral component of the health services is a basic objective of Government health policy. There were few institutions in China capable of the necessary research to validate the therapeutic properties of the vast national store of medicinal herbs. Therefore, MOPE instituted modernization of a respected research institution, the Sichuan Institute of Chinese Materia Modica, which had relatively good research staff and access to large botanical gardens for experimental cultivation of medicinal plants. 29-6. Both the rural health and medical education initiatives were conceived as pilot activities to provide up-to-date planning and budgeting information to guide the modernization of the nation's entire health services. There were, however, no suitably staffed national institutions to provide timely and reliable research data to support public health plasing and evaluation needs. To remedy this problem the Ministry created a new Research Center for Health Statistics, in 1982, with a mandate to improve and coordinate the national health statistics systems. Similarly, although there were a number of national technical institutions responsible for advanced studies iii public health$, such as the Institutes of Epidemiology, Parasitic Disease, Virology and Industrial Hygione, their concerns were mainly with pure research, rather than with operational studies of the nation's emerging problems in public health, health management and the preventive medicine needs identified in a recent health sector study. This task needed close coordint .ion of the several institutes under a common managment and with a greatly strengthened capability in modern epidemiological methods, including those applicable to chronic disease prevention. Therefore, in 1983, the Ministry established a National Center for Preventive Medicine.  -3- 3. Prceect Ob1ective and Deacrintion 3.1. The main goal of the project was to support the high priority objectives of the Government, namelys to develop a cost effective strategy to upgrade the rural health services; to modernize medical education in the nation's most advanced medical college.l and to develop national institutions capable of providing the scientific, statistical and epidemiological bases needed to strengthen national health planning and disease surveillance. 3.2. The project consisted of the following three parts: Part A. A rural health component, about 302 of the total investment, in 46 selected counties of three provinces and one autonomous region, serving over 30 million people. The project included financing for the rehabilitation and upgrading of the health facilities, provision of essential equipment, personnel training, technical assistance, and a small amount of incremental staff recruitment and training costs. It also included inputs to strengthen management capabilities of the four Provincial and 46 County Health Bureauz. Part B. A medical education component, about 60% of the investment, covering 13 key medical universities. The project financed necessary construction and equipment, faculty training, technical assistance for modernizing teaching, research, and developments of cont- Auing education. Part C. Strengthening of national management capability, about 102 of the investment, in: a) the National Center for Preventive Medicine (later the Chinese Academy of Preventive Medicine) to undertake research, coordinated national disease surveillance, advanced training and public health information services; b) the Research Center for Health Statistics (later the Central Health Statistics Institute) to carry out health policy analyses, research, and data collection and processing for the MOPE; c) the Sichuan Institute of Chinese Materia Medica to undertake research on the efficacy, safety and modern production of therapeutically important traditional medicines; and d) the two MOPE bureaux responsible for management of rural health services and medical education as well as the Ministry's World Bank Loan Office (later the Foreign Loan Office). The project provided appropriate physical facilities, equipment, staff training and technical assistance. 4. Project Desian and Oranization 4.1. The project concept was based on the findings of the Bank's health sector work (China. The Health Soctor, April 1984), which was carried out by a mission that visited China in September/October 1982, and on the experience under UNICEF and WHO primary health care activities in the early 1980's. In line with the recoumendations of the sector report, the project was designed to meet both existing and projected health problems of the rural population, to begin reorganization of the training of health manpowet in China, and to assist in strengthening MOPE'. planning  -4- capability. This project was China's largest internationally assisted health project at the time, helping major reforms in the most influential medical universities as well as improving rural heal7;h care directly benefiting over 30 million people. 4.2. Timing of the project was fortunate, meeting the need to provide technical and financial data to guide the Goverrnment'e recently proposed plan to upgrade rural health services in "One-third Counties" upgrading scheme. It also provided timely assistance in the development of the 13 key medical universities, begun in 1977 but inhibited by lack of adequate funditg snd technical support. 4.3. There were three new features in the medical education component in the Chinese context. Firstly, it introduced new subjects into the curriculum, notably the social and behavioral sciences and chronic disease aspects of preventive medicine. Secondly, it piloted the introduction of modern learner-centered teaching methods in place of outdated didactic teaching. Thirdly, each university was required to assume an expanded role in further education by establishing national specialized centers in some of the newly introduced clinical and pedagogical disciplines. 4.4. A major design factor which was to contribute to successful implementation was the prompt establishment of project leading groups as well as the well-staffed World Bank Loan Office (later renamed the Foreign Loan Office) in MOPE, and similar offices in the provinces and the concerned institutions. An expert advisory group was set up to coordinate the activities of the medical universities and, in 1987, the first of several annual national conferences on the progress of the medical education project was held to review initial outcomes and to inform all higher medical universities in the country of the progross of curricular and methodology reforms. 