India - Fifth (Bombay and Madras) Population Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 16092 IMPLEMENTATION COMPLETION REPORT INDIA FIFTH (BOMBAY AND MADRAS) POPULATION PROJECT (CREDIT 1931-IN) October 23, 1996 Population and Human Resource Operations Division Country Department II (Bhutan, India and Nepal) This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  Currency Equivalents Currency unit = Indian Rupee At appraisal: lJSS 1.00 =Rupee 12.9 At completion: lJS$1.00 = Rupee 35.54 Other Equivalents I meter - 3.28 feet 1 kilometer = 0.62 miles I crore - 10 million I lakh - 100.000 Government Fiscal Year April I - March 31 Abbreviations ANM Auxiliary Nurse-Midwife CPR Contraceptive Prevalence Rate DCA Development Credit Agreement DHFW Directorate of Health and Family Welfare FMPW Female Multi-Purpose Worker FVHW Female Voluntarv Health Worker GBMC Greater Bombay Municipal Corporation GOI Government of India HP Health Post ICDS Integrated Child Development Services ICR Implementation Completion Report IDA International Developmenit Association [EC Information. Education and CommunLicationis IPP India Population Project MCH Maternal and Child Health MIES Management Inforimiation and Evaluation System MMC Madras Municipal Corporationi NMMC Navi Mumbai Municipal Corporation PHD Public Health Departilmenit PM P Private Medical Practitionier PPC Post-PartiLIm Center PU Pediatric Unit PVO Private Voluntary Organization SAR Staff Appraisal Report TNA Training Needs Assessmenit URS Urbani Revamping Scheine  FOR OFFICIAL USE ONLY IMPLEMENTATION COMPLETION REPORT INDIA: FIFTH (BOMBAY AND MADRAS) POPULATION PROJECT (CR 1931-IN) Contents page Preface ..................... Evaluation Summary ................................. ii PART I: Project Implementation Assessment A. Statement/Evaluation of Objectives ............................. I B. Achievement of Objectives ............................. 3 C. Major Factors Affecting the Project ............................ 6 D. Project Sustainability ............................. 7 E. Bank Performance ............................ 8 F. Borrower Performance ............................. 9 G. Assessment of Outcome ............................... 9 H. Future Operation .................... 9 I. Key Lessons Learned .................. 10 PART II: Statistical Information Table 1. Summary of Assessments .11 Table 2. Related Bank Loans/Credits .13 Table 3. Project Timetable .16 Table 4. Credit Disbursements .17 Table 5. Key Indicators for Project Operation .18 Table 6. Studies Included in the Project .19 Table 7A. Project Costs by Component ....................................... 20 Table 7B. Project Costs by Category of Expenditure ....................................... 20 Table 8. Status of Legal Covenants ....................................... 21 Table 9. Bank Resources: Staff Inputs ....................................... 25 Table 10. Bank Resources: Missions ....................................... 26 Appendices A. The ICR Mission's Aide-Memoire B. Borrower's Contribution to the ICR This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otheriise be disclosed without World Bank authorization.   IMPLEMENTATION COMPLETION REPORT INDIA: FIFTH (BOMBAY AND MADRAS) POPULATION PROJECT (CR 1931 -IN) Preface This is the Implementation Completion Report (ICR) for the Fifth India Population Project, for which Credit No. 1931-IN in the amount US$57 million was approved on June 21, 1988. The credit was closed on March 31, 1996, after a three-month extension of the closing date. US$51.17 million, or 90 percent of the credit, was disbursed. The undisbursed balance was cancelled effective August 26, 1996. Preparation of this ICR began during the Bank's implementation completion review mission from November 27 to December 4, 1995. It is based on material in the project files, field visits, and interviews with beneficiaries, project staff, Government officials and Bank staff. The Borrower contributed to the preparation of the ICR by preparing its own evaluation of the project's preparation and execution. Comments were received from the Borrower on drafts of the report and taken into account in the final version. The cooperation and assistance of the Government of India, the Governments of Maharashtra and Tamil Nadu, and the Municipal Corporations of Madras, Mumbai and Navi Mumbai are gratefully acknowledged. This report was prepared by Anthony R. Measham (Task Manager) and Lessel H. David (Consultant), with technical assistance from R. Sethuraman, Ann Hammond, and Mark Schlagel. Nira Singh and Mark Schlagel provided office technology assistance. The report was reviewed by Richard Skolnik, Division Chief, SA2PH, and Kazuko Uchimura, Project Adviser.   - ii - IMPLEMENTATION COMPLETION REPORT INDIA: FIFTH (BOMBAY AND MADRAS) POPULATION PROJECT (CR 193 1 -IN) Evaluation Summary Introduction 1. IDA has been involved in India's family welfare program since the early 1970s through a series of India Population Projects (IPPs). Of the nine IPPs, five supported the program in backward and rural districts of eight Indian states; two, including the Fifth India Population Project (IPP V), supported urban programs, and two strengthened training in eight states. IDA is also supporting the Child Survival and Safe Motherhood Project across the country. Project Objectives 2. The original objectives of IPP V were to: (a) expand family welfare services with emphasis on maternal and child health, birth spacing, and increased use of temporary contraceptive methods; (b) improve the quality of family welfare services; (c) strengthen the capacity of Greater Bombay, Madras city and the Chingleput district in Tamil Nadu to plan, manage and implement family welfare programs in urban areas; and (d) increase the participation of Private Voluntary Organizations (PVOs) and private medical practitioners (PMPs) in urban family welfare programs. To meet these objectives, the Staff Appraisal Report (SAR) identified four components: (a) constructing, furnishing, equipping and staffing Health Posts (HPs) and back-up units; (b) staff training; (c) reorganization of Health and Family Welfare Bureaus, including additional manpower; and (d) assisting PVOs to operate HPs and training PMPs in health and family welfare. 3. Initially, IPP V was limited to operate in the areas under the Greater Bombay Municipal Corporation (GBMC) and the Madras Municipal Corporation (MMC) and its four adjoining municipalities. By late 1988, however, Bank and project authorities realized that significant cost savings would accrue to the project, largely as a result of the depreciation of the Rupee against the SDR which had been occurring since 1986. These savings could be used to broaden the project's scope (including added service delivery activities) and geographic coverage. In response, the project was restructured in 1990.1 Subsequently, upon official GOI and IDA approval of expansion proposals (1992-93), the Navi Mumbai Municipal Corporation (NMMC) adjacent to Greater Bombay and all urban areas in Tamil Nadu with a population greater than 100,000 were added to the project, increasing the geographic scope substantially and increasing the population coverage of the project by approximately 25 percent. The Credit and Project Agreements were amended to increase coverage to all of the district of Chingleput and other municipalities or urban areas of Maharashtra and Tamil Nadu. Schedule 2 of the DCA was also revised to include Social Marketing of Contraceptives, Compensation to Acceptors, and the construction of Family Welfare Centers.  - 111 - 4. The main goal throughout the project was to improve the service delivery and outreach systems of family welfare services in urban slum areas. While the establishment of HPs manned by suitably qualified staff improved service delivery, the project also successfully improved the outreach system through the use of Female Voluntary Health Workers (FVHWs) in the slum areas. 5. The project objectives were mutually supportive and, prima facie, within the Borrower's capacity. In a significant departure from previous IDA-financed India population projects, the project's objectives were not expressed in terms of fertility reduction but in health services rendered to women and children. This change appears to have contributed importantly to the success of the project. 6. The project's financial objectives were largely fulfilled. US$51.17 million, or 90 percent of the credit, was disbursed. The undisbursed balance was cancelled effective August 26, 1996. Implementation Experience and Results 7. Implementation worked well with respect to three of the project's four objectives. Service units were established, equipped, and staffed, and services provided were of improved quality. In areas where the project was operating from its inception, the service delivery results were closer to SAR expectations than in those that were added later -- as expected. The expansion of the service delivery network is likely to continue, as are the measures to increase their outreach through inter-personal contact. Measures taken to strengthen program management, such as the reorganization of implementing agencies and revised monitoring systems, were also successful and are likely to be sustained. The involvement of PVOs and PMPs fell short of expectations. 8. Three major factors contributed to the project's success. First, both states -- Maharashtra and Tamil Nadu -- had a demonstrated capacity to manage successfully donor-assisted projects, including those in the social sectors. Second, there was continuity of skilled program management; as the project was in urban areas, personnel tumover was low. Third, IPP V's objectives were client-focused: individual clients saw services as being of direct and immediate benefit to them, resulting in their active involvement and a strong sense of satisfaction among service providers. 9. While there was a year's delay in initiating project implementation, this was more than compensated for by intelligent and enthusiastic commitment thereafter. The Bank provided competent and flexible support. 10. Service statistics indicate that the project has contributed significantly to lowered infant and child mortality and reduced higher-order births. Definitive results will be available upon completion of the end-line surveys. Summary of Findings, Future Operations, and Key Lessons Learned 11. The project's main objectives of establishing service outlets and initiating outreach activities were well met. The project's secondary objectives of involving PVOs, training PMPs, and commissioning special studies in time to fine-tune implementation, were less well met. Had all the project-related studies been completed in a timely manner and made more immediate use of, the project and its lessons would have been considerably enriched.  - iv - 12. The basic paradigm of service delivery, which builds on the Urban Revamping Scheme (URS), is likely to be sustained. While the sustainability of the partnerships with PVOs and PMPs is questionable, this is unlikely to affect the overall sustainability of the project. GOI has taken a number of steps with IDA support to enhance the sustainability of the Family Welfare Program. The ongoing Sixth and Seventh Population Projects are strengthening training capacity in seven states and in the overall program; the Eighth Population Project has expanded the IPP V approach to four more major cities; and the Ninth Population Project is enhancing the MCH strategy in the states of Assam, Karnataka, and Rajasthan. On a national scale, the Child Survival and Safe Motherhood Project, which ended on September 30, 1996, has provided further IDA support for the broader approach to MCH and family planning. And the proposed Reproductive and Child Health Project, scheduled for appraisal in early 1997, will further expand the service paradigm pioneered in IPP V. Finally, the GOI-Bank collaboration on sector work, culminating in the June 1995 report (India's Family Welfare Program: Toward a Reproductive and Child Health Approach - Report No. 14644-IN), describes the paradigm shift in the program's strategy. 13. The first lesson learned is that quality Maternal and Child Health (MCH) and family planning services can be provided to urban slum populations in India, and the choice of implementing agency is an important determinant of success. The density of service outlets and outreach worker per unit of population followed by URS and implemented in IPP V appears optimal. The second lesson learned is that a client-focused MCH project approach can work well in India. The emphasis on delivering services seen as of direct and immediate benefit both involved beneficiaries and gave providers immense satisfaction. The third lesson learned is that allotting a largely subordinate role to the private sector can lead to disappointing results. Ways to bring about a more equitable partnership between official and non-official agencies need to be further explored. Assessment of Outcome 14. Project outcome is rated "satisfactory", based on the successful achievement of key objectives. The project clearly made a strategic contribution toward the gradual shift of the Family Welfare Program from a top-down, demographically-driven approach to a broader, reproductive and child health care approach.   IMPLEMENTATION COMPLETION REPORT INDIA: FIFTH (BOMBAY AND MADRAS) POPULATION PROJECT (CR 1931-IN) PART I: Project Implementation Assessment 1. IDA has assisted India's family planning (later, family welfare) program since the early 1970s through a series of India Population Projects (IPPs). The first four IPPs supported the Government of India's (GOI) Model Plan: a paradigm of service outlets and field workers to strengthen health and family welfare services in rural and backward districts. 2. The Fifth India Population Project (IPP V) was directed to two major cities and supported the Urban Revamping Scheme (URS), launched in 1984 to strengthen urban health and family welfare services. While the cities were comparatively well-endowed with health facilities, these facilities were located at random and neglected the slums that absorb most of the increasing number of rural migrants. URS sought to correct this imbalance and to provide outreach through field staff, a new activity for urban service programs in India. A. Statement/Evaluation of Objectives 3. IPP V's operations were directed to India's second and fourth largest urban agglomerates: Bombay (Maharashtra) and Madras (Tamil Nadu). Each of these urban agglomerates comprises a major municipality coterminous with a metropolitan district and is ringed by smaller municipalities in adjoining districts. The project initially covered only the Greater Bombay Municipal Corporation (GBMC) and the Madras Municipal Corporation (MMC) and four smaller municipalities in the adjoining Chingleput district. The amendment to the Credit Agreement carried out in 1990 enhanced service delivery activities and added to the project's geographic coverage all of the district of Chingleput and other municipalities or urban areas of Maharashtra and Tamil Nadu. Expansion activity in new areas did not, however, become visible until mid-1993, soon after expansion proposals had been approved by GOI and IDA (1992-93). The approved expansion areas included, in Bombay, the Navi Mumbai Municipal Corporation and, in Tamil Nadu, four additional municipal corporations and 19 municipalities (Table 1). The final expansion increased the population coverage of the project by about 25 percent. 