India - Seventh Population Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 18976 IMPLEMENTATION COMPLETION REPORT INDIA SEVENTH POPULATION PROJECT (CREDIT 2133-IN; LOAN 3199-IN) February 05, 1999 Health, Nutrition & Population Unit South Asia Region 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 (As of February 1999) Currency Unit Rupee Rupee 42.52 US$1.00 Rupee 1.0 -US$0.02352 WEIGHTS AND MEASURES I Meter (m) = 3.28 Feet (ft) I Kilometer 0.62 FISCAL YEAR April I - March 31 ABBREVIATIONS AND ACRONYMS ANC Ante-Natal Care ANM Auxiliary Nurse Midwife MPW Multi Purpose Worker ANMTC Auxiliary Nurse Midwife Training Center ARI Acute Respiratory Infection CSSM Child Survival and Safe Motherhood CHC Community Health Center CPR Couple Protection Rate DM District Magistrate DTTC District Training Team Center ELS End-Line Survey FWP Family Welfare Program 0OI Government of India HRD Human Resources Development ICPD Intemational Conference on Population and Development IEC Information, Education and Communications IMR Infant Mortality Rate ISm Indian Systems of Medicine IPP India Population Project J&K Jammu and Kashmir MCH Maternal & Child Health MIS Management Information System MIES Management Information & Evaluation Systems MOHFW Ministry of Health and Family Welfare MTR Mid-Termn Review MPW Multi-Purpose Worker NFHS National Family Health Survey NIHFW National Institute of Health and Family Welfare NGO Non-Govemmental Organization PHC Primary Health Care PMIS Personnel Management Information Systems PNC Post-Natal Care PWD Public Works Department RCH Reproductiye and Child Health REW Rural Engineer Worker RIHFW Regional Institute of Health & Family Welfare RTC Regional Training Center SAR Staff Appraisal Report SC Sub-Center SIHFW State Institute of Health and Family Welfare SFD State Finance Department. TBA Traditional Birth Attendant TFR Total Fertility Rate TOT Training of Trainers WHO World Health Organization Vice President Mieko Nishimizu Country Director Edwin Lim Sector Manager Richard Skolnik Task Leader Badrud Duza  FOR OFFICIAL USE ONLY IMPLEMENTATION COMPLETION REPORT INDIA: SEVENTH POPULATION PROJECT (CR 2133-IN; LOAN 3199-IN) CONTENTS Page No. Preface .....................................i Evaluation Summary .................................... iii PART I: Project Implementation Assessment A. Project Objectives, Scope and Strategy .1 B. Achievement of Project Objectives .2 C. Project Costs and Implementation Timetable .10 D. Major Factors Affecting the Project .10 E. Project Sustainability .13 F. Bank Performance .14 G. Borrower Performance .15 H. Assessment of Outcome .16 I. Key Lessons Learnt .16 Table A. Selected Project Achievements ........................... ..3 Table B. Selected Family Welfare Indicators .............................4 PART II: Statistical Information Table 1. Summary of Assessments .18 Table 2. Related Bank Loans/Credits .20 Table 3. Project Timetable .23 Table 4. Credit Disbursements: Cumulative, Estimated and Actual .23 Table 5A. Key Indicators for Project Implementation (Training Facilities) . 24 Table 5B. Key Indicators for Project Implementation (Service Deliveries) . 24 Table 5C. Key Indicators for Project Implementation (Training Coverage) . 25 Table 5D. Key Indicators for Project Implementation (IEC Activities) .25 Table 6A. Key Indicators for Project Operation (Training Quality & Impact) . 26 Table 6B. Key Indicators for Project Operation (Upgraded Facilities) .27 Table 6C Key Indicators for Project Operation (Beneficiaries Assessment) . 27 Table 6D. Key Indicators for Project Operation (FMC Indicators) .28 Table 7. Studies Included in the Project .29 Table 8A. Project Costs by Disbursement Performance by Expenditure Category.32 Table 8B. Project Financing .32 Table 9. Economic Costs and Benefits .32 Table 10. Status of Legal Covenants .33 Table 11. Compliance with Operational Manual Statements .34 Table 12A. Bank Resources: Staff Inputs (Staff Weeks) .35 Table 12B. Bank Resources: Staff Inputs (Dollars) .35 Table 13. Bank Resources: Missions .36 APPENDICES: Appendix A. The ICR Mission's Aide Memoire Appendix B. Borrower's Evaluation 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.  i IMPLEMENTATION COMPLETION REPORT INDIA SEVENTH POPULATION PROJECT (CREDIT 2133-IN; LOAN 3199-IN) PREFACE This is the Implementation Completion Report (ICR) for the Seventh Population Project in India for which Credit No. 2133-IN in the amount of SDR67.10 million (US$86.7 million equivalent) and Loan No. 31990 in the amount of US$10.0 million were approved on May 17, 1990 and made effective on March 8, 1991. As a result of exchange rate adjustments in May 1993, the Loan and part of the Credit were cancelled, reducing the resources to US$63.96 million equivalent of Credit. In view of exchange rate adjustments since then, the revised amount of Credit available by the end of the Project was US$69.5 million equivalent. This gain is in favor of the US dollar and covered most of the Rupee costs of the Project which had remained unchanged since Project effectiveness. The Credit closed on the original Closing Date of June 30, 1998. The Credit amount was fully disbursed, the last disbursement taking place on November 20, 1998. In addition, an amount of US$ 2.65 million covered essential activities out of the RCH Project (Cr. NOI 8-IN), as agreed between IDA and GOI. The ICR was prepared by Badrud Duza (Task Leader), assisted by Tirtha Rana, Rashmi Sharma and Suneeta Singh. Elfreda Vincent provided office technology assistance and Doris Knoles looked after quality control. Richard Cambridge and Frances Plunkett provided valuable comments and historical perspective on Project formulation. Peer reviewers were Messrs./Mme. Maria MacDonald, Thomas Merrick and Christopher Walker. The ICR was reviewed by Richard Skolnik, Sector Manager, and Indra Pathmanathan, Team Leader; SASHP. Preparation of the ICR is based on materials in the Project files, baseline surveys, training needs assessments, communication needs assessments, end-line surveys (ELS), evaluation studies, field visits and interviews with beneficiaries, health workers, NGOs, Project staff and other senior Government officials as well as Bank staff. NIHFW conducted the end-line surveys for the training and civil works components in each Project State as well as evaluation studies on the IEC, NGO and Social Marketing components. The ELS for the training component included: field visits to 57 training institutions in 37 districts; interviews and observations of randomly selected samples of 122 trainees, 100 health personnel, 160 health workers (TBAs, AWWs) and 1350 beneficiaries. The ELS for the civil works component included field visits to 38 districts for inspection of 106 training institutions and 71 sub-centers as well as interviews with health personnel and beneficiaries.  ii The Borrower contributed significantly to the preparation of the ICR. Each Project State prepared its own evaluation of the Project's preparation and execution. These documents, together with other evaluation reports on the Project, were discussed in two workshops organized by the Ministry of Health and Family Welfare (MOHFW) in New Delhi (June 1998), and Srinagar (September 1998). Finally, the MOHFW prepared its overall assessment which is included in this report. The draft ICR was shared with the Borrower and their comrnments were taken into account in the final version. The cooperation and assistance of the Government of India (GOI), the National Institute of Health and Family Welfare (NIHFW) and the State Governments of Bihar, Gujarat, Haryana, Jammu & Kashmir, and Punjab throughout the implementation process and preparation of this ICR is gratefully acknowledged.  iii IMPLEMENTATION COMPLETION REPORT INDIA SEVENTH POPULATION PROJECT (CREDIT 2133-IN; LOAN 3199-IN) EVALUATION SUMMARY Introduction 1. The Seventh Population Project (IPP VII) commenced in March 1991 against the backdrop of the evolving maturity of the Indian Family Welfare Program (FWP) and growing understanding between the Bank and the Government of India (GOI) on the need to strengthen the national program, with expanded client access and quality of care as prime considerations. Since the early 1 970s, IDA supported India's family planning (later, family welfare) program through a series of nine India Population Projects (IPPs), besides the Child Survival and Safe Motherhood (CSSM) Project and lately, the Reproductive and Child Health (RCH) Project. The initial five projects focused on a limited number of backward districts or urban slums in the selected States. IPP VI started a new phase of Statewide operations, with multi-State capacity building and implementation support in FW and MCH. IPP VII was also designed along these directions. A total of eleven States and four large cities were covered between IPP VI to IX. The process culminated in the RCH Project in 1997 - moving from the traditional project approach to the new program approach; with reorientation of the nationwide FW Program beyond the earlier preoccupation with fertility reduction and numerical contraceptive targets; and underscoring policy reforms in reproductive health. Concurrently, a large number of nutrition, child survival, and health systems development projects were also developed with IDA support. 2. IPP VII covered five States - the three relatively more developed States of Gujarat, Haryana and Punjab; and the two relatively less developed States of Bihar, and Jammu and Kashmir (J&K). Some centrally administered components were implemented nationally. As originally scheduled, the Project was closed at the end of June 1998. Project Objectives 3. The Project hadfour major objectives: (a) expand the supply of family welfare services; (b) increase the demand for these services; (c) enhance the quality of the services; and (d) improve the efficiency of program management. Implementation Experience and Results 4. Overall Achievements. The Project substantially achieved its development objectives, especially those relating to institutional development, training systems and infrastructure expansion, and laid the foundation of enhanced quality of care in FW and MCH in the participating States. It also contributed to the process of development of the new RCH approach  iv in the Indian FW program. In terms of specific development objectives, the first and the third ones mentioned above - expansion of supply and quality of FW services - were covered well, while achievements with respect to the other two - increased demand for services and improved efficiency - were relatively modest. The implementation experience was uneven for the Project States. Gujarat and Haryana were able to complete most of the planned activities in more than a year prior to the closing date, and also undertook certain additional activities beyond the original plans; Punjab completed most of its activities; Bihar and J&K were relatively weaker performers. 5. The financial objectives of the Project were fully achieved. The original Bank support of US$96 million (US$10 million IBRD Loan and US$86 million IDA Credit) was reduced to only IDA Credit of US$63.96 million - as a result of exchange rate adjustments in May 1993 - with a cancellation of the entire IBRD component and US$22.74 million of the IDA Credit. However, the original Rupee allocation was retained unchanged. Due to exchange rate adjustments, the amount of the Credit available by the end of the Project was US$69.5 million, which was disbursed 100%. Some shortfalls were met out of the RCH Project (Cr. N-018-IN). 6. Human Resource Development (HRD). The Project was successful in developing a large network of training infrastructure in all Project States. The State Institutes of Health and Family Welfare (SIHFWs) were set up as the apex bodies at the State level, except for J &K which established two Regional Institutes of Health and Family Welfare (RIHFWs) - one each for Jamnmu and Kashmir Division. Altogether, 315 training institutions were founded or upgraded in the five States, exceeding the planned target by nearly 20%. These were adequately furnished and equipped, and provided with vehicles to facilitate field training - significantly enhancing the quality of service providers, supervisors and managers, and thus, contributing to better quality of services in the rural clinical and outreach settings. The National Institute of Health and Family Welfare (NIHFW) played a catalytic role in the process. The challenge remains in sustaining the future needs by providing qualified core trainers and financial resources, especially at the level of SIHFWs/RIHFWs. 7. Despite many constraints and make-shift arrangements with training staff and venue as a result of lack of regular faculty and lack of completion of a number of the training infrastructures even late in the Project period, the training mandate was carried out well. About a quarter million persons - nearly double the planned target - were trained. Of them, close to 115,000 were program functionaries, 12% above the goal - with about 1,100 key trainers; 20,000 medical officers; 24,000 field supervisors; 45,000 Female Multi-Purpose Workers (MPWs); and 23,000 male MPWs. The achievement was more pronounced with respect to the training of non-health functionaries - more than 119,000 trained, nearly four times the goal. 8. The performance of most of the States was noteworthy. Overall, Gujarat trained more than 105,000 persons, four times the target; Punjab, about 82,000, twice the goal; and Haryana, more than 24,000, 96% of the goal. Even the weaker performing States of Bihar and J&K achieved 80% of the overall target. Gujarat did exceptionally well by training more than 78,000 non-health functionaries, followed by Punjab and Haryana, which also did very well in this regard; Punjab was conspicuous in training more than 12,000 members of rural women's groups. Many senior trainers and program managers participated in international training programs and  v visits to various Project States for hands-on experience with the "best practices" in the area. All in all, Gujarat developed an excellent training system, with a focus on innovative field-based and practical training. 9. Upgrading of Service Facilities. There was substantial development of the infrastructure for service delivery. Project End Line Surveys confirm that the Project supported the construction and renovation of more than 3,000 such rural institutions - nearly 90% of the planned target - that were functional with trained personnel, adequate equipment, furniture and other supplies. In the process, about 2,600 Health Sub-Centers (SCs) were constructed - all of them with accommodation for the Multi-Purpose Health Workers (MPWs); nearly 300 Primary Health Centers (PHCs) were upgraded, with Operation Theaters (OTs); and some Indian System of Medicine (ISM) dispensaries, logistics stores, and other facilities in selected States. The overall achievement with respect to upgraded service facilities was more than 100% in Gujarat and Haryana; nearly 100% in Punjab; and about 75% in the other two States. Project Outcome 10. Overall, the Project outcome is satisfactory - and for some States, highly satisfactory - in terms of setting up essential building blocks for a well functioning FW program (see: paragraphs 7 to 29 in the main text). Between the beginning and the end of the Project, a large vacuum was filled in all Project States with respect to creating and refurbishing major infrastructures for FW services and human resource development for service providers, supervisors, managers and a vast network of non-health functionaries and opinion leaders. These would now need to be consolidated in order to ensure continued upgrading of the quantity and quality of services that the Project initiated. 11. While the quantifiable outcome indicators on infrastructure and personnel development provide evidence of considerable achievement in capacity building for training and quality service delivery, it is too early to assess the precise impact of the Project with respect to specific behavioral changes among the clients and the providers, and their implications for the family welfare and health indicators. The 1999 National Family Health Survey (NFHS) and the district- level surveys conducted for the Reproductive and Child Program are expected to provide this data by mid-1999. Nonetheless, beneficiary assessments confirm considerable expansion of client access to and satisfaction with the services available at the rural clinical and outreach settings. Similarly, studies carried out in connection with the Mid-Term Review (MTR) and the End-line Surveys (ELS) provide positive evidence of the impact of the training institutions and the training provided in effectively upgrading the skills of the program functionaries, thus contributing to the process of enhanced quality of care. Many of the Project's benefits are expected to come to full fruition only following the Borrower's continued attention to and investments in sustaining the development objectives pursued by the Project. The Borrower should also benefit from additional support from the ongoing and future IDA projects in the area of reproductive and child health (RCH), especially pertaining to the important agenda of training and quality enhancement in the field.  vi Lessons Learnt 12. The key lesson learnt was the need for flexibility in Project design to match the varying requirements and capacities of the individual Project States. Largely in line with the anticipation at the design stage, Project performance varied substantially between the five States, reflecting differing capacity, macroeconomic and political situations, and policy environment. Since the IPP VII design was too uniform, it strained implementation ability in the weaker States and now leaves concerns for some aspects of sustainability of the investments that may be beyond their capacity. 13. It is also critical to limit the Project scope and focus on key interventions, particularly in low capacity settings. In the weaker States, the Project focused on completing hardware (civil works and equipment) components rather than 'software' (demand generation, quality of training, and community participation). Lack of proper blending of the Project needs, thus, led to sub-optimal achievement of the objectives. 