5. Prolect Imniementation 5.1. Implementation of most project component. weut better than might have been expecteJ in view of their complexity, the wide dispersion of project units, the radical nature of the educational reforms and the weaknesses of rural health service management. However, the project was completed in seven years, two years behind the appraisal estimate. The main reasons for the delay were the time required to build necessary iustitutions, to gain experience with Bank Group procedures and to carry out additional activities mentioned in the next paragraph. Procurement under the project took longer than expected because of the delay In familiarizing the newly established MOPE Loan Office and the Chinese National Technical Import Corporation (CNTIC) responsible for importing the equipment under the Bank Group's procurement procedures. Due to inexperience, cumbersome methods were used in preparation of large tendering packages, evaluating bids, arranging contracts and opening letters of credit. End-users were frustrated by resulting delays In eelivery. Towards the end of the project, MOPE undertook more frequent and smaller tendering to reduce the workload.  - 5 - 5.2. Midway through project aplementation, it was evident that the project required a careful review to take stock of the progress achieved and to identify additional steps needed to meet the original project objectives as well as to address a few emerging priorities. There were also unused credit funds due to difficulties in utilizing allocations for techni_.i. assistance (Gee next paragraph) as vell as due to appreciation of the SDR vis-a-vis the US dollar. Therefore, in mid-1989, the credit was reallocated through some reductions in technical assistance and inereased funding for equipment, program support, and for disease surveillance and prevention, including activities related to chronic diseases. 5.3. The government was able to utilize foreign technical assistance provided under the project less effectively than was previously anticipated. This was mainly due to the inexperience of the government departments in p-oviding adequate guidance to the end-users in the selection and briefing of appropriate experts, insufficient planning and preparation of in-country activities to yield maximum benefits to all parties, and lack of overseae follow-up. MOPE has now taken serious Interest in strengthening its capacity to utilize external technical assistanee. 5.4. In the rural health component, the upgrading of equipment, capital construction and training goals surpressed expectations as the local governments provided up to 502 more counterpart funds than planned. As indicated in Table 6 (Part III), there have been significant improvements in health indicators. Referrals from lower levels to the county hospitals decreased to about 502 in Shandong and Sichuan and to about one-third in Ueilongjiang and Ningxia. Bed occupancy and average length of patient stay in hospitals were both positive. A total of about 85,000 bealth workers were trained in the project areas as compared to the target of about 41,000 workers; the proportion of 3-year trained village doctors rose by 302 to 502; the numbers and capabilities of higher level clinicians and laboratory workers increased dramatnically. Both infant and maternal mortality indicators showed pronounced improvements; and the prevalence of common infectious diseases recorded substantial decline. There were also substantial management gains, including improved and better utilized health information networks, disease surveillance, program planning and equipment management. All project provinces and counties established equipment maintenance centers. 5.5. There were some problems in the rural component, however. Most counties tended to give priority to strengthening the higher level curative services to the detriment of primary care and prevention. Sometimes, new services and clinical or laboratory procedures were developed that were Inappropriate to the role of county level institutions. Construction of now rural hospitals was frequently undertaken too soon after the project began and, in some cases, both the appropriateness of design and the quality of construction were suboptimal to the demands of modern medical and nursing practice. Rospital buildinge were often more difficult and expensive to maintain because of poor quality construction. Most counties overestimated the level of sophistication of equipment needed and sometimes rejected quite satisfactory Chinese-made items in favor of more costly  - 6 - imports without due regard to the utilization rates, long-tenrm recurrent costs and likely benefits of the equipment. There was also a tendency to make a profit by over-using new procedures and equipment to generate revenue for the institutions, regardless of clinical need. After a review of equipment utilization by the MOPE in 1987, the equipment plan for rural counties was revised to counteract these trends and there vas a considerable improvement during the later years. 5.6. The medical education component sharply increased both the numbere and the proportion of trained faculty, as more than 1,000 teachers benefitted from overseas training. In-country selection and preparation of candidates for overseas training, including language and computer literacy, were generally performed well. A few problems arose from the failure to plan the location and duration of overseas training posts adequately, and from the distribution of fellowships pro-rata to departments rather than according to institution-wide needs. On the whole, the overseas training experience was highly beneficial. A small percentage of teachers has so far failed to return to China after training, most having obtained temporary or permanent positions in the host countries. Nevertheless, in many cases, they continue to provide useful linkages between their Chinese institutions and host colleges. Foreign technical assistance was neither fully implemented nor utilized as well as possible by most of the 13 universities. 