4. Thus, in Maharashtra, two autonomous corporations in Bombay were supported, whereas, in Tamil Nadu, 24 municipalities across the state, including in Madras, were included, most of which were administered directly by the state government. While the two municipal corporations were the major players in the Bombay region, in Madras/Tamil Nadu, the state government had the dominant role. This difference, as discussed below (paras. 24, 26), had implications for project implementation and sustainability.  -2 - Table 1: Geographical Scope of IPP V Region Original (SAR) Added Bombay Greater Bombay Municipal Corporation Navi Mumbai Municipal Corporation Madras/ Madras Municipal Corporation and four All urban areas in the state with populations Tamil Nadu municipalities in Chengalpattu district of more than 100,000 Source: Project Reports 5. Specific objectives: Within the overall framework of URS, four components were identified for IPP V support: (a) Service delivery expansion, by constructing, equipping, and staffing health posts (HPs) and back-up maternal and child care facilities; (b) Quality improvement, by establishing training cells to plan and coordinate training; (c) Management improvement, by restructuring the administrative line organization, strengthening administration by adding posts, instituting management information and evaluation systems (MIES), establishing information, education and communications (IEC) cells, and commissioning special studies; and (d) Increased private sector involvement, by grants to Private Voluntary Organizations (PVOs) for operating selected health posts and collaborating in the design of IEC materials, and by enlisting the cooperation of private medical practitioners (PMPs), including training programs for them. 6. The expected outcomes were expressed in terms of: (a) facilities to be created; and (b) services to be delivered, as measured by increases in contraceptive prevalence, with emphasis on the use of reversible methods, maternal care and immunization coverage. In the case of (a) and (b) the expected levels of performance were specified and met substantially. The SAR did not specify any measures of quality. 7. Three types of service facilities were specified in the SAR: health posts (HPs), post-partum centers (PPCs) and pediatric units (PUs) for children and neonates. In Madras, 25 zonal offices were also to be created; though originally intended as administrative units, when operation theaters and wards were added, they functioned as referral service centers. The number of facilities to be established increased as new areas were added following approval of expansion proposals (Table 2).  - 3 - Table 2: Service Facilities to be Established, by Type TYPE OF FACILITY SAR TARGET ADDED SUBSEQUENT ACTUAL (PRE- (POST- SCALE DOWN ACHIEVED EXPANSION) EXPANSION) TARGET Greater Bombay Health Posts 139 - 120 120 Post-partum Centers 11 14 - 25 Pediatric Units 10 - 10 Navi Mumbai Health Posts - 1I II MCH Units with 25 beds - 5 5 First Referral Unit - I I Madras Health Posts 152 - 140 140 Zonal Referral Units 25 - 15 15 Other Tamil Nadu Urban Health Posts - 33 33 Pediatric Units - 21 21 Maternity Units - 9 9 Source: Project Documents B. Achievement of Objectives 8. The project met fully its objectives of establishing facilities and providing services. Service delivery and demographic targets were met to a substantial degree, and service quality improved. The training and management improvement components were carried out as planned. The monitoring and evaluation. special studies, and IEC components were carried out largely as planned, with varying degrees of effectiveness. The component concerning private sector and NGO involvement fell short of expectations in both cities. 9. Physical Objectives. The project achieved the physical objectives of service facilities established, with some modifications reflecting actual needs. In Bombay, against SAR estimates of 195 HPs, 176 are functioning (56 pre-existing and 120 added). The GBMC scaled down the number of HPs as it felt that the projected population by the year 2000 would be 12, not 13, million. Similarly, due to "need-based reorganization", the SAR estimate of 152 HPs for Madras and suburbs was scaled down to 140, which included the construction of 95 new health posts and the conversion to health posts of 45 existing, poorly functioning Urban Family Welfare Centers. In both Bombay and Madras, secondary- level facilities exceeded SAR estimates since clients preferred better-equipped facilities. 10. Service outlets were staffed with clinical personnel without delay. For outreach workers, there was a delay of two years in Bombay as female multi-purpose health workers (FMPWs) were not available and had to be recruited and undergo the mandatory two-year auxiliary nurse-midwife (ANM) training. At first, project authorities were unenthusiastic about using female voluntary health workers (FVHWS), as advocated by the Bank and included in the project. As such, no FVHWS were initially introduced, either in Bombay or in Tamil Nadu. When, and largely at the Bank's further insistence, they were introduced in Bombay and their utility became evident, not only were they institutionalized  - 4 - in Bombay, they were also extended to Madras. In Bombay they were paid Rs. 200 per month, later raised to Rs. 500. In Madras, FVHWs are indeed voluntary and receive no payment for their services. 11. Project service delivery was met to a substantial degree; the notable exception was in growth monitoring. For Madras, the reported performance on this parameter is half that of SAR expectations; GBMC did not collect these data. Program administrators explained that the Integrated Child Development Services (ICDS) program met this need in both cities but ICDS could not provide detailed data. The one demographic target, for birth order, was also met to a substantial degree. 12. The service delivery targets for Madras and Bombay were largely achieved, especially in the case of Madras, as shown in Table 3. Performance of the geographical areas that were added to the project naturally lagged behind the performance of those areas included originally. However, available data suggest that their rate of progress was faster than in the original areas -- evidence, perhaps, of learning from the earlier experience. Table 3: IPP V Key Indicators, SAR Targets and Achievements by Geographical Area, 1995 Achievements (as of December 31, 1995) (per cent) Indicators/ SAR Madras Tamil Nadu Bombay Goals Targets Expansion (per cent) MMC Suburbs Phase I Phase 11 GBMC NMMC' CPR 60 71.3 60.7 50.6 53.5 59.2 55.0 Immunization 95 99.7 99.5 99.6 90.5 82.6 92.0 Ante-natal 95 97.1 93.2 91.9 94.4 77.3 90.0 Care l Post-natal 95 87.6 81.9 82.8 89.0 88.4 90.0 Care l Institutional 98 99.3 97.9 98.3 95.2 94.6 83.0 Deliveries Growth 80 80.3 41.0 43.6 67.4 NA NA Monitoring Birth Order 3+ Reduction 25.2 33.5 to 20.6 reduced to NA NA to 12.9 15.6 to 18.7 20.1 Source: SAR and project reports 13. Quality Improvement. In the absence of any formal, independent evaluation, it is not possible to judge definitively if the quality of services improved over the project period. It would be facile to assess quality solely from service delivery performance, nor do field visits provide a sufficient basis. Nevertheless, project officials, clients, and Bank staff are unanimous that service quality increased substantially. 14. Training. The training component was carried out as planned and appeared to contribute importantly to the achievement of project objectives. The SAR considered training as the key  intervention to improve quality, and training cells were established in GBMC, MMC, and the IPP V directorate in Tamil Nadu. A substantial amount of training involved basic studies for ANMs, supplemented by three months of urban-based field training. The training cells helped to focus on in- service training, which otherwise would have been neglected. They also did well to draw in training associated with national programs, such as immunization, child survival and safe motherhood, which usually reach rural but not urban areas. Analysis of training reports shows that in-service training was spread evenly across the trainee universe, and analysis of training content shows that it was sufficiently hands-on for clinical skill development. 15. No definitive judgment is possible on the effectiveness of the training. Though program administrators paid considerable attention to training and were pleased with the results, an impartial assessment is lacking. Furthermore, a project of this size and duration, especially as it was breaking new ground (urban areas) would have profited from an initial and rigorous training needs assessment (TNA) and a longer-term strategy for in-service training. While the SAR did specify training areas, a TNA would have validated these from the trainees' perspective and helped in designing specific programs. In Madras, a TNA was done almost half-way through the project and limited to the areas added then. While a TNA for Bombay was done earlier on, its quality and relevance are doubtful. The supervision mission of April 1993 asked that it be repeated; it never was. 16. Management Improvement. The project implementation organization in each city was restructured as agreed during negotiations. A unified command structure was introduced, spans of control reduced, and staff and line functions separated. In Bombay, the span of control of the executive health officer was made much more manageable. In Madras, MMC's Child Welfare Unit was merged with that of family welfare giving the latter, inter alia, a more client-friendly identity. 17. The additional posts recommended in the SAR were created and filled, albeit with about a year's delay in GBMC. In Bombay, these were filled by medical officers of GBMC, whereas in Madras the state Directorate of Health and Family Welfare's (DHFW) larger pool was tapped for management information and evaluation systems (MIES), infornation, education and communications (IEC), and training, giving it an edge over Bombay in terms of specialized manpower. 18. Monitoring and evaluation cells were created as planned in the Public Health Department of GBMC and in the IPP V directorate in Tamil Nadu. In Bombay, a consultant was appointed and an MIES designed and introduced. There was some difficulty in filling the posts of computer operators. In Madras, posts were filled without delay by deputations from the DHFW. In both regions, extensive training had been done, and the system functioned smoothly as far as the flow of instruments and their analysis were concerned. Although the data were used at the apex level for reordering priorities, there is little evidence that they served the needs of middle-level management and field operatives for their own micro-planning. To this extent, the MIES tended to centralize planning and control at the cost of localized outreach approaches. 19. Special Studies. All of the planned studies were completed, as shown in Part II, Table 6. Baseline and community needs assessment studies were done. However, with the exception of NMMC, they were delayed to the point that they could not serve their intended purpose. None of these studies was repeated for the areas added in Tamil Nadu. Mid-term evaluations were more timely. Apart from these and other mandatory studies, such as assessing training and IEC needs, only two other studies were undertaken. With few exceptions, the studies tended to be more descriptive than analytical. It is  - 6 - for this reason, as well as the fact that they were delayed, that evidence of the influence of studies on implementation strategies is difficult to find. 20. Information, education and communications (IEC) activities were well supported by the IEC cells and commendable for the volume of materials produced, the quality of their production, and the energy with which they were disseminated. Several innovations were introduced to disseminate IEC materials. In Madras, barber shops were used to reach males. In Bombay, the use of street plays, a newsletter to medical practitioners, and information counters at all offices of GBMC were introduced. However, as a senior administrator pointed out, most of the IEC content was based on the provider's rather than the client's perception of needs. As such, the messages were more exhortative than educational and thus less likely to lead to sustained attitudinal and behavioral change. Furthermore, there was no systematic media planning. 21. Private Sector and PVO Involvement. This component fell short of expectations in both cities. The operation of some HPs was handed over to PVOs but discussions with program administrators and PVOs suggest that the involvement was more pro forma than out of conviction that PVOs would contribute much. No special accommodation was made to meet PVOs' needs. Efforts to involve PMPs did not yield significant results. Their training needs were not assessed, nor was there much evidence of involving local action groups. On the other hand, the collaboration with one private industry in Bombay to promote health and family welfare among its employees and to support IEC efforts was successful. 22. Financial Objectives. In 1995, GOI increased the rupee amounts sanctioned for Bombay, Madras and other Tamil Nadu cities, with Bank approval, in order to take advantage of exchange rate savings. GOI increased the sanction for Bombay from Rs.48 crores to Rs.71 crores, and for Madras and other Tamil Nadu cities from Rs.69 crores to Rs.89 crores. The project's financial objectives were ultimately largely fulfilled: US$51.17 million, or 90 percent of the credit, was disbursed. The undisbursed balance was cancelled effective August 26, 1996. 23. Disbursement Profile. In October 1989, GOI requested that the third, fourth and fifth population projects be restructured to include additional family welfare activities in the scope of the projects. The Development Credit Agreements (DCAs) for all three projects were amended accordingly on February 9, 1990. Subsequently, GOI submitted expenditure claims totaling US$29.6 million under IPP V. This amount was disbursed. However, in view of Bank concerns regarding the eligibility for disbursement of some of this amount, a special audit was requested and carried out in 1992. As a result, US$15.3 million of the US$29.6 million was disallowed and refunded by GOI to the Bank in April 1994. These expenditure claims and the subsequent refund account for the unusual disbursement profile are seen in Part II Table 4. C. Major Factors Affecting the Project 24. The location of the project. i.e., the states chosen and being confined to urban areas, was a major advantage. IPP V operated in Maharashtra and Tamil Nadu, two states notable for their good record in implementing projects, including those in the social sectors. Both states are socially well developed compared to others in India, ranking among the first four in female literacy, low fertility, and reach of health services. Furthermore, in these two states, the rural total fertility rate is only ten per cent higher than urban; in most others, it is 30 percent higher. As the overwhelming majority of rural in- migrants were from within the state, even in Bombay, where the beneficiary needs assessment showed  that 68.9 percent of the migrants were from Maharashtra, the convergence of rural and urban fertility was to IPP V's advantage. Furthermore, IPP V being confined to cities, and largely the state capitals, helped in two other ways: (a) the sheer logistics of civil works, performance monitoring, and communications were less formidable than they would have been in rural areas and backward districts; and (b) staff turnover was low, as those deployed in cities are less inclined to seek relocation than those in rural areas. 