Document of The World Bank FOR OFFICIAL USE ONLY -- _ ) & 2C -,,, Report No. 12771-IN INDIA STAll APPRAISAL REPORT FAMILY WELFARE (ASSAM, RAJASTHAN AND KARNATAKA) PROJECT NAY 26, 1994 MI CROGRAPH I CS Report No: 12771 IN Type: SAR South Asia Country Department II (India) Population and Human Resources Operations Division Ths. docament has a resticted dIsutIon and may be used by recipiet ody In the performae of thelc ofi ff duties Its cooke-t may not odhewise be disbosed wiou Wodd Baok authoriz CURRENCY EOUIVALINTS (As of December, 1993) Currency Unit = Rupee Rupee 33.9 - US$ 1.00 Rupee 1.0 - US$ 0.03 METRIC EOUIVALENTS I Meter (M) = 3.28 Feet (ft) 1 Kilometer = 0.62 Miles FISCAL YEAR April 1 - March 31 FOR OFFICIAL USE ONLY ANM - Auxiliary Nurse-Midwife ARI - Acute Respiraty Infections CBR - Cnude Birth Rate CDR - Crude Death Rate CDD - Control of Diarrhoeal Diseass (progam) CHC - Community Health Centre CIF - Cost,n lsuance, Freight CMHO - Chief Medical and Health Officer CPR - Contaceptive Prevalence Rate CSSM - Child Survival and Safe Motherhood (project) DGS&D - Directorate-General of Supplies and Disposal EFC - Expenditure and Finance Committee (GOI) FRU - First Referal Unit FW - Family Welfare GNM - General Nurse-Midwife GNP - Gross National Product GOI - Government of India HAC - Health Advisory Committee HFWTC - Health and Family Welfare Training Centre HMLS - Health Management Infonration System ICB - InteTnational Competitive Bidding ICDS - Integrated Child Development Services (rogram) IDA - Intratoa Development Association IEC - Information, Education and Communication IMR - nifant Mortality Rate IPP - India Population Project (I uough VM) LCB - lowCl Competitive Bidding LHV - Lady Health Visitor MCH - Maiernal and Child Health (care, services, program) MIS - Managemt Information System MPHW - Male Multi-Purpose Health Worker(s) MOHFW - Ministry of Health and Famdly Welfare MSS - MAhi&a Swastha Sangha (women's group) MTP - Medical Ternination of Pregnancy NGO - Non-Govenmental Organisation ORS - Oral Rehydration Salts/Solution PHC - Primary Health Centre PHN - Public Health Nurse PMO - Principal Medical Officer PMP - Private Medical Practitioner PVO - Private Voluntary Organisation PWD - Public Wor Departnent RNI - Rate of Natural Increase SC - Sub-Centre SIHFW - State Institute for Health and Family Welfare SMO - Senior Medical Officer TBA - Traditional Birth Attendant TFR - Total Fertility Rate UIP - Universal Immunisation Program UNFPA - United Nations Fund for Populaton Activities Tbis document has a resticted distibuton and may be used by rociients only in the Pefman h offlci duties. Its contents may not othewse be disclosed without World Bank autorzato DODIA FAMILY VVELFAR(A$SAM4 RAJASTHAN AND K]UATIAKAPOJ Page No. Basic Data ........ . ......................................... iv Credit and Project Summary ....... ............................. v I. POPULAION ISSUES AND THE HEALTH OF WOMND AND CHILDREN IN DIA ............................................ 1 A.DemographicTrends andIssues ............................. 1 B. Child and Maten Health ................................ 2 II. GOVERNMT POLICES AND PROGRAMS IN POPULATION AND MATERNAL AND HIl.LDL HEALTH ......... ............. 3 A. Population Policies and Progrms ..... ....................... 3 B. Policies and Programs in Maternal and Child Health ....... ......... 4 m.TH mm LkN PAMiLY WNELFARE PROGRA ............................. s A. Structure and Scope .................................... s B. Perfornance, Problems, Issues ............... 6 C. IDA nvolvement and Experience in Family Welfare ..... .. ......... 10 IV. THIM PROJCT ............................................. 15 A. Project Rationale and Scope . .............................. 15 B. Ptoject Objectives ..................................... 16 C. ProjectContent . ................... .................... 18 D.PPhnningfor TbalandotherSpecialPopuationGroups .............. 25 This report is based on the findings of an appraisal mismion that visited India in December, 1993. The mission comprised Althea Hill (rask Manager and Mission Leader), Claudia von Monbart 0Senior Economist), K.B. Banerjee (Public Health SpeciaList), R. Sethuraman (Fincial Specialist), Bnt Jacobson and Subbash Chakravarty (Architect Consultants), Joyce Lyons and Jennifer Huddart (Craming Consultants), Bonani Kakkar (IEC Consultant), Bruce Geimt (MIS Consultant) and Pradeep Kakkr (Mnagement Consultant). Frances Plunlett (SAPH) also contibuted to the appraisa. The Lead Adviser waS Tom Merrick (Senior Population Adviser, PHW and Peer Reviewers were Ane Tiker PN, Ricbard Heaver (Manila Res) and Scott Guggenheim (ENVSP). The report was produced by Jane Bekker. The Prqject is endorsed by Ricbard Sklnik, Chief, Population and Hunman Resources Operations Division and Heinz Vergin, Director, litia County Department. ii V. . ..PROJE.r.C=..E.............E.......M.Nrr.R.NG28 A. Costsnats ............................... ......... 28 B. FinancingPlan ............. . . ........................ 30 C.RecurmentCostsandSustinability ........................... 30 D. PbrojectImplementation .................................. 31 E. Status of Project Prepaation ....... . . . 33 F. Monitoring and Evaluation . ........ 35 G. Disbursements ........... .. . 36 H. .....ent .. ........ ... ...... 37 1. Accounting and Auditing: ............ ........... 41 VI. BENEFrS A SKS ....................... 41 A. Project Benefits ............. . 41 B. Prject Risks ................................ 42 ViI. AGREEMIENS REACHED ....................... 43 A-NE AnnexI: Latest Demographic Data and Family Welfare Key Indicators for al India and Major States. An= 2: Outlnen of the Action Plan for Revamping the Family Welfare Program Anm@ 3 Key Program and Demogrphic Indicaors. Ann 4: Summary List of Civil Works to be Undertaken under the Project in Assam, Rajasthan and Karnat Ape 5: Model Plans for Sub-Centre Buildings in Assam, Rajasthan and Kamataka) and Special Techniques and Procedures for Construction. iinnexI: Criteria for Selection of Communities and Sites to Receive Newly-Constructed Sub-Centre Buildings: Assam, Rajasthan, Kamata. A_ 7: List of Communities Selected to Receive New Sub-Centre Buildings in First Year of Project: Assam, Rajasthan, Kamataka. Mm A Design for Boat Clinic, Assam. Ami& 9: List of Vehicles to Be Provided under the Project in Assam, Rajasthan and Kanataka. Anmex 1 Community-Based Volunteer Schemes: Assam, Rajasthan and Karmaak An& 11: Summary of Traing Programs and Strategies: Assam, Rajasthan, KamaaZ Annea 12: Summary of Strategies for Improving Family Welfare Program Logistics in Assam and Rajastfan. Annx 13: Summary of IEC Strategies: Assam, Rajasthan and Karataka. Ann 14: Summary of Stategies for Improving MIS in Assam, Rajasthan and Knataka and General Stategy for Improving Family Welfare MIS through Introduction of EMIS. Annex15: Indicative List of Innovative Schemes: Assam, Rajastan, Kamataka. Annex : Major Findings of Training Needs Assessments and Benefiary Needs iii AssessmentsDone as PM of Projec Preparation: Assm, Rajastn, A1 : Sfor Improving Famiy Welfr Services to Tribal and Migratory Groups: Assam, Rajastiar, K,rnatam. Annex: Detaed Cost Table Ann 19: Delails of Expenditures & Diumet Annex 20: Summary Analyses of Sustiability of Proect Iwesmt and Recurrent Cost Implications in Assam, Rajasthan and Karnaka. Annex 21: Lis of StaffCommittee Members ad Orgnigams of Project Mana ent Structure: Assam, Rajasthn, Krataka AM 2: List of Additional Posts Creted undet te Project: Assam, Rajasn and KamtwaS AMa 23: OutLine of Scope and Methodology for Baseine Surveys and Other Evaluae Surveys and Studies. Ann 24: Outline of Layout and Content for Six-Monthly Proe Reports. Anne 25: Superion Plan. An2: 2 Outie of the mplmentaion Voluime and Plans. Annx27: Seleed Douments m Proet Files 1 Linags of the Projed to tie Action Plan for Revamping the Pamily Welfe Program ...... .................... . 9 2 Lessons Appled from IDA Expince i Famiy WYelfareLending . ........................... *e...... 13 3 Key Projea Intmediat bdion ........... . . . . . . . . . ......... 17 4 CostbyConmpoent .................................. . 28 5 Costs by Category of Exowditure ........................... . 29 6. nArrangemnents ........ ..................... . . . . 38 iv IDMA FAMILY -WELFARE (ASSAB4 RAJtASTHAN AND K&NAAKM}POlC BASIC DMT FOR ALL-INDIA Total Area (1991) 3,287,253 hm2 Total Population (Census count) (1991) 846 million Density per hn2 (1991) 257 Percent Urban (Census count) (1991) 26 Per Capita Gross Domestic Product (1991) US$ 256 Totd Fertiity Rate 1/ (1991) 3.6 Life Expetancy at Birth 1/ (1991) 61 hifant Mortality Rate 1/ (1992) 79 Matnal Mortaity Rate 2/ (1993) 5501100,000 Crude Birth Rate 1/ (1992) 29/1000 Crude Death Rate 1/ (1992) 10/1000 Rate of Natual Inncrese / 11992) 1.9% Age Struchue: Percent 0-14 years (1991) 36 15-64 years 60 65+ years 4 Adult Total Liteacy Rate (Census count) (1991) 52 Adult Female Literacy Rate (1991) 39 P:imary Schol Enrollment, Boys 3/ (1991/2) 117 Primary School Enrollment, Girls 3/ , (199112) 88 Population per Physician (1990) 2,460 Percent of Births Attended 1/ (1990) 44 by Trained Personnel Contraceptive Prevalence Rate 4/ (1993) 43 1/ Registrar General, data from India Sample Registration System 2/ WHO estimate 3/ Data from the iDepartment of Education, Ministry of Human Resource Development 4/ Data from MOHFW Note: Data from the World Bank World Development Report, 1993, where not otherwise noted. v IDIA Erm= WLFARE (ASSAM. RAASTI AD KARNATAKA)1RWEt pltE AND PRO.Iff SUARY :9mgw. EIndia, acting by its President States of Assam, Rajastian and Karnataka hmti: SDR 62.7 miion (US$88.6 million equivalent) Terms: Standard, with 35 years maturity Oe4mm Temr: (lGovemment of India (GOI) to the States of Assam, Rajasthan and Karnatasa: in accordance with standard arrangements for development assist;nce to States The prqject would strengthen and improve the functioning of GOI's Family Welfare (FW) program in Assam, Rajastian and Karnataka, imth the objective of thereby lowering current levels of fertlity and matnal and childhood mortality in the three sates. The PW program would be strengthened through five components: (1) stengthening of FW service delivery, including extension and upgading of infrastructure through construton of subo-centres and Primary Health Centres and upgrading of Community Health Centres to serve as first referral units for obstetic emergencies, and strengthening of outreach and community linkages through setting up of mobile clinis and establishment of community volunteer networks; (2) improvement of Family Welfare service quality, including rationalisation of taining institutions and planning, improveme-lt of program logistics, and promotion of Non-Governmental Orgnisation and privasector involvement; (3) strengthening of demand generation activities through improved Information, Education, and Communication planning and activities; (4) strengthening of program management and implementation capacit; (5) a fund for innovative schemes aimed at improving service quality, and for preparation of Family Welfare investment proposals for the heavily tribal North-Eastem states. _The project should lead to improved access to, demand for, and quality of Family Welfare services in Assam, Rajasthan and Rataka, particularly among poor, remote and tribal vi populations. Improvements would be assessed through service and community-based indicators of program performance and effectiveness. As a result of such improvements, matenal and child health should improve, and fertility and maternal and childhood morlity decline, both statewide and among these populations. Trends in these indicators would be assessed through popuiation-based surveys and servce statistics. The major risks relate to the current weak implementation capacity of the states, the possibility that infastcture and programs put in place by the project will not be maintained and fully funded during the project and after closure, and the new and innovative nature of many of the programs to be set up. In addition, there are still minor lingering securty concerns in Assam. To minimise these risks, program management will be strengthened under the project; project and program coordination fostered; state Family Welfare budget allocations reviewed in advance each year, civil works tightly managed and spesd and their maitenance assmred during the project; and new and innovatie p'rograms piloted, evaluated, and phased in gradually. Security risks caiinot be addressed directly, but project investnent and program strengthening should help maintain the program through any periods of stress. Es_mated NotLocal Forign Total -US$miion Strengthen Health & F.W. Service Delivery 46.0 4.1 50.1 Improve Quality of F.W. Sevices 21.1 0.9 22.0 Icase Demand for F.W. Senrices 10.0 0.3 10.3 Improve Management 8.2 0.6 81 Iunvative Schemes 4.0 0.1 4.1 Total Base Cost 89.2 6.0 95.2 Physical Contingencies 7.2 0.6 7.8 Price Contingencies 0.2 0.7 0.8 Total aL ject Cost 96.6 7.2 103.8 Including Taxes and Duties of US$5.3 million vil Financing Plan: Local Fcrelgp Total IDA 81.4 7.2 88.6 50I 15.2 - 15.2 lawl "A LsZ L Estimated VisbursementsfM P9 E7 EY29 F E20 PY20 0 Xf1 Fy20 Annual 3.4 8.6 13.0 15.9 16.4 14.2 14.2 3.0 Cumulative 3.4 12.0 25.0 40.9 57.3 71.4 85.6 88.6 Rat of Reb: Not applicable erty Catepry: groam= of, lIed Intevftions. The project supports ovefall strengthening of the Family Welfare progran, which is designed to deliver free pimary health and family planning services to poor women and children. One of its main components covers extension of srvces into poor aiJ undersrved areas, inlduding tribal, nomad and isolated populations, plus stengthening of outreach to poor nu families. Special stategies for serice delivery to triba, nomad and other isolated groups are included in the proect. IND FAMIL WELFAR (ASSAM, ItAJ,SHA AND KATNAKO P;OEC I. WELUaT101 ISSUES AND THE HtEALTH DE WOMEN AND CEDM -N IND1MA A. Demographic Trends and Issues 1.1 India has the second largest population in the world, enumerated in 1991 at 846 million or 16 percent of the world's total. TLe national rate of population growth has hovered around 2 percent per annum since Independence nearly 50 years ago, the product of steadily declining mortality combined with compensating falls in fertlity. There are signs of a gradual slight decline in the growth rate, but a major further drop in fertility wil be needed to offset continued falls in mortality and achieve genuine low growth. India's population has more than doubled since Independence, and at a growth rate of 2 percent will double again in another 35 years. The percentage of the population Iving in urban areas has also grown steadily to a current level of about 26 percent. 1.2 During the last 50 years, national life expectancy has risn from under 35 years to 60 years, while infant mortality has fallen from at least 200 to just under 80 per thausand births. The fall in childhood mortality has beer. particularly marked over the last few yas. This overall decline in mortality has been primarily due to ircreasing control of communicable and epidemic diseases, such as malaria, cholera, smallpox, tuberculosis and the communicable diseases of childhood, coupled with the virual elimination of penodic famines and general improvements in the food supply and nutrition. 1.3 During the same period, national fertility has dropped from a total fertility rate (TFR) of more than six births per woman to 3.6, with most of the decline occurring during the las 20 years. The fall is due in part to a steady rise in the average age at maniage for girls from under 16 years to nearly 19 years, but mainly to the increasing use of birth contmr among married couples to a current contraceptive prevalence rate (CPR) of over 40 percent There is conceem, however, that the increase in contraceptive use appears to bave stalled over the last few years. In combination with continued mortality decline, such a stall is liklly to prevent any further reduction in poplatn growth. 1.4 These national figures conceal large variations across the vast population of India (see Annex 1). Generally speaking, mortality and fertility are lower in the south than in the north. The southemmost slates of Kerala and Tamil Nadu are close to replacement-leve ferlity, while Kerala has achieved a life expectancy of over 70 years and an infant mortality rate (IMR) under 20. By contra, the big northern states such as Uttar Pradesh, Madhya Pradesh, Rajasthan and Orissa still suffer infant mortaity rates in the range of 89 to 114, while U.P, Rajasthan and Orissa also have total fertlity rates ranging from 4.6 to 5.1. It is these states that primarily impede national progress to levels of mortality, fertility and growth 2 similar to those of China. 1.5 India does not have the natural resource base to sustain such a huge and rapidly growing population Wefznitely. Population density has already reached 257 persons per kn2. Land is becoming increasingly scarce, leading to fragmentation of holdings, underemployment, and the growth of the landless rutal class. In turn, urban nmigation is producing constant growth in outlying slum populations for which cities cannot afford to provide services. Other natual resources, such as forests and water supplies, are under severe pressure. 1.6 In India, human resource development has suffered from under-investment and under-financing in the education, health, nutrition and population sectors, particularly at the lower levels. Over ten percent of girl children still receive no education at all, and less than Lalf of either boys or girls enrolled in primary school manage to complete it. Fifteen percent of the population are still not covered by any health or Family Welfare services, while the national Integrated Child Development Services (ICDS) program covers only half of children in need. In turn, this failure to develop human resources to their full potential will increasingly act as a drag on the national development effort. D. Child and Maternal Healt 1.7 Childhood levels of mortality and morbidity in India are still very high (see Annex 1). The national infant mortality rate has declined markedly in recent years, but is still nearly 80 per thousand births More than ten percent of Indian children still do not survive their first five years of life. The major causes of death in childhood are similar to those found throughout the developing world, namely respiaoly infectons, diarrhoeal disease, malnutrition, low birthweight, malaria, tetanus and the communicable diseases of childhood, notably measles. The effects of poor birth spacing and excessively early childbearing on the health of the children born have not been well studied in India, but are kinown to be important in other high-fertility countries. Deaths from all of these causes are largely preventable. 1.8 A peculiarity of Indian mortality pattems, rarely found outside South Asia, is the marked female disadvantage in childhood and through the young adult years. As a result, there is a significant male surplus in India's population, with the current sex ratio standing at 108 males per 100 females. The female it o-tality disadvantage has been found for as long as reliable mortality estimates go back in time, but has been declining gradually. It is a partcular feature of northern India and is considerably lessened or even absent in most of south India. 1.9 At present, national IARs are much the same for boys and girls, and female life expectancy recently rose slightly above male life expectancy. However the female disadvantage persists from early childhood up to the age of 35 years, after which it disappears. It is particularly marked in early childhood and in the early childbearing years. 3 The causes of the disadvantage in early childhood are thought to be prefetenial feeing and care for boys, including preferential recourse to medical treatment. The causes in the early childbearing years are thought to be largely related to the high level of matemal moftty and the continuing poor nutrition of women, again the product of the low status of girls and young women. 1.10 Maternm morality in India is among the highest in the world. The maten mortality ratio is estimated at around 550 deaths per 100,000 deliveries, implying that about 20 percent of all deaths to Indian women of childbearing age are matemal deaths. The most important causes of mautenal deaths in India are sepsis and hemorrhage, which together account for 40 to 50 percent of deaths. Other major causes are toxaemia, obstructed labour and abortion. Anaemia, which is a chronic condition of most Indian women, is an important contributing factor throughout, as well as unhygienic delivery conditions at home and reluctance on the part of families to take women with high-risc pregancies or complicated deliveries to health facilities for assistance. H. GOVUtNERNT POLCIDES AND PROGRAMS IN lbOl!UATIO AND AIATENL ANDCID BIEAM1 A. Population Pollcies and Prgam 2.1 Concern in India over the rapid growth of population, and its adverse consequences for national development and living standard improvements, has been high from Independence onwards. As a result, a national family plaing program was stated as early as 1952. It has continued in existence ever since, first as a free-standing program and later, since 1977, integrated with the MCH (matenal and child health care) program into te Family Welfare program. Government commitment and support for the family planning program has flucuatd over its 42 years of life, but has generally been strong. Recent evidence of commitment has been its effective protection under Idia's stuur adjustment program. 2.2 Technically speaking, the family planning program has always suffered from flaws of design and implementation which have limited its effectiveness and impact (see paras. 3.9-3.11), as well as from persistent underfunding relative to total needs in the sector. There has also been a lack of attention to interventions oter than famUily planing services which might increase demand for smaller families and birth control, such as iprvements in the education and stats of women. In response, GOI has caried out periodic r cgs of the program and has relied increasingly on donor funds for invesment financing. 