5.7. Overall, student-centered learning was given a much higher profile with more uncommitted study time available for the students, supplemented by better access to improved library resources, modern audiovisual teaching aids, computers, well equipped laboratories, and foreign language training. Practical clinical training was improved by partial decentralization from tertiary teaching hospitals to include field experienc, in small hospitals and clinics at new community teaching bases, which enabled the students to mdertake epidemiological studies of common problems and brought them into closer socio-medical contact with the rural people and their health problems. Enrichment of continuing medical education was a particularly effective subcomponent, with more than 70,000 in-service students enrolled in various types of general and specialist courses. Stomatology, an area of manpower shortage prior to the project and a weak area all over China, was considerably expanded by many colleges. 5,8. The Chinese Academy of Preventive Medicine (CAPS) implemented the project smoothly. By 1987, it had established a computerized disease surveillance system for the whole country, routinely collecting data from 71 surveillance points in 29 provinces. The program was, however, shown to under-represent the poorer rural areas and in 1989, 145 randomly selected surveillance points were added, leading to more accurate and timely data on infectious diseases. More recently, work has begun to add some major non- communicable diseases to the network. The Academy has carried out much major research; examples include the study of the national prevalence of hepatitis B; national smoking-related mortality and costs; occupatiomal disease patterns in rural enterprisesl and the early diagnosis of naso- pharyngeal cancer. It collaborated with Cornell and Oxford Universities in one of the largest studies of risk factors for chronic disease ever  - 7 - undertaken and with WHO and UNICEF in studying nutrition in rural children. These studies have contributed important data for health policy analysis. CAPM has also developed rapid and cheap laboratory methods for diagnosis of the common viral diseases and has become the nation's leading producer of hepatitis B vaccine. The academy has implemented a large program of technical assistance to the provincee, including professional training in epidemiology, direct consultations, and support for field research and program development. 5.9. When the project began, China had no unified nationwide health statistics reporting system and no regular tabulations of data on health manpower, facilities, workloads, economics or effectiveness of public health programs. The National Center for Health Statistics lacked trained staff and equipment to achieve its objectives. In 1985, external technical assistance helped to plan and organize the unit, establish links with leading foreign institutions, develop a staff training plan and identify necessary computer and other equipment needed. During the project period, the number of professional staff reached 30, two thirds of whom received substantial training overseas. The Center has developed into a training institution since 1987. In addition, several universities introduced training for specialists in health statistics and computer science, thereby providing about 130 graduates to staff the national and provincial institutions involved in the processing of health statistics. A large and well housed computer system with database library, survey analysis capability, signal/image processing and nationwide networking was provided, together with appropriate commercial software. The center is now producing software for specific national statistical needs and for the operational needs of the line departments of the Ministry. Production of computerized national health statistics has been implemented in phases, initially, in 1986, using floppy disks mailed by provinces to the Center. By 1989, several provinces were able to transfer data electronically and the basic in-house Ministry network has now been completed. 5.10. Under the project, the Sichuan Institute of Materia Medica received overseas training for ten executive staff, external technical assistance, in-country training for 60 supporting research personnel, re- equipping with modern analytical facilities, revision of research methodology, clinical trials, and new building. (from counterpart funding) for a library and several laboratories. The library has developed an impressive collection of Chinese and foreign texts and journals and at the same time initiated English language training for many of the staff of 400 technical personnel. Eight significant research projects were initially developed and five were successfully concluded. Many other studies have since commenced on the therapeutic efficacy of frequently proscribed and empirically effective herbs. The Institute has developed an extensive training program in modern analytical and clinical pharmacological methods for research workers of other Chinese traditional medicine institutes. It has also become the main reference center for native plant studies in China with extensive international connections.  6. Project Results 6.1. The project was very vauccessful in achieving practically all of its basic objectives. As stated above, the original project targets were exceeded in many key areas, including the construction of hospitals, provisior of essential equipment and materials, the training of rural doctors as well as the improvements in higher medical education. There was remarkable progress in the building of important national health institutions. The mapower study was completed in two provinces in 1988 and that provided valuable planning information. Improved management method., in the context of project preparation and implementation, benefitted considerably the MOPE, provinces and counties. Notable improvements in the approaches to equipment requests and the planning of hospital facilities were evident in the later parts of the project. Many long- term agreements have been concluded between the major Chinese colleges and institutes included in the project and leading overseas centers. Major reforms were achieved in the key medical universities whose effects and academic exchanges have favorably influenced the curricula and teaching methods of other non-project medical colleges in China. The number of higher academic posts increased in all colleges. 