25. The choice of project objectives for IPP V also contributed to its successful implementation: they were contextually realistic and mutually supportive. But even more importantly, they were mainly oriented to service provision rather than demographic impact. This boosted the morale of peripheral service providers, who now felt that they were catering to client-determined priorities such as mother and child care. It is significant that there was no "target" for the single demographic objective -- reduction of higher-order births. It was a welcome change from decades of "time-bound and target- oriented" reduction of fertility. 26. Continuity of middle-level management and field staff was a third major advantage. Those involved with the project at its design stages largely stayed with it for most of its duration. Thus, lessons learned could be applied for mid-course corrections. This is also part of the explanation for why progress in those areas that came into the project's fold midway was faster than in earlier areas (para. 12 above). Without detracting from the quality of administrative leadership or the Bank's accommodating flexibility, the continuity in management also contributed to the learning ethos of the project. For example, the location of HPs was not strictly according to URS norms (population-based) but based on distance and travel time of both clients and field staff. This reduced the number of HPs without adversely affecting accessibility. D. Project Sustainability 27. Issues of sustainability of the project fall into two categories: normative and financial. The normative perspective includes not only the administrative changes introduced formally, but also those of perception and ethos that came about and were as responsible as anything else for the project's achievements. 28. Normative Aspects. First, cessation of implementation unit activities raises no concerns. Since there is not likely to be much new construction or initiation of major activities, the need for the implementation unit will diminish. In Bombay, inasmuch as MIES, IEC, and training have been institutionalized within GBMC, these activities will continue, albeit at maintenance level. To a lesser extent, this will also apply to the changes in MMC. In Tamil Nadu, most of the staff will revert to the state government, carrying with them their IPP V experiences to the benefit of health and family planning services across the state. 29. Second, the emphasis on MCH services, which represented a strategic move towards a more client-focused approach emphasizing quality and meeting individual needs, is likely to be sustained. This large-scale project provided GOI with an important demonstration of this approach, which undoubtedly contributed to the recent decisions to adopt a similar strategy nation-wide and to drop method-specific contraceptive targets effective April 1996.  - 8 - 30. Third, the use of female voluntary health workers (FVHWs), generally considered to be a key factor in extending outreach, is likely to continue in Madras and possibly be introduced in other municipalities since they impose no fiscal burden. It is not possible to be equally sanguine about their continuance in Bombay. At Rs. 500 per month for each FVHW, an amount likely to increase, the burden is substantial. If the fate of community health volunteers in rural areas is any guide, in the event of a resource crunch it is likely that FVHWs will be the first either to be retrenched or lost to attrition and not replaced. If this were to occur, it would weaken the program in Bombay. 31. Fourth, the involvement of PVOs, already under strain in both Bombay and Madras, is not likely to be sustained in the long run. In MMC, support to PVOs has been extended up to June 1997. In GBMC, no plans for continuing support to PVOs have yet been formulated. The lack of unequivocal support to PVOs is not primarily due to financial reasons; GOI has sufficient money to support them. Moreover, the expenditure on HPs operated by PVOs is not additional since the government would have to spend this amount if it operated the HPs. The more intractable problem is one of mutual distrust. However, this is a complicated matter since in both cities and states there are programs that work extensively and successfully with PMPs and PVOs, and throughout India there are movements in these directions. Finally, if PVO involvement in the activities were not to be sustained, this in itself would not undermine the overall sustainability of the project. 32. Fifth, GOI has taken a number of steps with IDA support to enhance the sustainability of the Family Welfare Program. The ongoing Sixth and Seventh Population Projects are strengthening training capacity in seven states and in the overall program; the Eight Population Project has expanded the IPP V approach to four more major cities; and the Ninth Population Project is enhancing the MCH strategy in the states of Assam, Kamataka, and Rajasthan. On a national scale, the Child Survival and Safe Motherhood Project, which ended on September 30, 1996, has provided further IDA support for the broader approach to MCH and family planning. And the proposed Reproductive and Child Health Project, scheduled for appraisal in early 1997, will further expand the service paradigm pioneered in IPP V. Finally, the GOI-Bank collaboration on sector work, culminating in the June 1995 report (India's Family Welfare Program: Toward a Reproductive and Child Health Approach - Report No. 14644-IN), describes the paradigm shift in the program's strategy. 33. Financial Aspects. Ongoing activities are likely to be sustained financially. The SAR estimated recurrent cost implications on the order of Rs. 221 million per year, about equally divided between Bombay and Madras/Tamil Nadu. At the end of the project, this estimate appears to hold. Compared to the total expenditure on health and family welfare, the amount is not formidable. GBMC and NMMC are confident that they can finance activities introduced under IPP V from their own revenues while Madras/Tamil Nadu is seeking GOI support under URS. Both approaches appear promising, though in the event of GOI funding, the additional posts created outside the URS pattern are not likely to continue. Such an eventuality would not, however, have a major impact on the program now that it is well established. And although there remains some doubt about the future source of funding, especially in Tamil Nadu, financial sustainability does not appear to be at risk. E. Bank Performance 34. Bank staff assisted the project areas in developing an innovative strategy in relatively uncharted territory: providing MCH and family planning services to urban slum populations. The SAR was a comprehensive and practical document, fully subscribed to by the Borrower. Supervision missions  -9- were frequent enough and of appropriate composition. The decline in the frequency of supervision during the middle stages of the project, as seen in Part II, Table 10, did not adversely affect the project. Rapport between the Bank and Borrower was good. F. Borrower Performance 35. Bombay, Madras and the Government of India deserve great credit for pioneering a broad approach to reproductive and child health, which was subsequently endorsed by the 1994 Cairo Conference on Population and Development and has now been adopted nation-wide. 36. The project start was delayed by a year, and progress initially was slow. Although the GOI and IDA signed the credit agreement in September 1988, it did not become effective until nearly a year later, as GBMC, MMC, and the Tamil Nadu Government delayed signing it due to bureaucratic delays. However, the pace of implementation picked up and more than compensated for earlier delays. Once the project was operational, the implementing authorities were unusually enthusiastic, particularly about expanding the service delivery network, and disbursements picked up correspondingly. 37. Delays in commissioning and completing special studies were a problem; at the time of ICR preparation, the end-line surveys have yet to be commissioned. If studies had been done as scheduled and their findings considered, the project would have been considerably enriched and its lessons clearer. G. Assessment of Outcome 38. Based on the success of the project in achieving its key objectives (paras. 8-23), project outcome is rated "satisfactory." Currently available data on fertility and infant mortality in the project areas are based on service statistics rather than surveys, and to that extent of limited utility in judging overall impact. However, the service statistics show encouraging reductions in fertility and mortality; a reliable estimate of impact will have to await the end-line surveys. 39. A rating of "satisfactory" is also warranted if the project's outcome is assessed in terms of its impact on India's health and family welfare program. Assuming that a shift from a predominantly demographic orientation to one concerned with health, particularly of women and children, is desirable, the question is: did IPP V contribute? It would be presumptuous to overplay IPP V's contribution, but the demonstration value of a project that underplayed fertility reduction per se and gave priority to broader health issues, not only in its design but consistently and successfully through its seven-year life, cannot be minimized. This view of the project's contribution gained ground over the life of the project, and is now the predominant view in Ministry of Health and Family Welfare and the states. If it is on this canvas that IPP V's impact is to be assessed, then it is indeed seminal, particularly as an exemplar for projects that might choose to interpret family welfare more broadly to include reproductive and child health. H. Future Operation 40. The future operation of the services supported by the project seems assured in both major cities and the other municipalities. These services have been absorbed into the URS or other programs of the state governments concerned and are likely to be sustained in the long terrn.  - 10- I. Key Lessons Learned 41. Not all the reasons for IPP V's unusually high levels of achievement are replicable but three appear to show promise. One pertains to urban projects in India and two have relevance to a wider range of social sector projects in India and comparable settings. 42. Implementing Agency. The choice of implementing agency is an important determinant of success. IPP V was implemented through municipal corporations in the Bombay region while in Madras it was largely through the state government. In both cases, it appears that the project was implemented by the most appropriate entity. In the Bombay region, municipal corporations, particularly those of Greater Bombay, are autonomous and self-financing and have their own elected bodies. In Madras, they are creatures of the state govemment and, to a large extent, financially dependent on it. 43. Relevance of project objectives. Successful project objectives should ensure high staff morale and active beneficiary participation. The statement of IPP V objectives and its ensuing design unequivocally took the needs of both staff and beneficiaries into account. In evidence is the project's nearly exclusive concern for services: only service targets were quantified and measured. Almost all project administrators and field personnel not only agreed with IPP V's approach but felt that implementing it gave them considerable personal satisfaction. It took more courage to ignore fertility reduction per se in 1987 than it does now. 44. PVO and Private Sector Involvement. Allotting a subordinate role to the private and voluntary sector can lead to disappointing results. The promotion of PVO and private sector involvement in the project was the single comparatively unmet objective of IPP V. The fact that it did not have much negative impact on project performance is of little comfort. There is increasing evidence that official social sector projects succeed to the extent that they collaborate with non-official agencies and groups. In hindsight, it appears that IPP V saw the involvement of the private sector as an objective rather than a means. Furthermore, some middle-level managers saw PVOs as competitors. They failed to see that the private and PVO sectors could be an extra resource to meet the project's objectives. This perspective needs to be pursued more aggressively in future projects. If the private sector is to be a partner, it must also have a greater say in making decisions and have mechanisms to do so incorporated at the design stage.  - 11 - PART II: Statistical Information Table 1: Summary of Assessments A. Achievement of Objectives Substantial Partial Negligible Not Applicable Macro policies [ L L O Sector Policies 3 Ex Financial objectives Li Cl [ Institutional development E x I L Physical objectives E Li ] L Poverty reduction 3 i 0 L Gender issues E L L L Other social objectives i Li 0 Environmental objectives L L L 3 Public sector management [ Li IZ Private sector management L L [ 0  - 12 - Table 1: Summary of Assessments (continued) B. Project sustainability Likely Unlikely Uncertain C. Bank performance Highly Satisfactory Deficient satisfactory Identification E E ] Preparation assistance E E [ Appraisal |E El Supervision E E D. Borrower performance Highly Satisfactory Deficient satisfactory Preparation El L E Implementation El Covenant Compliance E E Operation (if applicable) E E Z E. Assessment of outcome Highly Satisfactory Unsatisfactory Highly satisfactory Unsatisfactory El El El C:  - 13 - Table 2: Related Bank Loans/Credits Credit No. 312-IN Title : First Population Project Year of Aprval 1972 Purpose : To support the family welfare program in five districts of Mysore (now Karnataka) and six districts of Uttar Pradesh Credit closed June 30, 1980 Comments: Project Completion Report (PCR) 6/81; PPAR 1/82 Credit No. : 981-IN Title Second Population Project Year of Approval 1980 PuEpose : To support the family welfare program in six districts of Uttar Pradesh and three districts of Andhra Pradesh Status Credit Closed March 31, 1988 Comments PCR 1/90; PPAR 8/90 Credit No. : 1003-IN Title Tamil Nadu Integrated Nutrition Project I (TINP I) Year of Approval 1980 Purpose : To improve the nutritional and health status of preschool children and pregnant and nursing women Credit closed March 31, 1989 Comments : PCR 1/91; Impact Evaluation Report 12/94 Credit No. 1426-IN Title Third Population Project Year of Approval 1984 Purpose : To support the family welfare program in six districts of Karnataka and four districts of Kerala Status Credit Closed March 31, 1992 Comments: PCR 8/93 Credit No. 1623-IN Tite : Fourth Population Project Year of Approval 1985 Purpose : To support the family welfare program in four districts of West Bengal Status Credit Closed March 31, 1994 Comments : PCR 12/94 Credit No. 2057-IN Tile Sixth (First National Family Welfare Training and Systems Development) Population Project Year of Approval 1989 Purpose : To support the family welfare program in the states of Uttar Pradesh, Andhra Pradesh and Madhya Pradesh Status~ : Credit scheduled to close March 31, 1997 Commnen Focus on strengthening of training aspects of the program on a statewide basis  - 14 - Table 2: Related Bank Loans/Credits (continued) Credit No. 2158-IN Titil Tamil Nadu Integrated Nutrition Project 11 (TINP II) Year of Approval: 1990 pose To extend the successful TINP program to all of Tamil Nadu's 20,000 villages Status : Credit scheduled to close December 31, 1997 Commnent: The project is addressing critical nutritional and maternal and child health needs in rural Tamil Nadu Credit No.: 2173-lN Title Integrated Child Development Services Project I (ICDS I) Year of Approval 1990 Purpose : To improve the nutrition and health standards of pre-school children and mothers in tribal, drought-prone and otherwise disadvantaged areas of Andhra Pradesh and Orissa Status : Credit scheduled to close December 31, 1997 Comments : The project supports India's on-going ICDS Program and comprises service delivery, communications, community mobilization and project management/evaluation components Credit No. : 2133-IN itk : Population VII (training) Year of A proval 1990 Puroose : To support lower-income women in the rural areas of Bihar, Gujarat, Haryana, Jammu, Kashmir and Punjab, through the training of new and existing health workers and non-Health Department personnel. Status . Credit scheduled to close June 30, 1998 Comments : Focus on increasing the supply and quality of family welfare services. Credit No. : 2394-IN LITit : Family Welfare (Urban Slums) Project (Population VIII) Year of Approval 1991 Purpose : To help the Government of India increase the supply of family welfare services in the slum populations of Andhra Pradesh, Karnataka, West Bengal and Delhi. Status : Project scheduled to close June 30, 2001 Comment: 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 ongoing 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.  - 15 - Table 2: Related Bank Loans/Credits (continued)- Credit No. 2300-fN Tilk Child Survival and Safe Motherhood Project Year of Approval 1992 Purpose : To support the Government of India's Maternal and Child Health Program. Status : Credit closed September 30, 1995 Comments Focus on child survival, safe motherhood (prevention of maternal morbidity and morality) and effective service delivery. Credit No. 2470-IN Title Integrated Child Development Services Project II (ICDS II) Year of Approval 1993 Purpose To improve the nutrition and health status of pre-school children and their mothers by strengthening and increasing the outreach of the ICDS program in Bihar and Madhya Pradesh Status Credit scheduled to close September 30, 2000 Credit No. 2630-IN Title Family Welfare (Assam, Rajasthan and Karnataka) Project (Population IX) Year of Approval 1994 Purpose : To support the family welfare program in the states of Assam, Rajasthan and Karnataka Status Approved by the Board on June 16, 1994 Comments : Focus on reduction of fertility and maternal and childhood mortality by strengthening service delivery including extension and upgrading of infrastructure, strengthening demand generation activities through improved information, education and communication planning and activities, strengthening program management and implementation capacity, and improving service quality including training, improvement of program logistics, promotion of private sector involvement, and funding for innovative schemes.  - 16 - Table 3: Project Timetable Steps in Project Cycle Date Identification/Preparation Mission February - March 1985 Appraisal Mission November 1987 Credit Negotiations May 3-9, 1988 Board Approval June 21, 1988 Credit Signing September 16, 1988 Credit Effectiveness December 23, 1988 Credit Closing Date March 31, 1996  - 17- Table 4: Credit Disbursements: Cumulative, Estimated and Actual (US$ millions) FY 89 FY 90 FY 91 FY 92 FY 93 FY 94 FY 95 FY 96 FY 97 Appraisal 1.66 6.74 14.93 25.46 36.10 45.38 53.40 57.00 Estimate Actual 2.86 34.31 35.96 37.33 38.38 24.47 37.73 45.65 51.17 l Actual as % of 172 509 241 147 106 54 71 80 90 estimate Final credit disbursement. The undisbursed balance was cancelled effective August 26, 1996.  - 18 - Table 5: Key Indicators for Project Operation Status of Key Indicators on December 1. 1995 -- Bombay Bombay New Bombay Appraisal Target Actual Appraisal Target Actual (%) Achievement to (%) Achievement to Indicators/Goals Date (%) Date (%) Contraceptive prevalence 60 59.2 60 55 Immunization coverage 95 82.6 95 92 Ante-natal care 95 77.3 95 90 Post-natal care 95 88.4 95 90 Institutional deliveries 98 94.6 98 83 Growth monitoring 80 NA 80 NA Birth order 3 plus Reduction NA Reduction NA Status of Key Indicators on April 1. 1996 -- Madras Madras City Madras Suburbs Appraisal Target Actual Appraisal Target Actual Achievement (%) Achievement to (%) to Date (%) Indicators/Goals Date (%) l Contraceptive prevalence 60 71.3 60 60.7 Immunization coverage 95 99.7 95 99.5 Ante-natal care 95 97.1 95 93.2 Post-natal care 95 87.6 95 81.9 Institutional deliveries 98 99.3 98 97.9 Growth monitoring 80 80.3 80 41.0 Birth order 3 plus Reduction 25.2 to 12.9 Reduction 33.5 to 15.6 Expansion Program for other Cities in Tamil Nadu Phase I Phase 11 Appraisal Target Actual Appraisal Target Actual Achievement (%) Achievement to (%) to Date (%) Indicators/Goals Date (%) l Contraceptive prevalence 60 50.6 60 53.5 Immunization coverage 95 99.6 95 90.5 Ante-natal care 95 91.9 95 94.4 Post-natal care 95 82.8 95 89.0 Institutional deliveries 98 98.3 98 95.2 Growth monitoring 80 43.6 80 67.4 Birth order 3 plus Reduction 20.6 to 18.7 Reduction Reduced to 20.1  - 19- Table 6: Studies included in the Project Title Purpose Status Impact (as in SAR) I Baseline Survey for IPP V, Demographic and Completed Used to measure Bombay program data 1990 achievements 2 Community Needs Needs of slum Completed Used for planning Assessment, Bombay population 4/91 services 3 Survey report of Demographic and Completed demography, health, family program data 8/91 welfare among slum population of Madras Metropolitan Area 4 Mid-term impact analysis Mid-term Completed performance review 11/92 5 Mid-term impact evaluation, Mid-term Completed Guided modifications IPP V, Bombay performance review 11/93 6 Evaluation of IEC activities, Not specified Completed Madras 4/94 7 Training Needs Assessment Not specified Completed Training strategy for of IPP V expansion areas 8/94 new areas 8 Study to evaluate the Not specified Completed Stipend to voluntary effectiveness of Community 10/94 workers raised Health Workers in Greater Bombay under IPP V 9 Mid-term external Not specified Completed FVHWs initiated in evaluation report on IPP V 11/94 Madras Bombay 10 A review of mid-term Not specified Completed/ evaluation of IPP V, Madras undated 11 Study of impact of IEC Not specified Completed activities, IPP V, Madras 1/94 12 Baseline Survey for IPP V, Demographic and Completed Facility planning Navi Mumbai program data 1/94 13 Survey of Health Posts of Not specified Completed Provided feedback on PVOs and PHD of Bombay 1/95 PVO performance Municipal Corporation 14 Reaching Out: A campaign Not specified Completed Role of voluntary to take family welfare 7/95 health workers more services to the slums of widely recognized Bombay and Madras  - 20 - Table 7A: Project Costs by Component Appraisal estimate (US$m) l Actual/latest estimate (US$m)/lI Component Local Foreign Total Local Foreign Total Service Delivery Expansion 37.70 2.33 40.03 Quality Improvement 2.91 0.34 3.25 Management Improvement 10.52 0.56 11.08 PVO and Private 5.66 0.35 6.01 Practitioners Base Costs 56.79 3.58 60.37 Contingencies - Physical 3.90 0.35 4.25 - Price 13.26 0.33 13.59 Sub-total 17.16 0.68 17.84 Total Project Costs 73.95 4.26 78.21 /I Data not available. GOI maintained expenditure records by category but not by component. Table 7B: Project Financing by Category of Expenditure Appraisal estimate (US$m) Actual Disbursement/2 Source IDA | GOI | Total IDA I GOI I Total Civil Works and Fees 6.28 1.11 7.39 7.98 2.04 10.02 Equipment, Books, 6.44 1.14 7.58 12.90 3.69 16.59 Furniture, Vehicles Consultants, Fellowships 5.64 0.16 5.8 1.34 1.74 3.08 Salaries, Materials, 38.6 18.84 57.44 28.93 11.77 40.70 Operations and Maintenance Special Account 0.02 0.02 Total Disbursement 56.96 21.25 78.21 51.17 19.24 70.41 /2 GOI maintains records only in rupees; a blended rate of 22.9 was used to convert GOI/Total expenditures into US dollars.  - 21 - Table 8: Status of Covenants Agreement Text Covenant Status Description of Covenant Comments Reference Class(es) Credit Art. III, 4,5 C The Borrower to cause Tamil Nadu, Yes, Maharashtra 3.01 (a) MMM, BMC, and Maharashtra to Government also perform their obligations under the allocated funds to New Project Agreement and the Bombay Municipal Maharashtra Agreement, respectively, Corporation. and provide resources as necessary for them to do so. 3.01 (b) 3 C The Borrower to make the Credit Yes. proceed available to Tamil Nadu for such parts of the Project as are carried out by Tamil Nadu and MMC and to Maharashtra for such parts of the Project as are carried out by BMC. Art. IV, 1 C (b) The Borrower to: (i) have the Yes. 4.01 (b) financial records and accounts audited each fiscal year; (ii) furnish IDA the audit report; and (iii) furnish IDA other related information. DCA 3.01 (b) 3 The Borrower to make the Credit proceeds available to Tamil Nadu for such parts of the Project as are carried out by Tamil Nadu and MMC and to Maharashtra for such parts of the Project as are carried out by BMC. Art. III, 10 C Procurement to be governed by the Yes. 3.02 provisions of Schedule I to the Project Agreement. Art. III, 4 C Concerning obligations relating to Yes. 3.03 insurance, use of goods and services, plans and schedules, records and reports, maintenance and land acquisition, Tamil Nadu to carry out in respect of such parts of the Project as are carried out in Chingleput, MMC as are carried out in Madras City and BMC as are carried out in Greater Bombay. DCA Art. IV, I C (a) The Borrower to maintain or cause Yes. 4.01 (a) to maintain adequate financial records and accounts to enable IDA representatives to examine such records. PROJECT Art. II, 3,5 C Tamil Nadu to carry out such parts of In addition, the project Status: C - Complied with CD - Compliance after delay NC - Not complied with SOON - Compliance expected in reasonably short time CP - Complied with partially NYD - Not yet due  - 22 - Table 8 (continued) Agreement Text Covenant Status Description of Covenant Comments Reference Class (es) 2.01 (a) the Project as are located in has been implemented in Chingleput, MMC as are located in a number of municipal Madras City and BMC as are located corporations and in Greater Bombay, with due municipalities in the diligence and efficiency and in state. conformity with appropriate practices and provide promptly the resources I_________ required for the Project. 2.01 (b) 5 C Tamil Nadu, MMC and BMC to each Yes. carry out the Project in accordance with the agreed Implementation Program set forth in Schedule 2 to the PA. 2.02 10 C Procurement of goods, works and Yes. services in accordance with Schedule I of the PA. 2.03 5,9 C Concerning obligations relating to Yes. insurance, use of good and services, plans and schedules, records and reports, maintenance, and land acquisition, Tamil Nadu to carry out in respect of such parts of the Project as are carried out in Chingleput, MMC as are carried out in Madras City and BMC as are carried out in Greater Bombay. 2.04 (a) 5 C Tamil Nadu, MMC and BMC to each Yes. Visits by project exchange views with IDA with regard officials in BMC and to progress of the Project. MMC were exchanged. 2.04 (b) 5 C Tamil Nadu, MMC and BMC to each Yes. promptly inform IDA of any condition threatening or interfering with the progress of the Project. 2.05 2 C Tamil Nadu to cause MMC to each Yes. perform its obligations under the PA and provide resources as necessary. PROJECT 2.06 3 C Tamil Nadu to make available to Yes. MMC the Credit given to it by the Borrower. Art. III, 1,9 C Tamil Nadu, MMC and BMC to each Yes. 3.01 (a) maintain adequate records and accounts. 3.01 (b) 1 C Tamil Nadu, MMC and BMC shall Yes. (i) each cause records and accounts to be Status: C - Complied with CD - Compliance after delay NC - Not complied with SOON - Compliance expected in reasonably short time CP - Complied with partially NYD - Not yet due  - 23 - Table 8 (continued) Agreement Text Covenant Status Description of Covenant Comments Reference Class (es) _______ audited. 3.01 (b) I C Tamil Nadu, MMC and BMC shall Yes. (ii) each furnish IDA certified copies of their audited records and accounts. 3.01 (b) 9 C Tamil Nadu, MMC and BMC shall Yes. (iii) each furnish IDA other related information, as requested. Schedule 5 C Tamil Nadu, MMC and BMC to each Yes. 2, 1 (a, b, prepare and each transmit to IDA: (a) c, & d) annual construction programs substantially; (b) training plans substantially; (c) annual IEC plans substantially; and (d) annual monitoring and evaluation plans. 2 (a & b) 2,5 C Tamil Nadu, MMC and BMC to each Yes. take the necessary steps to (a) ensure that HPs are provided with adequate suitably qualified staff and resources and (b) improve the effectiveness of the outreach program for the delivery of family welfare services. 3 5 C Tamil Nadu, MMC and BMC to each Yes. Steering take the necessary steps, including the Committees have been appointment of an adequate number set up. of suitably qualified staff and the establishment of supervisory committees. 4 (a) 9 C Tamil Nadu, MMC and BMC to take Yes. the necessary steps to strengthen monitoring and evaluation of family welfare services. PROJECT 4 (b) 9 C Tamil Nadu, MMC and BMC to each All necessary surveys undertake: (i) baseline survey for including Baseline Study project monitoring and evaluation; were undertaken. End- (ii) studies of needs and preferences line survey will now be of slum dwellers and studies to assess undertaken. training needs and potential of PMPs; and (iii) a series of smaller studies and final surveys for Project monitoring and evaluation. 