2.3 The most recent effort at restuctuing the Family Welfare program, including the family planning program, is the uAction Plan for Revamping the Family WeLfare Program in India, issued by the Ministry of Health and Family Welfire (MOHFW) earuy in 4 1992. This laid out a central strategy for improving the performance and impact of the entire program (see para. 3.12 and Annex 2) and led to creation of a national population commission intended to address these and other issues and interventions in the population sector. State Plans were next to be prepared. Substantial progress has been made on implementation of the national Plan but there is still much to be done at both national and State level (see paras. 3.12-3.14 and Annex 2). Formal State Plans for Assam, Rajasthan and Karnataka were drawn up during preparation for this project, with the project's design and content fully taken account of in their formulation. B. Poflcies and Programs in Maternal and Child Health 2.4 In the first two decades following Independence, India's public health services focused largely on curative and hospital care, together with vertical control progams for such diseases as malaria and leprosy. With the development of the primary health care philosophy in the 1970s, however, attention turned to the establishment of primary health services and preventive care, and to the creation of an appropriate infrastructure and trained workforce on the base of the already existing network of health facilities and staff. Matnal and child health (MCH) care became the focus of this effort, and MCH programs were established. Finally, the link with family planning was recognised and formalised and servce delivery for the two sectors was integrated under the title of the Family Welfare Program in 1977. 2.5 Within MCH, the emphasis was at first on child health, as elsewhere in the world. In the mid-1980s, the very successful Universal Immunisation Progmm (UIP) was launched, which now covers 85 percent of children and may have been responsible for the recent large drop in infant and child mortality. Other programs also began to be developed, including the Control of Diarrhoeal Diseases (CDD), interventions to control Acute Respiratory Infections (ARI) and the provision of supplements of Vitamin A and iron. 2.6 Tle Family Wela program had always included antenatal, delivery and postnatal care as one of its basic services, but maternal care at first took second place to child health care. In response to the worldwide Safe Motherhood initiative in the mid-1980s, attention has become increasingly focused also on the high leveis of maternal morbidity and mortality in India. 2.7 Under the Eighth Five-Year Plan (1991-95), a maternal and child health plan was developed to move forward in both maternal and child health. The plan called for packages of interventions for each aspect to be delivered through the Family Welfare program. The child health package was conceived as building on the base of the successful UEP and was entitled UIP Plus. Besides immunisation, it would include the ARI, CDD and Vitamin A and iron supplementation interventions, as well as newborn baby care. The safe motherhood package would include: antenatal care (regular check-ups, tetanus immunisation, anaemia control, screening and referral of high-risk cases); care at delivery (trained assi.4ance during delivery by traditional birth attendants (TBAs) or Family Welfare staff, together with timely 5' referral to properly-equipped higher-level facilities when necessary); postnatal care; and promotion of safe birth spacing and timing. In addition, first referral units for complicated delivenes would be made accessible through upgrading of Community Health Centres (CHCs) or district hospitals. This plan is now being implemented under the IDA-supported Child Survival and Safe Motherhtood (CSSM) project (see paras. 3.13, 3.21, 3.23). m. THE INDIAN FAMILY WELFARE PROGRAM A. Structure and Scope 3.1 The Family Welfare program provides the primary health care level in the Indian public health care system. Its focus is on women and children and on preventive health, and it is oriented towards the fidral and urban poor. In practice, many services offered Sy the program are also available and obtained from NGO and private sector providers of both allopathic and traditional systems of medicine, who overall provide around 80 percent of aU health care in India even among the poor. This is particularly the case for maternal care and all curative care. For some Family Welfare interventions, however, the program is almost the sole provider of services to the poor, notably for immunisation and sterilisation. 3.2 Because of thie national importance attached to the family planning program, the Family Welfare program is almost entirely centraUlly-funded, except for a few small but important items such as maintenance of Family Welfare facilities and salaries of male Multi- Purpose IHealth Workers (MPHWs). The program is however implemented by the states. By contrast, most financing of "health services" (comprising the hospital network and vertical disease-control programs for malaria, tuberculosis, leprosy, AIDS, etc) as well as their implementation are the responsibility of the sates, with some assistance from the centre to the disease-control programs. 3.3 The core Pamily Welfare program infrastructure in rural areas consists of Prhia Health Care Centres (PHCs), Community Healtn Centres (CHCs) and sub- centres. The key institution is the PHC, which is intended to cover a population of 30,000 and is the administrative headquarters of the preventive care system. Clinics providing minor curative care are also run at the PHC, and there are in-patient facilities for observation and medical treatment. They are also used for sterilisation and immunisation camps. PHC staff complements include one or more medical officers, who run the clinics, provide any in- patient treatment, and supervise the preventive care system. The medical officers are assisted by a complement of four or more support staff, consisting of Health Assistants (HAs), Multi- Putpose Health Workers (MPHWs) or Lady Health Visitors (LHVs), plus a Community Health Worker. 3.4 The sub-centre is the lowest level of Family Welfare institution and is often called the outreach arm of the program. There are generally around six sub-centres 6 depending from each PHC, each sub-centre serving a population of around 5,000 in one or more villages. In hilly, tribal or other remote areas, the population covered may be lowered to 3,000. The sub-centre is staffed by one Auxiliay Nurse-Midwife (ANM), also known as a female MPHW or Junior Health Assistant. She is responsible for promoting and delivering all preventive matemal and child health services in her community, as well as for motivation for family planning and supplies of pills and condoms; occasionally she may also be trained to insert IUDs. She will also provide some minor curative care. ANMs are super-rised in the field mainly by the LHVs (who are usually promoted ANMs), but also by the PHC medical officers during the regular monthly meetings at the PHCs. A male MPHW is sometimes also present. 3.5 The original design of the Family Welfare program included community linkages with the sub-centre through a system of community-based volunteers called Health Guides. These workers assisted the ANMs in promotion of MCH and family planning services and acted as a Liaison between them and the community. This scheme has been largely abandoned, and no substitute has yet been put in place. The only remaining links are through the village traditional midwives or TBAs (dais), who are supervised in an informal fashion by the ANMs and sometimes trained by them. 3.6 The CfC is one step up fiom a PHC, and is often crated from one by Upgrading. There is generally one per sub-district, and each is intended to cater to a population of 100,000. CHCs are supposed to provide specialist services, including minor surgery, and to be staffed by specialists, including a physician, surgeon, gynecologist, dental ugeon and pediatrician with support staff to match. Again, they are also used for camps. 3.7 These Family Welfare facilities, staff and services are supported by state-level training, MEC and MIS institutions, and managed from the state Health and Family Welfare department. However much of the content of the program and its support services, as well as maement systems of targets, norms and incentives, are centrally determined and controlled from MOHFW. 3.8 The urban Pamily Welfare system is broadly similar to the rural structure, except that the lowest level is called the health post and has a doctor, the maternity home or Post- Partum Centre takes the place of the PHC, municipal or Government hospitals take the place of the CHC, Public Health Nurses (PHNs) take the pLace of LHVs, and community linkage schemes have been or are being established in the largest cities. Management is done from municipal health departments. B. Performance, Problems, Issues 3.9 The Fanily Welfare program has had many successes. The UIP program has maised immunisaronrates for children to 85 percent from a starting point of ess than 40 pect in 1985, and recently received an extremely favourable evaluation from international experts. Contraceptive prevalence has rsen from around 20 percent in the late 1970s to more 7 than 40 percent today. Both childhood mortality and fertility have fallen significantly over the past decade. Yet despite these achievements, the Family Welfare program continues to suffer from long-standing problems of implementation throughout India. If not solved, they threaten further progress in i-ducing fertility and maternal and childhood mortality. 3.10 These problems are well-known. Program financing is inadequate for total needs, particularly for recurrent costs of maintenance and medical supplies. Program management is weak and over-entralised. The progran has been driven by mechanical, rigidly-administered and counterproductive systems of targets, norms and incentives. Supervision is punitive and/or inadequate. Training has been of poor quality. Workloads for lower-level staff are unrealistically high and their living conditions are often poor. Systens of outreach and community linkages are inadequate. Too little attention is paid to IEC. Although the Family Welfare program is designed to provide a wide range of family planning methods (male and female sterilisation, the pill, the IUD and condoms, backed up by MTP services in the event of contraceptive failure), the range of choice acually open to couples is extremely limited, with female sterilisation often the only option made available in practice. 3.11 These generic problems are co-npounded in poor or backward states vmd distrcts by their characteristically poor management and implementation capacity, difficulties of transport and access, cultural resistance to modern MCH and family planning services, and lack of adequate basic Family Welfare infrastructure. Taken all together, they tend to result in low morale among Family Welfare staff and dissatisfaction and low utilisation of services by the community. 3.12. The Action Plan for Revamping the Family Program drawn up by the MOHFW in early 1992 is designed to address many of these issues (see the summary in Annex 2). Its twelve components include: (1) generation of national consensus and policies for the Family Welfare program; (2) improvement of the quality and outreach of FW services, including creation, consolidation and maintenance of new and existing FW infrasucture and improvements in FW workers' living conditions and skills; 3) special initiatives in the 90 most backward districts of UP, MP, Bihar and Rajasthan, based on disaggregated, micro- level planning; (4) modification of the current system of targets and incentives for adoption of (female) sterilisation to make it more flexible and effective, including removal of rigid, centrally-imposed targets, discontinuation of payments to motivators, and devolution of more responsibility to the States; (5) promotion of a broader contraceptive method mix and greater use of spacing methods by younger couples; (6) upgrading and intensification of the performance of UIP and MCH programs; (7) improvement of FW services in urban slums; (8) salvage and revitalisation of community-based link worker schemes; (9) raonalisation and strengthening of FW field worker taning; (10) rvitalisation and intensification of IEC efforts (with specal mention of Rajasthan's integrated IEC bureau as a model); (11) greater involvement of NGOs; and (12) strengthening of intersectoral coordination between the FW program and other relevant Government agencies through creation of a high-level population commission and corresponding State and district-level bodies. 8 3.13 Progress has been made on putting most parts of this strategy into action, with major support from WDA-supported opertions (see paas. 3.16-3.24). The Child Survival and Safe Motherhood (CSSM) project of national scope, which is now completing its second year of implementation, is designW to support and strengthen the overall package of MCHI interventions included in the Family Welfare program, including birth spacing methods. In addition, special attention is being given to the creation of facilities for high-risk deliveies in the 90 backward districts. Under the Social Safety Net Credit, which became effective in December, 1992, GOI has begun to increase the standard allocation of drugs to Family Welfare centres and plan and implement special interventions (micro-planning for service improvements, augmentation of drug supplies, upgrading of facilities, posting of female doctors) in the 90 backward districts. Most of the major concerns of the components covering service improvement, urban schemes, field-worker training, community-based link workers, IEC and NGO involvement are being addressed in the States and cities covered by IDA-supported Area Projects, including the Fourth, Fifth, Sixth and Seventh Popuation Projects plus the Family Welfare (Urban Slums) Project, as well as by those covered by other donors. 3.14 On the Government side, a high-level Population Commission has been set up as a sub-committee of the National Development Council, a council which comprises all Chief Ministers of States. This Commission has undertaken and stimulated work on policy formulation, intesectoral odinadon and generation of national consensus. The preparation of State Action Plans, intended to put the Action Plan into implementation at State level, has begun. ITe package of incentives and targets underpinnig the dominance of steilisation is being gradually dismantled from the Centre; payments to motivators for steriLisation have been discontinued and targets for sterilisation acceptors have been devolved to the States and de-emphasised. Correspondingly, targets for spacing methods are being increased and emphasised. Several initial steps have been taken on the promotion of a broader method mix: Production of upgraded condoms and IUDs is due to begin shortly; production of oral pills has been restored from the temporary crisis of the past two years; clnical trials of implants have been initiated; injectables have been cleared for use in the private sector (with the intention of incorporating them in the Family Welfare program as soon as their popularity and acceptability bave been demonstated); and planning has begun for re-introduction of vasectomy using new and improved surgical techniques. Consideration and formulation of next step on program reform and development has begun. 3.15 This project would play an essential role in the implementation of the Action Plan in Assam, Rajasthan and Karnatka, as shown in detail in Table 1. It will ufilise key indicators relating to Plan goals and objectives for project monitorng and evaluation. It would support implementation of the Action Plan components covering service quality and outreach improvement, field-worker training, community-based link worker programs, IEC and NGOs (components 2,8,9,10,11) in Assam, Rajasthan and Karnataka. In addition, it would help support stngthening of MCH programs in these states through establishment of First Refenal Units (component 6) and the speial initative for 90 districts (component 3) tough FW program strengthening in Rajastfan. The project would also seek to advance 9 central and state-level progress on modifying the incentive/target system for sterilisation and promoting a broader method mix, throughi choice of appropriate key indicators for progress in fimily planning diversification and support of pilot schemes for mcre effective delivery of tenorary methods, including state-wide use of a network of community-based link workers who would hold stocks of contaceptive supplies and distribute them to users. able 1 sUa of Ihe rotect to Oe Acieo PHua or vanagg the FamEv We. r Pian Comonetll Corespoding Specific omens In Project Rerence 1. NadoW Strong JEC conent including auenin to opinn leaders Annex 13 on EC Stateges 2. St o Olity, Constuction t, ebabiiin of infastructue includi in Pams. 4.12-4.14,4.17 temote ad tribal areas Deav lopmt of nm baining modules iludig conunucauns Parm. 4.31, Annex 11 on akflla Training Sategis Mainanm usym for buildings, equinwtd, vehicles Pams. 4.16-17,4.24-26, Amnex 12 on Logidics Annex S on Model Building Plans Sunpervson yrov ene throgh better daff motbit Pan. 4.18 NW Planin8 State Ptoposals Improvement in ANM in, wtoring condio tuhug b f Parms. 4.15,4.18,4.19, SC dn, bee mobility, additional ain, communy- ad corresponding Annxes based a""ol workers 3. aDe¢I StWats. 90 DWi. Sub-ceaft c ecm Par. 4.14 tesive trining of daff Par. 4.23 Piloftin of likwot scheme and lin wih ICDS pram Pam. 4.19, Annex 10 on Community vostwWorkr voDvemet of DC In poect Pams. S.17, Annex S 4. Inovivo schehm to re-orient tarts (Rajsth Pars. 4.36, Aanex 1S on Inovativ Schms Innoatschem for community-baed ives Kamatak) Annex 1I S. Pmoo of Soacnu Mthods Depotholig, social mating and CID sceme Pan. 4.19,4.29-430 Annexes 10, iS Ipoveme of FP logtcs Pars. 4.244.26, Annex 12 6. U!JMP CH Pmgrsm bkImpem of CSSM pacwg (FRUs and other MCH) Pam. 4.13-4.14 and pasm ia Anexes 10, 11, 13, 1S 7. Utban Am Schsn Not Applcable i. Vilb4e agolill Guid Sdve Revitas of communty volmtee concept in all st Pam. 4.19, Annex 10 10 9. QIM T so Review and naisatuon of trtining ifstcture in all states Pams. 4.21-4.23, Amex I I Coordination of tmaining infiratrutrs Pana. 4.22, Annex 11 10. 13C uStengdn naSd expandonof MSS sch me Pars". 4.19, 4.29, Annexes 10, 13,15 Developmnt of tmaditional media sad in mersona1 comnunication Pars. 4.31-4.32, Annex 13 Detaled (statelvel) marWis prodwtion Pam. 4.31, Annex 13 Provisioa of ample, earmarked IEC budgts Annex 18 on Cost Tables WEV for mals Annex 13 Ful use of capabilies of Rajasthn WC bumeau Pam. 4.31, 5.20, Annex 13 11. bnvboleof NCOsB -deutication, retment, uwe of NGOs at local level Pares. 4.28-4.30, Annexes S. 10 at local Ied 13,15 Further development of NOO prcedues in all stes Pas. 4.28-4.30 Provision of more donor funds for NGOs Pas. 4.28-4.30 12. Ur intpemW Muldeectora proect governing boards in dae (with Chief Pare. 5.1 1, Annex 21 aUimi23 Secretay involved) DistrIct4level DC, ZilMa Parished, DRDA etc. involvemen Parm. 5.15, 5.17, Annex 21 in project implentaio Stae Poject Proposs i/ For detas of conten of each conent, see parn. 3.12 and Annex 2 C. IDA Involvement and Experience In Family Welfare 3.16 IDA Involvement in the Sector: Beginning in 1973, IDA has supported nine projects in the population/primary health/MCH sector. Eight of these were labelled Populon or Family Welfre projects, while the ninth was called the Child Survival and Safe Motherhood (CSSM) Project. All have supported the Family Welfare program or its forerunners. The first three projects have already closed; the fourth is closing shortly; three are under implementation; and the most recent has just been signed. The Social Safety Net Credit currently under implementation also contains provisions designed to support the Family Welfre program. 3.17 The history of IDA support in this sector has been one of gradually broadening scope and widening coverage across India. The underlying theme throughout has been investment in the Family Welfare program (or its forenunners), to build up its service delivery infrastructure, strengthen its support systems, and improve the quality of services delivered. 3.18 The first three projects (the Flrst, Second and Third Population projects, or India Population Project MIP 1, II and III), effective in May, 1973, June, 1980 and May, 1984 respectively, were relatively modest in scope; in fact the term "Area Projects" came into use within GOI to describe their type of operation. They supported the building of ll infrstrcture in selected districts of a few states, plus strengthening of selected aspects of suppt systems (training, IEC, MIS, operational resch) at either district or state level. The states covered were Uttar Pradesh and Karnataka in the first project, Uttar Pradesh and Andhim Pradesh in the second project, and Kerala and Karnataka in the third project. 3.19 With the Fourth Population Project (EPP IV), effective December, 1985, the scope and coverage of IDA assistance expanded. Though the project was confined to one medium-sized state, West Bengal, the entire state and all aspects of the program were fully covered and a new region of India was brought into the network. In the ifth Population ProJect (EPP V), effective December, 1988, the assistance network extended still further to go beyond the predominantly nrur focus of the first four projects and launch support to all aspects of Family Welfare services in urban slum populations. The two cities chosen to test out this new area for IDA involvement, again in previously untouched states of India, were Bombay (in Maharashtra) and Madras (in Tamil Nadu), and it was intended to extend support to other major cities along the same lines in due course if the project proved successful. 