6.2. Protect Imiact. The training of village doctorss the provision of equipment, and the improvements in management practices introduced under the project have significantly improved the quality and utilization of the health services in all project countieso. Most rural hospitals have reported lower average lengths of stay for patients and a rise in the proportion of outpatient attendance. The availability of more adequate tranaport greatly strengthened field supervision and enabled more rapid life-saving emergency services to be provided for maternal, neonatal and other cases of acute illness. Utilization rates of lower level services have risen with a reduction in referral rates for higher level care. At provincial level, the quality of planning and supervision of rural health programs has improved as a result of the management training, and its impact bas extended beyond the project counties and benefitted rural areas province-wide. The MOPE has reported that the response of the project provinces to the "one-third counties upgrading program" has been far better than that in non-project provinces, in terms of increased local interest and funding, better disease surveillance, efficiency in immnization and NCM activities and the prevention of chronic diseases. However, two issues have been identified for further attentiou by most counties: the improvement in the training of epidemic prevention station (BPS) staff and the strengthening of the county level management awareness of EPS and MCE staff in modern health edLucation theory and practices. 6.3. Medical technology policy in China has benefitted greatly from analysis of cost-benefit relationships and of recurrent costs as they relate to the provision of advanced medical equipment under the project. However, despite the existence of stricter guidelines for requests by end users, China still lacks a national office of medical technology assessment. This is a serious weakness which is retarding improvements in the quality of care and cost containment efforts.  9 - 7. Project Sustainabilitv and Renlicabilitv 7.1. There is little doubt th&t all project beneficiaries will have both the interest and ability to sustain the reforms introduced under the project. However, it is also clear that the rural health service units as well as the medical universities will have to do a better job of eatimating and providing the necessary recurrent costs for expendables, spare parts and maintenance in the future if the modern equipment and procedures introduced under the project are to be continuously and effectively used. Provision for amortization and equipment replacement must also be made from the revenues accruing from its use, but care should be exercised by the county health bureaus to prevent over-use of tests and procedures solely to raise income and without clear clinical benefit. Regular maintenance of the n.iv and renovated hospitals will be essential if they are to remain in good functional and hygienic condition; this implies the need for proper maintenance and for economic use of expendables. 7.2. Educational reforms in the 13 universities have progressed to the point where reversal to outdated didactic teaching is most unlikely to occur. But the reforms are not yet complete. The new emphasis on student self-learning requires that libraries be fully developed as learning resource centers. Future training of faculty will need to ensure that the attitudes and skills of younger staff are consistent with the new teaching theory and practice. There is some risk that the teaching of strategies for preventing diseases, including long-term care and rehabilitation, may decline in importance after the project has ended. This can be avoided if preventive medicine is emphasized In teaching by all the clinical disciplines, not only by departments of public health, and if sufficient progrcm cupport funds are made available to mautnin thz reutl -' community based experience for senior medical students. The subjects of mental health, geriatrics and child development still require further development by most of the colleges. The MOPH should consider the establishment of more National Centers at selected colleges to encourage research and enrichment of teaching in preventive and social medicine. 7.3. Improved financial management by the colleges, and possibly a change to global budgeting of colleges by the MOPE, will be necessary as the colleges absorb the full burden of operational costs. The rural counties may need to divert a proportion of their diagnostic and treatment revenues to support the important but non-revenue operating costs for the preventive program. 7.4. Replicability of many of the project inputs and methodology to the nation's rural health and higher medical education systems is fessible and the process has actrially begun in rural health as well as in medical education. MOPE should anlyse the costs and benefits of various components in collaboration with specialist line bureaus to identify critically important follow up actions, such ass a) review of the cost- effective aspects of the project that could modernize teaching in the provincial medical culleges; b) establishment of a national center for medical technology assessment; and c) strengthening of Foreign Loan Offices in the provinces to reinforce the improvements in rural health.  - 10 - 8. Association Performance 8.1. This project was the IDA's first experience working with the Chinese MOPH and it was an intensive learning exercise, for both parties, in identifying the components that matched the modernization objectives of the Government and that were also potentially replicable to the rest of the nation. The strength of thc Bank Group's contribution lay in thorough preparation by a large team of Bank Group staff and expert consultants, supplemented by inputs of WHO and UNICEF. The 1982 health sector study clarified the dynamics of China's health system and its changing health needs. This information was supplemented by case studies in each project province and some medical universities. The IDA assisted the MOPH to establish efficient loan management departments for the project. These efforts were effective in ensuring an efficient administration for all future health projects. 