5 (a, b & 5, 9 C Tamil Nadu, MMC and BMC to Yes. c) each: (a) undertake a midterm review of the progress of the Project; (b) furnish IDA for its review, the Status: C - Complied with CD - Compliance after delay NC - Not complied with SOON - Compliance expected in reasonably short time CP - Complied with partially NYD - Not yet due  - 24 - Table 8 (continued) Agreement Text Covenant Status Description of Covenant Comments Reference Class (es) findings and recommendations of such review, together with proposed action plans to overcome problems; and (c) take the necessary action to implement such findings and recommendations as agreed with IDA. 6 5 C Tamil Nadu to establish training; Yes. IEC, MIES and grants cell in its Department of Family Welfare. 7 5 C MMC shall establish training and Yes. MIES cells in District Family Welfare Bureau. 8 5 C BMC to establish training; IEC and Yes. MIES cells in its Central Coordination Office with responsibility for collaborating with local training and other institutions and for carrying out Project Activities. Status: C - Complied with CD - Compliance after delay NC - Not complied with SOON - Compliance expected in reasonably short time CP - Complied with partially NYD - Not yet due  Table 9: Bank Resources: Staff Inputs (staff weeks) FY Total 85 86 87 88 89 90 91 92 93 94 95 96 97 Lending .30 1.85 3.70 1.15 7.0 Develop- ment Pre- 37.17 54.73 70.43 48.77 211.10 Appraisal Appraisal 28.03 28.03 Negotiation 10.17 10.17 Supervision 17.03 16.60 9.16 12.46 22.95 32.70 11.83 6.70 .50 129.93 ICR .98 6.55 7.53 Procure- .20 .10 .68 .98 ment TOTAL 37.47 56.58 74.13 88.12 17.03 16.60 9.16 12.46 22.95 32.90 11.93 8.36 7.05 394.74  - 26 - Table 10: Bank Resources: Missions Stage of Month/ Number of Days in Speciali- Performance rating Problems' project cycle year persons field zation represented' Imple- mentation Dev. Object. Identification/ 2-3/85 Preparation 3-4/86 5 C, PH, MG 10-11/86 _ Appraisal 11-12/87 6 E, PH, POP, A, T, IEC, D Supervision 1 11/88 5 7 1 1 Supervision 2 3/89 5 8 1 Supervision 3 10/89 4 13 E, A, M, IEC I I F Supervision 4 6/90 5 E, A, M, D, P F, PR, Supervision 5 11-12/90 4 9 E, A, P, AD 2 2 F Supervision 6 9/91 4 POP, PH, T, I I F IEC Supervision 7 4/92 3 POP, PH I 1 Supervision 8 1-2/93 8 7 POP, A, P, I I M (Review of IEC, MG, T, mid-term E, PF evaluations) Supervision 9 5/93 7 5 POP, A, P, I I M IEC, MG, T, PF Supervision 10 12/93 5 13 POP, A, IEC, I I T, PF Supervision I1 5/94 7 8 POP, A, P, I I M, PR IEC, T, PF, MIS Supervision 12 9/94 1 3 PH HS HS Supervision 13 12/94 4 4 PHN, PH, F, HS HS PH Implementation 11-12/95 3 12 PHN, F, CON HS HS Completion Mission A = Architect; AD = Administrator; C = Communication Specialist; CON = Consultant PH Specialist; D = Demographer; E = Economist; F = Finance; IEC = IEC Specialist; M = Medical Educator; MG = Management; MIS = Management Information System Specialist; P = Physician; PF = Project Finance; PH = Public Health Specialist; PHN = Population, Health, Nutrition Advisor; POP = Population; T = Training. 2 = Satisfactory; HS = Highly Satisfactory; I = No Significant Problems; 2 = Moderate Problems (i.e., there are significant, but not critical problems from appraisal expectations). Please note that HS/S ranking codes were first utilized with supervision mission 12. 3Problem areas: F = Financial Performance; M = Project Management Performance; PR = Procurement Progress. Problem areas indicated are based upon a rating of 2 from the respective Form 590s; none of these areas rated 3 during the life of the project.  Appendix A Page 1 of 16 FIFTH (BOMBAY AND MADRAS) POPULATION PROJECT (IPP V) CREDIT NO. 1931-IN WORLD BANK IMPLEMENTATION COMPLETION MISSION: NOVEMBERJDECEMBER 1995 AIDE-MEMOIRE 1. A World Bank implementation completion mission visited Madras from November 25-28, 1995 and Bombay from December 4-6, 1995. The mission consisted of Dr. Anthony Measham (PHN Adviser and mission leader), Mr. R. Sethuraman (Finance Specialist), and Dr. Lessel David (Consultant Public Health Specialist). This aide-memoire sets forth the main findings of the mission. 2. The mission expresses its appreciation to the State of Tamil Nadu, and the Municipal Corporations of Madras, Bombay, and New Bombay, for their full co-operation and excellent hospitality. The mission undertook field trips in Madras, Bombay, and New Bombay. Wrap-up meetings were chaired in Madras by the Secretary, Health and Family Welfare Department, and in Bombay, by the Municipal Commissioner, Bombay Municipal Corporation. Mission Objectives and Overall Progress 3. The objectives of the mission were as follows to undertake a final review of progress before the project closing date of December 31, 1995: (a) provide advice and support to the Borrower in the preparation of its contribution to the Implementation Completion Report (ICR); and (b) to record the views of the Borrower and the Bank on project implementation. Overall progress in implementation of the project since the May/June 1995 review mission was judged to be very good in both Madras and Bombay. In Madras, excellent further progress has been made towards completion of the civil works prior to the project closing date. In both Madras and Bombay, the project will be fully implemented, performance against the key indicators appears to be very good, and the prospect for project sustainability is promising. The final (end-line) survey should provide additional information regarding project impact. 4. Attachments 1 and 2 provide the mission's findings on financial progress in the project. Bombay has already expended the full amount of Rs.48.3 crores sanctioned for the project, while Madras has expended Rs.62 crores out of the Rs.69.13 crores sanctioned. It is anticipated that the total sanctioned amount will be fully disbursed.  Appendix A Page 2 of 16 Project Issues 5. Project Extension. The Government of India (GOI) requested on October 18 and again on December 4, 1995 that the project be extended for three months beyond the closing date of December 31, 1995. The Bank responded to the first request by informing GOI that it was not possible to extend the project, which was expected to be fully implemented, for the purpose of using exchange rate savings, but that it would be possible to use those savings during the life of the project. After the May/June 1995 review mission, GOI began to prepare a submission to the Expenditure and Finance (EFC) Committee, requesting that an additional Rs.43.43 crores be sanctioned against the project. At the time of writing this aide-memoire, EFC approval had not been received. 6. In anticipation of EFC sanction of the additional amount, Madras and Bombay have gone ahead with procurement of additional civil works and equipment If EFC clearance is provided before the end of the project period, it will be possible for the Bank to disburse against expenditures committed before the closing date, and claimed up to April 30, 1996. Implementation Completion Review 7. The mission reviewed and commented on draft contributions to the ICR from the Madras and Bombay project authorities. The mission's main comment was that the drafts provided a good description of the achievements of the project but had not offered a critical analysis regarding the likely reasons for project success in various areas, or lack of same. The mission requested that this latter element be introduced into revised drafts, and that the contributions be not more than ten pages in each case. 8. The mission engaged in extensive discussions with project staff and other experts regarding the outcome of the project, and the factors responsible for success or lack of it. In addition, Dr. Lessel David stayed for several days after the main mission's departure, in order to undertake field trips and more extensive discussions. Dr. David will be responsible for drafting the Bank's contribution to the ICR, with the assistance of the other members of the mission. A draft of the Bank's contribution will be sent in January 1996 to the Government of India, the Madras and Bombay project authorities, and the concerned State Governments for review and comment, and will be submitted to Bank headquarters by February 28, 1996. 9. Key Factors affecting Project Implementation and Impact. There was substantial agreement between the mission and the project authorities in both cities regarding the key factors responsible for the outcome of the project. In many cases, factors were common to both urban areas. The following is a brief summary of the main factors agreed upon. The ICR itself will provide a more detailed exposition of these factors, and will note differences between the two cities, and in the views of the Bank and the implementing agencies, where they occur. 10. It was agreed that the project had achieved its main objectives in both Madras and Bombay. These were to:  Appendix A Page 3 of 16 (a) expand family welfare services with the emphasis on maternal and child health (MCH), birth spacing, and increased use of temporary contraceptive methods in Greater Bombay, Madras City and Chingleput district in Tamil Nadu; (b) improve the quality of family welfare services delivered in Bombay, Madras, and Chingleput; (c) strengthen the capacity of Tamil Nadu, Bombay, and Madras to plan, manage, and implement family welfare programs in urban areas; and (d) increase the participation of private voluntary organizations (PVOs) and private medical practitioners (PMPs) in the family welfare program in urban areas. While it was agreed that the achievement of the first three of the above four objectives was key to project impact, as measured by the performance indicators, this seemed less so in the case of the involvement of PVOs and PMPs. Involvement of PVOs and PMPs did increase, but the performance was mixed, especially in the case of the PMPs. In retrospect, it seems likely that the project would have succeeded in the absence of this objective, although the increased involvement of PVOs and PMPs was a positive factor in both cities. 11. The mission noted that, thanks to the vision of the project authorities in both cities, the project actually accomplished much more than had been originally envisaged in the project design. In the case of Tamil Nadu, it was possible to extend the project to all cities of 100,000 population in the state. In the case of Bombay, funds were made available to the New Bombay Municipal Corporation, which enabled it to provide family welfare services to over 400,000 inhabitants of that new and rapidly growing municipality. Several factors appear to explain how this expansion was possible. First, with the benefit of hindsight, the project seems to have been over-budgeted. Second, and importantly, the project authorities in both cities made savings where possible, for example, by not adding facilities and staff when this was advisable, by achieving efficiencies in project operation, and by being careful to limit the recurrent cost implications of the project wherever possible. Third, both project authorities demonstrated the commitment and flexibility to take these actions. 12. Overall, it appears that four factors were key to project success: * flexibility of project management; * broadening the family welfare services to give more emphasis to maternal and child health (MCH), to spacing, and to temporary contraceptive methods; * increasing demand by use of community workers and innovative information, education, and communication (IEC) techniques; and * the high level of commitment of the authorities in Tamil Nadu, Madras, Bombay, and New Bombay.  Appendix A Page 4 of 16 13. Examples of the flexible approach to project management have been cited above, in the expansion of project activities and the careful use of project funds. These approaches may be generalized by saying that the project authorities were flexible, opportunistic, and demonstrated the attributes of "learning" organizations, which are important factors for project success in any setting. 14. This project was in the vanguard of a more general shift in GOI strategy towards a broadened MCH approach to family welfare, and this shift was partly reflected in the Urban Revamping Scheme financed by GOI, and of which this project formed a part. The project therefore represented a demonstration of what could be accomplished through this strategy, and, by adopting a broad set of key indicators, allowed a good test of the approach. The project showed that demand for services increased when the broader approach was taken, and also demonstrated that the approach resulted in an equal, if not greater impact, on fertility and child mortality, than the more demographically-oriented strategy that had been pursued hitherto. The draft ICR will provide details of the demographic trends in the project areas over the life of the project, while Annex 4 gives the targets and achievements of the project. 15. A strong consensus suggests that the use of community workers - link workers in Madras and community health workers in Bombay - plus innovative IEC techniques, such as street plays, increased the demand for services and their quality. These accomplishments are well documented in the publication Reaching Out, just published in Bombay. The workers in Madras are unpaid volunteers, while those in Bombay (but not New Bombay) are paid (originally Rs.200/month and now Rs.500/month). Both approaches appear to have been successful. 16. Finally, the strong commitment to the project in both cities, and the track record in implementation of other projects, clearly was a key factor in the success of this project. The performance of the implementing agencies is rated as highly satisfactory. 17. Comments on the performance of the Bank will await the draft ICR. It can be said, however, that the project authorities considered Bank performance satisfactory, especially with regard to the progress review missions. However, the Bank was thought to have performed better in the management and finance than in technical areas, in the latter stages of the project. 18. Finally, this project clearly influenced policy in the two cities, in the state of Tamil Nadu, and in the GOI. This influence mainly occurred as a result of the performance in meeting the key indicators, within a broad set of MCH objectives. This, in turn, influenced the Government of Tamil Nadu to adopt this approach on a state-wide basis. The experience also informed the family welfare sector review (Report No. 14644-IN: India's Family Welfare Program: Toward a Reproductive and Child Health Approach), recently completed by GOI and the Bank. The sector report recommendations, in turn, may have had a bearing on GOI's decision to drop method- specific contraceptive targets in at least one district in each state (and in all districts of Tamil Nadu and Kerala). Some of the recommendations of the report are likely to be implemented in the Reproductive and Child Health project being prepared for possible Bank financing.  Aplendix A Page 5 of 16 Next Steps 19. The project authorities in each city are requested to proceed expeditiously with the final (end-line) survey for the project and to revise and summarize their contributions to the ICR. The mission will prepare and present its ICR contribution for review and comment by GOI, the project authorities, the State Governments, and Bank management. 20. The mission would like to commend the project authorities in Madras and Bombay for the successful implementation of this project.  