14. It is imperative to give top priority to monitoring and evaluation. Even more crucial is the creation of a culture, at all levels of management, for using service data as a proactive management tool for timely feedback and corrective actions. The weaker performing States would have benefited from more intensive monitoring but no special measures had been built into the Project to ensure that. A rigorous MTR needs to be planned and implemented on time. The project design did not include provision for a MTR. Although a MTR was completed, the Project lost a valuable opportunity for review and course correction because the MTR was completed too late in the Project cycle and did not provide the basis for in-depth assessment against a core set of monitoring indicators set during the design stage. 15. The Project experience reiterates the problem of under-utilization of certain physical facilities constructed under the Project, in particular Female MPW residential accommodation. At the same time, a good deal of beneficiary satisfaction also has been noted with respect to the services rendered by the Female MPWs, even though they had not been living on the Sub-Center premises. It is, thus, important to deternine the factors that contribute to Female MPW effectiveness, and make investments to reinforce them, rather than to continue wasteful expenditures on staff quarters per se. Appropriate studies and policy decisions need to be made on this issue. 16. There are chronic and persistent operational problems that adversely affect implementation of all Family Welfare Projects in weaker states. These include poor flow of funds to the implementing agency in states that experience fiscal problems, low procurement capacity, persistent staff vacancies and high turnover, and lengthy decision-making processes. These often relate to macro-economic difficulties and problems of governance at the State level, and are beyond the scope of individual Project teams to address effectively. Unless resolved at a more macro level, they continue to constrain implementation and create problems of long range sustainability. 17. An important lesson is the need for GOI to create incentives to the States through performance-based financing during Project implementation. In IPP VII, GOI released funds  vii regularly to the State Finance Departments (SFDs), but the onward flow of funds from the SFDs to the Project Units was impeded as result of financial difficulties at the State level. Such a situation would need to be guarded against through performance-based financing referred to above or through reallocation of funds to Project States. The latter mechanism was found effective in energizing performance as a result of reallocation of substantial funds by MOHFW from Bihar to three better performing States during the final year of the Project staff. 18. This project demonstrates effective use of lower cost supervision mechanisms based on a strengthened Bank field office presence. Local staff and consultants conducted Workshops and provided hands-on training for project officials. Multi-State workshops proved to be a valuable approach to sharing of lessons and experience. Joint IDA review missions in conjunction with MOHFW and NIHFW provided a useful opportunity for policy dialogue, exchange of infornation on technical and program matters, and swift resolution of implementation bottlenecks.  IMPLEMENTATION COMPLETION REPORT INDIA SEVENTH POPULATION PROJECT (CREDIT 2133-IN) PART I: PROJECT IMPLEMENTATION ASSESSMENT 1. The Seventh Population Project (IPP VII) commenced in March 1991 against the backdrop of the evolving maturity of the Indian Family Welfare Program (FWP) and the growing understanding between the Bank and the Government of India (GOI) on the need to strengthen the national program, with expanded client access and enhanced quality of care. In the process, increasing attention was devoted to: a broader mix of family planning services, as a departure from the earlier thrust on sterilization as the predominant method; to maternal and child health (MCH) interventions; and lately to a major paradigm shift in terms of support to reproductive and child health (RCH). As originally scheduled, the Project was closed at the end of June 1998. 2. Since 1972 and prior to IPP VII, IDA supported a series of India Population Projects (IPPs). The initial five projects focused on a limited number of backward districts or urban slums in the selected States. Beginning with IPP VI, the magnitude of IDA financing was substantially scaled up since the 1990s and a new phase of GOI-Bank collaboration started with major Statewide operations, with multi-State capacity building and implementation. IPP VII was also designed along these directions. A total of eleven States and slum populations in four large cities were covered between IPP VI to IX. The process culminated in the RCH Project in 1997 - moving from the traditional project approach to the new program approach; with reorientation of the nationwide FW Program toward enhanced performance by removing numerical contraceptive targets and underscoring improved resource utilization and increased program impact through effective client-oriented and better quality services. In parallel, a large number of nutrition, child survival, and health systems development projects were also developed with IDA support, with an increasingly conducive milieu for policy dialogue with the Government and better implementation efforts. The development of IPP VII needs to be appreciated in the above historical and programmatic context. A. PROJECT OBJECTIVES, SCOPE AND STRATEGY 3. The Project hadfour major objectives: (a) expand the supply of family welfare services; (b) increase the demand for these services; (c) enhance the quality of the services; and (d) improve the efficiency of program management and operation. It was designed for five States with more than 150 million population. Of these, Bihar is India's second most populous State and represents about 10% of the country's population. Part of the "Hindi belt" of northern India, it is more than 80% rural, socially conservative and economically backward, with very poor health and demographic indicators. Jammu and Kashmir (J&K) is one of the smaller States of India; is not economically developed; and had high birth, death and infant mortality rates as well  2 as poor health indicators and civil conflict. The other three Project States, Gujarat, Haryana and Punjab, are relatively more developed, with better demographic and social indicators. 4. Setting up improved institutional and management capacity was the principal strategy toward achieving enhanced service quality and working environment. The key focus was on training and skill development as the pivot of operational efficiency at all levels. Equity was built in by recognition of the needs of the weaker performing States of Bihar and J&K. The Project was conceived within the broad framework of the National Family Welfare Program, with an emphasis on "quality" of services and as a step toward a "program" approach - as distinct from the earlier "project" approach. In conjunction with several other IPPs of its cohort, IPP VII proved to be one of the important precursors of the vital transition that culminated in the RCH Project in the late 1990s. B. ACHIEVEMENT OF PROJECT OBJECTIVES Overall Achievement 5. The precise impact of the Project needs to be viewed in a much longer tirne frame than the brief implementation period itself. Some of the activities had barely been completed or were nearing completion toward the end of that period. While a number of indicators were specified in the Staff Appraisal Report (SAR), they were comprised mostly of measures of input and processes, rather than definitive measures of outcome and impact used in more recent Bank Projects. The assessments made in the present report are essentially based on the input and process indicators, supplemented by some outcome indicators based on the limited data available from the Baseline, Mid-Term Review (MTR) and End-line surveys, and other sources. 6. The Project substantially achieved its development objectives, especially those relating to training systems and infrastructure expansion, and laid the foundation of enhanced quality of care in FW and MCH. Disbursement was 100% of the IDA proceeds earmarked for the Project. In addition, the shortfall of US$2.65 million was met out of the RCH Project (Cr. N-01 8-IN). The overall level of achievements and pace of implementation of the Project, reflected in Table A, has been rated as satisfactory. 7. The experience has been uneven for the individual States. Gujarat and Haryana were able to complete most of the planned activities more than a year prior to the closing date, and undertook additional activities beyond the original plans. Punjab started off well and completed all its activities ahead of time, except for an unanticipated disruption in the fund flow during the final year, resulting in non-completion of the State Institute of Health and Family Welfare (SIHFW). Despite various administrative and macro-economic constraints, Bihar was able to accelerate implementation during the second half of the Project period and registered considerable progress toward the attainment of most of the objectives. Inplementation was very slow in J&K in the initial years, especially in the Kashmir Division - severely disrupted by civil disturbances - where significant progress was achieved during the final two years. Completion of a number of activities was impeded in these two latter States due to major fund flow problems throughout the Project period. The Regional Institute of Health and Family Welfare (RIHFW) in  3 Kashmir remained in its final but incomplete stage; and Bihar was unable to seek reimbursement even for some of the completed activities. MOHFW and the concemed States are seeking RCH Project support for completion of these facilities. Table A: Selected Project Achievements 1998 Project End-Line Surveys BIHAR GUJARAT HARYANA JAMMU& PUNJAB Total Number; KASHMIR Achievement Achievement Achievement Achievement Achievement Achievement (% of planned (% of (% of planned (% of planned (% of planned (% of planned target) planned target) target) target) target) target) No. of Training 87 121 29 17 61 315 Facilities (96%) (205%) (138%) (65%) (98%) (119%) established and functioning No. of Sub- 750 684 443 382 400 2659 Centers (75%) (114%) (98%) (76%) (100%) (90%) constructed and fully functional Number of 21,858 105,422 24,003 13,336 81,966 246,585 Health and (81.5%) (368%) (96.5%) (78.5%) (200.5%) (178%) Non- Health Workers trained No. of Female 10,673 7,661 6,702 3,717 15,770 44,530 Multi Purpose (84%) (90%) (86%) (149%) (239%) (108%) Workers (MPW) attended Training X % Female MPWs with critical knowledge in: -maternal health 74% 91% 55% 68% 82% -child health 82% 55% 53% 68% 85% -family 86% 89% 81% 53% 91% planning  4 Table B: Selected Family Welfare Indicators BIHAR GUJARAT HARYANA PUNJAB NA TIONAL Baseline Most Baseline Most Baseline Most Baseline Most Baseline Most recent recent recent recent recent data data data data data 1. TFR 4.4 4.5 3.1 3.2 4.0 3.7 3.1 2.9 3.6 3.5 2. IMR 69 71 69 62 68 68 53 51 80 71 3. %Infants 11 40 50 65 54 70 62 84 35 63 fully inununized 4. %Women 37 N/A 76 92 73 100 88 87 62 63 Receiving ante- natal care 5. %Assisted 27 33 57 73 84.4 92 94.5 98.2 46 53.4 at delivery by a doctor/nurse/tra ined midwife . Source: See Table 6D, p. 29. Expansion of Supply Objectives 8. The stated project objective of "expand the supply of family welfare services" may have raised undue expectation of increasing coverage, because in most cases the staff were already in place and providing outreach services, albeit from rented or make-shift premises. The project constructed sub-centers which enhanced the working environment of the outreach workers by providing a facility from which they could operate, maintain stores and records, and conduct clinic sessions. Similarly the add-on OTs at PHCs enabled sterilization operations to be done in a proper facility and not in make-shift "camps". Therefore expectation of impact in terms of greatly expanded numbers of clients would be unreasonable. 9. This component consumed nearly a half of the Project resources. The objectives were substantially accomplished, through support to the construction, upgrading and functioning of a large network of rural health facilities. Altogether, more than 3,000 outreach facilities received new or upgraded infrastructures, representing nearly 90% of the planned target. The overall achievement was more than 100% of the target in Gujarat and Haryana; 100% in Punjab; and about 75% in Bihar and J&K. The facilities included about 2,600 Sub-Centers (SCs) - all of them with residential accommodation for the Multi-Purpose Health Workers (MPWs); a large proportion with two beds for delivery; and nearly a hundred-(in Gujarat) with small wards. Similarly, about 300 Primary Health Centers (PHCs) were upgraded, with Operation Theaters (OTs). Further, 75 Indian System of Medicine (ISM) dispensaries were constructed (in J&K). These new facilities, besides a large number of existing SCs and PHCs, were fully equipped and furnished, and provided with essential supplies ranging from daily consumables to blood pressure measuring instruments and power generators; about 1.6 million pre-sterilized delivery kits were provided for use by the outreach workers; and 449 vehicles were purchased or made road worthy, strengthening the referral and supervisory process (Table 5A).  5 10. As a result, the unsatisfactory physical and operational facilities were significantly improved to render clinic based and domiciliary services. Enhanced client satisfaction as well as increased access was widely reflected in the beneficiary assessment during the End-line survey (Table 6C). Despite such improvement in the hardware and client satisfaction, full utilization, particularly of sub-center residential and bed facilities remains a problem. While most of the PHCs in the Project States have doctors residing in or near the PHC campus, the percent of sub- centers in which Female MPWs were resident was 10 percent or less in Bihar, Jammu and Kashmir and Punjab, almost 50% in Gujarat and 60% in Haryana (Table 6B). Non-residence has been attributed to cultural reasons that discourage females living alone in the sub-centers, as well as security considerations due to location of sub-centers outside the villages. Such sub-center sites had been donated by the community because land within the village was more valuable. 11. The issue of non-residence of the Female MPW in the sub-center has been persistent for the past decade. Residential accommodation for the Female MPW attached to the sub-center clinic facility is a feature of all Bank financed civil works in the Population projects. The rationale for the design is the hypothesis that provision of such accommodation would enable the Female MPW and the services delivered by her to be more accessible to the target beneficiaries. Experience from this project and the recently completed VI indicate that residential occupancy is about 50%-70% in "stronger" states such as Andhra Pradesh, Gujarat, Haryana, and Madhya Pradesh but much lower in "weaker" states such as Uttar Pradesh, Bihar and J&K. It is unclear whether beneficiary satisfaction is related to whether or not the Female MPW is resident in the sub-center. Two issues merit consideration: (a) the extent to which residential occupancy by Female MPWs is critical to the access and quality of care she provides; and, (b) if residence is critical, what are the measures required to facilitate residence. Demand Generation Objectives 12. The Project approached this important objective in several ways - creating quality infrastructures with well trained service providers and adequate equipment and supplies; orienting non-health functionaries and opinion leaders at the community level to FW and MCH services; and finally, promoting Social Marketing, Information, Education & Communication (IEC), and Non-Government Organizations (NGOs). These three latter components were centrally administered by the MOHFW and throughout the country as part of GOI's ongoing national programs. Additional activities were carried out by the five Project States. Although the Project disbursed over Rs.78 crore (more than 100% of the original allocation) for these three activities, the precise impact of the IDA investments is difficult to quantify, since the Project resources were combined with the GOI funds and programs for nationwide coverage. There was also inadequate docunentation on specific demand generation activities to be supported with IDA funds within the framework of the national program. 13. Nonetheless, around the start of the project, in the early nineties, MOHFW made a shift in its communications strategy from a narrow emphasis on sterilization to a broader reproductive health and multi-sectoral approach which emphasized spacing, delayed age of marriage, enhanced women's status, counteracting male-child preference and involving women's groups. In this context, Project funds were used to develop innovative materials together with strengthening all media channels, emphasis on interpersonal communication, audience  6 segmentation and area specific strategies (Table SD). Similarly, new mechanisms such as Society for Coordination of Voluntary Activities (SCOVA) were put in place in many States in the country; and channeling funds through Mother NGOs was introduced with some success in Punjab, Haryana and Gujarat but did not materialize in Bihar and J&K. Proactive states like Gujarat and Punjab were able to provide substantial support to local NGOs. However, overall utilization of the NGOs remained inadequate in the absence of a true partnership between the Government and the NGOs. As for social marketing of contraceptives, condoms and oral contraceptives were promoted through private marketing companies and NGOs, provided free or at a subsidized rate. While there has been some increase in nationwide sales of both condoms and oral contraceptives, the program suffered from poor distribution in rural areas; and irregular supply and quality contributed to reduced confidence in the products. The NIHFW study conducted in 1997 reported that the sale of condoms increased from 146 million in 1994-95 to 163 million in 1995-96 and sale of oral pills cycles from 14 million to 14.6 million in the same time frame. The study attributes this increase largely to social marketing efforts. Quality Enhancement Objectives 14. This objective was central to the Project, utilizing more than a quarter of the resources. The main thrust for quality was on upgrading the knowledge and skills of the staff, with focus on training as a core activity. The goal was to create 264 training facilities and train more than 138,000 service providers and related persons in the five States. The Project was highly successful in developing an extensive network of training infrastructure - a total of 315 institutions were built; and nearly a quarter million persons were trained (Tables SA and C). In addition to training, several strategies were pursued to improve quality - strengthening the supply dimension; upgrading physicalfacilities, equipment and vehicles; increasing the demandfor services; and revamping the managerialprocesses. Significant progress was noted above in these areas. 