3.20 A further broadening of scope occurred in the Sixth and Seventh Population Projects (IPP VI aud 1PP VWD, effective February, 1990 and March, 1991 respectively, which retuned to a rural focus. Each covered all program aspects in three and five states respvely, including most of the north of India and some of its largest states. These stat were Uttar Pradesh, Madhya Prdesh and Andhra Pradesh in the Sixth project, and Punjab, Bihar, Gujarat, Harydna, and Jammu and Kashmir in the Seventh Project. Moreover, these rojects focused additional attention on improving broad aspects of national program design and performance where there were acknowledged long-standing deficiencies, including taining, the involvement of NGOs, and social marketing of contaceptives. 3.21 The next project, the Child Survival and Safe Motherhood project (CSSM), effective March, 1992, still with a rual focus, branched out from the previous conventional investment and Area project approach. It adopted an even wider focus with elements of progam and sector lending. Coverage was more or less national (the sixteen major states); and the project provided direct budgetary support for the incremental costs to the MCH programs incurred in the implementation of the Eighth Plan's MCH Plan (see para. 2.7). In particular, CSSM supported the development of two new programs, UIP Plus and Safe Motherhood. 3.22 The eighth project, the Family Welfare (Urban Slums) Project (IPP VI,I), effective April, 1994, retuned to the urban sector in order to carry out the intended broadening of IDA assistance to urban slum populations along the lines of the successflly implemented Fifth Project It covers four large cities in different parts of India (Bangalore, Calcutta, Delhi and Hyderabad) and provides for prepartion of projects for 15 cities more. 3.23 The CSSM proect, effective March, 1992, also is helping to put some parts of the Action Plan strategy into action, as mentioned in parm. 3.13. In particular, it is strengthening the UIP and UIP Plus programs, and support is included under the Safe 12 Mothaehood program for birth spacing methods and the creation of infrastructure in the 90 backward disticts for first referral units. The Sixth and Seventh projects, now nearing their midpoints, are likewise designed to support the rationalisation of training, the involvement of NMOs and the broadening of access to a wider range of contraceptive methods through social marketing. And under the Social Safety Net Credit, effective December 1992, G01 has increased the standard allocation of drugs to Family Welfare facilities and begun planning and implementing of special interventions in the 90 backward districts. 3.24 Thus the IDA lending program in Family Welfare has now reached the point where it is supportng program change and development at national level, most recently in the framework of the Action Plan. In addition, it has expanded its geographic coverage of investment in strengthening of the Family Welfare program to the point where almost all the major states and largest cities have been brought into the network. 3.25 IDA Eperience in the Sector The first thee projects, all of them "Area" in pproach, have already closed (see the Project Completion/Audit Reports for the First, Seod and Third Population Projects, Report Nos. 3748, 8896 and 12278 respectively). In thee projects, physical objectives have been largely met. However major problems in implementation of civil works components have been :ommon, including delays, poor quality of work, and failure to maintain buildings. Problems in maintaining facilities has been marked in Kamataka. Programmatic objectives in service delivery, training, MIS and IEC have also been largely met. However one major problem has surfaced concerning the siting of sub-centres. This has not been adequately monitored to ensure that the safety of the ANM is procted through a central location in the community; hence ANMs, who are the backbone of the Family Welfare system, frequently do not live in the community they serve, are not available for out-of-hours emergency services such as deliveries, and are handicapped in their efforts to integrate themselves fillly into the communities. In addition, it has proved difficult to integrate prqect and program management and there have been frequent failures to absorb and sustain project progms and activities in routine program implementation after project closure. Financial management of the projects has been characterised by persistent problems in achieving timely and adequate flows of funds to them. Delays have been common at every stage of the flow. 3.26 The wider and long-term Impact of the first three projects on program edfecthves, and sdll more on trends in fertity, mortaLity and population growth, has been mixed. This was due partly to their restricted scope and the implemc-ntation problems mentiond above. 3.27 Among on-going projects, the Fourth and Fifth projects are in their last stages. By and large, these two projects have not only met their physical and progrmmfatic objectives, such as viruly complete immunisation coverage and contraceptive prevalence rates of close to 60 percent, but have also registered a significant impact, in the form of reductions in infant mortality and fertility among the populations covered. They have been manged and implemented well, and their widened scope has removed some of the 13 constraints on the earlier projects in achieving, impact. This indicates that the basic approch of the Population projects is sound in these circumstances. 3.28 Experience in the Sixth and Seventh projects and CSSM is still at an early stae and it is too soon to evaluate impact. Generally speaking, implementation progress has varied from good to very slow across states and across components; the better-administered states and project management units, and the most closely-monitored programs such as immunisation, generally are performing best. Thus the quality of program and project management and monitonng has emerged as a key determinant of project success. Close and supervison by IDA with a focus on field supervision and early identification of emerging issues is also proving to be critical to project performance, particularly in the less-advantagd states or project agencies. On the financial side, there have been continued problems with flows of funds in these rural-focused projects. 3.29 In addition, in all the on-going projects there is a major problem with a slow pace of disbursements regardless of the status of progress in actual implemental ou. A portfolio-wide investigation into the reasons for this problem is currently underway, and is revealing serious delays at every stage of the disbursement process. Steps are being taken to improve practices throughout the system. This initiative is being coupled with a new system for close monitoing of flows of project funds and disbursements by GOI and IDA. These mueasres are expected to improve the outlook for disbursement performance of all projects in the future. 3.30 The concerns and problem areas identified above have been addressed to the extent possible through project design, as shown in Table 2. Table 2 Lesson AnnIfe From IDA Exoerlenc in Family Welfar Lending Lessos Correspondinig Actin Taken in Ptoject Refece 1. Restrited Scope Project suppott to program is statewide, Pam. 4.3 of Project except for resticdon of infrastucture extension Interventions to backward or neglected distocts in Rajhan and Kamataka 2. Deign of Projet Project management systens designed to Pames. 4.22-4.23, 4.24-426, Management Must involve progrm management dunng project 433-4.34,5.10-.22 Promote Maximum life and achieve smooth transfer afRr project Annexs 11, 12, 21 Integration with closure through coordination systems, temporary Program deputaton of FW, PWD staff to project, and in Long-term long-term benefits to progrm through training provision of extra equipment, logistis faciLtes and office space 14 1as Corrapoddig Action Takef b ProJect Referen 3. Likelihood of Involvenent of program management desoribed above As for 2. above Absorption and eoxpcted to promote ownership and protecton Annex 20 Sustaining of of project-inithted progmams and actvities Project Progmn, also basing of design of project progams on Actviies Needs sateprpa assessments and sategies for To Be Maxim3zed sub-secdos; faul state-level analyses of project usuainbity done with states 4. Trimly and Empowered Committee Systm set up in all Paras. 5.11, 7.1, 7.3 Adequate Flows of sats to ensure smooth trasfer of funds within Funds to Project states; assumanoes provided by stas that full powrs Need to be will be guaranteed to them; assurance provided by Assured GOI that annual review of project expedius and esource requirements wil be caffied out with IDA in order to ensure adequacy of budgets for project S. Qulty and Projeot management units set up to be efficient PRas. 4-334.34, 5.10-.22 ctxveness of and adequately-staffed for woldoad; assuances Annxs 14, 23-26 Project provided by dsates that project director/ Manage_nt Needs coordinator and all other management staff will to be Assured to in place six months from project effectiveness; Maxinum Extent MIS strengthening and managemen traing included in prject Possible deailed guidelines for Implementation included in SAR and also for reporting, monitoring and evaluation; assurances prvided by states on adherence to guidelines for reporting, monitoring and evaluation 6. Implemetai of Adequate staffing of project mnagement civil wors for Pan. 5.17, Civil Wors Poor field supervision; implementing agencies carefuly Annexes S, 21, 25 appaised; rgar field supervision by local consultant included in Supervision Pln 7. Maintenance of Assurances provided by sates that maintenance will be Paras. 4.16.4.17, 7.3, 7A Buildings and adequtely budgeted and implemented during project period; Equipment Poor rehabilitaon or renovation of facilities included in project; assurance provided by lamnatak that al facilities in state in need will be renovated under state funding if not included in project; funds for maintenance duriAg project period included in project; Assam to set up program for maintenance of faclities by communities 8. Siting of Sub- Critera establse for location and siting of sub-centrs Parms. 4.8, 4.15, 5.35, 7.3 Centres Neods to including secure cental positioning to protect safety of ANM Annexes 3, 6 Assure Safety of and ensure her residence; assurances provided by states that the ANM, So Nat She will adhete to criteria; perentage of ANMs resident included in key Can Reide in project indicators, for use of which assurances provided by isates Communyit 15 IV. THE 3 RNIf A. Project Rationale and Scope 4.1 Country Assistance Strategy: The Bank Group's Country Assistance Strategy (May 12, 1994) is to support GOI's efforts to provide an enabling environment for broad- based, efficient, private sector-led growth while accelerating the development of human resources. A major aim of the strategy is to enhance access to and quality of basic social services for the poor and to support well-targeted safety net programs that protect the most vulnerable groups in Indian society. IDA assistance will focus on raising nutritional levels, reducing fertility, reducing morbidity and mortality from key endemic diseases; and raising educational attainments; and special emphasis will be put on improving access and efficiency and improving outcomes, as well as strengthening of links between the public and the private and PVO sectors. The focus will be almost exclusively on the poor, with special attention to girls, scheduled trbes and scheduled castes. Assistance to the Family Welfare program, which provides free maternal and child health and family planning services to mostly poor beneficiaries, is central to this country assistance stategy. The program contributes to human capital development through fertlity reduction, which cuts population growth and child dependency burdens, thus permitting greater investment in fewer children. It also provides direct health and welfare benefits to mothers and young children in the poorest and most vulnerable sections of society. This project supports the Family Welfare program in three states, with a focus on service delivery to the underserved and isolated communities of each state, which are generally the poorest, and to tribal and other minority groups. 4.2 Sectoral Staity: The thrust of IDA Family Welfare assistance over the years has been twofold. The first principle has been to widen Investment In program strengthening across India, in order to ensure ftat all states benefit from adequate program infrastructure and support services. The second principle has been to deepen support for policy change and program adjustment, in order to address long-standing deficiencies that are restricting the program's full potential. 4.3 This project would provide a state-level vehicle for completing IDA's long-term program of investment in the Family Welfare program in important states not previously covered under IDA projects. It would strengthen program services in a key state targeted for special attention in the Action Plan (Rajasthan) and in another state of high priority because of the lag in program development imposed in part by past security problems (Assam). In addition, it would seek to follow up and build on the previous F.irst and Third Population prqject interventions in Karnataka which did not realise their full potential. In each state, the project would target the poorest and most backward areas for extension and upgading of program infrastructure, while at the same time modifying statewide program strategy and strengthening its performance along the lines laid out by the Action Plan. 4.4 As a state-level investment vehicle, the project cannot and does not fully address 16 the second sectoral assistance principle of policy change and adjustment in the Family Welfare program at central and national level. This will be taken up in subsequent lending directed towards sectorially and policy oriented operations, in consistency with another element of the country assistance strategy which caUs for IDA lending to shift over time from investment lending to time-slice and sector approaches aimed at sector-wide strengthening. These sector operations would address major weaknesses in key aspects of the progrwn, with special attention to revamping and diversification of the family planning program. 4.5 Meanwhile, this project will act as a bridging operation between the previous series of projects designed to build up Family Welfare inf*structure and support systems in needy states and a future program of policy-based sector lending. In itself, it would substanty improve the performance of the currently weak Family Welfare program in these three states through the strengthening of program infrastructure and support systems necessary to maximise program coverage, accessibility and quality, as well its many innovative initiatives to improve on current service delivery approaches in conformity with the Acdon Plan strategy. Hence it would be worthwhile on these grounds alone. In addition, loolkng to the future, the prqect would endow these thrMe states with the indispensable basis of a strong, well-functioning program structure needed for effective implementation of future policy development in the program. 4.6 Without this project, it is likely that the Family Welfare program would perform much less effectively in Assam, Rajasthan and Knataka and would provide a much less solid base for future program improvements. Given current financial difficulties, needed investments in infrastructure and progam strengthening would probably be seriously delayed in the three states, thus particularly affecting the poorer population groups and more backward areas. It is likely that these states would also be very slow to put improvements and innovatons advocated by the Action Plan into effective practice without donor-assisted interventions to provide specific opportunitie- for it. B. Project Objetives 4.7 The project's objectives and content are linked to the national and state Action Plans for Revamping the Family Welfare program, as laid out in Table 1, and covers a substantial part of the investment needed for implementaion in these three states. It has two inter-related objectives. The first is to strengthen and improve the functioning of the Family Welfare programs in Assam, Rajasthan and Karnaak The second is thereby to lower current levels of fertility and matenal and childhood mortality in the three states. During negotiations, GOI provided an assurance that it will implement the Acton Plan for Revamping the Family Welfare Program (para. 7.1 )); and the States of Assam, Rajasthan and Kamataka provided assurances that they will implement the state Ac-Wn Plans (m 7.3 -4.8 Tfhe achievement of the first objective will be evaluated through trends in the key 17 intermediat progran indicators spelt out in Annex 3. These indicators are linked to key elements in components of the Action Plan; the most important are shown in Table 3 below: Table 3 Key Proe Ialktemedieh Key Intenmediate Indk_ar Cortspolug Action Plan Compont Percent of SCs with own building 2 Percet of SCs with resident ANM 2 Tminin Percent of PW personnel rceiving 3,9 specified types of in-service training Pcent of households aware of 10 specified IEC messag Famil PlYninn and Method Mix Contreptive pevalnce rate, temporary methods 5 Contaceptve prevalnc rate, pennnt methods S Conraceptiv prvalne ae, al methods 5 UPI and Child Healh Percet of young children fully immunised 6 Percent of diarhoea cases receiving ORT 6 Percent of young children receiving vitamin A supplements 6 Safo ofe di Perent of pregnant women receiving antenatal came, 6 mcluding iron supplemens and tetanus imunatin Percent of delivenes taJdng place at all insdtutions 6 Percent of deliveries aking place at FRUs Percent of delveries assisted by tained personad 6 4.9 The achievement of the second objective will be assessed hough trends in the key demographic indicators on which the national and state Action Plans also focus. These are spelt out in Annex 3, and will include the total fertility rate, the infant mortality rate, and matemal mortality data, by districts or groups of districts where appropriate. 4.10 A major project focus will be the development of supplementary outreach and 18 community-based linkge systems, supported by improved community-targeted IEC. Success in this area will be assessed through reriodic evaluations of the schemes implemented. Another major project feature will be the improvement of program access and quality of semices in remote and backward areas, and among tribal and nomad populations. Success in this area will be assssed through special studies and service statistics. C. Project Content 4.11 The content of the project will differ in detail from state to state, in keeping with the disaggegated approach to program design and planning advocated in the Action Plan. Overal project structure and approach will be similar however. Five components will cover. (1) Strengthening of Family Welfare Service Delivery (2) Improvement of Family Welfare Service Quality (3) Strengthening of Demand Generation Activities (4) Strengthen of Program Management and Implementation Capacity (5) Flexible Fund for Innovative Schemes and Project Preparation Conponent (1); Strengftening of Family Welfare Service Delivery (US$ 55.2 million) 4.12 This component wil support: a) the extension and upgrading of Family Welfare infrastructure in underserved areas; and b) the strengthening of outreach and community linkages. Its purpose is to provide the essential infrastructual underpining and broadening of outreach networks that are needed to improve the coverage and peetration into the commuimty of Family Welfre services and IEC in the ree states. 4.13 Extension and Ugading of FW Infrastructure in Underserved Areas: The project will support the establishment of an adequate network of Family Welfare service delivery facilities in underserved areas through construction of new facilities and rehabilitation or upgrading of existing facilities. The major activity will be construction and equipping of purpose-built buildings for sub-centres, which are mostly functioning now in rented accommodation. Construction, upgrading or rehabilitation of PHC and CHC buildings and equipment will also be carried out; this will include the fitting up of a certain number of CHCs and lower-level hospitals to function as first referral units for obstetric emergencies. The project will fund civil works, furniture, equipment and materials. A list of all civil works to be undertaken under the project is given in Annex 4; model plans for new sub- centre buildings are shown in Annex 5. 4.14 In Rajasthan, underserved areas occur throughout the ten western districts, all of which are included in the Action Plan's 90 priority districts, and also in all other districts 19 in the case of FRUs. The project will: construct, fiunish and equip 860 sub-centre buildings in partn-.ship with the District Rural Development Authorities (DRDAs) and with selected NGOs (see Annex 5); construct, furnish and equip 25 new PHCs; and upgrade 210 CHCs into FRUs across all districts of Rajasthan, of which 148 will require additional construction and all 210 will require additional equipment and furniture. In Asssm, underserved areas are found mainly in riverine or hill districts. The project will: construct, firnish and equip 800 sub-centre buildings; renovate 50 existing sub-centre buildings; construct ANM quarters at 88 existing PHCs; upgrade 100 existing state dispensaries into PHCs; renovate 39 CHCs or Civil Hospitals that are to become FRUs and upgrade facilities in another 37 of them. In Karnataka, underserved areas are located within 13 districts mostly not covered by previous IDA projects. The project will: construct, furnish and equip 1,039 sub-centre buildings, 94 new PHC buildings and 271 doctors' quarters at existing PHCs; renovate 2,212 existing sub- centres, 327 PHCs and 48 CHCs, and upgrade 72 CHCs into first referral units. 