8e2. The Association's missions provided important technical know- how. There were eight supervision missions with experts in many disciplines, such as computer science, technology assessment, institutional development, audio-visual production, hospital design, technical assistance management and equipment maintenance. 9. Borrower Performance 9.1. The Borrower's performance was excellent, especially because of well-organized and staffed loan management offices at the center as well as at local levels. Lack of familiarity with the Bank Group's management, financial, procurement and supervision requirements posed some problems in the beginning, but these were soon overcome as staff were trained. During the life of the project, the MOPE has adopted many of the lessons learned on project preparation, data presentation, reporting, facility design, equipment selection and procurement and project management in its regular practice. 10. Project Relationshins 10.1. Relationships between the Bank, the MOPE, provincial governments, health bureaus and health institutions were cordial. Throughout the project, the effectiveness of post-mission meetings with the provincial authorities, the Minister or Vice Minister of Public Health, supported by appropriate line bureau staff, and UN agencies was noteworthy. 11. Consulting Services 11.1. The project depended heavily on the technical assistance provided by more than 200 foreign and many local experts. Some disciplines were new or poorly developed in China, e.g., health management and economics, clinical epidemiology, social medicine, medical psychology and health education.  - 11 - 12. Prolect Documentation and Data 12.1. Several background working papers were prepared by IDA staff on the health status and services of the four provinces. The Staff Appraisal Report provided satisfactory guidance for project Implementation. The Development Credit Agreement was amended, in mid-1989, to reallocate the unspent credit balance from the technical assistance component and savings generated by SDR appreciation to cover unforeseen local costs of some rural counties, to add additional training for one province and to postpone the Closing Date for two years. 13. Pro1ect Monitorina 13.1. MOPE carried out the overall coordination of the project activities through its Foreign Loan Office (FLO), which is the successor of the World Bank Loan Office established in connection with this project. Although PLO initially suffered from the unfamiliarity of the Bank procedures, it gradually developed into a very efficient department of MOPE and was effective in monitoring the project's progress and coordinating different components of the project. Similarly, Loan Offices were also established in each of the other implementation units, like the universities and the provincial and county-level health agencies responsible for the implementation of different components of the project.  - 12 - PART IIs PROJECT REVIEW FROM THE BORROWER'S PERSPECTITVE ------------------------------------------------------ 1. Comments on Part I 1.1 In PART I of the World Bank Project Completion Report, a brief introduction was given to the background of the project, its objectives, isplementation plan, components, and goals expected to attain through the Implementation of activities under each respective component. It has analyzed the implementation process, the achievements and experiences, the existing problems, and the tendencies of a general nature as observed in its implementation. In the Borrower's view, this is a good, comprehensive summary of the project. 1.2 The evaluation in PART I of the Project Completion Report has mirrored, in the main, the actual reality including the level of sophistication and utilization of equipment. In fact, the situation of over-sophistication and under-utilization of equipment did exist in the initial stage of project activities performed in certain county epidemic prevention stations (EPS). Professional staff at county EPSs in all project provinces wers found unfamiliar with, and incapable of, handling these certain advanced monitoring and surveillance equipment. Therefore, the health bureaux of project provinces sponsored training courses with the hope to help them understand, in a shortest possible time, the way of its operation. The under-utilization of some equipment has thus been overcome leading to the attainment of the goals established for the project and to the fulfillment of the surveillance taske assigned to them by the project. But due to the lack of experiences, a few project provinces (i.e. Ningxia) got som more advanced and sophisticated equipment which were not suitable for the EPSs. The provinces corrected this by assigning those equipment to the higher level institutions and providing the county EPSs with more suitable ones. 1.3 Compared to BPS, the problems of over-sophistication and under-utilization of equipment were not so terrible at hospitals, both at county- and township-levels. It has been found that the advanced equipment, as purchased, have enabled them to improve and strengthen the quality of their diagnostic and therapeutic services. Actually, through the strengthening and improvement of equipment, the hospitals both at county- and township-levels enhanced their capability in providing qualified services, hence, reduced the rate of referral. 1*4 The Bank report ha. stated that the input from the counterpart funds to capital construction surpassed the original planed figures. It indicated that government at various levels were determined firmly to remedy the lack of health service facilities caused by the past "Great Cultural Revolution" by increasing financial input from the counterpart funds on one handg and on the other, it indicated the inappropriateness of  - 13 - plan. Since the project preparation had not paid attention to the entire plan, the Government had to increase the counterpart fund for construction during the project implementation. The rising cost was another major factor causing increase in counterpart funds. 