15. The extensive training infrastructure that was established included state, regional and district-level institutions. The State Institutes of Health and Family Welfare (SIHFWFs) were set up as the apex bodies at the State level, except for J & K with two Regional Institutes of Health and Family Welfare (RIHFW) - one each for Jammu and Kashmir Divisions. The achievement with respect to the total number of training facilities founded or upgraded in the five States exceeded the planned target by nearly 20%. These were adequately furnished and equipped, and provided with vehicles to facilitate field training. The achievement of Gujarat was about double the original goal; Haryana also exceeded its target; and Punjab accomplished its objective except for the failure to complete the SIHFW for unforeseen fund flow difficulties during the final months of the Project. Including the Regional Training Center (Patna), which the State built with its own resources - the facility was not paid for by IDA due to misprocurement associated with change of site without compliance to Bank procedures - Bihar was able to complete as many as 88 out of the planned 91 training facilities. Even J&K was able to complete about two- thirds of its planned institutions, including substantial progress with respect to the RIHFW in Kashmir (Table SA). 16. The National Institute of Health and Family Welfare (NIHFW) played an important role in the process, providing good technical and advisory support for: (a) planning and  7 establishment of the training system; (b) training the initial batches of trainers (TOTs); (c) staff and curriculum development; and (d) monitoring and evaluation of the training system. Personnel Management Information System (PMIS) and Human Resource Development (HRD) cells were set up in three States - Gujarat, Haryana and Punjab - although their use remained limited; Bihar and J&K were initiating the process. The 1998 Review of NIHFW conducted by MOBFW, reports that the Institute carried out regular monitoring visits to the States and organized workshops and meetings on technical and management issues. Training provided by NIHFW has been rated highly by the trainees and project management staff of the Project States. As confirmed by the Bank Missions and supported by the NIHFW monitoring reports as well as the Mid-Term Review and End-line Surveys, the apex institutes at the State and Regional levels carried out their leadership role in planning and implementing training objectives, with a fair amount of success, even pending the completion of some of the physical infrastructure. 17. The challenge remains in providing qualified core trainers, especially at the level of SIHFWs/RIHFWs. During the Project period, most of the training needs were met through part- time or visiting faculty members drawn from service delivery and management positions, rather than full-time professional and specialized trainers. While all the States have provided assurances of budget provisions in the Ninth Five Year Plan and the current financial year for running their training systems, only Gujarat has so far been able to put on board the core staff of professional trainers for its SIHFW. In most of the States, training is still not a recognized cadre and an attractive vocation, with lack of status, career prospects and other incentives. Some of the new training institutions also were handicapped due to the absence of vehicles or delay in their procurement - as a result of a Government moratorium on vehicles except for replacement for the old ones. 18. Despite the foregoing constraints, the Project carried out its training mandate well. As noted before, about a quarter million persons - nearly double the planned target - were trained. Of them, close to 115,000 were program functionaries, 12% above the goal - with about 1,100 key trainers; 20,000 medical officers; 24,000 field supervisors; 45,000 Female Multi-Purpose Workers (MPWs); and 23,000 male MPWs. The achievement was much more pronounced with respect to the training of non-health functionaries - more than 119,000 trained, nearly four times the goal (Table SC). Overall, Gujarat trained four times the target; Punjab, twice the goal; and Haryana, 96% of the goal. Even the weaker performing States of Bihar and J&K achieved 80% of the target. Gujarat did well by training large numbers of non-health functionaries, followed by Punjab and Haryana; Punjab also stands out conspicuously by training more than 12,000 members of rural women's groups. Bihar now has a good training capacity, with a large cadre of trainers - 474 out of the Project's total of 1,090. J&K remains handicapped in this regard; while Bihar needs to give attention to include non-health functionaries in training. The States of J&K, Gujarat, and Haryana took a lead in reorientation training of ISM practitioners. In addition, many senior trainers and program managers participated in international training programs and visits to various Project States for hands-on experience with the "best practices" in the area. The benefits were not fully utilized by some States due to lengthy procedures for selection of candidates. All in all, Gujarat developed an excellent training system, with a special focus on innovative field-based and practical training. 19. Training programs also adapted to the policy and program changes brought by the  8 post -ICPD (International Conference on Population and Development) environment to include greater quality orientation and client focus. Field visits and NIHFW studies confirm that in particular, the District Training Team (DTT) approach provided continuous on-the-job training to peripheral health workers at the Sub-Center level. The DTTs carried out regular team based visits to the health facilities and provided guidance to the service providers at the site by observing their work and making the required corrections. In training institutions, the content and process of training was noted to be participatory, problem solving, task oriented and focused on skill enhancement. The training materials were technically sound and developed by local trainers. 20. There has been some wastage of training resources and efforts due to frequent turnovers of the training staff as well as transfer of the trained personnel to other positions. The large number of vacant positions in the training institutions, especially in the SIHFWs/RIHFWs, since the inception of the Project and through Project closing also impeded realization of their full potentials. Except for Gujarat, it appears unlikely to have full staffing of the State level institutions in the immediate future. This was often attributed by senior officials to macro- economic constraints, with a freeze on new hiring. These systemic issues raise the question of realism in Project design, and could not be resolved despite repeated dialogue of the Task Team with the Government. Unless addressed, not only would training needs suffer, but a good deal of training infrastructure and staff accommodation built could remain grossly under-utilized. MOHFW and the Project States do share these concerns, and during the ICR workshop, requested continued assistance through the RCH Project and other possible Bank assistance to strengthen the software aspects of the training institutions for several years. 21. Conceding the above limitations, it needs to be reiterated that a significant number of trained managers, supervisors and service providers as well as non-health functionaries are now available to provide and support effective and quality service delivery. During the Mid-Term Review and the End-line surveys, different categories of health personnel observed and interviewed in the clinical and outreach settings received generally satisfactory ratings on most counts. A large number of functionaries in PHCs and SCs and their supervisors were found to have received in-service training, acquiring necessary skills in health and FW programs, such as: anti-natal care (ANC), post-natal care (PNC), the "five cleans" (clean surface, hands, blade, cord tie and cord stump), signs and symptoms of pregnancy, conduct of delivery, managing birth complications, immunization, family planning, record keeping, IEC, management and supervision. 22. Specifically, during the End-line surveys, Female Health Workers, Health Supervisors and Medical Officers were appraised on their knowledge and practice in five fields: family planning, maternal health, child health, communicable diseases, and work planning and management. Overall, Gujarat emerges at the top, followed by Punjab, Bihar and Haryana, with J&K at the bottom. As for Female Health Workers, Gujarat needs to give more attention to training in child health; Haryana to maternal health; and J&K to family planning and work planning. Family planning remains a weak area for the training of Health Supervisors as well as Medical Officers in J&K, where more attention is also needed on work planning and management among Female Health Workers and Medical officers. Similarly, attention is needed to communicable diseases in the training of Health Supervisors in Bihar and J&K, and for  9 Medical Officers of the three States other than Gujarat and J&K. Finally, work planning and management demand focus among Health Supervisors in Punjab and Medical Officers in the States other than Bihar and Gujarat (Tables A and 6A). All the three categories of workers had a positive response to the change in their working methods due to training. In particular, the Female Health Workers and Health Supervisors felt that training skills needed to be upgraded at regular intervals, preferably in clinical settings. 23. As for the impact of the training on service delivery itself, it is too early to make judgements. The 1999 National Family Health Survey (NFHS) and the district-level surveys conducted for the Reproductive and Child Program, are expected to provide this data by mid- 1999, which would provide evidence of progress towards impact objectives. Efficiency Improvement Objective 24. Apart from pursuing this objective through human resource development discussed above, about 16 percent of the Project outlay was specifically earnarked for improving the management and operation of the FW program by: (a) strengthening administration and management; (b) developing Human Resource Development Cells (HRDCs); (c) improving Management Information and Evaluation Systems (MIES); (d) establishing Personnel Management Information Systems (PMIS); (e) undertaking research on Program Management and Evaluation, and Human Resources Development; (f) setting up Technical Advisory Committees; and (g) instituting regular Monitoring and Evaluation Mechanisms to follow up implementation progress and bottlenecks. 25. This was a highly demanding agenda for all Project States as well as MOBFW at the Center. The States were able to establish State Empowerment Committees, headed by the Chief Secretary himself; but the Committees were unable to meet regularly and provide effective oversight over the Projects. Similarly, HRDCs, MIES, PMIS, and the Technical Advisory Committees set up in various States were yet to provide a sound basis for personnel management and quality control in operations. NIHFW conducted a number of management researches, and in collaboration with the Project States, also carried out the MTRs and the ELSs. Considerable additional investments and time would be required to develop the needed capacity in these important areas. 26. Persistent gaps at the State level included: (a) inadequate coordination between the Project Implementation Units and the Directorates of Health and other related Government Departments and NGOs; (b) weak ownership of the Project at the State and local levels; and (c) ineffective mechanisms to monitor service delivery and construction programs. NIHFW conducted fairly regular monitoring visits to the States, but its observations were only of a technical and advisory nature. Staffing and resource constraints seemed to have impeded intensive MOHFW field monitoring, keeping it limited to follow-up of specific programmatic and financial bottlenecks when urgently needed. During focus group interviews conducted by the IDA missions - where MOHFW also participated - current as well as former Project Directors and other senior State officials noted that more regular visits from the Center would have proved useful in resolving critical implementation issues through interventions and dialogue with the highest levels of State officials in administration and finance. The States  10 themselves also needed to be much more proactive, taking full ownership of their program and resource management and establishing vigilant monitoring mechanisms of their own. C. PROJECT COSTS AND IMPLEMENTATION TIMETABLE 27. Financial Objectives. The financial objectives of the Project were fully achieved. The original Bank support of US$96.0 million included $86.0 million IDA Credit and US$10.0 million IBRD Loan. The latter was necessary to supplement limited IDA funds. However, as a result of depreciation of the rupee against the dollar, in May 1993 the project resources were reduced to only IDA Credit of US$63.96 million - with a cancellation of the entire IBRD component of US$10 million and US$22.74 million ofthe IDA Credit. Subsequent fluctuations in the dollar/SDR exchange rate, resulted in the final Credit amount of US$69.5 million and this was fully expended. Since the original rupee allocation made for the Project by the Expenditure Finance Committee (EFC) was not reduced following the Loan/Credit cancellation, a large part of the expenditure overflow was met out of the exchange rate gain in favor of the US dollar, and the remaining from the nationwide RCH Project, as agreed between IDA and GOI. Most of the RCH funds of US$11.0 million earmarked for IPP VII in February 1997 to cover additional needs would have been utilized had fund flow constraints not impeded irnplementation in Bihar, J&K and Punjab in the final days of the Project. D. MAJOR FACTORS AFFECTING THE PROJECT 28. A number of factors affected the pace of implementation, as reflected in the IDA Mission reports, MTR and ELS, and focus group interviews carried out with former and current Project Directors and other senior officials as well as representatives of NGOs, local communities and beneficiaries. 29. The negative factors included the following: a. Design Issues. The Project design was too uniforn, proving to be too demanding for full coverage in the relatively weaker performing States like Bihar and J&K - the latter being particularly handicapped by long drawn-out civil disturbances and militancy. Such risks were anticipated during Project formulation, but were thought to be worth taking for reasons of equity, health indicators and State and local needs. However, no design features for weaker states nor any specific measures were built.in for ensuring implementation follow-up in these States. There was also a general lack of realism in the planning of infrastructure and staffing of the Project Implementation Units and major training institutions of all the States, without due anticipation of macro-economic capacities to afford and sustain the ambitious goals. b. Readiness and Quality at Entry. This was a challenge in all the States as well as the centrally administered components of NGOs, IEC and Social Marketing. Quantified monitoring indicators were largely in abeyance; the Borrower's knowledge of the Bank's procurement procedures was highly deficient; and staffing and decision making power of  11 the implementing units was inadequate, especially with respect to civil works, procurement, and financial management. c. Ownership and Commitment. This project was part of a larger centrally sponsored national Family Welfare Program. As such, states received 90% of the funds as a grant from GOI and themselves covered the remaining 10%. Also, Program interventions and content were designed by MOHFW, and implemented by the state. This approach created some natural internal tensions. On the one hand, it was beneficial from an equity view- point since it provided relatively protected funds for critical interventions for the poor, which would otherwise probably not receive state attention. However, it also resulted in weak state and local ownership. States expected the Center to take the lead in resolving major operational problems rather than being proactive themselves, and at the end of the Project most States wanted GOI to assume prime responsibility to mobilize resources for sustainability of the activities undertaken during the project period. Furthermore, implementation tended to be bureaucratic, without participatory involvement of communities and NGOs. d. Management and Staffing. The State Empowered Committees were set up with delay in some States; were unable to provide regular oversight in Project matters; and usually did not delegate necessary administrative and financial authorities to the Project Directors. This led to lengthy decision making and delayed implementation. Staff turnover was also a perpetual