Appendix A Page 6 of 16 Attachment I Fifth Population Project (IPP V) - MADRAS (November 25 - 28, 1995) IPP V Madras project has an approved project outlay of Rs.69.13 crores with a life span of seven years closing on December 31, 1995. The scope of the project was originally designed to cover the urban slums of Madras city and the neighboring urban agglomeration of Chengalpattu district. The project was extended under Phase I expansion program from September 1992 to the corporation areas of Madurai, Coimbatore, Salem and Tiruchirapalli and the municipal areas of Nagercoil, Tuticorin, Erode and Tiruppur with an outlay of Rs 8.78 crores; and under Phase 11 expansion program from April 1993 to 15 new municipal areas. To cover the entire Chengalpattu District, three left over municipal areas of the district were included during Phase III expansion with an outlay of Rs. 40.22 lakhs. Furthermore, under Phase IV expansion program, upgrading of maternity, neonatal and paediatric facilities has been agreed to in all the district and taluk hospitals in the State at an outlay of Rs.7.00 crores. Service Delivery Expansion Under the project, 140 Urban Health Posts (one for 50,000 population) in Madras city and suburban areas, 15 in Zonal centers were set up. Under Phases I and II, additional Urban Health Posts, Urban Family Welfare Centers, and PPCs were included. Repairs and renovations for Maternity Homes in the Phase I and II areas and the ICDS centers have also been completed under the project. Almost all the civil works have been completed and only finishing works are in progress, and expected to be completed and handed over to the respective municipalities/corporations before end- December 1995. To improve the quality of service delivery, additional equipment will be procured to strengthen Maternal and Child Health Care Services in 134 Taluk Hospitals and 8 district hospitals. In this process Taluk hospitals and district hospitals perform the functions of First Referral Units (FRUs). Financial Status Out of the total approved outlay of Rs.69.13 crores, the project has reportedly posted an expenditure of Rs.62.03 crores as on October 31, 1995 leaving an unspent balance of Rs.7.1 crores. In view of the commitments already made, this balance amount is expected to be fully utilized before December 31, 1995, the project closing date. However, the project outlay is not sufficient to meet the additional commitments made for strengthening the district and taluk hospitals. The additional commitments are estimated to cost Rs. 20 crores. The Ministry of Health and Family Welfare has, based on the recommendations made by the state government, initiated steps to obtain the approval of Expenditure Finance Committee (EFC) for allocation of additional amount of Rs.20 crores to be committed before the project closing date. A statement showing componentwise details of estimated  Appendix A Page 7 of 16 expenditure up to December 31, 1995 and the additional funds proposed for EFC approval is at Attachment I. The additional amount of Rs. 20 crores proposed to be spent after approval by GOI includes the following components: 1. Civil works 4.09 2. Equipment 8.28 3. Additional staff salaries 0.88 4. Equipment to taluk 6.00 hospitals The project authorities have cleared the bidding documents with the Bank and have also reportedly received bids in response to the tenders quoted under LCB and referred to Bank for prior clearance. It would be possible to process and place formal supply order(s) on the identified supplier/manufacturer firm(s) only after the EFC approval is obtained. Even if EFC approval is secured before mid December 1995, as expected, it is unclear whether it would at all be feasible for the suppliers to supply the entire quantum indented for before December 31, 1995 All equipment proposed to be procured under the project should be delivered to the project authorities on or before the project closing date so that the expenditure incurred would be eligible for reimbursement. Sustainability of Project Activities The additional recurring expenditure annually after the project closes is estimated to be as follows: Rs in crores Commitments 1.40 to Urban Family Welfare Centers/Urban Health Posts Commitments made 7.30 under IPP V Project in Madras, suburbs and Phase I Phase II commitment 2.16 Total 10.86 The annual recurring cost to sustain the project activities after the project would be of the order of Rs. 10.86 crores. The Govemment of Tamil Nadu has taken the stand that all recurrent costs to be incurred under the Family Welfare program should be met by GOI. The state govemment is awaiting the response of the MOHFW whom they have requested to fund the recurrent cost under the centrally sponsored Urban Revamping Scheme.  Appendix A Page 8 of 16 Summing Up Under this project there is a substantial increase in the level of civil works program covering both expansion and renovation over and above the provision made in the original project. Another striking feature is that the civil works expansion program covers 23 towns/municipalities spread throughout the state. The civil works expansion program which was taken up only two years ago has been completed in record time. This project has also improved quality of service delivery by strengthening MCH services in 134 Taluq Hospitals and 8 District Hospitals. This project has thus assisted the establishment of First Referral Units in almost all the districts at taluq level. These facilities, which had not been provided for under the project, have resulted from timely utilization of exchange rate savings. At the time of closure of this project the annual recurring cost for sustaining the project activities is estimated to be nearly Rs. 11.00 crores. The Government of Tamil Nadu has not made any commitment to meet this cost from the state budget. The state government has formally approached the MOHFW with a request to meet the recurring cost of the project under the centrally sponsored Urban Revamping Scheme. Approximately 20 Health Posts are run by Private Voluntary Organizations. It is necessary that the state government provide for their continued support from the state budgetary resources after the expiry of the project period. The state government has succeeded in optimizing the utilization of the project funds and extended the overall project to cover almost the entire state at taluq level.  Appendix A Page 9 of 16 Attachment I Table I INDIA POPULATION PROJECT V - MADRAS PROBABLE EXPENDITURE UNDER IPP V FOR ON GOING PROGRAMMES FROM 1.4.95 TO 31.12.95 Pojected Expenditure from 4/95 to 12/95 S.N Components Appro- Expendi- Within Expendi- Probable Additional Total priation as ture up to Existing ture up to up to Funds per SAR 31.3.95 Project 10/95 31.12.96 Proposed Outlay 1. Civil Works 927.00 549.00 0.00 0.00 0.00 123.00 123.00 2. Furniture 91.00 45.00 0.00 0.00 0.00 0.00 0.00 3. Equipment 558.00 984.00 204.00 107.32 96.68 828.00 1023.00 4. Vehicle 85.00 61.00 0.00 0.00 0.00 26.00 26.00 5. Local Adviser 260.00 11.00 4.00 0.34 3.66 0.00 4.00 6. Local Fellowship 44.00 59.00 10.00 7.75 2.25 0.00 10.00 7. Professional Fees 143.00 28.00 3.00 0.02 2.98 0.00 3.00 8. Foreign Fellowship 30.00 16.00 0.00 0.00 0.00 0.00 0.00 9. Books 0.00 1.00 0.00 0.00 0.00 0.00 0.00 10. Addi. Staff Salaries 3356.00 2106.00 546.00 319.77 226.23 88.00 634.00 II. Consumable 1241.00 755.00 180.00 27.74 152.26 0.00 180.00 Materials 12. Operation & 70.00 20.00 4.00 1.29 2.71 0.00 4.00 Maintenance of Vehicles 13. Other Operation & 108.00 283.00 21.00 8.05 12.95 0.00 21.00 Maintenance 14. PWI) IPP-V Div. 0.00 690.00 333.00 123.66 209.34 286.00 619.00 Construction 15. ICDS, Centres 0.00 0.00 0.00 0.00 0.00 49.00 49.00 Repairs 16. Equipment to Taluk 0.00 0.00 0.00 0.00 0.00 600.00 600.00 Hospitals I I.I_I _ III 6913.00 5608.00 130500 1 59594 79.06 200.0 330  Appendix A Page 10 of 16 Attachment 2 Fifth Population Project (IPP-V) BOMBAY (December 4 - 5, 1995) A. Municipal Corporation of Greater Bombay (BMC) IPP V Bombay project has a GOI approved outlay of Rs. 48.30 crores with a life span of seven years, closing on December 31, 1995. The project has reported an expenditure of Rs. 53.40 crores for the period ending 30th November, 1995. The expenditure projected for December 1995 is Rs. 5.10 crores. Details of actual and projected expenditure are given in Annex I. The project was originally approved to cover the slum population in Greater Bombay. Subsequently the State Government, in association with BMC, agreed to extend the project activities to New Bombay. The MOHFW issued two financial sanctions diverting a sum of Rs. 11.04 crores - one for Rs. 6.78 crores on July 19, 1993 and the other for Rs. 4.26 crores on July 26, 1993 for setting up a 100-bedded FRU - out of the approved project outlay for expansion of IPP V activities to New Bombay Municipal area. Bombay and New Bombay Corporations were allocated Rs.37.26 crores and Rs.1 1.04 crores respectively. Out of Rs.5. 10 crores to be incurred during December 1995 the following three components accounting for major share of the projected expenditure: Rs. in crores Civil Works 1.20 Equipments 1.26 Salaries 1.04 Expenditure for staff salary is a committed and will be utilized. In the wrap up meeting, it was assured that orders for supply of equipment would be placed within a week. However, in the case of import of Ultrasound equipment costing Rs.0.85 crores delivery would take place only after the project closing date. The Municipal Commissioner urged that expenditure incurred for all the equipment for which supply orders are placed before the project closing date be treated as committed expenditure eligible for disbursement irrespective of the date of receipt of goods by the project authorities. The Municipal Commissioner agreed that a formal request would be made by the BMC to the Bank on this account. In civil works, it was reported that construction of all nine Post Partum Centers and 47 Health Posts had been completed. Four Mobile Vans would be procured before end- December 1995 for commissioning mobile health posts.  Appendix A Page 11 of 16 B. Navi Mumbai Municipal Corporation (NMMC) Under this project all ten Urban Health Posts have been established in the Panchayat buildings by making additions and alterations. Five new MCH centers have been constructed and they are operational. One FRU Hospital (150 bedded) has already started functioning in the ESIC building. NMMC has reported an expenditure of Rs. 1 0.88 crores for the period ending November 1995. NMMC have sought allocation of additional sum of Rs.1.93 crores over and above the originally sanctioned amount (Rs. 11.04 crores), to complete the project activities. This forms part of the additional allocation of funds awaiting EFC approval. The total estimated expenditure by NMMC during the project period would be of the order of Rs. 12.82 crores subject to approval by the EFC. A statement giving the break up of expenditure from June 1993 to December 1995 is at Table 2. Bombay and New Bombay BMC and NMMC require Rs.58.50 Crores and Rs.12.82 crores, respectively, for completing all the project activities before the closing of the project. Therefore, EFC approval is being sought for a total revised project outlay of Rs. 71.32 crores. The annual recurring cost for BMC to sustain the project activities after the project is over is estimated to be Rs. 12 crores. The Municipal Commissioner of BMC has assured that this would be met out of their own budgetary resources. Likewise, Municipal Commissioner, NMMC has also certified that it would be possible to sustain the project activities out of their own budgetary resources. Summing Up Bombay Municipal Corporation (1) IPP V project has brought about establishment of 176 Urban Health Posts in slum areas of Greater Bombay. The project has set up 30 Post Partum Centers, each serving as First Referral Unit linked with 5-6 Urban Health Posts. These MCH centers provide high quality MCH services free of cost to poor people living in Bombay slums. (2) This project has promoted participation of Private Voluntary Organisations in the Family Welfare and MCH Programs. (3) The project has also extended its activities to New Bombay which had no basic health infrastructural facilities (4) This project has promoted the functioning of Voluntary Women Health Workers amongst the slum population of Bombay. New Mumbai Municipal Corporation Extension of IPP V project to New Bombay has brought about establishment of basic facilities in the form of 10 Urban Health Posts, 5 MCH Centers and one FRU Hospital with 150 beds.  Appendix A Page 12 of 16 Almost all the equipment and medicines required for operationalising these centers have been procured. A high quality health delivery system has been developed. The only area in which the NMMC is experiencing difficulty is in the recruitment of trained medical and paramedical personnel. Efforts are continuing to fill up all these vacant posts.  Appendix A Page 13 of 16 Attachment 2 Table I Bombay Municipal Corporation Break-up of Expenditure from 01 / 11/87 to 31/12/95 Rs. In Crores Description Expenditure Expenditure to be Total incurred up to end- incurred in Dec. 95 1. Civil Works 3.39 1.20 5.19 2. Equipments 6.07 1.26 7.33 3. Furniture 0.72 0.50 1.22 4. Vehicles 0.88 0.12 1.00 5. Salaries 37.04 1.04 38.08 6. Expert Services 0.59 0.01 0.60 7. Fellowship 0.16 0.05 0.21 8. Books 0.005 0.01 0.015 9. Consumables 1.57 0.35 1.92 10. Operation & 2.38 0.56 2.94 Maintenance TOTAL 53.405 5.10 58.50  Appendix A Page 14 of 16 Attachment 2 Table 2 Navi Mumbai Municipal Corporation Break-up of Expenditure from June 1993 to December 1995 Rs. In Crores Description Expenditure incurred Expenditure to be Total up to end-Nov. 1995 incurred in Dec 1995 1. Civil Works 2.9000 0.2315 3.1315 2. Vehicle 0.6740 0.1250 0.7990 3. Medical Equipment 2.5800 0.6000 3.1880 4. Office Furniture 0.6600 0.1500 0.8100 5. Staff Salary 2.5900 0.1500 2.7400 6. Consumable 0.5200 0.5000 1.0200 Medicines 7. ESIS Hospital Rent 0.1500 0.1500 8. Operation & 0.3500 0.1010 0.4510 Maintenance 9. Foreign Tour 0.0260 0.0400 0.0660 10. Advertisement 0.0620 0.0200 0.0820 11. I.E.C Training / 0.0820 0.0200 0.1020 Activities 12. Staff Training 0.0570 0.0570 13. Consultancy 0.0230 0.0230 Services 14. MIS Systems 0.2100 0.2100 TOTAL 10.8840 1.9375 12.8215  Appendix A Page 15 of 16 INDIA: FIFTH (BOMBAY AND MADRAS) POPULATION PROJECT (Credit 1931-IN) Status of Key Project Indicators on December 1, 1995 BOMBAY NEW BOMBAY Indicators/Goals Appraisal Actual Comments Appraisal Actual Comments (Percent) Target Achievement t Target Achievemen date t to date Effective 60 59.2 60 55.0 contraceptive nrevalence Immunization 95 82.6 95 92.0 coverage Ante-natal care 95 77.3 95 90.0 Post-natal care 95 88.4 95 90.0 Institutional Deliveries 98 94.6 98 83.0 Growth Monitoring 80 N.A. 80 N.A. Birth order 3 Reduction N.A. Reduction N.A.  