1.5 The irrational designing and .1.nadequate quality in hospital construction, as seen in the project implementation, have aroused the attention of the Ministry of Public Health, and governments of the project provincee, vho have respectively set up specific institutions to cope with it and adopted measures for a remedy. For instance, the Department of Planning and Finance under the Ministry of Public Health has set up an office specifically for the study of hospital construction design. The office is to take up the overall responsibility for the examination and verification of the conceptual design and blueprints of hospital construction with the aims to standardize the hospital design and construction, to ensure the functioning of hospital facilities to meet medical services' needs, and to improve quality of construction. Corresponding institutions and mechanism have been set up at all project provinces; and the system of examination and verification have been applied in the implementation on Health II and, even more effecti-elys, in Health III projects'. 1.6 Certain challenges and difficulties in organization and finance vere encountered in the carrying out of chronic disease prevention and control at the county level, but these are problem. over the whole nation. The Ministry of Public Health has become aware of it and has taken lead in the carrying out of control activities of the four target diseases in large municipalities such as Beijing and Tianjin where conditions are ripe as pilots. 1.7 At the initial stage of the project implementation, there was an issue of inadequate project operation and recurrent costs. This reflected the general tendency of putting more emphasis, when planning and financing health services, on one-time investment, including the physical facilities, but less attention on program activities and their operation and recurrent costs. The project provinces tried with every effort to re-adjust their plan and to find remedies. And, the Chinese Government and the World Bank decided, after discussion, to establish a disbursement category of "program support" to partly solve the issue of lack of operation and recurrent costs, and the shortage of these costs was overcome. Thesestablishment of "program support" has played a supportive role in the implementation of the project at the later stage. It is particularly crucial to the successful completion of a number of sub-items of research arising in the course of the project implementation; and the Program Support is of help to construction of community training bases for medical universities. 1. Health I means the Rural Health and Medical Education Project (Cr. 1472-CM), the subject of this PCR9 Health II means the Rural Health and Preventive Medicine Project (Ln 2723/Cr. 1713-CMA, of January 1987)9 and Health III means the Integrated Regional Health Development Project (Cr. 2009-CMA, of September 1989).  - 14 - However, its optimal solution depends .An certain changes and re-adjustents of policy at the national level. 2. Evaluation of IDA's Performance 2.1 Health I project was the first project with foreign loans implemented through the cooperation of the World Bank sad the Ministry of Public Health of China. The Bank officials have contributed fruitfully to the project in its course of preparation and evaluation as well as in the aspects of giving guidance and supervision in its implementation. 2.2 Most of the Bank officialo and the consultants invited for the project were most competent, and many of them were familiar with the conditions of the China. Their instruction and guidance have greatly inspired the project managerial staff of this side. 2.3 During their stay in China, officials on the Bank missious have manifested themselves with a rigorous scientific working style, and with an experienced and managerial skill. Their admirable performance is an inseparable constituent part to the success of the project. 2.4 In the first three years since the implementation of the project, five missions were despatched by the World Bank for investigation and supervision, and more than three missions for supervision were sent in the following years. The missions had an important role to play in the supervision of the project implementation, particularly so for departments concerned that are responsible for the implementation of project with foreign loans for the first time. We hope the Bank would continue the effort of making such supervision. 3*. Evaluation of Borrower's Own Performance 3.1 The Health I project is the first project undertaken by MOPE with large smount of loans from external sources. The project covers the sensitive issues in areas of rural health development, medical education reforms, and the raising of capability at the central level in managerial activities and policy studies. However, project managerial staff at all levels of this country are inadequate in their experience and are unfamiliar with the managerial procedures. As a remedy, foreign loan offices were set up and properly staffed respectively under MOPE and under each of the project provinces and counties. 3.2 In order to play its role to the maximum, the Foreign Loan Office of MOPE serves as a department directly under the Ministry and has due authority in the management and supervision of project activities performed by project provinces. While paying attention to the development of hardware facilities, it stressed much on activities relating to technical assistance and manpower development. It is through the visits of consultants and training of its working staff that the managerial capability of the Office has emoothly undertaken the increased workload arising from new health projects, including Health II, III, the Infectious  - 15 - and Endemic Disease Control Project (Cr. 2317-CdA of December 1991) and others under preparation, with a few additional new recruits. 3.3 Another causative factor of the smooth !mplementation of the project was the proper handling of working relationship in all departments concerned. They include the departments of MOPE and other ministries, commissions at the central level, the State Planning Commission, the Ministry of Finance, and the Ministry of Foreign Economic Relations and Trade. In health sector, the concerned departments weret the Foreign Loan Office of MOPE and other departments under the Ministry, including the Department of Medical Education, the Department of Medical Administration, and the Department of Planning and inance; and the governments and health bureaux of project provinces. The project objectives were unlikely to attain without the cooperation and support of all departments listed above. It was, therefore, the coordination role played by the MOPE and its Foreign Loan Office that facilitated the coordinated efforts of all departments and thus ensured the success of the project. 