4.15 In response to previous IDA experience (see Table 2), particular attention wil be given to the selection of suitable sites for the sub-centre buildings within the community boundaries, with the purpose of ensuring that they are central enough to assure the ANM's personal security and hence her residence in it. Criteria have been established for site selection which must be satisfied if a given sub-centre is to receive a building and for the selection of communities to be endowed with a building for their sub-centre (Annex 6). During negotatons, the States of Assam, Rajasthan and Kamataka provided assurances that they will adhere to the selection criteria for location and siting of sub-centres laid out in Annex 6 (para. 7.3 (g)) in the construction of all sub-centres built during the project period under either project or non-project funding. A list of communities to receive buildings in the first year of the project is given in Annex 7. 4.16 The project will provide funds for needed maintance of buildings and equipment provided under the project during the life of the project. During negotiations, the States of Assam, Rajasthan and Karmataka provided assurances that they will ensure that adequate resources are provided on a timely basis, through a series of measures agreed with the Association, for the maintenance of Family Welfare facilities and wiU ensure that the facilities are adequately maintained (para. 7.3 (h)). 4.17 In Karnataka, the maintenance of Family Welfare facilities, including those constructed under the First and Third Population projects, has been exceptionally deficient (see para. 3.25.). Rehabilitation of these and other existing facilities in the state outside the thirteen project districts would not be supported under the project; but a parallel program for their reabiitation will be carried out during the project period under state funding. The State of Karna ka also provided an assurance during negotiations that it would: (a) begin by July 1, 1995 implementation of a program, to be funded out of state non-project funds, of adequate rehabilitation of Family Welfare facilities constructed prior to the project, which will be carried out according to a timetable agreed with the Association; and (b) furnish to the Associaton evidence of satisfactory implementation of the rehabiitation program (para. 7.4). 20 4.18 Strengthening of Outreach and Community Linkages: The project will support several schemes designed to improve access, outreach and program linkages with the community; some will be funded under this component and some under innovative schemes, but all are described here in order to give the full picture. Mobile clinc using either boats or vans will be established in areas where stationary facilities are not suitable: these include nvernne islands and sparsely-populated hill tribal areas in Assam and remote and sparsely- populated desert areas in Rajasthan. A model plan for the 3 boats to be used for mobile boat clinics in Assam is shown in Annex 8. Either mobile clinics (vans, camel carts) or the already tested and effective system of rural health camps, or a combination of both, will be set up in Rajasthan to cover pockets of population in remote and inaccessible areas (see paras. 4.35, 4.36). Mobile health teams will be established in Karnataka to cover the remoter tribal communities (paras. 4.35, 4.36). Transport (eeps, cars, motorbikes, mopeds and bicycles) will be provided for Family Welfare facilities and staff for program outreach and supervision, using revolving-fund loan schemes and private-sector hire where feasible and cost-effective. The project will finance the costs of vehicles, vehicle hire, vehicle loan capital and opeatng costs for these outreach schemes. 4.19 To replace the dying or defunct Health Guide schemes, as advocated in the Action Plan, each state will also establish and support a network of community-based volunteers to assist the ANMs in EEC and motivation, besides acting as an informal liaison between the communty and the program and holding community stocks of supplies such as contraceptives, slected drugs, Oral Rehydration Salts (ORS) packets and iron tablets. In Aam, the volunteers will be called Women Health Ptomoters (WHPs) and each cover 60 households; they will receive performance-based awards, and can also obtain taining to be a dai. They will report to the ANM and the local MSS (Mahila Swastha Sangha, or women's group). In Kamataka, Health Advisory Committees (HAC) will be formed for each sub- centre, comprsing both program and community representatives. Each HAC will in tun recruit one community volunteer, caled a link worker, per village, who would be rewarded rough performance-based honoraria. In Rajasthan, a variety of approaches will be tried out, including expansion of an existing community-based distrbution system for contaeptive supplies, and the setting up of link worker schemes (connected with new MSS groups) which will be under NGO management or training, or in partnership with the ICDS system. Details of schemes for each state are given in Annex 10. The project will support training, kdts and awards/honoraria for community volunteers. Component (2); Improvement of Quality of Family Welfare Services (US$ 23.8 million) 4.20 This component supports a set of initiatives, as advocated in the Action Plan, to improve service quality in the areas of training, medical supplies, logistics, and the involvement of Private Voluntary Organisations (PVOs). Its pufpose is to improve the acceptability, uptake and impact of Family Welfare services in the three states. 4.21 Training: In aU three states, Family Welfare truining institutions and programs will be rationalised and strengthened in the light of an overall training strategy and plan for I 21 the Family Welfare program in each state. These are summarised in Annex 11. They wete based on the findings of Training Needs Assessments carried out as part of project preparation, which are summarised in Annex 16. Existing training systems are also described in Annex 11. 4.22 The training strategies focus particularly on the establishment of a strong in- service FW trining program, and include action to strengthen training capacity and improve taining quality, uptake and management. An important element will be the creation in each state of an apex training body, called a State Institute for Health and Family Welfare (SIHFW) which will manage and coordinate training programs and planning for the Family Welfare program, including materials development and maintenance of the training information system, provide training for all FW training staff plus selected specialist training of FW staff (such as management training of Medical Officers), and carry out evaluation, follow-up and operational research on FW training programs and courses. Other important elements of the strategies will include the creation, expansion or strengthening of networks of Health and Family Welfare Training Centres (EFWTCs) and other in-service and pre-service training institutes, development of training modules, and selected twning activities. The project wil support the construction, rehabilitation or upgrading, and equipping of training facilities as required by the strategy, transport for training facilities and staff, the salaries of new posts created, the production of training materials, and the costs of selected in-service raining activities. 4.23 Key activities in all states will include creation of an SIHFW. In Rajasthan this will entail construction of the entire establishment; Assam will upgrade the Guwahati HFWTC; and Karnataka will construct an office building for SIHFW office staff to complement a new training facility constructed recently under the Third Population project, which is to be transferred to the SIHFW's use. In addition, Rajasthan will strengthen existing Regional Health and Family Welfare Training Centres and establish one new RHFWTC, while Karnataka will expand one existing HFWTC and construct a new building for another. Assam will expand the capacity of existing Rural District Training Centres (for in-service training), while Rajasthan will upgrade 15 ANM training schools into District Training Centres, and Karnataka will establish 19 new District Training Centres. Assam will upgrade 16 Government ANM training schools (for pre-service training) while Karnataka will provide bildings for seven existing ANM taining sehools and a new building for an existing LHV Promotional training school. Rajasthan will form and train Block Training Task Forces, Assam District and Block training teams, and Karnataka district training teams. All states will also carry out extensive in-service training courses for FW staff in skills and aspects of performance -.ntified as ihs need of strengthening. 4.24 Prog.m Logistics In all three states, Family Welfare program logistics as regards transport and procurement and distribution of medical supplies have been very inadequate. Kamatala has already taken some independent action on this, but in Assam and Rajasthan the project will support rationalivation and strengthening of program logistics on the basis of strategies drawn up and agreed upon as part of project preparation. These are 22 summatised in Annex 12. 4.25 In Assam, support will go to: construction of warehouses at headquarters and district level, plus storage and material-handling equipment for new stores; provision of data processing equipment for computerised inventory control; and selected upgrading of transport workshops for specialised functions, plus appropriate tools and equipment. In addition, innovative schemes will be funded to test in two districts the concept of using hired vehicles for field supervision and to finance training in drug management and quality control, plus technical assistance for inventory management (see paras. 4.35, 4.36). 4.26 In Rajasthan, support will go to: construction of one central and 30 district warehouses, plus storage and material-handling equipment, vehicles for emergency deliveries and costs of additional staff salaries and training; upgrading of the drug-testing laboratory, plus laboratory equipment and supplies and salaries of additional staff; provision of data processing equipment for inventory management; and costs of technical assistance for making an inventory of FW program equipment and preparing standard lists of equipment and drugs. In addition, innovative schemes will be funded to conduct a pilot experiment in cost recovery for drugs through a revolving drug fund and to test in the Western districts the concept of using hired vehicles for field supervision (paras. 4.35, 4.36). 4.27 Dgsand Medical Supplies: In all three states, inadequate supplies of medicines and other essential medical supplies are a crucial constraint on the quality and effective functioning of Family Welfare Services. In all three states, an essential drugs list for the Family Welfare program will be established (see Annex 12), and all drug purchases will be confined to items on that list. All three states will also carry out a survey of drug and other medical supplies requirements, and formulate and implement a sustainable financing plan for meeting them. Until the plan is in operation, the states will mobilise sufficient incremental funds to supplement annual central Family Welfare program allocations up to the annual financing levels laid down as norms by the Planning Commission. During negotiations, the States of Assam, Rajasthan and Karnataka provided assurances that they will ensure that adequate supplies of drugs and other medical materials are made available to sub- centres, PHCs and FRUs on a timely basis, by, inter alia: (a) establishing an essential drugs list for Family Welfare program drug purchases by December 31, 1994; (b) from January 1, 1995 onwards, purchasing all drugs for the Family Welfare program, under either project or non-project funding, solely from among items on the essential drugs list; and (c) mobilising incremental resources for drugs and other medical supplies for Family Welfare facilities (par. 7.3 (i)). 4.28 Involvement of NGOs/PVOs: In all three states, a detailed program to nhance the involvement of PVOs in Family Welfare program activities is to be developed and implemented under project funding. They are planned to be most active in service delivery, IEC and innovative schemes. The management of PVO involvement will vary from state to state. 23 4.29 The role of PVOs will be particularly important and varied in Rajastban, where large numbers of NGOs already operate in the field of health and Family Welfare in collaboration with the Health Department. Twenty four such NGOs registered interest in participating in the project at an initial meeting, most with specific proposals for the kdnd of activity they would like to undertake. The range of NGO involvement will include, in addition to involvement in some sub-centre construcion (see paras. 4.13, 4.14): management of, or participation in, service delivery in remote areas; an expanded scheme for community- based distrbution of contraceptive supplies; social marketing of contraceptives; community link worker and MSS schemes; and many Family Welfare training and EEC programs. The program will be managed using the existing well-defined Grant-in-Aid procedures for funding NGO schemes of a state standing committee to review all proposed schemes with the Director of the IEC bureau acting as Nodal Officer for NGOs, but an NGO consultant will be added to the EEC bureau staff to act as liaison with NGOs and assist them in project formulation. 4.30 In Karnataka and Assam, the PVO presence and tradition is not as widespread as in Rajasthan, and collaboration with health and family welfare programs is not as common, particularly in Assam. Under the project, the first steps being taken in both states are the dentification of PVOs with potential and development of procedures for bringing in and managing their involvement. In Karnataka, the NGO program will be managed at the district level. The MOs of PHCs will identify potential PVOs, including the MSS groups proposed to be formed in large numbers shortly, and final selection of participants will be made by the District Health Officer and the Chief Secretary of the Zilla Parishad. Anticipated areas of involvement include FW service delivery and EEC, as well as management of an innovative scheme to recruit and post tribal girls as ANMs in tribal areas. In Assam, PVOs with potential for involvement have been identified and guidelines, application formats, selection criteria and rates of assistance are being finalised for publication as a booklet. In the longer run, an attempt will also be made to encourage formation of new PVOs that can work with the Family Welfare program. The main areas of collaboration wil be IEC, organisation of immunisation and steilisation camps, and community-based distibution and social marketing of contraceptive supplies. Dunng negotiations, the states of Assam, Rajasthan and Karnataka provided assurances that they will select NGOs for participation in the project in accordance with procedures and criteria agreed with the Association (pam. 7.3 (m)). Component (3); Strengthening of Demand Generation Activities (US$ 11.1 million) 4.31 The purpose of this component is to improve awareness, acceptance and uptake of Family Welfare services in the three states. It supperts the rationalisation and strengthening of IEC institutions and programs in the light of an overall EEC strategy and plan for each state, as advocated in the Action Plan. These are summarised in Annex 13. They were based on the findings of communication needs assessments carried out as part of proect preparation, which are summarised in Annex 16. State EEC institutions and their planning capabilities will be strengthened; Family Welfare service providers and community 24 volunteers will be trained in IEC and counselling skdlls; EEC materials will be developed and produced; and a full range of IEC activities will be canied out with special attention to segmenting of the market and targedng of key audiences with tailonnade messages. 4.32 Special feaues in the three states include: the experimental widespread use of video vans in Karnatala an emphasis on commun:ty-level activities with maximum community involvement in Assun; and the extensive involvement of NOOs in Rajasthan. The prect wil support the salaries of any additional posts created, the costs of IEC training for povis and volunteers, ansport and IEC equipment for IEC institutions and staff, the costs of IMC mati production, including technical assistance, and the costs of IEC activities, including technical assistance. Comiponen (4); Sgtreng ing of Pamily Welfare Program Management (IJS$ 9.6 m;llion) 4.33 The purpose of this component is to improve the inanagement of the Family Wefae program in the throe states, utilising the experience of past IDA Family Welfare projects. It supports the strengt'ening of state Family Welfare program management and implementation capacity through the development of MIS and planning capabilities and the develpment and monitonng of special serice delivery strategies for populations witb special needs. In all three states, the project will finance the costs of training in planning and management for program management staff, as well as any needed technical assistance provided under MOHFW supervi on to the project management. In Assam, the project will so finance the consruction and eqwupping of a new office building for the Family Welfare deprtmt, which currently operates in very crowded quarters; it will be used initially to house the project directoate during the project's lifetime. In addition, the Area Project division of MOHFW, which is responsible for superson of this and other Family Welfare projects, will be strengthened by the addition of five posts and upgrading and com-puteriztion of the Division's equipment. 4.34 The strengthing of each state's MIS will be based on an MIS strategy and plan deveoped in each of the states (Annex 14). The project will finance the costs of: facility upgrading to house computer systems; installadon and maintenance of the systems, including chnical assistance; computers and other equipment and supplies; training in the use of compute and MIS; and technical assistnce for the setting up of MIS systems. Cempoueut (5); Innovative Schemes/ Preparation of Further Investment Proposals (US$ 4.2 unio) 4.35 This component contains provision for two flexible funds. The first fund will prvide flexible financig to the states for additional small pilot innovative schemes designed tD improve service quality in the Family Welfare program, beyond the several innovative approaches and progrms already financed under component 1. An indicative list of schemes is given in Annex 15. The project will support the costs of pilot schemes plus their evalato. The second fund will support preparation of rosals for investments similar to 25 those in this MW for earlh of the North-Eastern states, other than Assam, which all have heavily tribal populations. This fund will be managed by MOHFW. 4.36 Inngy Shbemes Fund: In RPjasthan, key innovative schemes will include: the development and testing of experimental service delivery strategies for reducing materal and neo-natal mortality among tribal and migratory mothers and children, to be carried out in one tribal and one nomad block by an NGO in collaboration with health authorities; special promotion of institutional deliveries at selected sub-centres in the Westem districts; development of an experimental broadly-based maternal health surveillance system; experiments with alternative forms of mobility for staff in the sparsely-populated areas of the Western disticts, such as use of camel carts; and a small-scale exercise to re-orient the FW target system with involvement of FW personnel. In Assam, key schemes will include: experimentation in two districts with the private-sector hire of vehicles for the bulk of the Family Welfre fleet; small-scale experimentation with the phased replacement of govemment workshops by private-sector facilities for vehicle maintenance; support to NGOs who develop t'ieir own new initiatives in service delivery and IEC; and new approaches to Family Welfare service delivery in selected tribal populations (see pama. 4.42). In Ka1nataka, key schemes will include: a special sub-entre system for tribal areas with scattred or inaccessible populations which will establish one sub-entre per 500 population (rather than the usual tribal norm of 3,000 population) and make efforts to recruit and post tbal women as their ANMs; the involvement of large industral firms in developing IEC materials and financing air time; and assorted schemes for encouraging uptake of family planning, particularly spacing methods. During negotiations, the states of Assam, Rajasthan and Kanataka provided assurances that they will obtain approval from the Association for selection of innovative schemes to be carried out under the project (para.7.3 4.37 Investment Preparation Fund: As an extension of the support provided to the Family Welfare program in Assam, with its general lag in development and high concentraion of tribal groups, funding will be provided for preparation of proposals for investments in the neighbouring North Eastern States. These states also suffer from developmental lags and are all heavily tribal in composition; they include Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland and Tripura. The project would finance for each of tese states all costs of Beneficiary Needs Assessments, Training Needs Assessments, Communications Needs Assessments, facility surveys and any other preparatory studies or surveys required as a basis for investment preparation, as well the costs incurred in producton of a finaLised investment proposal. D. Panning for Tribal and other Special Population Groups 4.38 All three states contain significant tribal populatons. Data from the 1991 census indicate that the percentages of state populations that are of tribal affiliation stand at 12 percent, 16 percent and 4 percent respectively in Rajasthan, Assam and Karnataka. In addition, around two percent of Rajasdtan's population belong to nomad groups, whose 26 culture and way of life differ importantly from the bulk of the population. 4.39 In principle, the Family Welfare program covers these groups as part of its normal functioning. There are however special difficulties in providing services and generating demand among some groups that live in very remote areas, or are sparsely settled, or are very mobile, or have particular cultural characteristics that inhibit service demand and uptake. 