Appendix A Page 16 of 16 INDIA: FIFTH (BOMBAY AND MADRAS) POPULATION PROJECT (Credit 1931-IN) Status of Key Project Indicators on December 01, 1995 MADRAS CITY MADRAS SUBURBS Indicators/Goals Appraisal Actual Comments Appraisal Actual Comments (Percent) Target Achievement Target Achievement to date to date Effective contraceptive 60 67.4 60 57.9 prevalence l Immunization coverage 95 99.7 95 99.6 Ante-natal care 95 96.3 95 93.2 l Post-natal care 95 85.4 95 81.9 Institutional Deliveries 98 99.2 98 97.6 Growth Monitoring 80 79.5 80 32.8 Birth order 3 Reduction Decline Reduction Decline from 25.2% from 33.5% to 15.4% to 16.2% EXPANSION PROGRAM FOR OTHER CITIES IN TAMIL NADU PHASE I PHASE II Indicators/Goals Appraisal Actual Comments Appraisal Actual Comments (Percent) Target Achievement Target Achievement to date to date Effective contraceptive 60 48.0 60 49.5 prevalence Immunization coverage 95 93.5 95 85.6 l Ante-natal care 95 87.4 95 87.8 Post-natal care 95 81.5 95 89.6 Institutional Deliveries 98 98.3 98 95.0 l Growth Monitoring 80 39.3 . 80 60.9 Birth order 3 Reduction 20.6% Reduction 20.0%  Appendlx B Page 1 of 13 INDIA POPULATION PROJECT V - MADRAS Borrower's Contribution Reasons for the Success of the IPP V Project 1. Madras City is the Capital of Tamil Nadu State and the fourth largest Metropolitan City in the Country in terms of population. It had a population of 14.16 lakhs in 1951 and it increased to 32.7 lakhs in 1981 and 38.41 lakhs in 1991. The slums in Madras City which were 1413 in December '86, increased to 1847 by June '89 (i.e.) an increase of 30.71 percent. The reorganized National Family Welfare Programme (FWP) was being implemented by the Corporation of Madras with one City Family Welfare Bureau, 44 Urban Family Welfare Centres, 41 Child Welfare Centres rendering Family Welfare, Maternal and Child Health (FW & MCH) services for the City population apart from the teaching medical institutions, postpartum centres, private nursing homes and clinics functioning in the city. 2. The emphasis on the need to provide the FW&MCH services through the outreach programme for the slum and congested population was recommended by the Krishnan Committee and accordingly 29 Urban Health Posts were functioning under the Urban Revamping Scheme (URS) with 100% GOI financial assistance. Under these circumstances the World Bank assisted IPP V was proposed for Madras City with an outlay of 60.71 Crores and the DCA (Credit No. 1931) between India and IDA was signed in September 1988 with a revised Project outlay of 69.13 Crores. 3. As per the agreement, the entire Madras City and also the eight Municipal areas of Chengalpattu MGR District adjoining Madras City were included for the coverage of Project activities. The objective of the Project was to provide the slum population with basic health facilities with a special emphasis on MCH care and FW services. The cost of the project is shared by GOI and government of Tamil Nadu in the ratio of 90% and 10% respectively. 4. The nodal Department at the state level is the Health and Family Welfare Department of Government of Tamil Nadu. A separate Cell was established at the Secretariat to process the proposals relating to IPP V and get approval of the Government. A separate Project Directorate was formed at the State level to monitor the implementation of Project activities. Actual implementation at the field level was entrusted to the Corporation and municipal authorities with necessary supporting staff. 5. A Steering Committee under the Chairmanship of the Chief Secretary to Government was constituted to coordinate, monitor and clear the IPP V proposals and activities. An Empowered Committee was also formed to process and approve the proposals put forth by Project Director for implementation. A Tender Committee was also formed under the Chairmanship of Health Secretary to clear the tender proposals with reference to Civil Works. This administrative set up helped to clear proposals fast. It also avoided a lot of bureaucratic delay redtape. 6. As a first step, the integration of Maternity Centres and the Health Posts was done so as to ensure comprehensive health delivery both in the institution and through outreach. The entire Madras City area was reorganized into 'D' Type Health Post pattern of the URS of GOI with due allocation of 50000 population to each Post Partum Centre area and 30000 population to each Health Post area. Needbased  Appendix B Page 2 of 13 reallocation was done without leaving any of the areas uncovered while this integration and reorganization was done. Those pucca buildings where the centres already existed were taken over as it is and repairs needed were carried out whereas while taking up new constructions for the proposed new Health Posts, the location was identified in a central place and as far as possible in the midst of the slums to ensure easy accessibility of the MCH&FW services to mothers and children. 7. In order to identify suitable locations for construction and also to assess the fitness of sites, consultants were utilized. The construction works in the Corporation area were entrusted to the Building Division of the Corporation of Madras and in respect of the Municipal areas the work was entrusted to the Public Works Department. Periodical reviews were undertaken both by Project Director and by the Health Secretary to assess the progress and also to speed up the works and remove the bottlenecks if any brought to the notice. 8. The Project Directorate played a crucial role in close monitoring of the implementation of field level activities in the Corporation and Municipal areas, conducting periodical review meetings with all the implementing officials and communicating regular feed back to each area on the progress made and also on the action to be taken for improvement etc. The leadership under an IAS Officer as Project Director helped in coordinating the implementation of activities with other Directorates of Health and Family Welfare Department. Wherever shortfalls were noticed, those officers and field staff were given a feed back so that no area lagged behind the expected level of achievements at any given point of time. 9. The main factor for the success is the service rendered through outreach at the doorsteps of the slum dwellers and the Multipurpose Health Worker (F) (MPHW) plays an important role in this aspect. The initial step taken by the Project Directorate was to identify and select the field workers from among the slum dwellers and send them for full fledged 18 months' training course to qualify, as MPHW(F). Recognized government and Private Voluntary Organization (PVO) training institutions were involved for this purpose and all the trained MPWs were posted for field work in their respective areas which enabled quick rapport and recognition for them in the community to undertake the challenging task on MCH&FW activities expected under the project. 10. To ensure proper documentation of the field activities carried out by the MPHWs, the streamlined system of record maintenance and reporting was introduced under MIES. The comprehensive records introduced enabled the workers to concentrate more on outreach activities and the time spent in writing work was reduced to the minimum. Periodical field verifications were undertaken to ensure accuracy of records and reports by officials of the Project Directorate and the Corporation of Madras. 11. The baseline survey which was undertaken before the initiation of the Project helped in identifying the priority issues and the findings of the survey were utilized during implementation to ensure improvement. In addition, certain need based surveys, Training Needs Assessments, IEC impact assessments, etc., were also undertaken from time to time to fulfill the project objectives. The mid-term impact analysis undertaken by the Project Directorate and also the external mid-term assessment suggested by World Bank mutually undertaken both by Madras and Bombay IPP V areas helped in the course corrections during implementation. 12. Quality of services of the field functionaries improved through periodical short term training programmes undertaken by the training team of the Project Directorate. The training needs for various  Appendix B Page 3 of 13 levels of functionaries assessed by the TNA study were utilized for developing a curriculum for various levels of officials and field workers. Induction training, in-service training, refresher training, supervisory skill development training, records maintenance training, IEC training, sonar training, management development training, training on resuscitation of new born, trainers' training, anesthesia training, theatre training, health education and other need based technical training programmes were the activities carried out by the training team of the Project Directorate in coordination with the training wing of the corporation of Madras and other training institutions like Health and Family Welfare Training Centres, Egmore, Salem and Gandhigram and Institute of Public Health, Poonamallee. The programmes were participant oriented with practical suggestions. In addition, seminars and workshops were also organized for the supervisory officers to promote participation for achievement of project goals. Knowledge, skill and ability were the focus in the training programmes. 13. The district level hospitals as well as the taluk and non-taluk hospitals in the state were strengthened with supply of equipments and furniture for improved service delivery under MCH. The First Referral Units (FRUs) were strengthened to ensure the availability of specialized services in easy reach. Ultrasound scanners were supplied to the FRUs an the Medical Officers from FRUs were given 15 days training in handling the equipment. 14. Innovative types of IEC activities were undertaken to educate and motivate the community and to increase the levels of awareness of the FW&MCH Programmes. Women link leaders were selected among the slum dwellers at the rate of one worker for every 20 families to act as a liaison between the health workers and the community for an effective health delivery system. Their involvement in this task as voluntary workers without any remuneration for their services created a great impact. Timely referral of complicated cases if any to the nearest FRU for medical attention was ensured through this network. 15. Though the GOI had been implementing the URS, the health posts did not have any provision for drugs. This was a major drawback of the URS. IPP V ensured availability of drugs in all the areas under the Project which led to a better utilization of the health services by the public. Systematic supply of drugs was ensured so that there was no Health Post without drugs at any given point of time. The Government of Tamil Nadu subsequently established a Medical Services Corporation which streamlined the procedure for drug supply and distribution This uniform procedure has further helped all medical institutions in the State including the Health Posts to have a regular supply of drugs. 16. The involvement of the PVOs was one of the project objectives and accordingly as many PVOs as possible, including those already in existence, were involved. Most of the PVOs evinced keen interest and commitment. However, there were instances where there was no improvement in the performance in a few PVOs despite efforts to remedy the situation. Such of those PVOs who were chronic defaulters in rendering service had to be removed from the programme and those areas were re-allotted to other Health Post areas of the Corporation for coverage of health delivery services. 17. In the year 1992-93, it was estimated by the Project Directorate that all the proposed activities could be completed with a smaller rupee allocation of about Rs. 45 crores by the end of the project period and hence the balance funds from project outlay of Rs. 69.13 crores could be utilized for expanding the project activities to other urban areas of Tamil Nadu. The credit agreement was therefore amended to include other urban areas also.  AppedxB Page 4 of 13 18. With the concurrence of World Bank and Government of India, the Phase-I expansion was undertaken with effect from September 1992 to include two more corporations and six Municipal areas whose population was 2 lakhs and above. The outlay was Rs. 8.78 crores. Subsequently this issue was discussed with the World Bank Review Missions and concurrence for a Phase II expansion with effect from April 1993 with an outlay of Rs. 14.85 crores was again obtained from World Bank and GOI. This expansion covered 15 municipal areas having a population of one to two lakhs. The Municipal Commissioners and municipal Health Officers were the implementing officials of the project activities and the Deputy Director of Health Services of the districts were the technical supervisory officials in these areas. Reviews, monitoring and feedback were all carried out in similar lines as undertaken for original project area and the Project Directorate monitored the progress of service delivery at the State level. 19. Repairs and renovation works to the Maternity Homes in the expansion areas were undertaken utilizing the engineering staff of the respective Corporations and Municipalities. The maintenance of the ICDS Centres which function as units for service delivery under MCH and nutrition was felt to be essential and hence funds were provided to these areas for repairs and maintenance which helped in improving the delivery of MCH service. 20. In order to ensure complete coverage of Chengalpattu MGR District which was the original Project area, three left out areas were included for coverage under Phase III expansion and civil works for 10 bedded maternity ward were undertaken in these areas. Minor civil works were undertaken in all the FRU areas as Phase IV expansion in addition to supply of equipments so that the aims of the Project were fulfilled in all the urban areas in delivering effective MCH services. 21. The World Bank supervisory mission were flexible and encouraged the Directorate to expand its activities. 22. The IEC strategy focused on Project objectives and messages on social issues like age of marriage, literacy and education of women and the quality of life that could be achieved by a small family were all covered by different media. The IEC programmes reached the targeted slum community through the judicious combination of media mix and interpersonal and group strategies. Emphasis was given on interpersonal and group contacts by the grass root level workers. This was supported by mass communication programmes through film shows, video shows, TV, AIR and Press. Vehicles with paintings on MCH&FW messages were supplied to all the Corporations/Municipalities under the project area which were utilized for field publicity. IEC printed materials and manuals were supplied to all the workers. Competitions, auto stickers for propogating health and family welfare messages, etc. helped in increasing the awareness among the community. 23. A separate project directorate, continuity in tenure of project directors, availability of resources and manpower, focused objectives and a flexible administrative set contributed in large measure to the success of the project.  