India - Proposed Malaria Control Project (full EA available)

Report No. PIC3278 Project Name India-Proposed Malaria (@+) ... Control Project Region South Asia Sector Health Project ID INPA10511 Borrower India, acting by its President Beneficiaries States and Union Territories of India Implementing Agency Attention: Mrs. Shailaja Chandra, Additional Secretary, Ministry of Health and Family Welfare (MOHFW) and Dr. S. Lal, Director, National Malaria Eradication Program (NMEP), 22,Shamnath Marg, New Delhi, India, Phone: +91-11-291-8576; Fax: +91-11-251-8329 Projected Appraisal Date March 1997 Date this Document Prepared April 9, 1997 Projected Board Date May 1997 1. Project Objective. The medium-term objective of the IDA credit is to create an enhanced and more effective malaria control program (hereafter 'enhanced program') that: uses a better mix of effective malaria control interventions; is responsive to local needs; and strengthens the National Malaria Eradication Program (NMEP) and modifies its orientation. In the long-term, the enhanced program will reduce death, morbidity and social and economic losses from malaria. 2. Project Approach and Components. The IDA would finance eighty-five percent, net of taxes, of the incremental requirement of the enhanced program of the NMEP over five years. NMEP will oversee investments throughout the entire country, based upon local needs and district implementation plans, starting in certain rural districts with high malaria burdens. The main target population will be the more than 200 million people living in areas endemic for malaria, especially 62 million people living in rural areas with severe malaria. However, the benefits from reduced malaria outbreaks, reduced environmental damage, and institutional strengthening of NMEP will accrue to India's entire population of 930 million. 3. The enhanced program will include five components: (a) the component for integrated early detection and prompt treatment of cases will improve the quality and accessibility of malaria treatment at primary health units and in the private sector; (b) the component for selective vector control will replace widespread  insecticide spraying with more targeted spraying, shift the selection of insecticides toward more environmentally neutral options and increase the use of non-insecticide vector control methods such as larvivorous fish and biolarvicides; (c) the preventive medicated mosquito nets component will produce and distribute medicated mosquito nets and related products, including social marketing of their use; (e) the component for epidemic response and intersectoral collaboration will establish regional cells to identify and control outbreaks and epidemics, monitor resistance, conduct research, and build intersectoral collaboration; and (e) the institutional strengthening component will improve the management and planning skills of NMEP, state-and- district level staff, create and disseminate an IEC program, and conduct operational research. The project management unit will be part of this component. IDA financing would include funds for training and workshops, technical assistance, equipment, civil works, medicated mosquito nets, vehicles, social marketing, operational research studies, insecticides, drugs, and incremental salaries. 5. Environmental Aspects. Insecticide spraying is part of malaria control strategies worldwide and will continue to be one in the future in India and elsewhere. There is much precedent for the World Bank financing insecticides as part of malaria control programs. The Government of India prepared an environmental assessment which covered the entire country. This assessment found that: (a) the risk of increased death and morbidity from not using insecticides exceeds their negative environmental impact, especially among the rural poor; (b) the environmental risks from insecticide use in agriculture far outweigh those of spraying for malaria control; (c) in addition to cutting back on routine spraying, improved training and logistics, better environmental management, and diversifying to other biological agents may minimize environmental damage. The enhanced program will incorporate the guidelines from the environmental assessment into the revised operational procedures, and will repeat the assessment around the third year of the credit. 6. Project Objective Categories. Poverty Aspects. The enhanced program will benefit the rural poor, including tribal peoples, who most commonly suffer malaria. Districts with the severe form of malaria are more commonly rural, have lower literacy rates, have a higher proportion of scheduled tribe populations and slightly more women. The enhanced program will also save money on malaria treatments, especially for poor households. 7. Gender Issues: Malaria imposes an especially heavy burden on women, who provide most of the household care and who also contribute to agricultural work. Pregnant and lactating women are especially susceptible to malaria because of their lower immunity. Further, the enhanced program will provide some opportunities for grassroots enterprises by supporting women's cooperatives to manufacture and distribute medicated mosquito nets. The enhanced program will use several gender-specific performance and monitoring indicators. -2-  8. Indigenous Populations: The enhanced program has a tribal strategy that helps ensure social and economic benefits received by such groups are in harmony with their cultural practices. These actions are consistent with the World Bank's Operational Directive (OD) 4.2 on Indigenous Peoples, and include the use of local IEC and mass awareness programs, the integration of traditional healers and others as treatment providers, and efforts to institutionalize on-going consideration of less advantaged groups, including social assessment. 