problem, four of the five Project States having had five or more - one of them, eight - Project Directors in six years. Nearly perennial vacancies in many operational and training positions, coupled with concurrent holding of several positions by an individual - arising out of financial difficulties of the States and their concern to avoid permanent liability beyond the Project period - also proved debilitating. e. Monitoring. Perhaps the single greatest weakness in the Project was lack of a systemic and regular monitoring mechanism at the State and MOHFW levels. This was aggravated by lack of incentives for monitoring work and inadequate travel and subsistence allowances for field visits. However, this view of the ICR team is not shared by MOHFW. f. Coordination. In each state, project implementation was the responsibility of a unit that was separate from the State's Family Welfare Directorate. As a result, although the project was expected to strengthen the Family Welfare Program activities, there was poor coordination between project financed activities and activities of the Family Welfare Directorate that were financed by the GOI and state budget. As a result, in most of the project states, mainstreaming and sustainability of project activities pose a serious challenge. g. Fund Flow. While GOI released the Project funds regularly to the State Finance Departments (SFDs), flow of funds from SFDs to the Project Units was a major constraint in three States - Bihar, J&K and Punjab - virtually throughout the entire course of the Project. Even during the final week prior to the closing date of June 30, 1998, SFDs in these States were each withholding more than Rs. I0 crore (US$2.0 million) out of the corresponding GOI release of Rs.63.93 crore, Rs.46.38 crore and Rs.43.79 crore. Such  12 repeated bottlenecks were explained in terms of macro-economic difficulties and complex fund release procedures of the States, resulting in low morale and periodic stoppage of salaries for the Project staff; non-completion of major activities; and outstanding liabilities to creditors. Joint IDA-MOHFW Missions had occasional success in improving fund flow through follow-up with the State Governments. However, since the problem is clearly systemic, it was beyond the realm of an individual Project. h. Financial Reporting and Audits. Weak financial reporting and lack of timely reimbursement claims and audits disrupted smooth fund flow from IDA virtually for all the States and the centrally administered components at different times throughout the Project's life. About mid-point in the Project cycle, two States - Bihar and J&K - and three centrally administered components had simultaneously been flagged with "problem status," due to financial reporting reasons, among others; J&K remained in SOE suspension for more than two years at a stretch; and during the final week of the Project, two States - Gujarat (by far the best performing State otherwise) and J&K were both facing SOE suspension. i. Civil Works. Lack of the appropriate engineering cells in the Implementation Units (stipulated under the Project) and ineffective coordination with the agencies responsible for construction - the Public Works Department (PWD) in most of the States for many activities, the Rural Engineering Wing (REW) in J&K and District Magistrates (DMs) in Bihar for the decentralized construction of SCs - led to problems of quality control, delayed completion and cost escalation. At the closing date, Bihar was unable to obtain the final figure on the completion status of 250 SCs, planned for construction under the DMs, for which there was no clear means of accountability and monitoring; and was unable to claim some possible reimbursements. Lack of rigorous compliance with IDA procurement procedures also led to compromise with efficiency and economy in certain cases. Maintenance was also not built into the Project. Finally, lack of a participatory mode led to tangential involvement of the local communities, at times associated with allocation of marginal and unsuitable construction sites. j. Procurement. Procurement in other matters also suffered, especially during the early years, due to inadequate familiarity of the States with IDA procedures or their reluctance to follow them diligently. MOHFW and Project States specifically urged that the Bank procedures be simplified. One specific issue that affected the Project was the GOI ban on procurement of vehicles except on a replacement basis. This posed a serious problem for full functioning of the new training institutions like SIBFWs and DTTs, a problem that could not be resolved despite repeated IDA mission dialogue with senior officials in MOHFW and DEA. k. Mid-Term Review (MTR). Although not mandated, an MTR was carried out for the Project. However, the Project was unable to incorporate the key lessons learnt, since the MTR process took too long (nearly two years) - because of contracting and completion delays - and the findings were available too late (during the fifth year of implementation) for major course corrections for the Project.  13 30. In view of the challenges noted above, the Project's final achievements need to be especially appreciated. The following were some of the positive factors: a. Proactive Initiatives. Committed Project Directors and top management at the State level did make a difference from time to time. Apart from the three better performing States, this was evident in J&K during the Project's final two years. b. Joint IDA-MOHFW-NIHFWMissions. IDA supervision missions were joined by MOHFW and NIHFW officials and this offered an opportunity for dialogue and interventions with the political leadership and key senior decision makers in the States and the Center. To some extent this helped to resolve the impasse on fund flows, delegation of authority to the Project Directors, and long pending audits and stalled decisions on staffing and procurement. They also provided occasions for intensive field visits, interaction with the key stakeholders, and first-hand feedback and guidance to the Project Directors, service providers and trainers. Multi-state workshops were held regularly and provided particularly useful opportunities for exchange of experiences and lessons learned between the Project States. c. Review of Procurement and Disbursement Matters. The Bank provided formal training of the Project staff in these areas, joint review and consultations during IDA missions and continued additional support from consultants and the Bank's New Delhi Office. These were effective mechanisms for mitigating confusions and expediting decisions. d. Flexibility and Reallocations. Continual review of Project needs and reallocations of the available resources for various activities - within the overall Project framework for the States - were useful in adapting to local needs, as in allocating resources for ISM Centers in J&K and training of mothers' groups in Punjab; building warehouses in Haryana; and small wards attached to SCs in Gujarat. Similarly, the MOHFW initiative in making major reallocations between the Project States - Rs.30 crore (about US$8.0 million) from Bihar to Gujarat, Haryana and Punjab during the Project's fifth year - enhanced overall utilization of the IDA resources as well as posed a challenge to Bihar itself to scale up Project efforts. E. PROJECT SUSTAINABILITY 31. The issue of sustainability in the context of the evolving demands of the family welfare program needs to be approached with realism and as a process much beyond the limited horizon of the present Project. This needs special attention in the context of relative isolation of Project efforts from mainstream activities in health and related areas during the implementation. Nevertheless, significant strides have been made toward setting up a vast network of infrastructure and staff development for enhanced training and service delivery. Their potential contribution is certainly promising. At the same time, considerable additional investmnents must be made to bring the investments made to full fruition over the course of the next five to ten years. This would demand: (a) consolidation of software aspects of the prograrm in support of and for the full utilization of the facilities already put in place; (b) graduation of the program  14 toward expanded RCH mandate for quality care in the field; and (c) ownership by the State and local community in conjunction with other major stakeholders. 32. It would be most opportune to seek needed support from the RCH resources, especially for continued human resource development and monitoring. Nodal institutions for reinforcing training efforts under the RCH Project have already been identified in three of the five IPP VII States. Further GOI-Bank collaboration in this regard would be useful in ensuring that the institutions created under the current Project are made fully functional, with the expertise and material support required for them. The apex institutions like the SIBFW, Punjab and RIHFW, Kashmir that remained physically incomplete would require special attention to avoid the wastage of investments already made. While important beginnings have been made under IPP VII for the demand generation and efficiency improvement objectives, the gains would need to be reinforced through further support. In earmarking its resources for meeting the potential shortfalls under the current Project, the RCH Project already registered its commitment to cover the comprehensive "needs of the national program." BANK PERFORMANCE 33. During Project formulation, Bank staff worked closely with the Borrower representatives in defining the Project strategies and identifying the vast potential demands of the Family Welfare Program for enhancement of quality based services in the rural health facilities. During the process of implementation, the program strategy was further strengthened with elements of the emerging RCH agenda and the expanded GOI-Bank collaboration in the area. However, although Bank staff were able to identify the implementation risks in two of the Project States, considerations of equity and desperate client needs in these potentially weak performing States led to uniform and full coverage of all components in them as in the other Project States. Special implementation and monitoring modalities were not set up to obviate the difficulties foreseen. 34. The Project represented a challenge for supervision, It involved five states whose capitals were geographically distant, and also had field sites that were scattered throughout large territories. In addition, two states had weak institutional capacity. Resource constraints restricted the number of mission field visits that could be made, and therefore weaker performing States were not visited as frequently as would have been desirable. Several alternatives to the "traditional" mission mode of supervision were used with significant success. Multi-state workshops and joint review missions with MOHFW and NIHFW were regarded by the Bank and the Borrower as highly effective in resolving implementation bottlenecks, and in providing vehicles for exchange of experiences and for technical inputs. Furthermore, the Bank's New Delhi office (sector specialist, procurement and disbursement specialists) provided continuing support and hands-on training in procurement and helped resolve funds flow and financial management issues. Extensive use of local consultants provided readily accessible technical reviews, particularly for civil, works and training. This project also creatively utilized the "problem" project status to focus management attention of Bank as well as the Borrower on more intractable implementation problems in Bihar and Jammu and Kashmir. This greatly helped to resolve bottlenecks.  15 35. The Bank's contribution during project implementation was particularly appreciated by GOI and state officials. In particular, the Bank was rated to be highly effective in mentoring the Project officials in various aspects of project implementation and monitoring, and in helping expedite on-the-spot decisions. However, several turnovers in Bank task management posed some problems of continuity and the institutional memory was found somewhat strained due to recent archival arrangements in Asia Files and the sector unit itself. G. BORROWER PERFORMANCE 36. The Borrower extended a collaborative partnership to the Bank throughout the process of formulation and implementation of the Project, GOI as well as the State Governments were also responsive to the demands of the broader program approach under the RCH Project, toward the end of the current Project. Despite many systemic and macro-economic constraints, the overall performance of the States was noteworthy. Gujarat and Haryana did well throughout the Project period; Punjab also was able to complete most of the activities on time; the recovery of Bihar during the second half of the Project was appreciable; and scaling up of implementation in the Project's final two years was phenomenal in J&K, given the unusual dislocations arising out of wide spread civil disturbances. 37. In the weaker states, Bihar and J&K, financial constraints led to delays in release to the Project funds sent to State Finance Departments (SFD) by GOI. This problem was a feature throughout the entire project period in Bihar, for most of the time in J&K and, emerged as a serious constraint towards the end of the Project period in Punjab. In addition, Bihar in particular, faced delays in decision making and poor delegation of authority to the project implementing staff. In general, there were gaps in institutional arrangements. Most State Empowerment Committees did not provide regular oversight with respect to timely execution, delegation of authority and fund flow. The Project was handicapped as a result of inadequate staffing and high staff turnovers in the management, training and civil works units. Delays in decision making impeded the pace of implementation. The timeliness and quality of financial reporting as well as procurement planning were often sub-optimal. The most critical weakness was the absence of an effective system of monitoring and feedback, backed by sufficient staff, resources and accountability. It should be noted that the above observation is not shared by MOHEFW. 38. MOHFW monitored closely the financial progress of the Project States but monitoring of other aspects of the Project was weaker. There were limited field visits mainly confined to joint participation in Bank missions. During focus groups interviews conducted by the Bank jointly with MOHFW, former Project Directors and senior State officials noted that more regular visits from the Center would have proved useful in resolving critical implementation issues. In the later years of the Project, review meetings were held between MOHFW and state officials to review progress and identify critical bottlenecks. A significant and extremely effective corrective action was the strong signal given by the MOHFW decision that funds originally ear- marked for specific states could be re-allocated to other project states if performance of a particular state was unsatisfactory.  16 H. ASSESSMENT OF OUTCOME 39. Overall, the Project may be rated as a satisfactory intervention in setting up key building blocks for a well functioning family welfare program. Between the beginning and the end of the Project, a large vacuum was filled in all Project States with respect to creating infrastructures for family welfare services and human resource development. These would now need to be consolidated in order to ensure continued upgrading of the quantity and quality of services that the Project initiated. While the quantifiable outcome indicators on infrastructure and personnel development provide evidence of considerable achievement in capacity building for training and quality service delivery, it is too early to assess the precise impact of the Project in terms of specific behavioral changes among the clients and the providers, and their implications for the family welfare and health indicators. Many valuable lessons emerged out of the design and the implementation experience that are discussed below. KEY LESSONS LEARNT 40. The key lesson learnt was the need for flexibility in Project design to match the varying requirements and capacities of the individual Project States. Largely in line with the anticipation at the design stage, Project performance varied substantially between the five States, reflecting differing capacity, macroeconomic and political situations, and policy environment. Since the IPP VII design was too uniform, it strained implementation ability in the weaker States and now leaves concerns for some aspects of sustainability of the investments that may be beyond their capacity. 41. It is also critical to limit the Project scope and focus on key interventions, particularly in low capacity settings. In the weaker States, the Project focused on completing hardware (civil works and equipment) components rather than 'software' (demand generation, quality of training, and community participation). Lack of proper blending of the Project needs, thus led to sub-optimal achievement of the objectives. 42. It is imperative to give top priority to monitoring and evaluation. Even more crucial is the creation of a culture, at all levels of management, for using service data as a proactive management tool for timely feedback and corrective actions. The weaker performing States would have benefited from more intensive monitoring but no special measures had been built into the Project to ensure that. A rigorous MTR needs to be planned and implemented on time. The project design did not include provision for a MTR. Although a MTR was completed, the Project lost a valuable opportunity for review and course correction because the MTR was completed too late in the Project cycle and did not provide the basis for in-depth assessment against a core set of monitoring indicators set during the design stage. 