4.40 In preparing the project, steps were taken in accordance with OD 4.20. To identify and address any special tribal or nomad disadvantages under the project, special needs assessments were carried out among major tribal and nomad groups in the three states. These gathered data on health status and access to health and Pamily Welfare services among each group relative to its non-tribal neighbors. At the same time, the objectives and scope of the project were presented to tribal communities and discussed, in order to gain their views on and informed consent to the project. The findings of these assessments are summarised in Annex 16. On this basis, tribal strategies were prepared for remedying the disadvantages found. These are summarised in Annex 17. During negotiations, the States of Assam, Rajasthan and Karnataka provided assurances that they will implement fully their tribal strategies as laid out in Annex 17 (para. 7.3 (1)). On the basis of the above, the projct complies with the requirements of OD 4.20. 4.41 In Assam, which has a substantial tribal presence and an impressive history of action to improve their status and progress in development (see Annex 17), much has already been done. The state's Tribal Sub-Plan includes specific attention to health and Family Welfare. Family Welfare program coverage norms have been adapted to the generally sparse settlement patterns of the hill tribal groups, and a substantial infirastructure has been created across all tribal areas in the state, consisting of two Civil (referral) Hospitals, 297 30-bedded hospitals, 148 PHCs and 843 sub-centres. Further infrastructure will be created under the project, as part of Component (1). 4.42 This stationary infrastructure will be supplemented under the project by mobile health clinics offering a range of services equivalent to a PHC in tribal hill areas where stationary facilities are not suitable. Traditional tribal methods of construction may also be allowed for new sub-centre buildings in very remote areas where the logistics of standard Government construction methods may be exceptionally difficult (see Annex 5), and community participation in building or access road maintenance will be tried out. All other components of the project will of course cover the program in tribal areas, but separate and special efforts will be made in community linkage schemes and IEC activities to suit particular needs in tribal communities. Suitable innovative schemes will be targeted to pockets of tribal communities with specal disadvantages in order to try to remedy them. The continuing participation of tribal communities in the project will be assured, as elsewhere, through the community linkage schemes to be set up under Component (1) of the project. 4.43 In order to monitor progress in tribal areas, they will be individually tracked 27 tirough the MIS and regularly compared with overall progress. In addition, a repeat needs assessment will be carried out as part of the project Midterm Review. In order to evaluate the overall impact of the project among tribal populations, a further special tribal baseline survey will be carried out at the start of the project, following the same methodology as the recently completed National Family Welfare Survey in Assam; the state NFWS itself will serve as comparator and yardstick (see Annex 23). The same tribal survey will be repeated at the end of the project, and again compared with the state repeat survey. In this way, the impact of the project among tribal populations can be evaluated both absolutely and in comparison with state-level impact. 4.44 In Karnataka, the level of development and living conditions of tribal groups vary greatly across the state. For some groups they are comparable to those of their non- tribal neighbors, but other groups are classified as primitive and have poor living conditions (see Annex 16). The state's Tribal Sub-Plan again includes specific attention to Family Welfare, and program coverage norms are again more generous. 4.45 Under the project, mobile health teams will be established to supplement the stationary program infrastructure by visiting areas identified as having particularly poor health conditions. The teams will carry out health checks, immunisations, treatment of minor ailments and referral of more serious illnesses. An innovative scheme to reduce sub-centre coverage to a population of 500 and staff the new sub-centres with tribal ANMs will also be tested (see paras. 4.35, 4.36). In addition, further in-depth studies of all tribal groups will be conducted to identify any pockets with special needs, to be followed by special programs for them, and special IEC and community efforts will be made in tribal areas. Monitoring and evaluation will be carried out by separate MIS tracking of tribal areas and repeat tribal needs assessments for the Midterm review and at the end of the project. 4.46 In Rajasthan, tribal and nomad groups are mostly concentrated in the south and west of the state respectively. Family Welfare services for them have been neglected to date, and are often unacceptable in their standard form because of different cultural norms. The provision of adequate Family Welfare services for migratory populations is also inherently difficult, and a special strategy for these groups will be developed after a special needs assessment study covering the entire annual migratory cycle has been completed. 4.47 Under the project, mobile clinics and health camps will be used to supplement the stationary infrastructure, with heavy involvement from NGOs. Innovative schemes to improve maternal and newborn care among tnbal and migratory populations will be tested, under NGO management. I addition, special IEC and community efforts will be made in tribal and nomad areas, again with heavy NGO involvement. Monitoring and evaluation will be carried out as in Kanataka. 4.48 No involuntary resettlement within any population group is expected to occur as a result of the construction programs outlined in paras. 4.13-4.15, 4.23, 4.254.26 and 4.33 above. 28 V. ROJECT COSTS. FINANCING. IMPLENTATION AND MONITORING A. Cost Estimates 5.1 Summary of costs. The total cost of the project, including duties and taxes, is estimated at about Rs. 4,409.8 million or US$ 103.8 million equivalent. The breakdown of costs of the proposed project by component and categories of expenditure for the project is summarized in Tables 4 and 5 below. Table 4 - Cost by Component (Run. Millibn) tSUS Million) % X Totl Fon Be Componn Jl Po Totl tja F.heiu Toti Costb SfteglhiF.W. S DviceDdiveqy 15 59.1 39.2 1,699.0 46.0 4.1 50.1 8% 53% ov.Qu.EtyofP.W. Servics 714.1 30.8 744.8 21.1 .9 22.0 4% 23% 4_aDing Demad for F.W. Services 339.2 8.8 348.0 10.0 .3 10.3 3% 11% MggajotlImprovmt 276.9 21.0 297.9 8.2 .6 8.8 7% 9% innovalvoscheSd 134.5 2.8 137.3 4.0 .1 4.1 2% 4% Tdal BASELNE COSTS 3.024.5 202.5 3.227.1 9.-2 6.0 95.2 6% 100% Phyacal Cogence 244.4 20.3 264.7 7.2 .6 7.8 as 8% Ptic Coeiinicies 835.5 82.5 918.1 .2 .7 .8 78% 1% Todd PROJECT COSTS 4,104 5 3053 4,409.8 96.6 7.2 103.8 7% 109% 5.2 Basis of cost estimates. Estimated costs for civil works are based on current unit costs for construction which vary from US$ 70 to US$ 90 per square meter of gross floor ar of construction. These costs are reasonable for comparable IDA-assisted construction in India. Costs of professional services for design reflect the scale of fees established for similar services provided by local architectural consulting firms. Costs for supervision of construction reflect the standard establishment charges of the Public Works Department (PWD) in each of the project states. Estimated equipment, vehicles and educational materials costs are product of lists developed by GOI and the project states, and include import duties and taxes. Furniture and consumable material costs are based on GOI and the state estimates and reflect current prices. Estimated costs for the salaries of additional staff are based on basic pay scales including standard alowances for social and other benefits applicable in the project states. 5.3 Customs duties and taxes. All imported goods are subject to customs duties and taxes. The estimated cost of the project includes import duties and taxes estimated to cost at about US$ 5.3 million. 29 Table 5 - Costs by Category of Expenditure (RUneMi li_ ($US Millon) % % TOtal Foreign Bate Loal Foeis Total Jj 1E4m Tobl Exchan Cooc nirvamt Coda Civil Wo0* (New) 920.4 102.3 1.022.7 27.2 3.0 30.2 10% 32% Civl Woarts (Rab & Upgrade) 256.3 28.5 284.8 7.6 .8 8.4 10% 9% Fumnibur 102.8 10.2 112.9 3.0 .3 3.3 9% 3% Eqipmea 201.6 27.5 229.1 5.9 .S 6.8 12% 7% Vehicl 120.0 13.3 133.3 3.5 .4 3.9 10% 4% Books 10.9 1.2 12.1 .3 .0 .4 10% Tnbing Mal 49.5 - 49.5 1.5 1.5 - 2% IBC Mataril & Activitiea 144.9 144.9 4.3 - 4.3 4% Hedb Kits 43.6 4.8 48.5 1.3 .1 1.4 10% 2% Loa Trag Sevice 254.7 . 254.7 7.5 7.5 * 8% LocalCo _uhantB 33.3 33.3 1.0 . 1.0 I 1% b3novativaScbe 111.4 111.4 3.3 - 3.3 3% Vchidl for Fld Staff (PART 2c) 167.8 167.8 4.9 - 4.9 5% G,anr to NCOos 70.0 - 70.0 2.1 2.1 - 2% Gas%atolbwarnacyInts" 3.0 3.0 .1 .1 FE:dWships 15.0 15.0 A - A - Toad Iuvedmai Cod 2.505.2 187.8 2.693.0 73.9 S.54 79.44 7X% 3% Raasmmi Code Ssiar ofMAddidomlStaff 146.3 - 146.3 4.3 - 4.3 5% Horaiumto Commuity Voheem 95.3 95.3 2.8 - 2.8 3% T.AID.A. of Staff 8.3 8.3 .2 .2 ConZmablI 50.0 5.6 55.6 1.5 .2 1.6 10% 2% Cil Wolb Maint SS. - 5S.1 1.6 1.6 - 2% Euinment & Flet Opemionand Maint 81.6 81.6 2.4 - 2A * 3% Mediie & Medcl Materal 82.6 9.2 91.8 2.4 .3 2.7 10% 3% Tedl Reerrat Coa 471.7 62.4 534.1 13.9 1.9 15.8 12% 17% Tol BASEWNE COSB 3.024.5 202.5 3227.1 89.2 6.0 95.2 6% 10O% Phsia Cstein 244.4 20.3 264.7 7.2 .6 7.8 8% 8% Price Cotigaeies 835.5 82.5 918.1 .2 .7 .8 78% 1% ToldiPROJECT COSTS 4.104.5 30S.3 4,409.8 96.6 7.2 103.8 7% 109% 5.4 Contingency allowances. Estimated project costs include physical contingencies (US$ 7.6 million) estimated at 10 percent of all physical components and at 5 percent for salaries, local consultants and training services, and operation and maintenance costs. The estimated costs of the project also include price contingencies (US$ 0.8 million) to cover expected price escalation at the following rates. For civil works, goods, salares, technical assistance, and operation and maintenance - foreign costs: 2.5 percent in FY95 through FY2002; local costs: 6.5 percent in FY95, 6.5 percent in FY96, 5.5 percent in FY97, and 5 percent in FY98 through FY2002. 5.5 Foreign exchange component. The estimated foreign exchange component of US$ 7.2 million is calculated on the basis of estimated foreign exchange proportions as follows: (a) civil works 10 percent; (b) furniture 9 percent; (c) equipment 12 percent; (d) locally produced vehicles 10 percent; (e) health kits, books, consumables, medicines & medical materials 10 percent. 30 B. FInancing Plan 5.6 The estimated total project cost of US$ 103.8 million will be financed by an IDA credit of US$ 88.6 million equivalent, which would cover 89.9% of costs net of taxes. The GOI would finance the remaining costs of US$ 9.9 million and all taxes. C. Recurrent Costs and Sustanability 5.7 The Family Welfare program is funded almost entirely by GOI through investment and operating budgets transferred to the states (the "Plan" budget), but a few small and important expenses are borne by the states out of their own 'non-Plan" funds (para. 3.2). During the implementation period -f the project, both investment and recurrent costs will be almost entirely the responsibility of the center. The total additional FW program expenditure required to finance recurrent costs during the implementation period will amount to Rs. 44 milion at current prices, or only 0.4 percent of GOI's estimated total FW budget of Rs. 12 billior, for FY94. Current central FW allocations for Assam, Rajasthan and Karnataka would have to increase annually by only 5 percent, 2 percent and 2.5 percent resectively. Even were the total FW budget not to increase in real terms, the implied reallocation of resources between states would be modest and not distortionary. During negotiations, GOI provided an assurance that it will carry out with IDA in December of each year a review of the actual expenditures incurred under the project during that fiscal year, and by March 31 of each year a review of the resources required for the project for the following fiscal year, in order to determine that there will be full provision for that year's planned project activities (para. 7.1 (a)). 5.8 More important is the issue of sustalnability of recurrent costs after project completion. For Assam, annual recurrent costs generated by the project after completion (including contingencies) are estimated at Rs. 34 million. This is equivalent to 12 percent of Assam's estimated FY94 Family Welfare budget (Plan and non-Plan) of Rs. 283 million. For RaWa&IOaM costs after completion are estimated at Rs. 64 million, or 8.4 percent of the estimated FY94 FW budget of Rs. 760 million. For Karna, costs after completion are estimated at Rs. 57 million, or 9.5 percent of the estimated FY94 FW budget of Rs. 601 million. For all three states combined, the annual recurrent cost burden generated by the project after completion amounts to an estimated Rs. 155 million, or 9.4 percent of the FY94 budget of Rs. 1,644 million. 5.9 Of these Rs. 155 million annually, the FW Plan budget would bear about Rs. 146 million if the current Plan/non-Plan funding split of 94 to 6 percent respectively were maintained. This is equivalent to 1.2 percent of the Rs. 12 billion FY94 FW Plan budget and should not present any problem. The states would bear about Rs. 9 million, made up of Rs. 1.6 million in Assam, Rs. 4.3 million in Rajasthan and Rs. 3.4 million in Kamataka. These small absolute additional amounts are clearly affordable, and are equivalent to increases of 12, 9 and 9 percent respectively in the three states' FY94 non-Plan FW budgets of Rs. 13, 49 and 38 million resectively. 31 D. Project Implementation 5.10 The project will be implemented by the states of Assam, Rajasthan and Karnataka, with supervision from the Area Projects Division of MOHFW. Project management in Assam and Karnataka will be established in three tiers, and in Rajasthan in four tiers. Lists of staff or committee members plus organigramns are shown in Annex 21 for the entire structure in all three states. 5.11 In all three states, the top of the project management tiers will be a state-level Empowered Conunittee (Assam and Rajasthan) or Project Governing Board (Karnataka) which will include high-level representation from all relevant parts of state government. This body will be fully empowered to make major policy decisions, authorise transfers of funds from the centre to the project and other financial approvals and sanctions, and monitor overall project progress. During negotiations, the States of Assam, Rajasthan and Karnataka provided assurances that they will ensure that the Empowered Project Committees hold regular meetings at a frequency adequate for effective project direction ani1 supervision, but in any case at least twice a year (para. 7.3 (c)). 5.12 The second tier in all three states wil consist of a Project Management Committee (Assam), Steering Committee (Karnataka) or Monitoring Committee (Rajasthan), which will be principally composed of top-level managers from the state Health and Family Welfare departments, plus the Project Director or Coordinator. These bodies will supervise and monitor project implementation and report up to the state-level top-tier committee. 5.13 In Rajasthan, there will then be an intermediate tier, the Project Secretariat. This will be headed by the Secretary, Medical and Health, who will be the Chief Coordinator of the Project. He will be assisted by the Special Secretary, Medical and Health, who will be the Additional Chief Coordinator. They will review project implementation and provide direction and guidance to the Deputy Secretary, Department of Medical and Health, who will be Project Director and responsible for the implementation of the project. 5.14 The bottom tier in all three states will be a project management unit or Project Directorate which would carry out actual project implementation under a Project Director (Assam), a Project Coordinator (Karnataka), or in Rajasthan, a Project Coordinator acting under the Project Director (see preceding para.) and assisted by an Additional Director (Project and Human Resource Development) who will actually manage implementation of the project. In Karnataka, the Project Coordinator will be an Additional Director (Projects). In Rajasthan, the Director, Family Welfare will be Project Coordinator for the project. These project management units or directorates will be composed of the project director or coordinator's office plus a range of technical Cells (Assam) or Wings (Karnataka and Rajastban) (see Annex 21). 32 5.15 In Rajasthan, there wiU also be a parallel management structure of three tiers to coordinate project activities at district level. At its bottom will be the district Chief Medical and Health officers, who will have overall responsibility for implementing project acdvities in the district. Each will be assisted by the Deputy CHMO for the district, who will acually manage implementation of activities. The tier above will consist of a set of DIfstlit Coordiuation Committees, each chaired by the District Collector and staffed by representatives of relevant district departments, plus NGOs and community leaders. The district CMHO will be the member secretary, and the committees would meet formally every three months. The regional-level top tier will be composed of the Joint Directors of the zone/division, who will coordinate the activities of the district CHMOS in that division and act as a link between the Project Director and project directorate on the one hand and the distnct coordination committees on the other hand. S.l# The technical Cells/wmgs under the project director/coordinator wil include Engineering/Construction, Health Manpower Development/Training, IEC, and MIES/Monitoring & Evaluation/Management units; Assam will also have a Mateials Management Cell. Generally speaking, they will be staffed to the maximum extnt possible through temporary deputation of appropriate staff from the Family Welfare program or other corresponding state government departinents. The intention is that these staff should retm to their programs or departments of ongign at project closure, to strengthen them permaendy tirough the training and experience acquired on the project. Where needed, expertise would also be recruited on a temperary basis from the private sector. No new government posts wil be established. 5.17 The largest technical units will be the Engineering/Construction umts overseeing the implementation o; civil works. These will be staffed mainly through deputation from the state Public Works Department (PWD). The responsibilities of the units in Assam and Karnataka will be to manage the contacting out of construction and other civil works to private-sector architects and contractors and to supervise their performance either directly or through local departments of PWD; and they will be structured and adequately staffed to carry out full field supervision (Annex 21). The responsibility of the Rajasthan unit will be as in the other states for buildings other than sub-centres. In the case of sub-centres, for which construction will be primarily implemented through DRDA-managed Gram Panchayat construction units with some involvement also from NGOs (see Annex 5), the role of the project unit will be supervisory only. 5.18 In Assam there will also be a Materials Management Cell which will have three functions. The first will be to oversee implementation of the logistics sub-component; the second to manage all supplies of materials under the project; and the tiird to set up a permanent material management system for the Family Welfare program. It will be staffed largely through deputation from the Department of Health & Family Welfare. 5.19 The Training/Health Manpower Development units in Assam and Kamataka wil oversee implementation of the training sub-omponent of the project; in Assam, the cell will 33 also take on the responsibility of managing human resources in the Family Welfar sector. A Human Resources Development CeJl will be set up within the Family Welfare program in Rajasthan with similar responsibilities. The units will be staffed by deputation from Health and Family Welfare departments or associated training institutions. 5.20 IEC units will oversee the implementation of the EEC component of the project in Assam and Karnataka; in Assam, the cell will also oversee programs to involve PVOs and the pnvate sector in the Family Welfare program. Again, the units will be staffed from Health and Family Welfare departments. In Rajasthan, the existing state Health and Family Welfare IEC bureau will implement the project. 5.21 The MIES/Monitorng and Evaluation/Management units will have two functions as implementors of the MIS subcomponent of the project. The first will be the tracking of activities and progress in all other components in the project. The second will be to develop and refine the existing Family Welfare program MIS in order to improve its scope and effectiveness. The units wil be pardy staffed from Health and Family Welfare detments, and partly coordinate with other technical MIS institutions in the state, such as the Nationa Informatic Centre and (in Karnataka) the state Population Centre. 