3.4 Foreign loan offices at the provincial level have played a prominent role in the implementation of project mainly in the management, supervision and giving guidance to activities performed by the foreign loan offices at the county-level. They have been proved competent not only in their managerial capability over the project counties, but also in their guidance to the routine health activities of non-project counties of the province, particularly in their dissemination of the modern managerial procedure as learnt from the World Bank. Health services as a whole in all counties of the provinces have been strengthened. Take the disease surveillance activities, for instance. With the establishment of the project with foreign loans, the provincial network of disease surveillance has taken shape and perfected. It helps to further improve the accuracy of data collected and further lower the drop-out rate. Thanks to the efforts and work performance of the foreign loan offices at the provincial level, health and other services of the project counties have become, in general, model and exemplary counties of the province. 4. Proiect Relationship 4.1 In the course of implementation of the project, there has been a good cooperative relationship between this side and the World Bank, and between MOPE and its affiliated Foreign Loan Office and the World Bank is particularly fruitful. There has been an attituds, of friendly cooperation and mutual support prevailing in the past seven years of project implemeatation between China and the World Bank 4.2 The World Bank has rendered important support and guidance relating to hard- and soft-ware facilities to the MOPE and its Foreign Loan Office by despatching its top-ranking consultants to this side. Errors and difficulties in implementation activities have been properly handled after reaching a consensus through consultation. In the course of implementation, both sides tried, with every efforts, to exchange views and opinions in order to attain common understanding and agreement for solution of issues.  - 16 - 4.3 The fruitful cooperation between this side and the World Bank has found its expression also in the close communication by the electronic mail between the two sides. The Foreign Loan Office of MOPS has maintained a very frequent contact with the World Bank, which ensures a prompt feedback to all information and proposals provided, and both sides are vell informed of the latest progress of the implementation activities of the project. 5. Evaluation of Co-financiers' Performance 5.1 This project received, from its preparation stage till its completion, valuable help and support from all departments concerned within the country and all international organizations from outside, a clear manifestation of their solicitude for the project. Of particularly worthy of memtion is the efforts extended by the World Health Organization (WHO) in the preparation stage of the -roject. WHO played an important promotional role in the establishment of the first health project in this country with loans from the World Bank. The Chinese side is deeply impressed with the efforts extended by all international organizations concerned towards this project. 5.2 Due contributions have been made towards this project by the State Planning Commission, the Ministry of Finance, the governments at provincial and county levels, and local health bureaux of project provinces and counties. The guidance and input of the State Planning Commission and Ministry of Finanue is a good manifestation of the importance attached to and supports toward the health services of the country, as well as the strong determination of the state for the realization of China's modernization. The active inputs (in terms of manpower, material and finance) of prov*icial and county goverments is a clear indication of their confidence in the success of the project. The endeavor of all staff of health bureaux and all professionals at the grassroots have been proved fruitful constituting a basic guarantee to the successful fulfillment of the project. 6. Comments on Part III Tables 6.1 It is confirmed that the factual information provided in Part III are adequate and accurate.  - 17 - Table 1 - Related Bank Logas and IDA Credits Loan/Credit Purpose Year of status Title Anuroval Rural Health Improve access and quality June All component & Preventive of rural health, immuniza- 1986 satisfactorily Medicine tion, drug quality and completed. Project chronic and communicable Vaccine plants diseases care. under construction. Integrated Introduce new apprvaches April Satisfactory Regional to health policylplnaning 1989 progress. Health Devel. of integrated health to Project improve health services. Infectious & Support national program December Implementation Endemic Dise- to control TB and schisto- 1991 started satief- ase Control somiasis and to stren;then actorily. Project related institutions. Table 2 - Prolect Timetable Item Date Planned Actual Date Identification December 1, 1982 Preparation June 1983 Appraisal September 1983 Negotiations March 1984 Board approval May 8, 1984 Credit Signing June 1, 1984 Credit Effectiveness September 4, 1984 August 29, 1984 Project Completion June 30, 1989 December 31, 1991 Credit Closing December 31, 1989 December 31, 1991  - 18 - TJAI&3t Cumulative Eetmated sad Actual Disbursements (US$ million) Cumulative Actal Actual Appraisal gstimated Actual Actual as 2 of as 2 of Bank FY Estimates Cumulative Disbursement Disbursement Cumulative Total 1985 lot -- -- 1.90 1e90 -- 22 2nd 15.5 15.5 4.61 6.51 422 72 1986 1st 15.5 31.0 18.84 25.35 822 262 2nd 13.0 44.0 15.26 40.61 922 422 1987 lot 13.0 57.0 7.46 48.07 842 502 2nd 9.5 66.5 8.62 56.69 852 592 1988 lot 9.5 76.0 3.66 60.35 792 622 2nd 3.0 79.0 13.67 74.02 942 772 1989 lot 3.0 82.0 1.32 75.34 922 78% 2nd 1.5 83.5 1.16 76.5 922 792 1990 let 1.5 85.0 1.33 77.83 92S 81X 2nd -- 85.0 4.49 82.32 972 852 1991 lot -- 85.0 3.49 85.81 1012 892 2nd -- 85.0 2.85 88.66 1042 922 1992 1st -- 85.0 5.85 94.51 1112 982 2nd -- 85.0 2.16 96.67a1 1142 1002 a/ The actual amount disbursed Increased in terms of US$ due to devaluation US$ vs. SDR durinS Implemetation. Sources MSI Disbursement Information  Table 4a. P lt bM an In Prowincas Shandong toIlonga Sichuan Nlngxla Ruml Co1aniIs Plafl Actual Remars Plannd Acual Remars Planned MaI ROmarks Planned ,Actual Remarcs Total consuctin (mi) 91400 164637 (1) 74.5 152494 190486 320087 37202 50455 HospkalbedfW000 1.01 1.18 1.46 1.66 1.18 1.26 (6) 1.10 1.18 EqulpmentproWded(US$10Q 7900 08 (2) 7000 7768 10605 11792. 