43. The Project experience reiterates the problem of under-utilization of certain physical facilities constructed under the Project, in particular Female MPW residential accommodation. At the same time, a good deal of beneficiary satisfaction also has been noted with respect to the services rendered by the Female MPWs, even though they had not been living on the Sub-Center  17 premises. It is, thus, important to determine the factors that contribute to Female MPW effectiveness, and make investments to reinforce them, rather than to continue wasteful expenditures on staff quartersper se. Appropriate studies and policy decisions need to be made on this issue. 44. There are chronic and persistent operational problems that adversely affect implementation of all Family Welfare Projects in weaker states. These include poor flow of funds to the implementing agency in states that experience fiscal problems, low procurement capacity, persistent staff vacancies and high turnover, and lengthy decision-making processes. These often relate to macro-economic difficulties and problems of governance at the State level, and are beyond the scope of individual Project teams to address effectively. Unless resolved at a more macro level, they continue to constrain implementation and create problems of long range sustainability. 45. An important lesson is the need for GOI to create incentives to the States through performance-based financing during Project implementation. In IPP VII, GOI released funds regularly to the State Finance Departments (SFDs), but the onward flow of funds from the SFDs to the Project Units was impeded as result of financial difficulties at the State level. Such a situation would need to be guarded against through perforinance-based financing referred to above or through reallocation of funds to Project States. The latter mechanism was found effective in energizing performance as a result of reallocation of substantial funds by MOHFW from Bihar to three better performing States during the final year of the Project staff. 46. This project demonstrates effective use of lower cost supervision mechanisms based on a strengthened Bank field office presence. Local staff and consultants conducted Workshops and provided hands-on training for project officials. Multi-State workshops proved to be a valuable approach to sharing of lessons and experience. Joint IDA review missions in conjunction with MOHFW and NIHFW provided a useful opportunity for policy dialogue, exchange of information on technical and program matters, and swift resolution of implementation bottlenecks.  18 PART II: Statistical Information Table 1. Summary of Assessments A. Achievement of Substantial Partial Negligible Not Objectives Applicable Macro policies X Sector Policies X Financial objectives X Institutional X development Physical objectives X Poverty reduction X Gender issues X Other social objectives X Environmental X objectives Public sector X management Private sector X management  19 Table 1: Summary of Assessments (continued) B. Project Sustainability Likely Unlikely Uncertain x C. Bank performance Highly Satisfactory Deficient satisfactory Identification X Preparation assistance X Appraisal X Supervision X D. Borrower Highly Satisfactory Deficient performance satisfactory Preparation X Implementation * X Covenant Compliance X Operation (if applicable) E. Assessment of Highly Satisfactory Deficient outcome satisfactory x * The performance of the five Project States was uneven. Haryana and Gujarat are rated as Highly Satisfactory; Punjab as Satisfactory; and, Bihar and J&K as Deficient  20 Table 2. Related Bank Loans/Credits Credit Title Purpose Year of Status Approval First Population Project To support the farnily welfare program in 1972 Credit closed Cr. 312-IN five districts of Mysore (now Kamataka) 06/30/80. and six districts of Uttar Pradesh Project Completion Report (PCR) 6/81; PPAR 1/82 Second Population Project To support the family welfare program in 1980 Credit closed Cr. 981-IN six districts of Uttar Pradesh and three 03/31/88 districts of Andhra Pradesh PCR 1/90; PPAR 8/90 Tanil Nadu Integrated To inprove the nutritional and health 1980 Credit closed Nutrition Project I (TINP) status of preschool children and pregnant 03/31/89. Cr. 1003-IN and nursing women. PCR 1/91; Impact Evaluation report 12/94 Third Population Project To support the family welfare program in 1984 Credit closed Cr. 1426-IN six districts of Kamataka and four 03/31/92. districts of Kerala. PCR 8/93. Fourth Population Project To support the family welfare program in 1985 Credit closed Cr. 1623-IN four districts of West Bengal 03/31/94. PCR 12/94. Fifth (Bombay and To reduce infant, child and matemal 1988 Credit closed Madras) Population morbidity and mortality and to moderate 03/31/96. Project fertility in the cities of Bombay, Madras Cr. 1931-IN and other urban areas of Tamil Nadu, and ICR 10/96. to assist the Municipal Authorities in designing and implementing improved health and family welfare programs. Sixth (First National To support the family welfare program in 1989 Credit closed Family Welfare Training the states of Uttar Pradesh, Andhra 05/31/97. and Systems Pradesh, and Madhya Pradesh. Development) Population ICR 2/98. Project Cr. 2057-IN) Tamil Nadu Integrated To extend the successful TINP program 1990 Credit scheduled Nutrition Project II (TINP to all of Tamil Nadu's 20,000 villages. closed 12/31/97. II) Cr. 2158-IN Integrated Child To imnprove the nutrition and health 1990 Credit scheduled Development Services standards of pre-school children and closed 12/31/97. Project I (ICDS I) mothers in tribal, drought-prone and Cr. 2173-IN otherwise disadvantaged areas of Andhra Pradesh and Orissa.  21 Table 2. Related Bank Loans/Credits (continued) Credit Title Purpose Year of Status Approval Eighth (Family To help the Government of India increase the 1991 Credit scheduled Welfare Urban supply of family welfare services in the slum to close 06/30/01. Slums) Population populations of Andhra Pradesh. Kamataka, Project West Bengal and Delhi. Cr. 2394-IN Child Survival and To support the Government of India's Maternal 1992 Credit closed Safe Motherhood and Child Health Program. 09/30/95. Project Cr. 2300-IN ICR 03/97. Integrated Child To improve the nutrition and health status of 1993 Credit scheduled Development preschool children and their mothers by to close 09/30/00. Services Project strengthening and increasing the outreach of (ICDS II) the ICDS program in Bihar and Madhya Cr. 2470-IN Pradesh. Ninth (Family To support the family welfare program in the 1994 Credit scheduled Welfare - Assam, states of Assam, Karnataka and Rajasthan. to close 12/31/01 Rajasthan and Kamataka) Population Project Cr. 2630-IN Andhra Pradesh To (i) improve efficiency in the allocation and 1994 Credit scheduled First Referral Health use of health resources through policy and to close 03/31/02. System Project institutional development; and (ii) improve Cr. 2663-IN system performance of health care through improvements in quality, effectiveness and coverage of health services at the first referral or secondary level to better serve the neediest sections of society. State Health To assist the Government of Kamataka, Punjab 1996 Credit scheduled Systems II Project and West Bengal to (i) improve efficiency in to close 03/31/02. Cr. 2833-IN the allocation and use of health resources through policy and institutional development; and (ii) improve performance of the health care system through improvements in the quality, effectiveness and coverage of health services at the first referral level and selective coverage at the primary level to better serve the neediest sections of society. Reproductive and To assist the FWP to: (a) improve management 1997 Credit scheduled Child Health performance by nationwide implementation of to close 03/31/03 Cr. N-018-IN policy change referred to as the "participatory planning approach" and institutional strengthening; (b) improve quality, coverage and effectiveness of existing FW services and progressively expand scope and content; and (c) increase access while improving quality in selected disadvantaged districts and cities.  22 Table 2. Related Bank Loans/Credits (continued) Credit Title Purpose Year of Status Approval Second State Health To (i) improve efficiency in the allocation and use 1997 Credit Systems of health resources through policy and institutional scheduled to Development development; and (ii) improve performance of the close Project Cr. 2833-IN health care system through improvements in the 03/31/02. quality, effectiveness and coverage of health services at the first referral level to better serve the neediest sections of society. TB Control Project To reduce mortality, morbidity and disability due 1997 Credit Cr. 2936-IN to TB and to reduce the incidence of infectious TB scheduled to by focusing on the cure of infectious patients. close 12/31/02. Malaria Control To reduce death, morbidity and social and 1997 Credit Project Cr. 2964-IN economic losses from malaria through an scheduled to improved malaria control program including: (i) close using a better mix of effective malaria control 03/31/03. interventions responsible to local needs; and (ii) strengthening the Directorate of the National Malaria Program (NMP) and modifying its orientation. Orissa Health To assist the Government of Orissa (GOO) to: (i) 1998 Credit Systems improve efficiency in the allocation and use of scheduled to Cr. N-04 l-N health resources through policy and institutional close on development; and (ii) improve the performance of 03/31/04 the health care system through improvements in the quality, effectiveness and coverage of health services at the first referral level and selective coverage at the community level to better serve the neediest sections of society. The project would support other health programs aimed at reducing infant and matemal mortality rates, which are especially high in Orissa. Women & Child To improve the nutritional and health of pre- Development school-aged children and women, by increasing Project the quality, imnpact, and cost-effectiveness of the Project ID 35827. Integrated Child Development Services (ICDS) program in the states of Kerala, Maharashtra, Rajasthan, Tamil Nadu, and Uttar Pradesh. In addition, the project aims to strengthen the ICDS program in the remaining states and union territories by improving the quality of worker training in each of them. Maharashtra Health To assist the Government of Maharashtra (GOM) 1998 Credit Systems to: (i) improve efficiency in the allocation and scheduled to Development use of health resources through policy and close Project institutional development; and (ii) improve the 09/30/04 Project ID 50651 performance of the health care system through systemic enhancements in the quality, effectiveness and coverage of health services at the first referral level and selective coverage at the community level.  23 Table 3. Project Timetable Steps in Project Cycle Date Preparation October 1, 1989 Depart Appraisal January 12, 1990 Negotiations April 11, 1990 Board Approval May 17, 1990 Signing October 23, 1990 Effectiveness March 8, 1991 Mid-Term (if applicable) May 31, 1997 Credit Closing June 30, 1998 Table 4. Credit Disbursements: Cumulative, Estimated and Actual (US$ millions) FY 91 FY 92 FY 93 FY 94 FY 95 FY 96 FY 97 FY 98 FY99 Appraisal 3.11 16.42 38.60 60.95 77.81 87.51 93.01 96.70 Estimate Revised Estimate 9.84 12.66 22.30 34.97 43.53 47.03 56.03 63.03 63.95 after cancellation of exchange rate savings Actual 9.84 11.55 19.30 32.36 38.86 50.97 61.08 67.86 69.59 Actual as % 316 70 50 53 50 58 66 70 of appraised estimate Actual as % 100 91 87 93 89 100 100 100 100 of revised estimate  24 Table 5A Key Indicators for Project Implementation: Number of Training Facilities Established and Functioning TRAINING FACILITY BIHAR GUJARA T HARYANA JAMMU & PUNJAB TOTAL KASHMIR p _ P c p C p C p C p C SIHFW/RIHFW* 1 I 1 1 I 1 2 1 1 6 4 RTC MIF 14 - - - -- -- -- -- 14 1 1 DTT Centers 39 39 16 16 17 15 9 8 12 12 93 90 ANMT Facilities 22 21 32 32 2 2 15 8 71 63 MPW (Male & Female) 5 3 7 7 12 10 Training Facilities HA Training School 1 1 1 1 H & FW Training School 1 I I I Other: PHC Training 15 15 40 40 55 55 Amnex 10 72 1 8 11 80 Exp. Of Training Facilities Total 91 87 59 121 26 29 26 17 62 61 264 315 *NOTE: RIHFWKashmir is near completion; SIHFWPunjab is about halfcompleta P = Planned; C = Completed Table 5B Key Indicators for Project Implementation: Upgrading of Service Delivery Facilities SERVICE BIHAR GUJARAT HARYANA JAMMU& PUNJAB TOTAL DELIVERY KASHMIR P C P C P C P C C P C Sub-Centers 1,000 750 600 684 451 443 500 382 400 400 2,951 2,659 ISM Dispensary 100 75 . 100 75 Upgraded PHCs 144 81 3 3 50 47 85 57 100 100 382 288 Logistic Stores | | 12 8 2 2 - - 10 Total 1,144 831 603 687 5513 498 687 516 500 500 3447 3032 Number of vehicles 72 34 - 142 100 142 120 100 53 314 449 (purchased or made road worthy) _ _ Transport Repair -- -- -- - -- -- 2 1 2 1 Workshop I I Delivery Kits 9,651 - | 950,000 4,999 250,000 66,000 600,000 600,000 859,651 1.62M NOTE: P = Planned; C Completed  25 Table 5C Key Indicators for Project Implementation: Training Coverage CATEGORY BIHAR GUJARA T HARYANA JAMU & PUNJAB TOFTAL KASHMIR p c p C P C P C P C P C Key Trainers 474 256 242 100 212 - 130 162 486 1,090 Medical Officers 4,704 3,884 2,050 2,034 1,284 1,234 1,396 1,176 9,100 11,220 18,534 19,548 Supervisors 2,980 2,051 11,880 11,469 2,661 3,364 110 105 3,147 7,019 20,778 24,008 MPW - Female 12,776 10,673 7,950 7,661 7,798 6,702 2,482 3,717 6,600 15,777 37,606 44,530 MPW - Male 6,354 4,776 5,639 4,896 2,544 1,549 5,900 11,978 20,437 23,199 ISM practitioners . 795 762 498 498 3,969 1,263 5,262 2,523 Non-Health 78,358 10,000 10,444 9,032 7,075 15,000 23,500 34,032 119,377 Functionaries Members of Rural 1,000 12,310 1,000 12,310 Women's Groups Total 26,814 21,858 28,570 105,422 24,885 24,003 16,989 13,336 40,877 81,966 138,135 246,585 NOTE:: P = Planned; C = Completed !. The figures for Punjab for Non-Health Functionaries includes Dais. Table 5 D Key Indicators for Project Implementation: List of IEC Activities Conducted Annually Activity Average Number Per Year in all Five Project States Electronic Media: Radio Programs 54,444 Interactive Listener Participation on Radio 156 Television Programs and Spots (paid) 3700 Free Air Time on radio 2 minutes/day Free Air Time on TV 2 minutes/day Intensive Interactive and Area Specific Song and drama performances 36,700 Film shows 47,600 Oral communication sessions 22,500 Photo Exhibitions 110,670 TV shows 5,910 Inter Personal Communication Mahila Swasthya Sangh 75,568 Joint training of ICDS and ANM 1,10,105 Training of BEEs 517  26 Table 6A Key Indicators for Project Operation: Training Quality and Impact Percent having critical knowledge (Data from Endline Surveys) CATEGORY T BIHAR GUJARAT I HARYANA J& K PUNJAB Female Health Workers Family Planning 86 89 81 55 91 Maternal Health 74 91 55 68 82 Child Health 82 55 53 68 85 Comm. Diseases 95 99 96 66 100 Work Planuing 87 95 90 41 99 Female Health Supervisors Family Planning 81 90 86 45 90 Maternal Health 60 95 82 60 100 Child Health 72 62 42 80 71 Comm. Diseases 35 93 94 35 82 Work Planning 61 68 80 63 56 Medical Officers Faniily Planning 72 100 79 55 82 Maternal Health 90 73 82 83 79 Child Health 85 81 77 86 74 Comm. Diseases 57 70 44 82 40 Management i 100 78 27 32 53  27 Table 6B Key Indicators for Project Operation: Utilization of Upgraded Facilities BIHAR GUJARAT HARYANA J& K PUNJAB ELS ELS ELS ELS ELS % of Sub-Centers with 11 47 60 0 10 resident HW (F) % of PHCs with MOs 86 67 57 100 30 residing in/near campus Table 6C Key Indicators for Project Operation: Beneficiaries Assessment on Delivery of Family Welfare Services at Sub Centers TOPIC BIHAR GUJARAT HARYANA J& K PYNJAB Sub Center (SC) Suitability of Hours of SC 84.5% 87.2% 100.0% 72.6% 82.6% Time to reach SC (less than 63.5% 73.3% 93.0% 85.2% 75.2% 20 minutes) Mode of Travel (by foot) 90.1% 87.2% 99.5% 98.5% 80.5% Satisfactory behavior of 84.2% 98.4% 98.4% 100.0% 78.0% CHW'S at SCs Home visit by ANM Conducts home visit 64.5% 93.3% 100.0% 99.1% 33.8% Home visit (monthly) 26.5% 35.7% 38.2 3.8% 4.0% Advises on Immunization, 61.9% 72.3% 60.0% 99.1% 61.0% Family Planning & Ante- Natal Care.  28 Table 6D Key Indicators for Project Operation: Fertility, Mortality and Coverage Indicators BIHAR GUJARAT HARYANA PUNJAB NA TIONAL Baseline Most Baseline Most Baseline Most Baseline Most Baseline Most recent recent recent recent recent data data data data data 1. TFR 4.4 4.5 3.1 3.2 4.0 3.7 3.1 2.9 3.6 3.5 2. IMR 69 71 69 62 68 68 53 51 80 71 3. %Infants 11 40 50 65 54 70 62 84 35 63 fully irmnunized 4. % Women 37 N/A 76 92 73 100 88 87 62 63 Receiving ante- natal care 5. % Assisted 27 33 57 73 84.4 92 94.5 98.2 46 53.4 at delivery by a doctor/nurse/tra ined midwife ___ __ ___ _ Sources: (1) From Sample Registration System (SRS). Baseline 1991; most recent date 1995. (2) From SRS. Baseline 1991; most recent data 1997. (3) and (4) Baseline data (1992-93) from National Family health Survey (NFHS); most recent data (1995-97) from UNICEF Multi-Indicator Cluster Surveys in India (MICS) (5) SRS. Baseline 1991; most recent data 1997 Note: Surveys may not be entirely comparable as definitions and questions may vary. N.B.: Data for Jammu and Kashmir are not available.  29 Table 7: Studies Included in Project Study | Purpose as Defined at Status Impact of Study Appraisal/Redefined Bihar Training needs assessment study To identify training needs. Completed Used to develop training plan Report on Baseline Survey in Bihar To provide baseline data Completed Used in project evaluation for project planning. Mid-term Evaluation of IPP-VII Project in To assess project Completed Recommendations of the MTR Bihar - A Final Report September, 1997 performance. implemented during remainder of project Endline Survey on Training Activities To collect endline survey Completed Utilized to prepare ICR. data upon completion of project Report of Endline Survey of Civil Works To collect endline survey Completed Utilized to prepare ICR. data upon completion of project. Punjab Baseline Survey To provide baseline data Completed Used in project evaluation. for project planning. Mid-term evaluation To assess project Completed Recommendations of the MTR performance. implemented during remainder of project Endline Survey on training needs To collect endline survey Completed Utilized to prepare ICR. data upon completion of project. Report of Endline Survey of Civil Works. To collect endline survey Completed Utilized to prepare ICR. data upon completion of project. Jammu and Kashmir Communication Needs Assessment Study Examine existing behavior Completed Used to prepare Jammu & Kashmir Volume I and II communication strategies. Training needs assessment study To identify training needs. Completed To develop training plan. Mid-term Evaluation. To assess project Completed Recommendations of the MTR performance implemented during remainder of project Endline Survey of civil works. To collect endline survey Completed Utilized to prepare ICR. data upon completion of ____________________________________________ project.  