5.22 Under the project director or coordiator will also be a number of admir and financial staff to carry out routine project administration and financial management. These staff also will mostly be deputed from elsewhere in state government. During negotiations, the States of Assam, Rajasthan and Kanataka provided assurances that they will establish the full project management structure, including all Committees and technical units, by October 30, 1994 (para. 7.3 (a)). They also provided assurances that they will engage al other key additional staff to be recruited under the project by December 31, 1994 (para. 7.3 (b)). They also provided assurances that they will prpare and submit to IDA for approval by January 31 of each year, annual civil works, training, MEC, MIS and service delivery plans for the following fiscal year substantially in accordance with content and timetables embodied in Annex 26 (para. 7.3 (d)). E. Status of Project Preparation 5.23 Civil Works. Vehicles, Equipment. Lgistics: Model plans for buildings that ame to be duplicated many times, such as sub-centres (Annex 5), MO quarters and some training facilities, and plans for most of the one-off buildings such as the project office building in Assam, have been prepared and approved. The designs for the mobile clinic boats have been prepared and approved (Annex 8). A list of sub-centre buildings to be constructed in the firt year of the project has been prepared and approved (Annex 7). Criteria have been prepared and agreed upon in all states for selection of communities to receive newly-constrcted buildings for their sub-centres under the project, and for selection of sites for the buildings in each community (Annex 6). Lists of vehicles (Annex 9) and equipment to be provided under the project have been drawn up and approved. 34 5.24 A facility survey has been completed in Assam and Karnataka to identify Family Welfare facilities to be upgraded into first referral units and to specify the work needed to be done. A facility survey of Family Welfare facilities has been completed in Assam and Karnataka to identify renovations and rehabilitation needing to be done. A survey combining both these topics is to commence shortly in Rajasthan. 5.25 Strategies for improving Family Welfare logistics in Assam and Rajasthan have been drawn up and agreed upon (Annex 12). They have served as the basis for packages of interventions to be undertaken under the project (Annex 12). 5.26 Service Delivery and Special Groups: Beneficiary Needs Assessments focusing on health status and access to health and Family Welfare services among tribal groups have been carried out in each state (Annex 16). Focus group interviews have also been carried out among tribal groups to present the project and obtain their informed consent and participation (Annex 16). A strategy for remedying disadvantages among these groups has been drawn up, agreed upon and incorporated into project design in each state (Annex 17). 5.27 An in-depth, longitudinal survey of migratory groups in Rajasthan which covers the annual migration cycle is underway; it combines features of a baseline survey and a beneficiary needs assessment. A strategy for these groups also will be drawn up or the basis of the survey's findings, which wil be financed under a lump sum set aside fol Nhis purpose in the project budget. Community Volunteer schemes (Annex 10) have been designed and agreed upon on the basis of a process of widespread consultation among Family Welfare staff. 5.28 Training: A training needs assessment has been carried out in Assam and Karnataka; Rajasthan had recently had one financed under a UNFPA project (Annex 16). A training strategy for the Family Welfare program has been drawn up on the basis of their results and incororated into project design (Annex 11). 5.29 IE: A communication needs assessment has been carried out in Assam and Rajasthan; Karnataka did not do a full-scale one since it had the benefit of the experience of a strong IEC component in the recently-closed IPP m (Annex 16). EEC stategies for the Family Welfare program have been drawn up on the basis of their results and incorporated into project design (Annex 13). 5.30 MS: A stitegy and plan for the development and strengthening of the MIS in each state has been drawn up and agreed upon, and incorporated into project design (Annex 14). 5.31 Innovative Schemes: An indicative list of innovative schemes has been drawn up and agreed upon (Annex 15). 5.32 Mogitoring and EvaluatioWn: Methodologies and outlines for progress reports, 35 MIS tracking and baseline, midterm and final evaluative studies and surveys have been drawn up and agreed upon (Annexes 14, 24, 26). 5.33 Procurement: Procurement arrangements have been discussed and agreed upon (Chapter V, section H). Standard Bidding Documents based on Bank models have been agreed with all states, and technical specifications for aU packages of equipment for which contracts will be put out to tender in the first year of the project are prepared. 5.34 Spervision: A supervision plan has been drawn up and agreed upon (Annex 25). F. Monitoring and Evaluation 5.35 Progress in the project will be measured in terms of the agreed key project indicators (Annex 3). Routine implementation of the project will be monitored through: (a) MIS tracking (Annex 14); (b) six-monthly progres reports prepared by the state project management units (Annex 25); (c) and the Midterm Review (Annexes 23, 25). During negotiations, the States of Assam, Rajasthan and Karnataka provided assurances that they would utilise the key project indicators laid out in Annex 3, and related to national and State Action Plan goals and objectives, for project monitoring and evaluation of project implementation and impact (para. 7.3 (k)); and that they will submit six-monthly progress reports to IDA in conformitv with the format and timetable laid out in Annex 24 (Ra=. 7.3 f. 5.36 Evaluation of the project's effectiveness and impact wil be carried out through a series of studies and surveys (Annex 23). A population-based sample baseline survey will be carried out in Rajasthan and Kamataka within the first six months of the project; it will provide an independent measure of initial health and family planning status and access to health and family planning services, including key indicators, and will aRow disaggregation for tribal groups. In Assam, the results of the National Health and Family Welfare Survey held in 1993 will substitute for the state-level baseline survey, but a conesponding survey for the tribal population will be carried out within a year of project effectiveness. 5.37 In the final months of the project, a final evaluative survey, consisting of a repeat of the baseline, will be carried out. In Assam, this will be done in two parts, a general and a tribal survey, to match the original baselines. Trends in health and family planning status and service access, including key indicators, will be analysed to provide some assessment of the impact of the project. Trends in tribal areas, and in differentials between tribal and non-tribal groups, will receive particular attention. 5.38 A similar survey will be carried out at the project midpoint also, as part of the Midterm Review, if IDA and the states agree that it could usefully be done at that point. This will depend largely on the pace of implementation and progress in the early years of the project. 36 5.39 In addition to these population-based surveys, repeat; of the training, communication and beneficiary needs assesments conducted as part of project preParation will be carried out at the end of the project; and also at the project midpoint, as part of the Midterm Review, if progress in project implementation is on track. These repeats will be used to determine the effectiveness and impact of the project in improving taining and IEC programs, as well as the coverage and quality of service delivery. Again, trends in tribal areas will be a particular focus. 5.40 Finally, final evaluative studies of all new programs and approaches pioneered under the project will be canied out towards the close of the project, in order to determine their value and effectiveness. These would include any innovative programs covered under the four main components of the project and any innovative schemes that have survived their initial testing and evaluation period. Again, similar studies could also be done at midpoint, by agreement between IDA and the states, if there has been sufficiently early progress to render evaluations useful at that stage. During negotiations, the States of Assam, Rajasthan and Karnataka provided assurances that they will each carry out a baseline survey, a Mtidterm Review, and final and other evaluative studies and surveys according to the protocols, methodologies and timetables laid out in Annex 23 (para. 7.3 (f)). G. Disbursements 5.41 Disbursement profile. The proposed IDA credit would be disbursed over seven years, consistent with the standard profile for PHR projects in India. The project is expected to be completed on June 30, 2001 and the credit closed on December 31, 2001. The experience with other PHR projects reinforce the justification for a standard disbursement profile. The table below shows forecasts of expenditures and disbursements (more details are given in Annex 19). Ftimated Disbursements IIDA FY FY95 FY96 FY97 FY98 FY99 FYOO FYOI FY02 Annual 3.4 8.6 13.0 15.9 16.4 14.2 14.2 3.0 Cumulative 3.4 12.0 25.0 40.9 57.3 71.4 85.6 88.6 5.42 Disbursement percentages and required documentation. The IDA credit would be disbursed against 90 percent of expenditures on civil worlcs; 95 percent of consultants, grants and fellowships; 100 percent of CIF and 80 percent of other local expenditure on furniture, equipment & health kdts and vehicles; 95 percent of training materials and books; 80 percent of training, publicity, services and materials for EEC; and an average of about 75 percent of incremental staff salries, honoraria to volunteer workers, incremental operating and maintenance costs, including medicines and medical materials on a declining basis, beginning with 90 percent in the first three years, declining to 80 percent for the fourth and fifth year, and 60 percent for the remainder of the project. Disbursements for construction, rehabilitation and repair would be made against Statements of Expenditure based on 37 certificafion of satisfactory completion of each stage of the work (foundation, walls, and roof). The state government would maintain complete records, by site, of work accomplished and funds disbursed, including certificates of completion signed by the block engineer and countersigned by the District Engineer and District Project Officer. Disbursements for procurement of goods and services under contracts of less than US$ 200,000 and US$ 100,000 respectively, civil works contracts under US$ 500,000, civil works maintenance, fellowships and grants, incremental salaries and operating costs would also be made against Statements of Expenditure, with supporting documentation retained by the state government for review by IDA during supervision missions. All other disbursements would be made against fully documented withdrawal applications. 5.43 Seci In order to accelerate disbursements in respect of IDA's share of expenditures pre-financed by the GOI and the state government, and to allow for direct payment of other eligible local and foreign expenditures, a Specal Account would be opened in the Reserve Bank of India in the amount of US$ 3.0 million equivalent to cover four months of expected requirements for IDA financed items. 5.44 Retoctive financing. Retroactive financing in the amount of US$ 1.0 million is recommended to cover eligible expenditures incurred in implementing appraised prject activities after December 31, 1993. Retoactive financing would support initial staff appointments, development of the project monitoring system, and other related start up costs. All procurement would be made against eligible categories of expenditures in the project, and would follow IDA procurement guidelines. H. Procurement 5.45 Table 6 on the following page summarizes the project elements and their esdmated costs and proposed methods of procurement. Project-related procurement for goods and services would follow procedures acceptable to IDA. Project-financed consultants would be selected according to Guidelines for the Use of Consultants by World Bank Borrowers. Procurement of equipment, vehicles, furniture, and health kdts would be buled to the extent possible and any individual contract exceeding US$ 200,000 would be procured using ICB. Purchases of off-the-shelf items (excepting vehicles) through rate contrats would be acceptable in packages of less than US$ 100,000. 5.46 Civil Works: Civil works in the project consist mostly of Family Welfare program PHCs, sub-centres, training centres, hostels, offices and staff quarters, valued in total at US$ 36.2 million. These are dispersed in remote locations and will be coucted during the seven year of the project. They are of small value, with contacts ranging in size from US$ 10,000 to 1 million, hence they are unikely to attract foreign competition, and will be procured following local competitive bidding procedures acceptable to IDA. Foreign contractors would not be precluded from participating in the LCB bidding. Repairs, rehabilitation and upgrading of existing buildings will in some cases be carred out by the established force accounts units of Public Works Departments or by selected voluntary of 38 Table 6 - Prcrement Arrangements (Tota Costs hi US$ MliMs) Ci_98 C_iiM S1di BMW" Oihts N.B.F. TOWta CIL WORKS avii wik - 36.19 6.6D - 42.78 (32.7 (5.94) (38.50) GOODS vdim 3.9 - 0.30 - 4.29 (3.19) (0.24) (3.43) Mopeds&. Bkyds*r PF M Stf 5.48 5.48 (4.39) (4.39) 2.71 0.98 - 3.69 (2.17) (0.79) .95) E@qpmm & HUalMh il 6.69 2.43 9.12 (5.35) (1.94) (7.29) .-diabgMamthl&boah . 1.67 - 1.67 (1.57) (157) Causommabls 1.84 - 1.84 (1.35) (1.35) iau&Muideu"lMIwt - 3.04 3.04 A) (122) TBNCALASTJSANc$ P,n$ etPrsu timi & Wsmwamn - 15.67 - 15.67 &qwthedmftatf I fnm uS Aiem. (14.92) (14.92) PtCPrades1a& u mmuasIai - 1.30 1.30 SqVn GPUbli@1ay UtviGSo (1.04) (1.04) .Md*dau Dewiqvop (h i ' 3.04 3.04 MC& Ia a) (2135) (213) Suiu of Adlio Staff - - 4.56 4.56 (3.37) (3.37) lHaa V_w Com.a ny V*m - 2.83 - 2.83 (209) (2.09 T.AJD.A. of .S tf - 0.27 0.27 clv Weds opgam & ma 1.73 - 1.73 (1.24) (1.24) EyIdp&FktOpwdM&M"t - - 2.5 - 2.55 (1.87 (1.87) TOWal 3.99 45.58 54.00 0.27 103.84 (3.19) (4.09 (45.31) (88.58) Now Figues inp u mdi imediw mumd to DA(i lusive o f co dlnsacl 39 agencies (NGOs). In the case of some buildings (dispersed sub-centres small value) where the estimated cost is US$ 10,000 and below, contracts may be let out on the basis of invited quotations from three qualified contractors; but keeping within the overall ceiling for these works of US$ 6.6 million. Materials required for works carried out under Force Account will be procured under local shopping. Monitoring of works carried out under Force Account will be done under procedures acceptable to IDA. 5.47 The execution of major worls will be overseen by staff of State Public Works Departments deputed to work on this project. They will use bidding documents which closely follow the Bank's Standard Bidding Document (small works model) and are satisfactry to IDA. Type designs for new buildings, including detailed specifications, for PHCs, sub- centres, staff quarters and offices have been made available to IDA for review and comment, and will be approved prior to Board Presentation. 5.48 Goods. Euipment and Vehicles: Vehides for the p.roject consist of jeeps, cars, mini-buses, mobile clinic vans and boats, costing US$ 4.3 million in total. Vehicles and boats for immediate requirements, with each contract costing US$ 100,000 and below, up to an aggregate ceiling of US$ 0.3 milion, will be procured using rate contracts (in the case of vehicles) of the Diretort eral of Supplies and Disposal (DGS&D), New Delhi, or local si opping procedures (in the case of boats), comparing price quotations from at least three suppliers to ensure competitive prices. 5.49 The rest of the vehicles, valued in aggregate at US$ 4.0 million, will be procured during the first two years of the project, following Iternational Competitive Bidding (ICB) procedures acceptable to IDA and using the Bank's Standard Bidding Document (goods model). A domestic preference of 15 percent of the CIF bid price of such goods, or prevailing customs duties (whichever is lower), would be applied for domestically manufactured goods meeting eligibility requirements. 5.50 Mopeds, bicycles or motorcycles valued in aggregate at U3S$ 5.5 million for Family Welfare staff, to be financed tlrough a project revolving loan fund, will be procured directly by the end users throughout the seven year project period. There is good competition among local suppliers and agents, and selection by the direct end users also allows for local choice. 5.51 Equipment (office, labotory or medical, health kits) and Jfrnitue, valued in aggregate at US$ 9.4 million, will be procured at different times over the seven year life of the project by each of the three states. Since the quantities for each individual purchases would be relatively small, they will be procured using LCB procedures in accordance with the Bank's Standard Bidding Documents. Contracts valued at US$ 50,000 and below, up to an aggregate of US$ 3.4 million, may be procured following local shopping procedures, comparing price quotations from at least three suppliers to ensure competitive prices. All DGS&D rate contracts will be acceptable for procurement under local shopping. 40 5.52 Teaching aids, books, medicines, and consumables will be procured in contract valued at US$ 50,000 and below following shopping (international or local) or direct contctng procedures acceptable to IDA as indicated below: (b) for contracts esdmate to cost more than US$ 25,000 but equivalent to or less than US$ 50,000 up to an aggregate amount for the project of US$ 4.2 million may be procured using local shopping procedures, comparing price quotaions from at least dhee suppliers to ensure competitive prices. AU DGS&D rate contracts will be acceptable for procurement under local shopping. (a) for conucts estimated to cost less than $25,000 up to an aggregate amount for the project of US$ 2.3 million, using (i) local shopping procedures, comparing price quotations from at least three suppliers to ensure competifave prices or (ii) under direct contracts with suppliers thereof in accordance with prcedures acceptable to IDA. 5.53 Puublcity Servies estimated to cost up to an aggregate value of US$ 1.3 million for the proect shall be procured under direct conts with the Borrower's Ministry of Information and Broadcasting, or with the relevant department or agency of the State Governments. 5.54 IEC Servic estimated to cost less than US$ 25,000 per contact up to an agregate value of US$ 3.0 million for the project shall be procured under direct contracts with local commercia suppliers of such services in accordance with procedures acceptable to IDA. 5.55 .ulUM Con: Consultants required under the project will be hired following procedures prescribed in "Guidelines: Use of Consultants by World Bank Borrowers and by the World Bank as Executing Agency"; August, 1981". 5.56 Review of C:onbts During project supervsion, IDA-financed contracts for works and goods valued at US$ 200,000 and above would be subject to prior review by IDA. The review process will cover about 20 percent of the totl contracs proured under ICB/LCB. This relatively low percentage is considered satisfctory since the state governmebts have gained expiece in procurement in previous Bank prqects. Selective post review of awarded contracts below the theshold levels would be carried out. 5.57 In respect of consultancies, the model documents used for inviting proposals, terms of refen for all consultancies, single-source contracts irrective of their value, and all contacts valued at US$ 100,000 or more awarded to firms and US$ 50,000 or more to be awardod to individuals will be subject to prior review. 5.58 Procurement information will be collected and recorded as follows: 41 (a) prompt reporting of contt award information by the Borrower (b) comprehensive half-yearly reports to IDA by the Borrower, indicating: (i) revised cost estimates for individual contracts and the total project (ii) revised timing of the pement actions, including advertising, bidding, contact award and completion time for individual contracts (iii) compliance with aggregate limits on specified methods of procurement (iv) a completion report by the bofrower within three months of the loan closing date. L Accouting and Auding: 5.59 The project would be subject to normal GO accounting and auditing procedures which are considered acceptable to IDA. During negoions, G01 and the States of Assam, Rajasan and Kamataka povided assurances that they will prepare and have audited by independent auditors acceptable to IDA, accounts and financial statements for the project for each fiscal year, maintain statements of expenditure according to sound accounting practices, retain them for at least one year after completion of the audit for the fiscal year in which the last withdrawal was made, and include a separate opinion on them in the annual audit; and furnish copies of these accounts to IDA as soon as possible, but not later than nine months afer the end of each fiscal year (para 7.2). VL BENEFllS AND RISK A. Project Bendits 6.1 The project should: improve the quality of Family Welfare services in Assam, Rajasan and Karnata increase access to services in underserved areas and by poor and disadvantaged population groups including tribal and migratory groups; increase demand for serices both among the general population and among poor and disadvantaged groups; and stenthe progam mnnagement. These benefits will be assessed by the key project indicators and evaluaton mechanisms agreed upon with GOI and the States (pams. 4.7-4.10, 5.35-5.40, and Annexes 3 and 23-25). 6.2 Evidence to date indicates that improved progrm effectiveness should lead to increased service utlhsation, which in tun should result in better health for mothers and chldren and accelated declines in fertliy and materna and childhood mortality. These 42 declines siould be mutualy reinforcing, since lower fertility would improve child health and welae and decrease the risk of death in pregnancy and childbirth, while lower childheod mortalitY would decrease the need for large numbers of births to assure survival of some to adulthood. Eventually, fertility would fall low enough to bring about a reduction in the natural itinuse of population in the three states and nationwide. State overall goals for the year 2000 are a crude birth rate of 20 or 21, a contraceptive prevalence rate of 60 percent and an infancy mortality rate of 50. Again these benefits will be assessed by indicators and evaluation mechanismns agreed upon with GOI and the States (see preceding para.). 