9. Project Implementation. The NMEP will be the key executing agency and will provide revolving funds to those districts with completed district implementation plans and satisfactory accounting, financial, and audit arrangements. The NMEP and the Ministry of Health and Family Welfare (MOHFW) will be responsible for project coordination. The project oversight will by done by NMEP and MOHFW and the annual program development review, a partial third-party expert review group. 10. Project Financing. The total cost of the proposed project is under discussion. Tentative estimates are between US$200 to US$210 million. IDA would finance about 85 percent of the project cost, net of tax. Contact Point: Public Information Center The World Bank 1818 H Street N.W. Washington, D.C. 20433 Telephone No.: (202) 458-5454 Fax No.: (202) 522-1500 Note: This is information on an evolving project. Certain components may not necessarily be included in the final project. Processed by the Public Information Center week ending April 11, 1997. - 3 -  Annex Environmental Assessment The IDA gave the proposed credit a "B" rating for environmental assessment because of its concern about the potentially high level of indoor residual spraying. Insecticide spraying is part of malaria control strategies worldwide and will continue to be part of the strategy in India and elsewhere. There is much precedent for the Bank financing insecticides as part of malaria control programs: insecticides constituted thirteen, six and three percent of spending in the Brazil, Sri Lanka, and Cambodia projects, respectively. These projects, like the enhanced project, follow WHO guidelines for insecticide use in public health programs. The GOI contracted the National Environmental Engineering Research Institute to conduct a detailed environmental assessment, in consultation with NMEP, the MRC, the Ministry of Environment and Forestry, and the WHO. Given the national scope of the credit, the environmental assessment adopted a "sectoral" approach that involves sector wide environmental analysis and supports integration of environmental issues into long-term planning. The sectoral approach obviates the need for an environmental assessment in any district in which the IDA credit would spend resources, and creates guidelines that are incorporated into normal procedures. The environmental assessment fulfills OD 4.00 on Environmental Assessment and Operational Procedure 4.09 on Pest Management. The key results from the environmental assessment include the following: (a) All insecticides harm the environment to some extent. However, the risk of increased death and morbidity from not using insecticides exceeds their negative environmental impact, especially among the rural poor. (b) The environmental risks from insecticides use in agriculture far outweigh those of spraying for malaria control. (c) The proposed insecticide choices should be based upon efficacy, cost and safety. Synthetic pyrethroids are the most effective and safe, but cost substantially more than DDT. Other older insecticides, such as BHC, are much more toxic and should be eliminated as quickly as possible. (d) In addition to cutting back on routine spraying, improved training and logistics, better environmental management, and diversifying to other biological agents may minimize environmental damage. The environmental assessment included guidelines on better environmental management. As a result of the environmental assessment, the IDA credit design was modified in the following ways: (a) The IDA credit will help catalyze the phasing out of some insecticides commonly used in India, such as BHC and DDT on both - 4 -  demand and supply sides. Demand for these insecticides will drop because of the Revised Insecticide Guidelines and the revised operational procedures, better IEC, and alternative interventions. To address the supply side, the enhanced program will include feasibility studies for privatizing and diversifying the manufacture of some insecticides. (b) The IDA credit will finance another environmental assessment around the third year of the IDA credit. The enhanced program will also finance the costs of an on-going operational committee comprising NMEP, MRC and other staff to discuss environmental issues. The results of these meetings will be reported to the annual program development review. (c) Key parts of the guidelines on the environmental management plan in the environmental assessment will become part of the revised operational procedures, which will be created during the first year review of implementation and which IDA will review. The revised operational procedures will include efforts to improve the quality of spraying, ensure the safety of spray workers, and reduce spillage. (d) The IDA credit will finance operational research studies including studies related to environmental impact. - 5 -