30 Table 7: Studies Included in Project (continued) Study Purpose as Defined at Status Impact of Study Appraisal/Redefined Gujarat A Report on Training Activities in Gujarat. To identify training needs. Completed Used to prepare training plan. Report on Baseline Survey in Gujarat Vol. I To provide baseline Completed Used in project evaluation. (Household and Eligible Couple) training for project planning. Report on Baseline Survey in Gujarat Vol. II To provide baseline Completed Used in project evaluation. (Services Providers) training for project planning Report on Baseline Survey in Gujarat Vol. III To provide baseline Completed Used in project evaluation. (Training Dais) training for project planning Report on Baseline Survey in Gujarat Vol. To provide baseline Completed Used in project evaluation. IV (Executive Summary) training for project planning Monitoring Communication Needs for Examnine existing behavior Completed Used to prepare Health and Family Welfare The communication strategies. Communication Needs Assessment in the USAID Assisted Areas Projects in Gujarat, Haryana, Himachal Pradesh, Maharashtra and Punjab Mid-term Evaluation To assess project Completed Recommendations of the MTR performance implemented during remainder of project Endline Survey on Training Activities To collect endline survey Completed Utilized to prepare ICR. data upon completion of project. Endline Survey of Civil Works IPP VII To collect endline survey Completed Utilized to prepare ICR. Gujarat Report August 1998 data upon completion of project. Harayana Report on Baseline Survey in Haryana Vol. I To provide baseline Completed Used in project evaluation. Households & Eligible Couples MODE training for project planning Report on Baseline Survey in Haryana Vol. To provide baseline Completed Used in project evaluation. II Health Infrastructure MODE training for project planning Report on Baseline Survey in Haryana Vol. To provide baseline Completed Used in project evaluation. III Trained Birth Attendants training for project planning  31 Table 7: Studies Included in Project (continued) Study Purpose as Defined at Status Impact of Study Appraisal/Redefined Harayana Report on Baseline Survey in Gujarat Vol. To provide baseline Completed Used in project evaluation. IV (Executive Summary) training for project planning Monitoring Communication Needs for Examine existing behavior Completed Used to prepare Health and Family Welfare. The communication strategies. Communication Needs Assessment in the USAID Assisted Areas Projects in Gujarat, Haryana, Himachal Pradesh, Maharashtra and Punjab Mid-term Evaluation of Training and Civil To assess project Completed Recommendations of the MTR Works Activities under World Bank Assisted performance implemented during remainder IPP-VII Project in Haryana August, 1996 of project. Endline Survey India Population Project-VII To collect endline survey Completed Utilized to prepare ICR. Haryana data upon completion of project Endline Survey of Civil Works Under IPP To collect endline survey Completed Utilized to prepare ICR VII in the State of Haryana data upon completion of project National Component Report of Role of National Institute of End of project evaluation. Completed j Utilized in preparation of ICR. Family Welfare, 1998 I Report of Social Marketing, Dept. of Family End of project evaluation. Completed | Utilized in preparation of ICR. Welfare, 1998 I Status Report - Involvement of Voluntary End of project evaluation. Completed | Utilized in preparation of ICR. organizations in Family Welfare Programme, IPP-VII Project, 1998 l  Table 8. Project Costs and Disbursement Performance by Expenditure Category (in million US$) Appraisal Estimate (US$M) Revised Estimate (US$M) Actual Estimate (US$M) Item Local Foreign Total Local Foreign Total Local Foreign Total Costs Costs Costs Costs Costs Costs Civil works and related professional 30.55 6.25 36.8 28.69 3.91 32.6 29.13 3.97 33.1 fees Equipment, furniture, books and 10.85 4.65 15.5 9.9 1.10 11.0 7.83 0.87 8.7 vehicles Consultant's services and local and 30.8 - 30.8 14.2 - 14.2 14.2 - 14.2 overseas fellowships Incremental salaries, consumable 9.09 1.01 10.1 10.88 0.82 11.7 12.55 0.95 13.5 materials and operation and maintenance costs Unallocated - 3.5 3.5 Total 81.29 15.41 96.7 63.67 5.83 69.5 63.71 5.79 69.5 Table 8B: Project Financing .______________ Appraisal Estimate (US$M) Revised Estimate (US$M) Actual Estimate (US$M) Source Local Foreign Total Local Costs | Foreign Total Costs Costs Costs IBRD/IDA _ | 96.7 | | 69.5 l l 69.5 GOI | | 78.9 | | 78.9 l | 75.9 | TOTAL |_______ |_______ 175.6 __l_l 148.4 l l . l 145.4 Table 9: Economic Costs and Benefits - Non-applicable.  33 Table 10: Status of Legal Covenants Agreement Text Covenant Status Description of Covenant Comments Reference Class CREDIT Article IV 1 C The Borrower shall maintain records and accounts adequate Complied with. to reflect in accordance with sound accounting practices the operations, resources and expenditures of the Project. The Borrower shall furnish to the Administrator, as soon as available, but in any case not later than nine months after the end of each such year, the report of such audit by said auditors, of such scope and in such detail as the Administrator shall have reasonably requested. 3.2 5 CP The Borrower shall maintain the Administrative Cell Complied with established by it in its Ministry of Health and Family Welfare partially. for the purpose of coordination project activities between the Center and Project States, in accordance with a key staffing __________ _________ plan agreed to by the Borrower and Association. 3.3 10 C The Borrower shall review and revise the job descriptions Complied with. and work routines of health workers and assistants. 3.4 10 C The Borrower shall review the existing procedures for Complied with. providing grants to private voluntary organizations involved in the family welfare program and by January '92 take appropriate action to enable such organizations to participate more effectively in the national family welfare program. 3.5 10 C The Borrower shall, as part of its concurrent evaluation of the Increased use of National Family Welfare Program, review the impact method temporary specific incentives in the strategy to increase the use of contraceptive temporary methods of contraceptives amongst lower parity method is part of couples. The findings of this review shall be made available the ongoing to the Association for discussion during the Annual Review development of the the following year. family welfare ____________ ________ __ _strategy. 2.1 10 C The Project States shall each prepare and furnish to the Bank Complied with. Group for its review and comment, an annual IEC plan. 2.2 10 C The Project States shall in conjunction with the Borrower, Complied with. adequately fund and maintain their respective CHCs, PHCs, and sub-center facilities and equipment provided under the project. 2.3 5 CP The Project States shall each establish and staff according to Partially complied a key staffing plan agreed with the Bank Group (a) an with. Institute of Health and Family Welfare; (b) Human Resources Development Cell; (c) District Training Center/Teams; and _________ (d) Construction Cells. 2.4 10 CD The Project States shall in conjunction with the Borrower Under identify blocks/districts for the operational research on implementation measurement and evaluation of the family welfare program nationwide as part and release those from present target-setting procedures. of the Reproductive and Child Health (RCH) Project. 2.5 10 CP The Project States shall cause its HRDCs to (a) develop and Plans underway for institute a Personnel Management Information System; (b) sustainable staffing establish systems intended to maintain the agreed staffing arrangements. pattern with reference to key institutional personnel. 2.6 10 CD The Project States shall in conjunction with the Borrower, Under prepare and furnish terms of reference for additional implementation as innovative schemes in support of the family welfare program part of the RCH to the Bank Group for review and comment. Project.  34 Status: C Complied with CD Compliance after delay NC Not complied with SOON Compliance expected in reasonable short time CP Complied with partially NYD Not yet due Covenant Class: 1 Accounts/Audit 2 Financial performance/generate revenue from beneficiaries 3 Flow and utilization of project funds 4 Counterpart funding 5 Management aspects of the project or of its executing agency 6 Environmental covenants 7 Involuntary resettlement 8 Indigenous people 9 Monitoring, review and reporting 10 Implementation 11 Sectoral or cross-sectoral budgetary or other resource allocation 12 Sectoral or cross-sectoral regulatory/institutional action 13 Other Table 11: Compliance with Operational Manual Statements No significant lack of compliance with any applicable Bank Operational Manual/Statement (OD or OP/BP) was noticed. With the introduction of LACI, more attention is being paid to financial management.  Table 12A. Bank Resources: Staff Inputs (Staff weeks) 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Project Cycle SW SW SW SW SW SW SW SW SW SW SW Preparation to appraisal 18.2 38.4 Appraisal 18.0 Negotiations 6.1 9810 369 Supervision 9.1 18.7 21.8 50.9 30.6 52.9 71.5 23.1 Completion 18.0 Table 12B. Bank Resources: Staff Inputs (US Dollars) ._________________ 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Project Cycle $ $ $ $ $ $ $ ,$ $ $ $ Preparation to appraisal 41.0 108.8 Appraisal 40.3 Negotiations 18.1 Supervision __ 23.5 41.4 57.9 112.8 92.6 94.4 123.2 69.9 w Completion _ 28.4a _/planned  36 Table 13. Bank Resources - Missions Stage of Project Month/Year Number Days in 'Specialization 'Performance Rating Problems Cycle Of Field Represented I O.S3 Dev. obj. Persons Familiarization Familiarization Preparation 03/89 Preparation 07/89 Pre-Appraisal Appraisal 1/90 4 16 Supervision 1 9-10/90 5 12 ME, D, A, E U U AF, SP, OS Supervision 2 12/91 3 4 ME, CA, CTS S S IP Supervision 3 9/93 6 4 CA, CTS, ME U U PR, OS, AF, IP Supervision 4 2-3/94 6 23 ME, CA, SIS U U PR. IP. AF Supervision 5 11-12/94 5 7 ME, CA, CTS S S AF Supervision 6 8/94 7 12 CA, CTS, ME S S AF, IP Supervision 7 11/95 4 8 CA, CTS, MS U U IP, AF, IP, __ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ O S Supervision 8 6/96 6 14 MS, CTS, ME S S AF Supervision 9 10-11/96 5 17 MS, CA, C, ME S S AF MTR 4/97 5 18 MS, CA, C, S U IP, PM I____________ ________ |____ _ SIS, D Supervision 10 11/97 4 18 MS, CA, C, D S S IP, PM ICR 6/98 6 15 MS, D, SIS, SS AF, PM CTS, SS A=Architect, C=Consultant, CA=Consultant Architect, CE=Consultant Educator, CTS=Consultant Training Specialist, DEM=Demographer, ME=Medical Educator, MS=Management Specialist, SIS=Senior lmplementation Specialist, SS=Social Sector Specialist 2 The earlier performance ratings were based on a numbered system 3 IOS=Implementation (overall status) 4 AF=Availability of finds, CL=Compliance with legal covenants, IP=Implementation progress, OS=Overall status, PM=Project management performance, PR=Procurement progress SP=Studies progress  Appendix A Page 1 of 6 INDIA WORLD BANK IMPLEMENTATION COMPLETION MISSION Aide Memoire June 1998 A. INTRODUCTION 1. As part of the thematic supervision of the India Population Portfolio, the final IDA Review Mission for the Seventh Population Project was held between June 8 to 22, 1998. The key objectives of the Mission were to: (i) assess the status of Project implementation on the eve of the imminent closing date of June 30, 1998; (ii) review the End Line Surveys (ELS); and (iii) finalize the preparations for the Implementation Completion Report (ICR) in consultation with the GOI-MOHFW. Special attention was devoted to: following up on the implementation benchmarks agreed to during the November 1997 mission; intensifying efforts for implementation completion during the remaining days; setting up arrangements for financial closing and institutional sustainability beyond the Project period; and completing the documentation for ELS and ICR. The Mission participated in a two-day workshop on ELS arranged by the National Institute of Health and Family Welfare (NIHFW) in its premises in Delhi, which was attended by senior officials of MOHFW and all five Project States. Field visits were undertaken by the Mission in Bihar, Haryana, Jammu and Kashmir (J&K), and Punjab, jointly with representatives of MOHFW and NIHFW. Valuable dialogue was carried out with the Project authorities as well as a number of former Project Directors and other senior officials associated with Project implementation in preceding years. The Mission's consultant architect had earlier visited Bihar, Gujarat, Haryana and J&K. 2. The Mission comprised of Messrs./Mmes. Badrud Duza (Mission Leader), SASHP; Tirtha Rana (Health Specialist), SACKA; Suneeta Singh (Consultant/Public Health Specialist); M. C. Gupta (Consultant/Management and Budget); Rajiv Aggarwal (Consultant/Architect); and Rashmi Sharma (Consultant/NGO and related components), SASHP. Dr. Indra Pathmanathan, India Population Team Leader, led the initial discussions with the MOHFW and DEA on the broad Population portfolio issues. Messrs. Mam Chand (Senior Procurement Engineer) and K. Radhakrishnan (Financial Analyst) of NDO provided advice on procurement and disbursement matters, respectively. The present Aide Memoire summarizes the conclusions of the Mission, and will need to be confirmed by IDA management through a post-mission letter. 3. The Mission conveys its deep appreciation to the Union and State Government officials for valuable consultations on critical issues at this concluding stage of the Project. Special thanks are due to Mr. K. S. Sugathan, Joint Secretary (MOHFW); Mr. A. K. Mehra, Joint Director, Area Projects (MOHFW); and Dr. H. Helen, Director, NIHFW, for deliberation on Project issues. The wrap-up meeting, held on June 22, was chaired by Mr. Sugathan, and attended by representatives of all five Project States and concerned officials of MOHFW and NIHFW.  Appendix A Page 2 of 6 B. KEY IMPLEMENTATION ISSUES: GENERAL 4. Overview of Performance. This has been the final supervision mission, the closing date being June 30, 1998. The development objectives of the Project have been significantly achieved in terms of: (i) vast expansion of the physical infrastructure for family welfare and related service delivery at the outreach level; (ii) enhanced demand for services through IEC, NGO and social marketing efforts; (iii) significant improvement in the quality of services through the development of a wide network of training institutions for different levels of - program functionaries, community leaders and opinion makers from the State to the District level; and (iv) strengthened management and MIS. Project implementation has been completed with reasonable satisfaction for the Centrally administered components of IEC, NGO, social marketing, and NIHFW; would be attained more than originally planned for the States of Gujarat, Haryana, and Punjab; is substantially over in Bihar; and is getting close to reasonably satisfactory conclusion in Jammu and Kashmir, despite a late start and continuation under formidable circumstances. 5. The final disbursement is expected to exceed the IDA Credit of US$69.5 million (exchange rate adjusted) by about US$5-7 million. The expenditure overflow would be adjusted out of the RCH funds of US$11.4 million, as arranged in January 1998. The RCH funds might not be fully utilized in view of: (i) slow progress in the implementation of additional activities undertaken in Haryana and Punjab; (ii) persistent fund flow problem in Bihar, Janumu and Kashmir, and Punjab, aggravating implementation problems during the last six months of the Project; and (iii) exchange rate changes, resulting in higher proceeds in terms of Rupees available to the Project. The Endline Surveys and related documentation in connection with completion of the project are in progress and GOI and the Project States are preparing for a final workshop on Project Completion around the end of September 1998. 6. Outstanding Issues. Despite the constraints noted above, the pending issues identified during the November 1997 mission have been largely resolved (see: Annex IA). New benchmarks relating to implementation completion and Project closing and related documentation were also agreed to during the current mission (see: Annex 1B). 7. Project Closing. The Mission briefed the Government on the process relating to the closing of the Project on June 30, 1998. It was clarified that subject to confirmation by IDA management, up to October 31, 1998 (i.e., four months following Project closing), withdrawals from the Project funds would be permitted for eligible expenditures to cover payments made, or payments due for goods, work and services provided for approved activities carried out on or before the closing date (June 30, 1998); and that advances made would not be treated as expenditures incurred for the purpose of reimbursement from IDA. It was pointed out that the stipulation on freezing expenditures as of June 30, 1998 would be applied to all Project expenses including the State component (10 percent) of Project costs, the remaining 90 percent of which are covered by GOI as grant to the States. 8. Funding Shortfall, Fund Flow, and Expenditure Performance. Annex 2A reflects on the funding resource and shortfall scenario; Annex 2B, the overall expenditure performance; and Annex 2C, expenditure perfornance by year and components. The exchange rate adjusted  Appendix A Page 3 of 6 Credit (net of cancellations) of US$69.5 million is now left with a balance of US$2.7 million. Against this, claims eligible for reimbursement could be of the order of US$12.9 million. However, fund flow problems could retard Project implementation, resulting in a possible shortfall of US$5 to 7 million. This could be met from RCH Project funds as noted above. 