6.3 These benefits would be particularly important in Rajastian and Assun. Rajasthan is one of the conservative northem states where progress in reducing fertlity and mortality has been particularly slow, and which as a block are impeding further national progress. A program bretough in Rajasthan would thus have regional and national significance. Assam has suffered for many years from lack of development and investment in the proga.-m, due to the continuing security problems in the state. The project should therefote bring about particularly marked progress in Assam. B. Piroject Risks 6.4 The prqect carries several risks which are itemised below. Most of them are endemic in Family Welfre projects, but can be reduced if not eliminated through careful prject design. Measures have been incorporated in the project to minimise these risks, swveral of which are also laid out in Table 2. 6.5 Basic IwnkmtajoQ P ertorm.anm : Current institutional capacity and program effectiveness varies across the three states and across sectors, and basic implementation risls vary accordingly. On the basis of past experience, however, including that in Karnataka under the First and Third Population Projects, the risk of poor implementation is significant everywhere. To minim this risk, tight specifications and control measures have been built into the project for past problem areas, such as design, management, supervision and mintenance of civil works and mechanisms for strengthening and coordination of program and project management. 6.6 Sustainabifliy: Likewise, the risk that the infrastuctu and programs put in place under the project will not be maintained and fully funded is substantial ev here, and is exemplified in the First and Third Projects in Karnatak. This risk has been minimised through project agreements on building and drug budget maintenance during the project period and by building in project-program coordination and management strengthening measures. 6.7 Innovative .roaches Many of the approaches and programs to be put in place by the project are new, innovative and untested in the Family Welfare program, particularly toe relating to outreach and community linkage schemes, mobile clinics, and transport and logistics. To minimise tis risk, the project design calls for pilots, evaluations and gradual 43 phaing in of new pogms and approaches. 6.8 S.In in Assam I Assam, there are also lingering minor security related concerns. Control of this risk is beyond the scope of the project, but security conce, which have been easing, have not interfered with project preparation. In the judgement of GOI and the state, they are ulikely to jeopadise investment in the Family Welfare pogram significantly. in the longer term or in any but a few smal areas of the state. VII. ARAEI&1ACHED 7.1 During negotiations, 001 provided an assurance that it would: (a) carry out with IDA in December of each year a review of the actual vpenditures incutred under the project during ta fiscal year, and by March 31 of each year a review of the resources required for the pruect for the following fiscal year, in order to determdne that there will be ful provision for that year's planned project activities (para 5.7); and Ib) imploment the Action Plan for Revamping the Family Welfare Pogram (Ian. 4.7. 7.2 During negotiations, (OI and the Staes of Assam, Rajasthan and Kanataka provided assurances that they would: prepar and have audited by independent auditors acceptable to IDA, accounts and fincial sWements for the project for each fiscal year, maintin statements of expenditure according to sound accounting practices, retain them for at least one year after completion of the audit for the fiscal year in which the last withdawal was made, and include a separate opinion on them in the annual audit; and fumish copies of these accounts to IDA as soon as possible, but not ater than nine months after the end of each fiscal year (pa. 5.58). 7.3 During negodations, the StWes of Assam, Rajasthan and Kama also provided assurances that they would: (a) establish the full project management structure, including all Committees and technical units by October 30, 1994 (para. 5.22). (b) engage all other key additional personnel to be recruited under the prqect by December 31, 1994 (para.5.22). (c) ensre that the Empowered Project Committees hold regular meedngs at a frequency adequate for effective project direction and supervision, but in any case at least twice a year (par. 5.11). (d) prpare and subnit to IDA for approval by January 31 of each year, annual civil works, taining, IEC, MIS and service delivery plans for the followig fiscal year substantially in accordance with content and timetables embodied in Annex 26 (par. 5.22). (e) subnit six-monthly progress reports to MDA in confornity with the fornat and timetable laid out in Annex 24 (pam. 5.35). (f) carry out, in each state, a baseline survey, a Midterm Review, and final evaluative stde and surveys accoring to the protocols, methodologies and timetables laid out in Annex 23 (para. 5.40). (g) adhere to the selection criteria for location and siting of sub-centre buildings laid out in Annex 6 in the construction of all sub-centres during the project period under either project or non-project funding (pam. 4.15). (h) ensure that adequate resources are provided on a timely bais, through a series of measures agreed with the Association, for the maintenance of Family WeLfare facilities and will ensure that the fcilities are adequately maintained (para. 4.16). (i) ensure that adequate supplies of drugs and other medical material are made avaiable to sub-entres, PHCs and FRUs on a timely basis, by, inter alia (a) establishing an essential drugs list for Family Welfare program drug purchases by December 31, 1994; (b) from January 1, 1995 onwards, purhasing all drugs for the Family Welfare program, under either project or non-project funding, solely from among items on the essential drugs list; and (c) mobilising incremental resources for drugs and other medical supplies for Family Welre facilities (par. 4.27). (j) implement the State Action Plans (pam. 4.7). (k) utilise the key project indicators laid out in Annex 3, and related to national and state Action Plan goals and objectives, for project monitoring and evaluation of project implementation and impact (pam. 5.35). (1) implement fully their tribal strategies as laki out in Annex 17 (para. 4.40). (m) select NGOs for participation in the project in accordance with cntena and procedures agreed with the Association (pax. 4.30). (n) obtain approval from the Association for selection of innovative schemes to be carried oiut under the project (m 4.36). 45 7.4 The State of Kamataka also provided an assurance during negotiations that it would: (a) begin by July 1, 1995 implementation of a program, to be fimded out of state non-project funds, of adequate rehailitation of Family Welfare facilities constructed prior to the project, which will be camed out according to a timetable agreed with the Association (pam. 4.7); and (b) furnish to the Association evidence of satisfactory implementation of the rhabilitation program (pam 4.17). 7.5 Subject to the above conditions and assurances, the proposed project constutes a suitable basis for an l)A Credit of US$ 88.6 million to India at standard IDA tems with 3S years martuity. 46 Annel Latest Demographic Data and Family Welfare Kev Indicators For All India and MaJor States (pog. 10 million or more) Table A:1:1: Sununary Demographic Indicators for All India and Major States State Population Pop as' CBR CDR RNI IMR TFR Age at2 (millions) % of (0/00) (0/00) (%) (per % Effective Total Woman) Marriage for Girls, (Years) 1991 1991 1992 1992 1992 1991 1991 1991 Major States Andhra Pradesh 66.5 8 24 9 1.5 71 3.0 18 Assam 22.4 3 31 10 2.0 76 3.5 21 Bihar 86.4 10 32 11 2.1 72 4.4 19 Gujarat 41.3 5 28 9 1.9 67 3.1 20 Haryana 16.5 2 32 9 2.3 75 4.0 19 Karnataka 45.0 5 26 9 1.8 73 3.1 19 Kerala 29.1 3 18 6 1.1 17 1.8 22 Madhya Pradesh 66.2 8 34 13 2.2 104 4.6 19 Maharashtra 78.9 9 25 8 1.7 59 3.0 19 Orissa 31.7 4 28 12 1.6 114 3.3 20 Punjab 20.3 2 27 8 1.9 56 3.1 20 Rajasthan 44.0 5 35 10 2.4 89 4.6 18 Tamil Nadu 55.9 7 21 8 1.2 58 2.2 20 Uttar Pradesh 139.1 16 36 13 2.3 98 5.1 19 West Bengal 68.1 8 25 8 1.6 64 3.2 19 INDIA 8C3 100 29 10 79 79 19 Figures may not add exactly to totals, due to rounding 'Note that major states make up about 95 percent of the total of population of India: thus percentages wIll not add to 100 2Age at Effective Marriage means mean age at consummation of marriage Sources: Population Totals: 1991 census data. Crude Birth Rates. Crude Death Rates. Rates of Natural Increase. Total Fertilitv Rates. Infant Mortality Rates. Aneat Effective Marria&e: Provisional data from the sample Registration System 47 AnL I Table A: 1:2: Key Family Welfare Indicators for All India and Major States State CPR Imm. Ratese Attended Deliveries 1+ Measles 1993 1992 1992 1990 Major States Andhra Pradesh 45 52 Assam 25 27 Bihar 24 25 Gujarat 55 56 Haryana 53 88-100 76-93 82 Karnataka 52 62 Kerala 37 96 Madhya Pradesh 53 77-83 30-54 25 Maharashtra 38 96-98 71-76 48 Orissa 71 81-82 42-54 25 Punjab 29 90 Rajasthan 54 22 Tamil Nadu 54 100-100 93-93 73 Uttar Pradesh 33 29 West Bengal 34 38 INDA 43 4 tInm. Rate brniu aiton coveage aes 1 + Percent of Chdr Under Two Years having rceived at least one dose of any vaccine Measles = Percent of Children Under Two Years having received measles vaccination (which i6 one of dte last to be given) Note: The coverage survey covered only 2 randoly-selected districts in Haryana. Madhya Pradesh and Otissa, I district plus Boayty dq in Mahaashim and I district plus Madras city in Tamil Nadu. Figures given are the 2 district/city averages obtained in each sate. Atended Deliveries - Percent of Deliveries attended by Trained Medical or Pamedical Pasonnel (i.e. doctors. turses, ANMs LHVs, staimd TBAs) Sources: 2Attended Deliveries: provbional data from the Samiplc Registration System. Contraceotive Prvalen R data compiled by MOHFW from State reponl. h_munisation Rate: covrage asrvey of Auigst/September 1992 by MOHFW and national and international expehb in h sats of Haryana, Orissa, Mahazrshtra, Tanil Nadu, MPadhya Nads 48 naexl1 TABLES PROVIDED) BY M011FW The tables presented in this Anmex have bem supplied by the MInistry of Health anW Faily elfare and are rqxrdiced as received. They are presented for information, and their inclusion here doe not leply that the World Sank has critically revieved or accepted the data and estimates contained in thaeL 1BLE- 1 POPULATIO 6ROUTH. CRUDE BIRTH S DEATH RATES AND SEX RATIO - INDIA 1901-1991 Year Population Percentage Average Crude Crude Sex Ratio (in million) Decadal annual Birth Death (Mates per variation exponentiaL Rate Rate 1000 growth rate Females) (percent) 1901 238.4 - 1029 1911 252.1 5.75 0.56 49.2 42.6 1037 1921 251.3 -0.31 -0.03 8.1 47.2 1047 1931 279.0 11.00 1.04 46.4 36.3 1053 1941 318.7 14.22 1.33 45.2 31.2 1058 1951 361.1 13.31 1.25 39.9 27.4 1057 1961 439.2 21.51 1.95 41.7 22.8 1063 1971 548.2 24.80 2.20 41.2 19.0 1075 1981 683.3 24.66 2.22 37.2 15.0 1071 1991 846.3 23.56 2.14 NA NA 1079 Source Registrar General of India, Census figures. Sex Ratio 1070 -.--------.-------------------------I----------------- 1070~~~~~~~~~- - -- - - - - . .. ......... ..................... . ..... . 1060.------------... 1060 ------------- . ............. ........................................ ... 1030 ......... ......... ... ........................ ............. ... ......... ... ... ..... 1010 -- - -- - -- - - -- - -- - - -- - -- - - --------- --------- --------- --------- --------- -------- 100. 1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 Year 49 Annex 1 TMBLE 2 MUE BIRTH AND WEATH RATES M RURAL AND RBA AREAS, 1980-92 Crude Birth Rate Crude Death Rate Year Rural Urban Combined Rural Urban Combined 19a0-8 35.4 27.6 33.8 13.6 7.7 12.3 1981-83 35.4 27.8 33.8 13.3 7.7 12.1 1982-84 35.3 28.6 33.8 13.3 8.0 12.1 1983-85 35.0 28.6 33.6 13.3 8.1 12.1 1984-86 34.6 28.2 33.2 13.0 8.0 11.8 1985-87 34.1 27.5 32.6 12.4 7.6 11.3 1986-88 33.6 26.9 32.1 12.0 7.6 11.0 198?-89 33.0 26.3 31.5 11.7 7.4 10.7 1988-90 32.3 25.4 30.8 11.2 7.2 10.3 1989.91 31.6 24.7 30.1 10.7 7.1 9.9 1992 30.7 23.1 29.0 10.8 7.0 10.0 Source : Registrar General, India,; Sampte Registration System (SRS) 1971-92 CBRJCDR & RNI SO.O 0:i -- ................................... .-.--........................... .................. 45.0. ........................................ 40.0.-------- 35.0..-- CBR ............................. C 30.0 -. -------- ..... ........ ... .. . ..... ... ..*CBR 30.0 .. . ......... i25.0 . ... ..... . -El1----- CD R 20.0. ........................ 25.0 .-. . .. . .-.........-.------------- URNI 10.0 .,-.-.-''-- .-.------------ S.O . .... -------- .. ....... .......................... .. .. 0.0 . ; . , i 1911 1921 1931 1941 1951 1961 1971 1981 Year Page 1 50 Apnn I TAILE 3 IIIFUT ORTALIUT TES, 1971-92 Infant Mortality Rate Year Rural Urban Combined 1971 138 82 129 1972 150 85 139 1973 143 89 134 1974 136 74 126 1975 151 84 140 1976 139 80 129 1977 140 81 130 1978 137 74 127 1979 130 72 120 1980 124 65 114 1981 119 62 110 1982 114 65 105 1983 114 66 105 1984 113 66 104 1985 107 59 97 1986 105 62 9 1987 104 61 95 1988 102 62 94 1989 98 58 91 1990 86 so 80 1991 87 53 80 1992 85 53 1 79 Source Registrar Genral, India, SRS 1971-92 Infmt Motaity Rates 140. 120- too I---------.....------------------ " '''''''' ----------------- 60 --------------------------------------------------------------------------------------------------------- 40 .....--.....................------------...................................................................... 20. 60. 71 73 75 77 79 81 83 85 87 89 91 year 51 Annxl TABLE 4 EXPECTATION OF LIFE AT SIRTH 1901-1988 Expectation of tife at birth Year xales Females 1901-10 22.6 23.3 1911-20 19.4 20.9 1921-30 26.9 26.6 1931-40 32.1 31.4 1941-50 32.4 31.7 1951-60 41.9 40.6 1961-70 46.4 44.7 1970-75 50.5 49.0 1976-80 52.5 52.1 1981-85 55.4 55.7 1986-88 57.0 57.4 Scuree: Registrar Geeralt India; Census estimates until 1970 and for period 1970-75, 1976-80 accessionaL Papers SRS 1989; 1981-88 Finat Poputation Totals 1991 - Paper-2 of 1992 Life Expec 60 ---------------------------------------------- --------------------------------- ------------- SO -- -- -- -- -- -- -- -- -- - ---- -- -- -- -- -- -- -- - ............. ........... .... 40 -- - - - - - - - - - -- - - - - - - - - - .................... I _ r *~~~~~~~~ Males 30 ~ ---------- .................. ... 20 . ............................................................................ 0. 1901 1921 1941 1961 1975 1986 Year 52 Annex t TABLE 5 PERCENTAGE DISTRIWI ION OF POPULATION BY AGE AlD SEX, INDIA. 1951-90 Period 0-14 | 15-49 50+ Male Female Male Female Mate Female 1951 38.2 38.6 49.7 49.1 12.1 12.2 1961 40.9 41.1 47.2 47.1 11.8 11.7 1971 41.7 42.2 45.8 46.0 12.3 11.8 1981 39.6 39.8 47.7 47.7 12.7 12.5 1990 37.1 36.6 50.4 50.3 12.5 13.1 Source Registrar General, India, Census Publications, SRS, 1990 Mean Age at Effective Mariage Aum~~~~~~~g WR# _ Bii1i _ 1| §l g1 _ |_ 1 E|| 3 U __ 1I ! s!hI- Tmd - -Na &|| l Pdn b_:|i i - _ Ub'_= iili . _l l s _ P SS 4 Ib 164 1 17 19 20 21 22 23| M-_ __l 1|1| | | | t 3Age 53 Ann I TABLE 6 NEAM AGE AT EFFECTIVE MARRIALE, INDIA AND mAJOR STATES, 1991 India/Major Combined Rural Urban States India 19.5 19.2 20.6 Andhre Pradesh 18.2 17.9 19.2 Assam 20.5 20.3 22.0 Bihar 18.8 18.6 19.6 Gujarat 20.2 20.1 20.7 Haryana 19.2 18.9 20.3 Karnataka 19.4 19.1 20.3 Kerata 22.0 22.0 22.2 Nadhya Pradesh 18.6 18.3 20.2 Maharastra 18.9 18.4 20.4 Orissa 19.8 19.7 20.7 Punjab 20.4 20.3 20.8 Rajasthan 17.9 17.8 18.7 Tamit Nadu 20.3 20.1 20.7 Uttar Pradesh 19.1 18.8 20.7 West Bengal 19.3 18.9 21.1 Source : Registrar General, India; SRS 1991 TABLE 7 AGE SPECIFIC FERTILITY RATES AND AlE SPECIFIC MARITAL FERTILITY RATES FOR INDIA 11984 & 1991 (PER 1000 MOM) Rural Urban Age Croup I 1984 1991 1984 1991 ASFR ASMFR ASFR ASMFR ASFR ASMFR ASFR ASMFR 15-19 93 225 85 238 58 289 46 284 20-24 267 318 245 309 195 323 201 316 25-29 246 263 202 220 187 228 159 183 30-34 175 185 129 137 118 124 82 88 35-39 107 115 76 82 60 65 37 41 40-44 53 60 35 40 25 R6 15 17 45-49 25 30 14 17 9 11 5 6 Source Registrar General, India, SRS Publications for respective years. 54 ARM l ASFR (Utban) 150-1 202 252 303 3-3 404 4-4 so- 0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age Group of Women ASFR(Rr) 300- 250- ,1i 4 too 15-19 20-24 25-29 30-34 35-39 4044 45S49 Age Group of Womnen 55 AnnexI TAKLE 8 ToTAL FEWTILIII ATES, INDIA, 1971-91 Totat Fertitity Rate Vwr Ruwal Urban Combined 199Z 5.4 4.3 5.2 1s9 5.2 3.? 4.9 1974 5.2 3.7 4.9 1975 5.2 3.7 4.9 1976 5.0 3.6 4.7 1977 4.8 3.4 4.5 197 4.8 3.4 4.5 1979 4.? 3.4 4.4 1960 4.7 3.4 4.4 1961 4.8 3.3 4.5 1962 4.9 3.4 4.5 19J3 4.9 3.4 4.5 19S4 4.8 3.5 4.5 1985 4.6 3.3 4.3 1986 4.5 3.1 4.2 1987 4.4 3.2 4.1 1988 4.3 3.1 4.0 19J9 4.2 2.8 3.9 1990 4.1 2.8 3.8 1991 3.9 2.7 3.6 Sume : Registrw Gnrrl, India; SRS CPR vs. TR 50. . ........................ 30.0 ;:---------------------------------------..................... 40.0 ................. 20.0 ... ,CPR.j C _ * ~~~~~~~~~~~~TFR (xlO) 10.0. 72 74 76 78 80 82 84 86 88 90 Yeaw 56 Amex I TP1E 9 IT66N E SISTEIWTIWI OF LIVE StIRTTS BY ORDER OF BIRTH 11N, 1972-19" Ofder of Live 1972 1984 1991 BI rth Rurat Urban Rurat Urban Rurat Urban 1 19.9 21.6 26.2 29.4 30.6 34.6 2 17.4 18.2 21.5 24.0 25.4 27.9 3 1S.7 16.2 17.7 17.9 18.8 17.3 4 13.6 14.4 12.9 11.4 25.2 20.2 5+ .2 29.5 21.6 17.2 Total 10.0 100.0 100.0 100.0 100.0 100.0 Soure : Registrar Gerat, India; Special Survey Report for 1972 and 1984; SRS 1990 % Distribuio of Birfts by Order (MRAN) 4S ...... .............................. .......... I 43* .. ............ ¢ 3 2 40 . .... ... ....... ............... 30 - - 4 + -l.- 2S3. 20 g : : ---~~~---------------- ------------------------- - t 15;........................................................................... 0. 1972 1984 1991 Year 57 Annex I er Rural Dlstributlon of Births !zJ O,rder 1972 19.9 1.4 15.7 4 1984 20.2J 21.5 17.7 34.5 19911- 30.6 25.4 18.8 25.2 % Distribution of Births by Orde (RUR.A L 45 ------ -------- ---- - - - - -- - - - - -- - - - - -- - - - - 40 ~~~- 1 .. .... ..O4 35.~~~~~~~~~~~~~~~~~1 45 - ............... ....... ............. 30.-~~~~~~~~~~~~~~~~~~ 40 - - - - - - - --................. i ::_ 5..2 .. 30 15 I---- ------------------------------- 10 ... .....---....................... .......................................... - 0 5 ------------------------------------I---------------------------------I--------- 1972 1984 1991 Year 58 Annex I TA*E 10 D0STIBWTrlG OF MIu NAVORS 11 ISIA By IUSTRIAL CATEA, 1991 Industrial No of workers Percent of Category (in mitlion) Workers Total Hale Femalo Totat Male Femate I 107.1 85.6 21.5 38.41 39.63 34.22 II 73.7 45.5 28.3 26.44 21.05 44.93 III 5.3 4.3 1.0 1.90 1.99 1.60 IV 1.7 1.5 0.2 0.62 0.70 0.34 V(G) 6.7 4.5 2.2 2.42 2.09 3.53 V(b) 21.6 19.2 2.4 7.76 8.89 3.88 VI 5.4 5.0 0.4 1.95 2.32 0.66 Vlt 20.8 19.4 1.4 7.46 8.98 2.26 VlIl 7.8 7.6 0.2 2.81 3.54 0.32 Ix 28.5 23.3 5.2 10.23 10.80 8.26 ALL 278.9 216.0 62.9 100.00 100.00 100.00 Iniintrial Catumories I cutivators It Agrialuttrat laboers III Livestock, forestry, fishing,hunting,and ptantations.orchards and attied activities IV Nining an quwrying V(a) NXPawcturin., prcessing. servicin and repairs in hbsehold indatry Vib) Nmfaacturing, processing, servicing and repairs in other tham hausthold istry VI Co uctions VII Trade ad c mrc VIII Trrauprt, storage aid caomicatiors IX Others srvices Sorwc: Registrar 6neral, lIndfa, Final Poputation fotats Series 1; Paper - 2 of 1992 TAIE 11 TM OF URSAUISATION l I*IA. 1901-91 Cemma Muwer of Urban Urban Decennial Annual Year Urban Agg- population Population growth Exponential lomeration million as X of rate of growth rate Towns Total urban (M) population Poputation (%) 1901 1 827 25.9 10.84 1911 1 815 25.9 10.21' 0.4 0.03 1921 1 949 28.1 11.18 8.3 0.79 1931 2 072 33.5 11.99 19.1 1.75 1941 2 250 44.2 13.86 32.0 2.77 1951 2 843 62.4 17.29 41.4 3.47 1961 2 365 78.9 17.97 26.4 2.34 1971 2 590 109.1 19.91 38.2 3.21 1981 3 378 159.5 23.34 46.1 3.83 1991 3 768 217.6 25.72 36.5 3.09 Source : Registrar General, India; Final Popualtion Totals, Series- I Paper-I of 1992 Vol. It 59 Annex 1 TABLE 12 PERCENT DISTRIWTION OF INTERNAL NIGRANTS OF EACH SEX IN DIFFERENT MIGRATION STREAMS EASED ON PLACE OF BIRTH AND PLACE OF ENUMERATION.INDIA. 1961-81 Migration Stream Year Sex Rural- Rural- Urban- Urban Total to- to- to- to- Rural Urban Urban Rural 1961 Total 73.7 14.6 8.1 3.6 100 Mate 56.7 25.7 13.0 4.6 100 Female 81.3 9.7 5.8 3.2 100 1971 Total 70.3 15.3 8.9 5.5 100 Male 53.5 26.0 14.0 6.5 100 Female 77.8 10.5 6.7 5.0 100 1981 Total 65.2 17.6 11.2 6.0 100 Male 45.6 30.0 17.4 7.0 100 Female 73.3 12.5 8.7 5.5 100 Source : Premi, M.K., t981 2; Census of India 1981, 1984 TABLE 13 FAMILY PLUNING ACCEPTORS BY METHODS, INDIA, 1971-93 (in thousands) Year Steril- IUD Eq. CC Eq. OP Totat Eq. zations insert- users users Steril- ions zations 1970-71 1330 476 1963 3769 1598 1971-72 2187 488 2354 5029 2481 1972-73 3122 355 2398 5875 3373 1973-74 942 372 3010 4324 1233 1974-75 1354 433 2521 4308 1638 1975-76 2669 607 3495 32 6804 3068 1976-77 8261 581 3634 58 12534 8663 1977-78 949 326 3175 78 4528 1242 1978-79 1484 552 3387 82 5505 1865 1979-80 1778 635 2987 82 5482 2165 1980-81 2053 628 3718 91 6490 2479 1981-82 2792 751 4439 120 8102 3302 1982-83 3983 1097 5765 183 11028 4689 1983-84 4532 2134 7661 729 15056 5750 1984-85 4085 2562 8505 1290 16442 5555 1985-86 4902 3274 9387 1358 18920 6665 1986-87 5043 3935 9825 1829 20632 7104 1987-88 4940 4356 11342 2064 22702 7251 1988-89 4678 4851 12422 2416 24368 7254 1989-90 4188 4942 14159 279S 26082 6932 1990-91 4126 5370 14735 3125 27356 7082 1991-92 4090 4385 13873 3276 25624 6686 1992-93 4242 4683 14910 3020 26855 6967 Eq. CC Users Equivalent Conventional Contraceptive Users Eq. OP Users Equivalent Oral Pills Users Source : Goverrument of India, Family Welfare Programme in India, Year Book 1990-91; Ministry of Health & Family Welfare. Also Quarterly Bulletin on Family Welfare Statistics 1992-93 60 Annex 1 TABLE 14 COUPtE PROTECTIGI RATES, INDIA, 1971-93 (percent) Couple Protection Rate by Methods Year Steriliz- IUD Others Total ation 1971 8.0 1.4 j 1.0 10.4 1972 9.7 1.3 1.2 12.2 1973 12.2 1.1 1.2 14.5 1974 12.2 1.0 1.5 14.? 