Table 1: INDIA POPULATION PROJECT V Expendituire Claims up to March 1996 SI.no. Coiiiponent Appropriation Total expdr. Claim filed Expenditure Claim filed Total expdr. Total clain Details of grants as per SAR for from 1986 from 1988 for 4/95 to from 4/95 to from 1988 filed from received fron the project to 3/95 to 3/95 31.3.1996 31.3.1996 to 31.3.96 1988 to 31.3.96 GOI I. Civil Works 20820000 129192679 106680847 50227685 45204917 179420364 151685764 2. Funiture 4500000 4522847 7368788 0 0 4522847 7368788 Rs. In lakhs 3. Equipment 241200000 98438407 81984543 89867126 76387058 188305533 158371601 upto 4. Vehicle 8700000 6095017 5420730 0 0 6095017 5420730 89-90 = 466.00 5. Local Adviser 8000000 1084875 1006013 155451 155451 1240326 1161464 90-91 = 300.00 6. Local Fellowship 1000000 5955010 6119224 723193 723193 6678203 6842417 91-92 = 900.00 7. Professional fees 3100000 2376384 2212214 367189 330470 2743573 2542684 92-93 = 837.00 8. Foreign Fellowship 1000000 1616919 1955322 0 0 1616919 1955322 93-94 = 2400.00 9. Books 100000 96353 81900 2264 1924 98617 83824 94-95 = 1558.26 10. Addl. Staffsalaries 284400000 213105340 169984803 71969662 43181792 285075002 213166595 -------------- 11. Consumable material 93500000 75466408 56674957 22674862 13604916 98141270 70279873 Total 6461.26 12. Maintenance of vehicle 2400000 1977686 1575058 304064 182439 2281750 1757497 -------------- 13. Other Operation & Maintenance 35200000 28786352 24496390 23392819 14035691 52179171 38532081 95-96 2016.00 Total 891300000 568714277 465560789 259684315 193807851 828398592 659368640 847726 -Tolal expenditure from 1988 to 31.3.1996 828398592 For the month of April 1996 216000 For the month of May 1996 18966558 Total Expenditure 847581150 (IQ e 3  Appendix B Page 6 of 13 INDIA POPULATION PROJECT V MUNICIPAL CORPORATION OF GREATER MUMBAI PUBLIC HEALTH DEPARTMENT Borrower's Contribution Project Objectives and Activities 1. India Population Project V has been implemented by the Public Health Department with the financial assistance of Rs. 48.30 crores from the World Bank/Govt. of India since October 1988. Out of this amount an amount of Rs.37.26 crores was allocated to Mumbai Municipal Corporation and the amount of Rs. 11.04 crores was diverted to Navi Mumbai Municipal Corporation for development of infrastructure. The project was to get over by 31 st March 1995 initially but its period was extended up to 31st December 1995 and again up to 31st March 1996. The Municipal Corporation Mumbai had incurred an expenditure of Rs.43.49 up to 31.3.95 on the project. The additional grant of Rs. 15.01 crores over and above Rs.43.49 crores was sanctioned by the World Bank/Government of India for the project making the total outlay of Rs.58.50 crores. The project period is over on 31st March 1996. 2. The Project in nutshell is the strengthening and expansion of preventive and promotive health care services with special emphasis on Family Welfare and Maternal and Child Health with effective Out Reach Services to the door steps of Urban Slums and shanties through scientific organizational systems. The Project aims at (i) bringing down the mortality rates amongst children and mothers; (ii) promotion of Family Welfare Services to accelerate decline in fertility and restricting population and growth rate. 3. The goal is revamping the organization, service delivery and out reach systems for Family Welfare in Urban slums and congested areas and the objectives are: * Expansion of Family Welfare Services with emphasis on Maternal and Child Health through various methods * Improving the quality of services * Strengthening the capacity to plan, manage and implement Family Welfare Programme in Urban areas * Increasing the participation of Private Voluntary Organizations and Private Medical Practitioners in the programme 4. This was to be achieved by establishing in all 180 Health Posts and 30 Post Partum Centres to cater to the entire population of Greater Bombay. Each of these health posts caters a specific area covering about 65000 population in slums and 1,00,000 population in non-slum areas. Until now, the people had to come to our health centres, dispensaries, maternity homes and hospitals. Under this project, the health post staff goes to the doorsteps of our citizens to assess their needs and provides health care either preventive, promotive or curative. We have established 176 Health Posts out of which 8 Health Posts are run in collaboration with Private Voluntary Organizations. We have also introduced  Appendix B Page 7 of 13 Innovative Scheme with help of Private Voluntary Organizations known as Mobile Creches which render health care services to migrant construction workers and their children. 30 Post Partum Centres have been established under the Project. 5. Out of 176 Health Posts, 50 Health Posts are in new constructions out of which 7 new construction have been done and health posts have been established therein. Besides this, there were 9 new constructions for Post Partum Centres which have been completed and the Post Partum Centres have been started therein. We have also procured 21 ambulances for Post Partum Centres. Some sophisticated items and equipments viz. Semi Auto Analyzers, Colposcopes and Ultra Sonography Machines have been procured for rendering specialized services in our Post Partum Centres. At every ward office and in every Municipal Hospital or Maternity Home a service-cum-information counter has been put up. This counter is attended by para medical staff of the centre by rotation. The counter is utilized to carry out I.E.C. activities. The application forms for birth certificates are given at this counter so that community comes into contact with this counter. This approach has improved the use of contraceptive devices. The condoms and oral pills are distributed free of charge at this counter. the community is given all the information about how to use it etc. I.E.C. material of different diseases like Gastro, T.B., Malaria, AIDS is distributed from this counter. These counters are found very useful in building up good rapport with the community. 6. The novel features of the project are establishment and development of (a) Management, Information and Evaluation Systems Cell; (b) Information, Education and Communication Cell; (c) Training Cell and increased participation of Private Voluntary Organizations and Private Medical Practitioners. 7. The Information, Education and Communication Cell is the mouthpiece of the project. It deals with the following: * It creates awareness of the facilities and services, their benefits etc. among the slum dwellers through different Mass Media facilities, establish inter personal communications and provide Mass Education in communication, behavioral and social sciences through group/community meetings. The cell is equipped with modern media machinery and equipments. * The training is an important feature of the project. The pre-placement, inservice, technical, managerial and up-grading training programme is arranged from top level officers to lower workers (macro level to micro level) and periodic assessment of the trainees and training of trainers is undertaken by this Cell with specific responsibility of collaborating with local training institutions. The Cell also prepares training manuals, schedules and materials for the service delivery and various health programmes. The Private Voluntary Organizations and Private Medical practitioners are also involved in the implementation of the project. the Private Voluntary Organizations are involved in developing Health Posts under revised grant-in-aid procedure with appropriate compliment of staff. The Private Medical Practitioners are also involved by undertaking their training in various methods of Family Welfare to upgrade their skills, providing them with supplies of planning devices etc. so as to achieve maximum motivation and results. 8. The Management, Information and Evaluation System Cell is the monitor of the project in the sense that it is responsible to develop and implement monitoring and evaluation programmes. This is  Appendix B Page 8 of 13 achieved through installation of computers to analyze the feedback from the health posts and provide management tools to improve performance. This cell has developed a system to provide various statistical data of information bases and performance factors. This cell also provides orientation and traininig for staff about new procedures and technology for implementation of the Management, Information and Evaluation System Plan. The main functions of this cell are Monitoring, Evaluation and Research. 9. The expenditure incurred on implementation of the project till 31.3.1996 is Rs.59.89 crores as per details given in the accompanying table. Constraints 10. Procedural delay in purchase of equipments and instruments. Delay in purchase of ambulances, vehicles for Mobile Health Posts for transport department. Shortage of staff. There are number of vacancies in the category of Auxiliary Nurse Midwives but because of reservation for backward class, we are not getting suitable candidates despite advertising the posts. Besides there is no facility of hostel for ANMs which also results in not getting candidates. Sustainability of the Project I I. The project period is over on 31st March, 1996. Under the project a big infrastructure has been developed and the entire area of Municipal Corporation of Greater Mumbai is covered and many other programmes such as T.B. Control, Malaria Eradication, AIDS Control, PID Project, etc. are undertaken in this project. The activities of the project are to be continued. The infrastructure also provides a good system to integrate all the health care services to the periphery. The ultimate idea is to provide Voluntary Women Health Workers to every slum family living in Mumbai and therefore this project has to be sustained after 31st March 1996, for which sufficient budget provision for the year 1996-97 has been made by the Corporation. Conclusions 12. India Population Project-V has made an impact on total health delivery system giving new insights to both project authorities and the beneficiaries. The project although tackled one of the most complicated area of social development has shown increasing results and has become a model in the field of Family Welfare and Mother Child Health especially in respect of Training, I.E.C. and M.I.S., health care service delivery and referral systems and collaboration with PVO's.  Appendix B Page 9 of 13 Table 1: INDIA Population Project V Municipal Corporation of Greater Mumbai Public Health Department Training Cell Cumulative Report Yearwise Year Induction Inservice Subjects of Inservice Training PMP's Total Training Training Training 1988 - - AIDS, Foetal Medicine - - 1989 766 147 Administrative Matters 138 1051 1990 1765 927 Street Theatre, Computer 66 2758 1991 1942 445 Software, Eye Care 232 2619 1992 3425 1574 Child to Child, National 258 5257 1993 483 4151 Health Programme 277 6966 1994 68 6671 Mental Health 227 6966 1995 70 7603 Breast feeding, Video Grafites and VCR, 187 7860 (Up to Oct). Package Environmental Sanitation, Medical Nov. 1995 997 Emergencies, Growth Monitoring, Cancer - 997 up to of Mar-96 Female, Acute Respiratory Tract Infection, Using Audio-Visual for Health Education, Sonography Community Out reach, Community Participation, Control of Diarrhoeal Diseases and Preparation of ORS, Sonography, Oral Communication, Puppetry Show, Drug-Deaddiction, Colposcopy, Child Survival and Safe Motherhood, Diseas-: Surveillance, Immunization and Cold Cihain maintenance, Planning and implementation, Cervical Cytology Total 8519 22515 1385 34474  Table 2: Break-up of Expenditure from 01/11/87 to 31/3/96 Coll. Project Fatal Mcd. Dcscription Tot. Anioutnt D.M.C. CCD + Ward Ml.IS. I.E.C. Trainiig Bureau 1I1P. P.P.C. Sion llosp. Sioii llosp. PPC & PBW P.V D. Civil Works 45312536.64 0.00 160458.38 0.00 0.00 0.00 233748.00 17468447.82 26791226.64 0.00 185392.65 473263.15 0.00 Equlipme,lts 72855810.72 780.00 1697178.81 4153982.80 1699195.95 544662.68 1128200.00 3466661.02 56970391.29 287968.00 2238071.75 415332.72 253385.70 Furniture 7536889.86 79191.90 964165.50 360151.94 103183.56 504565.17 167004.25 3442724.12 1413466.92 0.00 75924.00 169307.05 257205.45 Vehiclcs 9201840.65 0.00 372950.00 0.00 1288383.60 1210839.60 1067956.50 0.00 5261710.95 0.00 0.00 0.00 0.00 Salaries 411243914.76 1221883.76 40636050.10 8015715.92 5240627.03 5319590.69 30013419.33 266804713.53 41737422.61 0.00 0.00 0.00 12251965.90 Expert Services 6202294.33 0.00 843314.65 730200.00 847979.16 3776423.02 4377.50 0.00 0.00 0.00 0.00 0.00 0.00 Fellowship 1679795.35 0.00 999977.85 105250.00 6595.65 546699.85 16272.00 0.00 0.00 0.00 0.00 0.00 0.00 Books 51219.90 0.00 7579.65 165.00 10966.00 24676.90 0.00 0.00 150.00 0.00 7682.35 0.00 0.00 Consuimiiables 19392995.62 11810.20 3247238.74 1564086.52 3012888.02 610374.78 4638309.16 545387.93 3085351.10 47284276 1945582.91 0.00 259115.50 Operation & Nlainltclladcc 25437921.55 442835.90 9979346.07 1183282.76 1633826.92 765859.20 1643793.30 7783849.99 1279674.17 5000.00 0.00 377308 39 339983.35 Total 598915219.38 1756501.76 58908259.75 16112834.94 13843645.89 13303691.89 38913080.04 299511784.41 136539393.68 765810.76 4452653.66 1435211.31 13361655.90 .~~~~~~~~~~~I  Appendix B Page 11 of 13 Table 3: Municipal Corporation of Greater Mumbai Public Health Department India Population Project V Sr.No Category 1988 1989 1990 1991 1992 1993 1994 1995 1995 1. Number of 218300 209325 218437 215466 211127 193408 202819 births 2. Birth rate 21.4 19.9 20.1 21.7 20.8 18.7 19.3 3. Death Rate 7.2 7.0 6.8 8.0 8.0 7.3 7.2 4. IMR 53.1 51.6 48.0 49.2 47.2 43.4 41.3 5. MMR 0.4 0.6 0.6 0.5 0.3 0.1 0.1 6. BCG 88.0 89.0 93.8 93.3 94.8 98.8 97.0 7. DPT- III 79.0 88.0 85.2 87.4 89.8 92.1 94.6 8. OPV- III 79.5 80.0 85.5 87.9 90.9 94.1 94.1 9. Measles 38.5 42.0 59.8 65.0 75.2 76.9 85.5 10. CPR 20-30% 42.6 42.4 47.3 52.2 54.2 56.0  Appendix B Page 12 of 13 Table 4: Program Implementation Performance - Central Office Activities 1989 1990 1991 1992 1993 1994 1995 1996 (Jan-Dec) (Jan-Mar) I. Film Shows 694 336 201 570 636 520 512 95 2. Beneficiaries 76529 20407 13382 41930 44467 219830 122855 7700 3. Health Exhibitions 269 161 171 309 504 375 476 95 4. Beneficiaries 47827 11644 12262 19338 35082 101571 107837 7725 5. Health Talks 557 589 - - - 756 1078 236 6. Special Program - 23 45 205 45 117 199 96 7. Printing material 6774 8307 14927 90687 64971 553672 2746866 49301 distributed  Appendix B Page 13 of 13 Table 5: Program Implementation Performance - Health Posts Activities 1989 1990 1991 1992 1993 1994 1995 1996 (Jan-Dec) (Jan-Mar) 1. Interpersonal - - - - 3638582 4511184 4294831 1098245 contacts 2. Beneficiaries - - - - 3022036 4510614 4297063 1098245 3. Health Talks - - 5117 11082 23937 14488 13385 3492 4. Beneficiaries - - 227276 407847 597970 511022 453685 142778 5. Exhibition - - 1265 2232 2822 3146 3619 942 6. Beneficiaries - - 62501 141563 183094 185872 189816 62171 7. Video Shows - - 273 255 353 227 28 - 8. Beneficiaries - - 19319 38968 24794 16335 6407 - 9. ANC/PNC - - 821 3843 3378 4777 5578 749/573 Activities 10. Beneficiaries - - 33214 115451 95578 102522 112963 17428/ 15976 11. Special Program - - - 282 528 786 1404 455 12. Beneficiaries - - - 160582 55282 237947 294090 34843 Post Partum Centers 1. Video Shows 3367 4810 1865 2. Beneficiaries 131998 190689 64141 3. Health Talks 11261 14142 3961 4. Beneficiaries 248801 361368 100380    D 7 : -di lA - i- 9 ; ': I'i . Ol'J,-Ii 1 I r: q ^