9. As of March 1998, the Project expended Rs.296.2 crore (88 percent) out of the total Project cost of Rs.335.7 crore -- Project States, Rs.223.5 crore (81 percent of allocation); and Centrally administered components, Rs.72.8 crore (over 100 percent of allocation). Subject to availability of funds in all States, total Project expenditure by June 30, 1998 could be Rs.362.6 crore. In this context, the Mission noted the grossly insufficient release offunds from State Departments of Finance to the Projects in Punjab, J&K and Bihar, severely constraining Project implementation (Rs.18 crore in Punjab, Rs.15.8 crore in J&K and Rs.10 crore in Bihar, pending release during the last fortnight of the Project), which needs immediate resolution. 10. Infrastructure. The Mission reviewed the status of all civil works and confirmed the final actions. As detailed in the update of civil works component in Annex 3, construction of the original targets for various facilities is largely complete in all the States; and additional construction in Gujarat and Haryana are nearing completion. While the construction is generally of satisfactory quality, initial review identified many buildings with defects and missing utilities that need further attention. Outstanding constructions and minor works are mostly in Bihar and J&K, and in Punjab the SIHFW remains incomplete due to fund flow problems. It was agreed that as part of the ICR documentation referred to below, by July 21, 1998: (i) Bihar, J&K, and Punjab would provide complete information on the status of all remaining constructions; (ii) all States, except Gujarat, wouldfinalize identification of defects and undertake rectification in the completed works; and (iii) by July 31, 1998, MOHFW would confirm the approved cost for additional activities undertaken in Haryana. Additional comments on the status of civil works in the Project States are noted in the text on individual States and detailed in Annex 3 (A- D). 11. Procurement. It was agreed that the Project States would update the inventory of all procurement done for civil works, equipment, vehicles, supplies, and consultants, indicating the costs involved and the procurement methods followed, such as force accounts, national shopping, and sole source. The States would also provide IDA with the final lists of distribution of vehicles and major items of equipment to various facilities. These tasks are to be completed by July 21, 1998, in conjunction with the documentation for the ICR. 12. End-Line Survey (ELS). The Mission participated in the ELS workshop organized by NIHFW on June 9 and 10, 1998. Project States would submit to NIHFW, any outstanding documentation requests by June 30, 1998, enabling NIHFW to finalize the ELS report by July 31, 1998. Related consultant reports on the NIHFW and the centrally administered components of IEC and NGO activities would also need to be completed by July 31, 1998. (See: Annex 1B for detailed benchmarks and Annex 4B for Central components guidelines). Observations emerging from the ELS workshop reflect the following early insights from the Project implementation process: (i) delayed implementation as a result of problems of flow of funds, high tum-over of staff (four States had five or more Project Directors in six years, some of them holding additional charge of other positions), and slow decision making at the State level;  Appendix A Page 4 of 6 (ii) lack of sufficient monitoring and follow-up from GOI; and (iii) problem of timely clearance of procurement matters from IDA, partly related to inadequate familiarity of the Project Officials with IDA procurement guidelines. Notwithstanding such difficulties, a good infrastructure has been developed for quality training at the State, regional and district levels. Extensive augmentation of physical infrastructure has also been supported by the Project towards expansion of service delivery capacity. The challenge remains to ensure sustainability of these efforts, and maintenance and utilization of these facilities beyond the Project period. The GOI and the Project States will need to address these critical areas in their reports for the ICR, benchmarks for which are indicated below. 13. Implementation Completion Report (ICR). The Mission briefed GOI and State governments about the ICR to be prepared by IDA within six months from the date of closing of the Project. The Report will assess the achievement of development objectives and glean important lessons learnt during the process of implementation, including factors facilitating or impeding timely and full implementation. The ICR will contain a brief assessment of the implementation experience by GOI. Towards this end, it was agreed that MOHFW willforward a ten page report on the Project by August 15, 1998. This will be based on short (ten-page) reports by Project States to be submitted by July 21, 1998, ELS findings and other relevant information. IDA expects to prepare the draft ICR by September 15; the revised draft by October 15; and the final ICR by November 15, 1998. Benchmarks for ICR preparation are noted in Annex lB and a suggested outline of key points to be covered is given in Annex 4A. The Mission noted the MOHFW request to hold an ICR workshop so as to share and disseminate lessons learnt in the implementation process. Subject to confirmation by IDA management, the Mission agreed to follow up on the arrangements for the workshop to be held around the end of September, 1998. C. KEY IMPLEMENTATION ISSUES: STATE SPECIFIC All States 14. Rationalization of the training framework has been a key goal of the Project, with SIHFWs (RIHFWs in J&K) as apex institutions of the training networks in the States. The sustainability of accomplishments beyond the Project period remains a major concem. In this respect, the States wouldfurnish by July 21, 1998 (as part of ICR documentation noted above), a plan for sustainability of the structure and approach, staffing (with the necessary specialized skill mix) and operational arrangements for training. The States would also make adequate resources available for: (i) identification and rectification of defects and provision of utilities for the physical infrastructure, (ii) maintenance of buildings and equipment; and (iii) staff salaries and other training related expenses. It was agreed that the States would explore with the MOHFW/NIHFW, support available to them through the RCH Project and other sources. The States would also provide to IDA, audited statements of accounts for FY 1997-98 by December 31, 1998 andfor the relevant period ofFY1998-99 by March 31, 1998. Specific guidelines in this respect would be confirmed by PDAT Unit of the Bank's New Delhi Office.  Appendix A Page 5 of 6 Bihar 15. Major activities envisaged under the Project are expected to be completed by the closing date. Nonetheless, the Mission was concerned that the recurrent problem offundflow (Rs. 10 crore pending release by the State Departrnent of Finance) had seriously decelerated Project implementation in recent months -- especially procurement of ANM kits, vehicles, and certain training and operational activities -- and needs immediate resolution. The long awaited confirmation of the construction status of 140 HSCs and 37 OTs, being executed through the District Magistrates, is calledfor urgently so as to complete the documentation on civil works and related expenditures. The Mission noted persistent weakness in expenditure reporting, resulting in huge backlogs in reimbursement claims pending with GOI and IDA. It was agreed that GOB would urgently meet the pending audit objections for FY1995-96 accounts and expedite SOE reconciliation for FY 1997-98, with assistance from specialized consultants for the task. While appreciating the appointment of eight core staff for SIHFW during the field visit, the Mission urged GOB to expedite confirmation of the autonomous status of the SIHFW, making it fully operational with the additional staff and resources. It was also agreed that MOHFW would confirm to IDA by July 31, 1998, the final reallocation offunds for Bihar, covering the total costs incurred for Project activities. Gujarat 16. The Mission appreciates the completion of the State's original Project goals about a year ago as well the timely completion of new activities undertaken with the reallocation of Rs. 10 crore by MOHFW in February 1997. Gujarat has also proved to be the lead State in setting up a strong field based training system, and has identified and initiated rectification of defects in physical infrastructure constructed under the Project -- efforts that other States need to emulate. The only major outstanding issue has been the SOE suspension since May 12, 1998 in connection with the FY 1995-96 audit that needs to be resolved urgently. Haryana 17. Project implementation was virtually completed about a year ago and additional construction activities are under way with new fumds reallocated by MOHFW in February 1997. The Mission received a request from GOH for condoning requirements of prior review of architectural designs and compliance to the cost escalation clause in the bidding document relating to certain physical facilities being constructed with these additional funds. Subject to confinnation by MOHFW on the approval of these undertakings, the Mission reviewed and cleared the new designs and provided the waivers requested as a special case. It was agreed that MOHFW would confirm the approvalfor these additional activities, along with the costs involved, by July 31, 1998. It was also agreed that GOH would confirm by July 21, 1998, the finalphysicalprogress on the new infrastructure construction currently in progress as well as the final Project expenditures.  Appendix A Page 6 of 6 Jammu and Kashmir 18. Considerable progress in Project implementation was noted since the last mission. However, the long-standing problem of fund flow makes the prospect of completion of the ongoing civil works and the planned procurement of equipment and vehicles unlikely. An amount of Rs. 15.76 crore was still being held by the State Department of Finance during the Project's last fortnight, resulting in huge pending bills and impeding ongoing work. The suspension of the SOE disbursement since May 12, 1998 due to noncompliance with the audit requirement of FY 1996-97 is another major issue. The Mission is also concerned at the lack of documentation on the exact status of the remaining 40 percent of the physical facilities that are under construction by PWD and REW. The Project needs to have the procurement process reviewed by PDAT in order to ensure compliance with IDA guidelines. It was noted that the full complement of the staff for the RIHFWs at Jammu and Srinagar is not yet decided upon, and that many vehicles procured out of the Project are not provided to most of the training institutions. In particular, the Mission calls for immediate release of the funds; urgent steps for withdrawal of SOE suspension; confirmation on the status of the physical construction by July 21, 1998; urgent IDA review of the ongoing procurement process; and confirmation of staffing and related arrangements for RIHFWs and other training institutions by July 21, 1998. Punjab 19. Except for the SIIFW, Punjab materially accomplished full Project implementation about a year ago. The Mission noted that the completion of this remaining major task as well as fresh activities taken up subsequent to additional allocation of fimds by MOHFW in February 1997 remain severely constrained by insufficient release of funds to the Project by the State Department of Finance (Rs. 18 crore still pending). The Mission calls for confirmation on immediate action on release offunds to facilitate completion of SIHFW construction and allow pendingprocurement before June 30, 1998. It was also agreed that MOHFWwould confirm to IDA by July 31, 1998 the amount offunds finally approvedfor new activities with resources additionally allocated to the State.  Appendix B Page 1 of 10 VI1 Family Welfare Training and System Development Population Project Credit No. 2133 - IN Borrower's Evaluation EXECUTIVE SUMMARY 1. Area projects are being implemented since 1972 with financial assistance from World Bank and other donor agencies, with the objectives of reducing Maternal and Child Mortality and morbidity and Birth rate. These objectives were sought to be achieved by improving the quality and availability of Health and Family Welfare services through strengthening of the service delivery infrastructure and improving the skill of the medical and para-medical personnel through better training and programme management. India Population Project (IPP) -VI and IPP-VII were the first projects which deviated from the earlier area project approach of implementation in certain selected districts/urban areas and focussed on Human Resource Development activities on State-wise basis. 2. IPP-VII project was initially sanctioned for five years with effect from 02.11.1990 in five States namely Bihar, Gujarat, Haryana, Jammu &Kashmir and Punjab with the objectives of strengthening the Human Resource Development Capacity of the Health & Family Welfare System and to create cadres of adequately trained manpower and to strengthen the infrastructure so as to bring overall improvement in the efficiency and effectiveness of Family Welfare Services. The pattern of assistance was a soft loan from the World Bank to Government of India and Grants-in-aid to the State Governments by Government of India. The Project was extended upto 30.06.1998 with permission to file claims on eligible expenditure incurred up 30.06.1998 by 331st October, 1998. 3. The original committed project outlay at the time of approval of the project in November, 1990 was 67.1 SDR million which was reduced to 49.5 SDR million after canceling 17.6 SDR million for structural adjustments in 1991. The original total outlay of the project sanctioned by Government of India in November, 1990 was Rs.335.72 crores - Bihar Rs.88.18 crores, Gujarat Rs.43.90 crores, Haryana Rs.42.42 crores, J&K Rs.51.54 crores and Punjab Rs.48.66 crores. 'NHFW' and 'Central Component' comprising IEC, Social marketing and NGOs' were earmarked Rs.1.48 crores and Rs.59.54 crores respectively. After reviewing the physical and financial performance of the Project States during the mid term review in 1996, the original allocation of Bihar at Rs.88.18 crores was reduced by Rs.29.80 crores. This amount of Rs.29.80 crores was distributed to the better performing implementing States viz. Gujarat-Rs. 10.00 Crores, Haryana-Rs.9.9 crores and Punjab-Rs.9.9 crores. To adjust the expenditure overflow at the end of the project, the World Bank allowed reimbursement from RCH funds to the tune of US $ 11.4 million.  Appendix B Page 2 of 10 4. Main Goals and Objectives of the Project GOAL The major goal of the project was to support the National Family Welfare Programme by assisting Government of India and participating States in achieving improved quality, efficiency and effectiveness through Family Welfare Programme of appropriate Family Planning services to men and women and MCH services to pregnant women, mother and young children. OBJECTIVES:- To achieve these goals, the following main objectives were envisaged:- i) Expanding the supply of Family Welfare Services ii) Increasing the Demand for Family Welfare Services - Social marketing of contraceptives Support to Private Voluntary Organizations (POVs) Information, Education and communication (IEC) iii) Improving the quality of Family Welfare Services iv) Rationalization of the Training Infrastructure v) Improving the Management and operation of Family Welfare Programme 5. Financial Achievement As on 3 1st October, 1998, the Project reported an expenditure of Rs.322.38 crores (95.9%) against the total Project outlay of Rs.335.72 crores - Project States Rs.249.51 Crores (90.7% of the total allocation of Rs.274.70 crores earmarked for States); AND CENTRALLY SPONSORED COMPONENTS, Rs.72.05 crores (over 100 percent) and NIHW Rs.0.82 crores (55.4% of the allocation of Rs.1.48 crores). Against the expenditure ofRs.322.38 crores, the claim were filed for Rs.255.30 crores. 6. Project Monitoring and Evaluation Every implementing State constituted a Steering Committee under the chairmanship of their Health & Family Welfare Secretary to monitor the progress of IPP-VII project and also to clear the proposals and to issue the sanctions for budgetary items. These States also constituted the Governing Body/Council under the chairmanship of Chief Secretary to review the progress of activities of IPP-VII and to take policy decisions and to issue guidelines from time to time. Secretary (FW) of these States also reviewed the project activities independently from time to time. In the Ministry of Health & F.W., the monitoring was done through monthly feedback reports, review meetings taken by Joint Secretary from time to time and reviews taken by the Ministry in collaboration with the IDA mission. NIHFW also monitored the Project activities with particular emphasis on training through desk monitoring and field visits. The project was  Appendix B Page 3 of 10 evaluated through End line Survey reports, & Central components evaluatory report submitted by Consultant appointed by NIHFW and evaluatory reports on NIHFW by Consultants appointed by GOI. 7. Project Sustainability All the five implementing States have ensured to sustain the technical staff in the Training Institutions, maintenance and utilization of the buildings after completion of the project by making provision of sufficient funds in States' Five Year/Annual Plan budgets. 