3219 3821.00 Told count lecWfprsJO000 1.41 1.55 1.77 2.12 1.49 1.70 1.78 Chief & atending pysninO0O 00004 0.021 0.0034 0.022 0.29 0.32 Vilagedoctoru'1000 1.54 1.61 0.7 0.84 1.29 0.9 0.97 VUL s. &Jun.med. tralned % 15 47 3906 10874 (5) sO 72.01 80 81.13 Tolal tech. persons tmd 7008 19414 (3) 8578 20771 (5) 13399 23579 966 1896 _ _ _ _ _ _ _ _ _ _ _ _ _ (4 5 81 ) ( 9 7 84 ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1. The numbw of 91400 m Is composed of 290 m contrucd for the province evel 2. The diference between Planned and Actual Is caused by the exchange rate. 3. In this Une, the mmber of village doctors trained Is Included. 4. In this ene, the number of village doctors trained Is not Included. 5. Person times 6. Hosptal bedsIlO00 of 1.18 under the column ot Planned" In Slchuan Is thenumber In 1984.  - 20 - TABLES A. PROJI COSTS (US D1?LLARS 1.000) Appraisal EsUmate Actual Local Foreign Local Foregn Cos Costs Construction 140.986 248,408 Equlpmnt, Vehices 497,769 65,436 100,539 74,412 Tralning 10,168 9,221 5,824 9.054 Tech, assistance 1,999 6,974 1,809 3,215 Pesonnel Rcuitment 4,929 22 s. PROJECT FINANCING (US S 1.000) Source of Funds Planned Actual A. Rural Health 28,800 37,406 8. Medical Educatlon 36,000 46,00 C. Strengheonn of management miatlon research 4.8 6,482 D. Project ImplemeoL 2.700 6,694 E Confngencies 12,700 DQMEESI A. Cntal Govt 178,400 124,663 B. Provincial Govt. 14,300 82,105 . County Govt. 38,400 0. Sub-County sources 6 1t IDA sJar Incred In terms Of US dollar as SOR spprOciated 21 Fncana reoranizaton in China changed the shares of different Pawes&  TABLE 4b: Proect leMeaon - UneutMles Enrotlments and Faclt Stall W___ ____ _ _ Enrollment St' __ Undergraduate Graduate Faculty Staff Faculty Stalf Facutly Staff (numb) (numbe) posls total Prof. & Assoc. Lectr. & Assist. Before After Before After Before After Bstore After Before After Project Prolect Project Prolect Prolect Prolect Prolect Prolect Prolect Prolect L1)0 (1991 1! f Lili) 11f~ (199f (j! 1991) (18) (1991) song Colle deTCM 240 258 24 316 261 434 47 ',145 234 289 BeqlngModlcal Unlvty 426 630 130 267 529 1086 281 359 248 n7 Peking Union Medical Unet 121 ChlMedloaldiUnW y 536 435 164 184 956 969 92 266 377 Guangzhou COlW of TCM 383 785 35 151 348 634 Hunan MdlcalUnbvrsky 248 630 51 125 916 138 283 156 508 NomrnBelmeMedlcalUnher 496 630 13 130 919 281 443 154 476 hanghaMedlcaUnverufty 400 58 78 241 878 310 575 154 603 Shandog Medcal Unverst 353 5iB 40 96 572 753 87 215 156 538 West Chlna MdlcalU Wnlv 342 610 s0 165 1224 1012 160 291 160 720 Tong Medcal nWety 473 600 63 202 859 257 293 158 620 Xlan MedkaUnlveruty 240 540 37 82 1104 314 168- 790 SunYatsenUrdv. ofMed.So. 400 470 62 183 650 152 189 179 479 ToaJ~~s> :~'~ ~ '4154~; 5885 274g'991 3925 1036 t.1335 i. 1.676" * t  Shandong HeioajIngw f4ngxa Siciwuan Beore After Before After Beore After Before After pW roecgj Remar s o fc Rein P Prolec Pjdj Remark Pe t Remarks Infan motaly ras 21.65 19.67 35.53 23.21 45.50 34.41 42.09 31.34 Matemalamonttyr"d 0.05 0.04 0.08 0.02 0.11 0.09 0.12 0.06 Antenatal exam. rae 62.66 85.38 68.90 97.30 54.51 84.75 61.95 75.05 Incidence nfetilous diae 339.28 127.76 243.90 142.14 490.81 238.14 436.64 351.41 1_c1dEnce To 338.68 163.48 528.54 445.33 1155.80 567.70 743.24 531.44 Incidence lnfant pneumonia 4.77 4.24 688 0 .71 30.38 5.68 4.71 3.17 lcldemcelnfantdarrhoea 1659 15.13 7.26 6.99 56.49 .11.96 11.29 6.66 4-vacne rate children 89.05 97.56 88.56 97.73 91.79 97.26 74.53 93.58 Hoskal oopaM nre 38.21 59.04 5645 57.03 69.70 77.61 61.33 60.96 " Refer to county rate 0.10 0.06 0.10 0.03 0.14 0.04 0.01 0.01 Aveae lenh hoSp. stay 7.55 8.74 7.43 6.18 12.24 10.56 7.09 7.22 Heafteducaton stall no. 24300 330.O0 56.00 190.00 88.00 105.00 745.00 1109.00 % heallh educ. In pmay school 0.81 70.21 12.32 80.99 2.05 52.42 5.81 59.74 % health educ. In scdarysch 10.16 82.95 3.22 80.40 12.84 43.90 7.02 80.18 Comet on Takbe 6 .Itesulsl 8Seected cositiv Indcaors 1. Substantial falls In IMR and MMR, folowing improvements In MCH care. The mbovmen was lss In Shandong. where pre-proect URand VWU were already low. 2. Ag prOvinces report large reductons In communcable diseases. 3. Health eduation progams have been considerably deveoped. 4. Immunatin of school children has reached almost 100% cove,ag  - 23 - lz~be Z Staras of CovNants Covenant Subject DeadlLiae Status Credit Agreement Section 3.02 Borrower to pass part of Credit to local Entities under terms satisfactory to IDA/GOC N.A. Fulfilled Section 3.03 Employ conxultants With terms/qua'lifications satisfactory to IDA .A Fulfilled Section 3.06 (a) Carry out health manpower study; 6/30/86 Completed in June 1988 (b) furnish report for IDA's coments Fulfilled Section 3.09 laintain KOPH Loan Office with approp- riate staffing - Fulfilled Section 4.01 Submit audited accounts Each 6/30 Fulfilled Prolgct Agremet= Section 2.01 (a) Each Local Entity to provide adequate funds to implemet its part. F- Fulfilled Section 2.0' Each Local Entity to maintain a Loan Office throughout project implementation --- Fulfilled T*be 8A - B*k rn Saff Innue (Staff veeks) Stage of Project Cycle Planned Actual Preappraisal 80.2 Appraisal 62.2 NegotiationA 28.0 Supervision _IZ Total 295.1  - 24 - Table 9 - Bank Group Missions Project Cycle Month/ No of Specialization' Performance Year Persons Rating Reconnaissance 3/82 4 PH, EP, EC Identification 9/82 5 EC, PH, EP HE, PE Preparation 1/83 4 EC, ME, PH Preparation 3/83 2 PH Preparation 4/83 2 EC, HE Preparation 6/83 3 PH, FMi Appraisal 9/83 7 EC, PH, FM, AR, ME - Post-Appraisal 2/84 3 EC, PH Supervision 7/84 3 EC, PH, HE 1 Superwision 3/85 2 PE, EC 1 Supervision 8/85 3 PHt, PR Supervision 5/86 7 EC, HE, PH, MEI 1 Supervision 10/86 1 pH4 1 Supervision 12/86 3 FM, EC, PH 1 Supervision 3/87 3 Pit I Supervsion 11/87 1 Fl 1 Supervision 9/88 6 IN4, CH, PH, ME 1 Supervision 4/90 1 P1M 1 1 Specialization: AR - Architect CM - Computer EC - Economist Specialist E1 - Epidemlo- FM - Finance & HE - Health Economist logist Managmnt HE - Medical PE - Population PH - Public Health Educator Economist Specialist Pa - Pharmacist