8. Achievements & Shortfalls: i) Inspite of slow start and weak and tardy performance in early years, the overall objectives of the project were achieved by all the five implementing States with varying degree of achievements. This has been possible due to timely interventions, intensified monitoring, reappropriation and redistribution of funds, more flexibility and vigorous efforts made by the States, MOHFW and the World Bank particularly in the second phase of the implementation. ii) All the implementing States constituted/established (i) Administrative Cells/Units; (ii) Governing Board/Council; (iii) Steering Committee; (iv) Personal Management Information System (PMIS) and (v) Management Information & Evaluation system (MIES). iii) Under civil works for upgrading of service delivery facilities, 2571 buildings of sub-centers against the target of 2951, 75 ISM dispensaries against the target of 100, 285 PHCs upgraded against the target of 359 and 8 Logistic Stores against the target of 12 were completed. Most of the rest of the buildings are at final stages of completion. The State-wise details are as under:- UPGRADING OF SERVICE DELIVERY FACILITIES Service Bihar Gujarat Haryana Jammu & Punjab Total Delivery Kashmir P C C P P C P ( C P C Sub-Centers 1000 750 600 684 451 443 500 382 400 400 2951 2571 ISM Dispensary --- -- --- --- -- 100 75 100 75 Upgraded PHCs 144 81 3 3 50 47 85 57 100 100 359 285 Logistic Stores --- --- --- --- 12 8 --- - -- 12 8 Total 1144 831 603 687 513 498 685 514 500 500 3445 3039 Note: P=Planned C=Completed In addition to above, the other major civil works inter-alia included: (i) 10 residences for DTOs - (at final stage of construction) in Haryana; (ii) 66 operation theaters in Bihar; (iii) 3 PP units in Gujarat; (iv) 100 LHV quarters in Punjab; and (v) 73 operation theaters (57 completed  Appendix B Page 4 of 10 and 16 at final stage of construction) & 2 SHTO workshops one each in Jammu & Kashmir completed. iv) The Project established 4 SIHFW/RIHFW against the target of 6 (RIHFW in Kashmir is near completion while SIHFW in Punjab is about half complete); 11 Regional Training Centers against the target of 40, 90 DTT Centers against the target of 93; 63 ANMT facilities against the target of 71, 10 MPW (MIF) Training facilities against the target of 12, 1 HA Training School, 1 H&FW Training School. The State-wide details are as under. The other Training facilities established inter-alia included 55 PHC Training Annex, 80 expansion of training facilities. NUlMBER OF TRAINING FACILITIES ESTABLISHED Training Bihar Gujarat Haryana Jammu & Punjab Total Facility Kashmir P . P C P C C P C P C SIHFW/RIHFW* I 1 1 1 1 1 2 1 1 6 4 RTC M/F 14 11 1 4 - 14 DTT Centers 39 39 16 16 17 15 9 8 12 12 93 90 ANMT facilities 22 21 32 32 2 2 15 8 71 63 MPW (Male & - l _ 5 3 7 7 12 10 Female) Training Facilities HA Training School I_ I- 1 H& FW Training I -- -- - -- -- School Other: PHC Training Annex 15 15 - 40 40 55 55 Exp. Of Training 10 72 1 8 11 80 facilities _ _ Total 91 87 59 121 26 29 26 17 62 61 26 315 4 Note: P=Planned C=Completed In addition, the Project also constructed 66 staff quarters in SIHFW/DTT in Gujarat; 1 Hostel for RIHFWTC in Rohtak, (at the final stages of completion) 1 conference hall for Rohtak training center (completed), 50 community education cum demonstration centers (47 completed and 3 under construction) in Haryana. The project considerably achieved in improving the staff competency by improving their clinical and counseling skill of service delivery staff in all the five implementing States. This was achieved by regular training in training institutions, upgrading the skills of trainers, revising and upgrading training curriculum, teaching method by strategic planning and management of Human Resources Development for Family Welfare programme. Against the target of 1.38 lakhs, 2.46 lakhs key personnel of different categories were trained. The State-wise details are stated in the following table:-  Appendix B Page 5 of 10 Category Bihar Gujarat Harayana Jahmiu & Punjab Total P C P C P [C P C P IC P lC Key Trainers 474 256 242 100 212 1 30 162 486 1090 Medical Officers 4704 3884 2050 2034 1284 1234 1396 1176 9100 11220 18534 19548 Supervisors 2980 2051 11880 11469 2661 3364 110 105 3147 7019 20778 24008 MPW-Female 12776 10673 7950 7661 7798 6702 2482 3717 6600 15777 37606 44530 MPW-Male 6354 4776 5639 4896 2544 1549 5900 11978 20437 23199 ISM practitioners 795 762 498 498 3969 1263 5262 2523 Non-Health 78358 10000 10444 9032 7075 15000 23500 34032 119377 Functionaries Members of Rural 1000 12310 1000 12310 Women's Groups TOTAL 26814 21858 28570 105422 24885 24003 16989 13336 40877 81966 138135 246585 Note: P=Planned C=Completed v) NIHFW assisted States in setting up of HMD cells with a strong MIES and PMIS, development of SIHFW, faculty selection, administrative structures, development of curriculum, preparation of annual plan for training, learning material besides conducting courses, workshops and preparation of various types of training/curriculum materials. NIHFW also monitored the project activities with broad emphasis on training through desk monitoring and field visits. The Endline evaluation was conducted by NIHFW through consultants. vi) The project substantially achieved its institutional development and thus established foundation for reproductive and child health project. vii) The Project played a vital role in generating demand under Social Marketing of Contraceptives and provided greater support to Voluntary Organizations and I.E.C. It improved contraceptives prevalence by popularizing use of Condoms, Oral Pills and ensured their easy availability at retail outlets. This project also achieved higher utilization of MCH services and helped in increasing demand for FW services which was one of the main objectives. 9. IMPACT OF THE PROJECT The infrastructure constructed under the project has improved accessibility of services preferably in rural areas. The comprehensive infrastructure of Training Institutions have improved the clinical and counseling skills which have further accelerated the inter-personal communication to enhance the project impact among women groups in panchayat, youth groups and Indian system of Medicines and private allopathic practitioners. The project assisted the States to develop and organize properly their HRDC, PMIS and MIES which were earlier not attained properly, to mobilize and coordinate the health functionaries.  Appendix B Page 6 of 10 The project also contributed to a great extent to help the States in strengthening their community involvement and participation, stimulating greater demand for Family Welfare Services through better utilization of private Voluntary Organizations and IEC. This resulted in reducing Crude Birth Rate (CBR) and Infant Mortality Rate (IMR) in all the five Implementing States. The details are as under:- STATE CBR IMR 1990 1997 1990 1997 BIHAR 32.9 31.7 75.0 71.0 HARYANA 31.9 28.3 69.0 68.0 GUJARAT 29.6 25.6 72.0 62.0 J&K 31.4 - 70.0 - PUNJAB 27.6 23.4 61.0 51.0 10. MAJOR FACTORS WHICH AFFECTED IMPLEMENTATION OF THE PROJECT i) The project had a slow start up and slow pace of implementation during the first four years. Contributory factors inter-alia included (a) delays in land acquisition; (b) delays in financial sanctions due to cumbersome State approval procedures; (c) unfamiliarity with World Bank procedure regarding procurement, submission of claims, timely audit; (d) frequent transfers of project director; (e) delay in appointing the critical administrative and technical staff; (f) low priority by States to the project in the initial phase; (g) lack of professional approach and shortage of skilled man-power; (h) delay in construction work; (i) ban on creation of new posts by the State Governments etc. ii) District officers did not depute the adequate number of staff for training. In some cases the staff trained under the project was transferred to departments not concerned with the project activities. iii) In some places ANMs did not utilize the accommodation provided to them in the sub-centers due to lack of basic amenities such as water, electricity and inconvenient location. Personal problems and security reasons also restrained many of the ANMs in utilizing such accommodation. iv) The coverage and quality of the training got adversely affected due to factors such as (a) not deputing the adequate number of staff for training (b) less incentives, honorarium given to trainee compared to other programs (c) shortage of teaching/ learning material (d) low priority given to training (e) talented persons not attracted due to non-autonomous status to SIHFWs (f) weak co-ordination between Project Director and Director SIBFW (g) less mobility in training programs due to non-availability of vehicles etc. etc.  Appendix B Page 7 of 10 v) The mid-term review was conducted after 6 years of implementation which left very little time with states to complete additional activities out of additional funds. vi) The other major constraints inter-alia included the following:- (a) In many cases the charge of the Project Director was given to another official already holding another post due to which due attention could not be paid in the implementation of the project. (b) In certain cases, training institutes were used for activities other than training. (c) Very few research proposals undertaken by the States despite courses and workshops on research methodology conducted by States. (d) Less attention paid to involvement of non-governmental sector in the project implementation process. (e) Despite release of advance money by the GOI the states took a long time in release of funds to the project authorities. This became a very dominant factor in slow implementation of the project. (f) Late release of 10% state share by the State Finance Department. (g) Political conditions and militant activities in the valley of Kashmir affected adversely the overall implementation in J&K particularly the civil works in remote areas. (h) Provisions of vehicles on replacement basis resulted in non-availability of vehicles for the institutions envisaged. 11. LESSONS LEARNT From IPP-VII project, a few lessons were learnt which could be utilized for bringing improvements in the implementation of other on-going and future projects. Important ones are as under:- i) In the beginning of the project itself, administrative machinery in the Implementing States should be geared up and proper coordination developed among various administrative wings so as to avoid delay in issuing necessary sanction orders for the smooth flow of funds. States could consider constituting State level societies to overcome this problem. ii) Proper care should be taken in the selection of sites for construction of sub- centers with provisions of necessary accommodation having minimum basic amenities  Appendix B Page 8 of 10 such as electricity, water, etc. so as to enable ANMs and other para-medical staff to stay there. iii) There should be enough provision for engaging Experts/Consultants/Professionals from outside on contract basis. This is so because many a times, the staff recruited on deputation and on transfer basis from other Departments, are not the most suitable. iv) The World Bank should examine the possibilities for simplifying the procedures for Civil Works, procurement of Equipment, Drugs, etc. v) District Officers should take advance action for deputing the adequate number of staff(using PMIS) having requisite knowledge keeping in view their present and future job requirements for various training programs under the project; vi) States should encourage inter-State visits, seminars and workshops relevant to the projects so as to have the staff gain experience of the projects in other States/Areas; vii) The mid-term review should be conducted during the mid way so as to enable States to complete new activities within the project period. viii) Personnel having aptitude to work in training institutions and trained manpower should be preferred in training organizations. If possible there should be a separate cadre for these people. ix) To avoid delays more financial powers should be delegated to Project Directors and a Sub Committee to be formed for approving items upto a certain limit. x) Purchases/procurement should be allowed from State Government approved agencies at DGS&D approved rates without calling for tender in order to avoid delays. xi) SIHFW should be given autonomous status so as to attract talented people having the right perspective in training and to develop its functional linkages with RTC/DTC for better planning and monitoring. xii) During project implementation, soft components like HRD through PMIS and HMIS, monitoring system, involvement of private practitioners and practitioners of ISM&H, utilization of IEC and NGOs which were essential for improvement in managerial and operating aspects, generating the demand and improving the efficiency and effectiveness of services received relatively less attention in the implementation of project while expensive hardware components like civil work, procurement etc. were given higher weightage xiii) Special arrangement/provision should be made at Accountant Generals level for timely auditing of the Project expenditure so as to enable filing of Reimbursement claim to GOI/World Bank in time.  Appendix B Page 9 of 10 xiv) The State Governments should identify (a) Agency for taking up the Project, (b) Future strategy, (c) Resources, (d) Deployment of manpower for taking up of moveable and immovable assets well in advance before the completion of project. xv) Purchasing of vehicle on replacement basis have not yielded the desired results. The vehicles purchased under the project have reached to the places/officers where from the old one were received. New vehicles were not made available to the facilities/institutes for which they were envisaged. Vehicles were also not used for mobilization of activities/staff and for referral cases for want of post of drivers in the project. An alternative mechanism should be explored to ensure availability of vehicles in institutions envisaged. xvi) Monitoring and evaluation should be done more frequently and should not be confined to the state and district level, and for civil work and equipment. The monitoring and evaluation should be comprehensive and more coherent and decentralized stressing on the qualitative aspects along with the quantitative. xvii) Vacancy should be filled up in time by creating the post and appointing persons as per job requirement and not on transfer basis. This would help sustainability of the project after the completion of the project. 12. FUTURE PLANNING It is quite often observed that poor planning lead to bad results. Therefore, to avoid the problem of coordination and delays due to improper planning, such a comprehensive project with multi objectives should be implemented in phased manner - (i) Preparatory Planning Phase and (ii) Implementation Phase. Under preparatory phase, the pre-construction activities such as appointment of administrative and technical staff and other specialists like Architects, Engineers, procurement and medical specialists should be appointed. Besides this, the land acquisition, site selection, establishment of MIES and PMIS and documentary work like sanctions, drawings, maps etc. should be accomplished within a short period. In the Implementation phase, the hardware components like construction, procurement and supply and training should be completed. The final phase should focus on Institutional Operationalisation, rectifications, evaluation, assessing impact of the project and ensuring sustainability after completion of the project period. i) Expansion and increase of demand of Family Welfare Services can be improved and accelerated if we are successful in making ANM occupy the residence in sub-centers. This task can be achieved if sub-centers are constructed near the residential areas and ANMs are appointed on contract basis and paid on their performance. User's participatory involvement and participation of Panchayats in selection of sites for building, sub-center is very essential. ii) Software components like training, IEC and NGOs which are very essential for meeting the objectives of the project should be given more weightage.  Appendix B Page 10 of 10 iii) Alternative possibilities of release of fimds in the form of personal ledger account PLA/DD in favor of Project Director as being done in case of DRDA's, District panchayats and training institutes to ensure timely receipt of funds by the Project authorities should be explored. In this connection, one could consider releasing of funds through a society strictly linked with performance. iv) There should be provisions for new vehicles along with the post of drivers for new institutes as against on replacement basis for improving mobility and expanding services. v) Monitoring by Government of India through field visits should be an integral part of the project for which there should a separate cell in the Ministry. vi) In the States there are set procedures for purchases in Government. Some approved corporations and agencies are identified from where State Departments can directly purchase without going through the procedure of inviting tender. There are organizations like CSPO (Central Stores Purchase Organizations) and CMSO (Central Medical Stores Organization) headed by senior officers of the rank of secretaries. They oversee the purchase of all medicines for the State and vehicles, machineries and equipment by inviting tenders, evaluation of bids and take decisions for the whole State and enter into annual rate contracts for State offices. It is suggested that Project authorities should be allowed to follow this procedure instead of separately following IDA's instructions in matter of procurement. vii) The State Governments should intimate the project authorities about the resource, strategies for running project in future, deployment staff on pennanent basis in the institutions created and taking over of the project well before the completion of the project. viii) The Bank's procedures should be simplified and workshops/seminars should be conducted in the beginning of the project to make project officials conversant with these procedures. ix) The States where the implementation was affected due to some unforeseen reasons, provisions should be made available to complete important unfinished activities/infrastructure from the other programs. x) The release of money should be in a phased manner and strictly linked with performance instead of releasing money in advance. M:/population/ipp7/icr/icr-febO 1-edited.doc