1975 12.6 1.0 1.2 14.7 1976 14.2 1.0 1.? 17.0 1977 20.7 1.1 1.7 23.5 1978 20.1 0.9 1.5 22.5 1979 19.9 0.9 1.6 22.4 1980 19.9 1.0 1.4 22.3 1981 20.1 1.0 1.7 22.8 1982 20.7 1.1 2.0 23.7 1983 22.0 1.4 2.5 25.9 1984 23.7 2.2 3.7 29.5 1985 24.9 2.9 4.4 32.1 1986 26.5 3.7 4.7 34.9 1987 27.9 4.5 5.1 37.5 1988 29.0 5.2 5.7 39.9 1989 29.8 5.9 6.2 41.9 1990 30.1 6.3 6.9 43.3 1991 30.3 6.7 7.2 44.A 1992 30.3 6.3 6.9 43.5 1993 30.2 6.3 6.9 43.4 Source Government of India, Family Welfare Programme in India, Year Book 1990-91; Ministry of Health & Family Welfare. Also Quarterly Bulletin on Family Welfare Statistics 1992-93 ~~ ~Sterilization CPR By Methods 45.0 -- ---- 40.0 - Other -------------------------------------------------------- 35.0 O - Total ---------------------------- ----------- --------- 30.0 . ---------------- 25.0 -- - - - - - - - - - - - - -- - - - - - - - - - - - - --- -------- -- -------------------. .. 20.0 -- - - - - - - - - - - - -----------------------------------------------. 1 5.0 - --- -- -- -- -- -- --- -- -- -- -- -- --- -- -- -- -- -- --- -- -- -- -- -- -- 5.0 - ------------- .............-------.------- --- ---- -------------------- 0.00 1 14**E= I 1 1- 1 1 1 71 73 75 77 79 81 83 85 87 89 91 93 Year 61 Anx TAKLE Is FIVE tEM PLANS : TOTAL CUTLAY AND FANILY WELFARE OUTLAt (IN NILLION RUPEES) Plan Total Outlay for (3) as X Period Outtay FW Prog. of (2) (1) (2) (3) (4) First (1951-56) 19 600 1 N Second (19f6-61) 46 720 50 0.1 Third (1961-66) 85 765 249 0.3 Annual Plan (1966-69) 66 254 704 1.1 Fourth (1969-74) 157 788 2 780 1.8 Fifth (1974-79) 394 262 4 918 1.2 Amusat Plan (1979-80) 121 765 1 185 1.0 Sixth (1980-85) 1 092 917 13 870 1.3 Seventh (1985-90) 2 187 296 31 208 1.4 Aiual Plan (1990-91) 583 694 7 849 1.3 Annual Plan (1991-92) 647 512 7 490 1.2 Eighth (1992-97) 41 341 000 65 000 1.4 Source : Ministry of Health & Family weLfare, Govt. of India TABKE 16 P-OJECTW PFOULATICE AND LAUo FORCE 1996-2006 Year Population Growth Rate _ Labour |Growth (in millions) (per cent) Force Rate(X) 1996 924 1.8 420 2001 1003 1.6 471 2.29 2006 1082 1.5 522 2.06 Source: Planning Commfssion, 1989 62 Annex 1 TABLE 17(1) POPULATIOU STATISTICS FOR INDIA.STATES AMD UNION TERRITORIES India/States or Population Annual Union Territories (in Q000) Exponential 1991 Growth RateCX) (1981-91) INDIA 846 303 2.14 STATES ANDHRA PRADESH 66 508 2.17 ARUNACHAL PRADESH 865 3.14 ASSAM 22 414 2.17 SIHAR 86 374 2.11 GOA 1170 1.49 GUJARAT 41 310 1.92 HARYANA 16 464 2.42 HINACHAL PRADESH 5 171 1.89 JAMUW & KASHMIR 7 719 2.54 KARNATAKA 44 977 1.92 KERALA 29 098 1.34 MADHYA PRADESH 66 181 2.38 MAHARASTRA 78 937 2.29 NANIPUR 1 837 2.57 MEGHALATA 1 775 2.84 NIZORAM 690 3.34 NAGALAND 1 209 4.45 ORISSA 31 660 1.83 PUNJAB 20 282 1.89 RAJASTHAN 44 006 2.50 SIKKIN 406 2.51 TAMIL NADU 55 859 1.43 TRIPURA 2 757 2.95 UTTAR PRADESH 139 112 2.27 WEST BENGAL 68 078 2.21 WIoC TERRITORIES A & N ISLANDS 281 3.97 CHANDIGARH 642 3.52 D & N. HAVELI 138 2.89 DAMAN & DIU 102 2.52 DELHI 9 421 4.15 LAKSHDWEEP 52 2.51 PONDICHERRY 808 2.90 Source : Registrar General, India; Census 1991 63 Ann 1 TABLE 17(Ui) India/States or Literacy Rate Work Participatfon Rate Union Territories (total workers as per. cent oftotal population Person Male Female Person Male Female INDIA 52.2 64.1 39.3 37.5 51.6 22.3 ANDHRA PRADESH 44.1 55.1 32.7 45.1 55.5 34.3 ARUNACHAL PRADESH 41.6 51.5 29.7 46.2 53.8 37.5 ASSA 52.9 61.9 43.0 36.1 49.5 21.2 BIHAR 38.5 52.5 22.9 32.2 47.9 14.9 GOA 75.5 83.6 67.1 35.3 49.6 21.0 GUJARAT 61.3 73.1 48.6 40.2 53.6 26.0 HARYANA 55.9 69.1 40.5 31.0 48.5 10.8 HINACHAL PRADESH 63.9 75.4 52.1 42.8 50.6 34.8 J.1*MU & KASHMIR N.A. N.A. N.A. N.A. N.A. N.A. KARNATAKA 56.0 67.3 44.3 42.0 54.1 29.4 KERALA 89.8 93.6 86.2 31.4 47.6 15.9 MADNrA PRADESH 44.2 58.4 28.9 42.8 52.3 32.7 NAHARASTRA 64.9 76.6 52.3 43.0 52.2 33.1 ANIPUR 59.9 71.6 47.6 42.2 45.3 39.0 MEGHALAYA 49.1 53.1 44.9 42.7 50.1 34.9 NIZORAN 82.3 85.6 78.6 48.9 53.9 43.5 NAGALAND 61.7 67.6 54.8 42.7 46.9 38.0 ORRiSSA 49.1 63.1 34.7 37.5 53.8 20.8 PUNJAB 58.5 65.7 50.4 30.9 54.2 4.4 RAJASTHAN 38.6 55.0 20.4 38.9 49.3 27.4 SIKKIN 56.9 65.7 46.7 41.5 51.3 30.4 TAMIL NADU 62.7 73.8 51.3 43.3 56.4 29.9 TRIPURA 60.4 70.6 49.7 31.1 47.6 13.8 UTTAR PRADESH 41.1 55.7 25.3 32.2 49.7 12.3 WEST BENGAL 57.7 67.8 46.6 32.2 51.4 11.3 UNIN TERITORIES A & N ISLANDS 73.0 79.0 65.5 35.2 53.3 13.1 CHANDIGARH 77.8 82.0 72.3 34.9 54.3 10.4 DADRA & NAGAR HAVELI 40.7 53.6 27.0 53.3 57.5 48.8 OAMAN & DIU 71.2 82.7 59.4 37.6 51.6 23.2 DELHI 75.3 82.0 67.0 31.6 51.7 7.4 LAKSHADIEEP 81.8 90.2 72.9 26.4 44.2 7.6 PONDICHERRY 74.7 83.7 65.6 33.1 50.6 15.2 Source : Registrar General, India; Census 1991 64 hiDI Table 17(iif) Life Expectancy St. India/ States/ at birth (1991-96) CPR No. Union TerritorIes C.8.R. C.D.R. (X) 1992 1992 male Female 1993 INDIA 29.0 10.0 60.6 61.7 43.4 1. Andhra Pradesh 24.1 9.1 61.4 64.5 45.3 2. Arunachal Pradesh 26.3 9.3 NA NA 11.7 3. Assam 30.6 10.3 58.7 58.5 25.2 4. Bihar 32.2 10.9 60.8 60.1 24.0 5. Goa 14.5 7.3 NA NA 33.7 6. Gujarat 27.9 9.1 60.9 62.7 54.5 7. Haryana 31.9 8.6 65.2 64.2 52.7 8. Himachal Pradesh 27.9 8.8 NA NA 55.2 9. Jsmu & Kashmr NA NA NA NA 19.3 10. Karmataka 26.2 8.5 64.2 65.3 48.1 11. Kerala 17.5 6.3 68.6 75.0 52.3 12. Nedhys Pradesh 34.4 12.7 59.2 58.0 37.4 13. Naharashtra 25.1 7.9 64.0 65.9 53.2 14. Nanipur 19.4 5.5 NA NA 23.0 15. Neghataya 29.8 8.5 NA NA 4.4 16. Mizoram NA NA NA NA 43.5 17. Nagaland 19.2 3.6 NA NA 6.4 18. Orissa 27.8 11.7 60.1 58.4 38.1 19. Punjab 27.1 8.2 66.6 66.5 70.9 20. Rajasthan 34.7 10.4 60.5 61.3 29.0 21. Sikkim 20.9 5.8 NA NA 21.9 22. Tamil Made 20.7 8.4 62.3 63.1 54.4 23. Tripura 23.1 7.6 NA NA 17.4 24. Utter Pradesh 36.2 12.8 57.1 52.8 33.2 25. West 8engal 24.6 8.3 61.9 61.9 33.5 UNION TERRITORIES 26. A&N Islands 20.0 5.2 NA NA 44.1 27. Chandigarh 15.4 3.3 NA NA 42.7 28. Dadra & Nagar Havel 40.0 11.5 NA NA 44.1 29. Damn & Diu 24.8 7.5 NA NA 33.2 30. Delhi 26.0 6.5 NA NA 43.1 31. Lakshadweep 24.4 4.2 NA NA 7.9 32. Pondicherry 19.5 6.7 NA NA 62.2 Source : Registrar General, India; SRS Estimates. 65 eO Female & Male Kerala - ; Punjab -- Harn ' __i _''' - _ Kamnata __ i Tamil Nadu WagBenga Oo Andbm PraPdh eOf Bthar~~ __ _., O R fa& _ .'__! Asiam n I Uta Fa eh -_. _ _ _ _ _ ,___ __ _ .__ _ _ 45.0 50.0 55.0 60.0 65.0 70.0 75.0 Years Couple Protecion Rate Punjab_ _ ...._ Tamil Nadu. HMana _ Karat _ __ _ _ Andhra Pradesh~ 11 _ _ West Bengal _ _ _ sP UttarPbs i ll_ Rajasth __ Assam__ Bihar s__ 1 - / f 0.0 10.0 20.0 30.o 40.0 SO.O 60.0 70.0 80.0 Percent 66 A-nnex I Difference between eOfemale and eOmale in Years Kerala_ Andhra Pradesh_ Maharashtra Gujara.i Tamil NaduJ West Bna Punjab. Bihar 1 Madhya Pradesh r Ornssa_ Uttar Pradesh. p Ilnfit Mortali Rate Madhya Pradesh- Bihar. Tamil Nad Ptuz _ _ Kaa .a 0 20 40 60 so 100 120 Deathstl,000 Live Births 67 Annex 1 TABLE 17 tiv) India/States Total Fertility Rate,1991 Infant Mortality Rate,1992 (per woman) (per 1000 live births) Combined Rural Urban Combined Rural Urban INDIA 3.6 3.9 2.7 79 85 53 ANDHRA PRADESH 3.0 3.1 2.5 71 78 42 ASSAM 3.5 3.6 2.1 76 78 50 BIHAR 4.4 4.5 3.5 72 74 49 GUJARAT 3.1 3.2 2.9 67 71 54 HARYANA 4.0 4.3 3.0 75 79 55 KARNATAKA 3.1 3.3 2.5 73 82 41 KERALA 1.8 1.8 1.7 17 17 13 MADHYA PRADESH 4.6 4.9 3.4 104 109 74 MAHARASTRA 3.0 3.4 2.5 59 67 40 ORISSA 3.3 3.4 2.3 1 114 I 117 80 PUNJAB 3.1 3.2 2.8 56 60 41 RAJASTHAN 4.6 4.9 3.7 89 93 65 TAMIL NADU 2.2 2.3 2.0 58 67 40 UTTAR PRADESH 5.1 5.4 3.7 98 102 78 WEST BENGAL 3.2 3.6 2.1 64 70 38 Note: SRS data on these indicators are not availabLe for smalLer States and Union Territories. Source : Registrar Generalt India; Censu 1991 Total Fertility Rate Uttar Pradesh Rajasthan __ Madlha Pradesh Bibar HaAnaa West Bna Guljarat Z Andhra Prha _ _ Tamil Nadu _ _ Kerala 0.0 1.0 2.0 3.0 4.0 5.0 6.0 Aveage Live Biths(Woman 68 Annex 1 Population Uttar Pradesh .l Biha ! .1 West Bengal Andhra Pradesh _ Madhya Pradesh - i Tamil Nadu 9 Karn=atk __ RajashnE Gujarat } I Orissa _ Kerala Punjab_ H aryana X , 0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 Milions Rate of Natural Increase Rajasthan __ Utlar Pradesh _ Madhya Pradesh Punjab _ ___ Gujarat_ Karnataka _|1 Maharashtra ___ WestBengal_ Andhra Pradeshu Tamil Nadu 0.0 0.5 1.0 1.5 2.0 2.5 Percent - 69 - Annex-2 Outline of thy Action Plan for Revamping the Family Welfare Program And Steps Taken to Implement It To Date 1. The India Family Welfare Program, though very successful in many ways and responsible for significant declines in fertility and childhood mortality, has not realised its full potential. In particular, fertility and contraceptive prevalence levels have in recent years remained at a plateau still too high to reduce population growth in the face of continuing declines in mortality. Many primary health care issues also remain difficult to resolve, in particular safe motherhood care and child health interventions such as ORT, ARI treatment, vitamin A supplementation and neonatal tetanus prevention. 2. Recognising these problems, MOHFW issued an "Action Plan for Revamping the Family Welfare Program" in early 1992. This Plan identifies major policy issues in the program and lays down strategies for addressing them. Its twelve principal components are as follows: (1) National Consensus and Effo4b: generation of strong commitment and contribution to the program at national and state level, including among political, religious and other opinion leaders. (2) bImrovement of the Quality and Outreach of Services: this includes several subcomponents, as follows; - consolidation of existing infrastructure - creating and strengthening new infrastructure in remote and tribal areas and urban slums - developing and using new integrated training modules which would include communication skills, and instillation of proper values and motivation - emphasis on setting up adequate maintenance systems for buildings, equipment and vehicles - considerable improvement of supervision, with a focus on problem solving and enhancement of provider performance - construction of new PHC and sub-centre buildings under Area projects and State Minimum Needs Programs - improvement of living and working conditions for field workers such as ANMs - appointment at the State level of a carefully-selected separate Secretary/Special Secretary-level officer to be responsible for the Family Welfare program, with a stable tenure of 2-3 years. (3) Specal Strategy for 9 Districts: a disaggregated approach to program strateg (as exemplified in on-going donor-assisted Area projects), with - 70 - Annex 2 particular emphasis on a strategy for the 90 districts with the worst demographic indicators in the four worst States (UP, MP, Rjasthan and Bihar) including: micro-level planning by the four States to identify needs in the districts for the purposes of additional resource allocation filling of all posts in the districts with good-quality staff priority to these districts for sub-centre construction under Area projects intensive training of service providers involvement of minority community leaders in family planning IEC programs promoting a variety of methods piloting of link worker schemes to improve outreach communications, together with efforts to cover all districts with ICDS programs that are well linked to the Family Welfare program full involvement of the District Collector in program coordination/supervision in these districts (4) Package of Incentives/Disincentives: modification of the current system of targets and incentives for adoption of sterilisation and the IUD to make it more flexible and effective, by: removing overall 'tyranny of targets", though retaining micro-level planning targets for monitoring purposes providing greater flexibility to the States and covering younger couples through spacing methods (details of resource devolution to be worked out by a committee of nominated members) developing a package of disincentives for GOI employees, which States and large employers may also adopt, to promote the small-family norm discontinuing fees for service providers who motivate (in order to broaden method mix) scrapping the States Award Scheme for good (to discourage unhealthy competition and falsification of figures) developing an innovative package of incentives/disincentives with emphasis on community-based incentives (linked to benefits from government development plans) and social security measures. (5) Promotion of Different Contraceptive Methods/Devices: broadening of the contraceptive method mix from primarily sterilisation for older couples with completed families to enhanced coverage of younger couples by a variety of spacing methods, through: good follow-up services for IUD acceptors to reduce discontinuation rdtes better distribution systems for conventional contraceptives and pills in rural -71 - Anne -2 and slum areas through strengthening of social marketing and launching of community-based distribution schemes improved quality of contraceptives, notably the replacement of dry by lubricated condoms improved production of pills introduction of new methods such as Norplant and injectables popularisation of no-scalpel vasectomy through a training program for providers fertility research programs, with particular focus on vaccines, anti-fertility drugs and indigenous medicine system contraceptives/abortifacients (6) UIP and MCH Programs: special attention to parts of these programs that are still lagging behind, including: special attention to areas where UIP coverage is sfill low investigation of all cases reporting UIP coverage over 100 percent (to avoid unwarranted over-complacency) concentration on improvement of UIP service quality and documentation of disease reduction, including initiation of active surveillance in low-incidence areas, setting up of a network of polio testing labs to test increased numbers of field vaccine samples, and prompt investigation of adverse vaccine reactions improvement of UIP program management by filling all supervisory posts created so far takdng over of cold chain maintenance by the States more vigorous promotion of ORT through training of providers and health education of the public, particularly mothers implementation of the CSSM project (with particular mention of Vitamin a and iron supplementation, ARI program expansion, strengthening of infrastructure and dai training) (7) UrbanA Schemes: improvement of Family Welfare services in urban slums, by: opeaionalising urban revamping schemes to strengthen infrastructure and services with funding support from the Central budget and donor agencies enhancing involvement of voluntary agencies in these areas monitoring and superv.sing urban facilities strictly, and if necessary closing down or moving those not performing well developing suitable coordinating mechanisms to ensure urban facilities function in an integrated manner (8) VI Ia Health Guide Scheme: salvage of as much as possible of the scheme under its current problems of implementation, including the - 72 - Annex 2 following steps: follow-up of pending court cases to obtain a prompt decision utilisation of existing VHGs by States to the extent possible, perhaps primarily as motivators and depot-holders for contraceptives, ORS, iron tablets etc. further in-depth examination of how to revitalise, or alternatively disband, the scheme (9) Continuation of ANM/LHV Training Schools: rationalisation of ANM training schools in the face of declining needs for ANMs and under- recruitment of male multi-purpose health workers, as follows: thorough review of existing ANM/LHV training infrastructure in each state to ensure proper and effective utilisation, with gradual closure of schools without buildings or under PVO management and use of remaining schools for integrated training modules and in-service training creation hy States of MPW(M) posts to fill existing gaps and utilise training infrastructure development of networking and coordination between training infrastructures at different levels to ensure uniformity of modules and non-duplication of efforts (10) Information. Education and Communication: revitalisation of IEC programs through a new IEC strategy with the foDowing elements: IEC messages which: associate Family Welfare with planned parenthood, not just adoption of contraception; emphasize quality of life issues and the merits of the Family Welfare program; and are balanced in such a way as not to offend cultural sensitivities strengthening of Mahila Swasthya Sangh schemes if pilots are successful, to promote community involvement special development of traditional art forms, field publicity and interpersonal communication, in order to reach the 40 percent of the population not currently covered by mass media decentralised IEC material production, in order to cater to regional diversity and local needs regular refresher training of IEC staff to improve motivation and managerial skls preservation of IEC funds strictly for IEC, with full realisation of the importance of IEC by the States focus on IEC for males to promote the use of condoms and vasectomy study by other States of the Rajasthan experiment of an integrated IEC bureau for all Health and Family Welfare TEC, with linkages to other relevant sectors, - 73 - Annex 2 with a view to possible replication. (11) Involvement of Non-Governmental Sector: a pro-active effort to bring in non-governmental groups systematically into the Family Welfare program, such as youth groups, panchayat leaders, PMPs, commercial/industrial organisations, trade unions, Zilla Parishads, PVOs etc., through: - identifying, recruiting, motivating and training such groups or individuals at local level - giving increased powers to State governments (which may in turn devolve them further to districts) to sanction NGO schenurs - arranging study tours for NGO workers from poorer-performing States to well-performing States, together with use of training infrastructure to train them in managerial skills - establishing a suitable central organisation to sanction and transfer funds for NGO schemes with adequate flexibility - increasing Central Budget allocations to NGO schemes, together with greater donor agency funding. (12) Intersectoral Coordination: strengthening of coordination between the Family Welfare program and other Government agencies also involved in the population control program (in the sectors of Human Resoure Development, Finance, Information & Broadcasting, Environment and Forests, Labour, Women and Child Development, Rural Development, etc.), through: - development of a suitable institutional mechanism at central level to achieve intersectoral coordination and periodic review of the population control program, such as a high-level Population Commission chaired by the Prime Minister - development of corresponding committees at State-level, chaired by the Chief Minister and involving the Chief Secretary - involvement at district level of Deputy Commissioners and Chief Executive Officers of the Zilla Parishads. Prress to Date on Implementation of the Action Plan 3. In the two years since this Acdon Plan was drawn up, much has been accomplished by GOI and the States, with important assistance from Bank lending. The 90-District strategy (component 3) is being launched under the Social Safety Net project. The CSSM oiect is addressing many of the issues and actions identified as needed in the UIP and MCH programs (component 6). The process of modifying the targe:/incentive system (component 4) has begun with the abolishing of motivating payments to providers and the decentralisation and de- - 74 - Annex 2 emphasising of sterilisation targets, which now are set by states rather than MOHFW, and on the basis of expected feasiwe achievement rather than needs as calculated from demographic simulations. Most of the major concerns of the quality-improvement, urban schemes, VHG, ANM-training and TEC components (2,7,8,9,10) are being addressed in the States and cities covered under Area projects, notably the Bank's Urban Slums project (IPP VIII) and this project. The involvement of NGOs (component 11) is being pursued under various Area projects, notably the Bank's IPP V (Bombay and Madras) project and Seventh Population (IPP Y II) pect and USAID's new UP project. And a high-level Population Commission has been established as a sub-committee of the National Development council, under the chairmanship of the Chief Minister of Kerala, and has begun work (components 1 and 12 on generation of commitment, intersectoral coordination and population program review). 4. There are however some reas in which progress has not been as good. The intended next step of drawing up State plans for implementing the strategies set out in the Action Plan has not gone far except under this project, thus hampering efforts to develop the full commitment and contributions from every lev& .imed at in component 1. Similarly, the effort to stabilise Family Welfare management is still no; fully underway. Nor is it likely to be possible to implement many of the recommended actions in program quality, training, IEC, urban schemes, and community link workers in States or cities which do not benefit from Area project funding. 5. Most noticeably, progress has been slow on component 5, the promotion of a wider mix of contraceptive methods with emphasis on younger couples and spacing methods. Some small advances have been made; the combined pill has been cleared for social marketing, an area for which funding is also available under the Bank's Seventh Population (IPP VII) project; injectables have been licensed for the private-sector market; trials of Norplant are underway; and some effozis have also been made to promote greater uptake of the pill and the IUD in the regular program. Overall, however, little change in the method mix has yet occurred. 75 Key Projct ludicators * proiect inOacldkt Key Indicaton 1ns2zucd4on: Infraonm on kby indbcaom should be provide bond on avaiabl izmauwi. The physil compkletio sg,a should be zeponed oan a six-nt bs. Addk_nly, any apppriae pprg=op i,di& s sh be iclded in the repot A a naysi of Sid sm should be . _ edmatti and a usented withX the sem!trt Asasm _ _Etk ________a_r-Line . Lt B8eLn .owt Bwase-n rw CBR (Da 1000) 27.5 21 28 20 33.6 2! CPR%(TOl)- 29.3 60 47 60 _ ___60 CPR X PennanentMet.tods ___ CPR % Teorn rvjMethods TotalaFertliy Rate R) _C ) IM (PerC1000) 77 SO 7 so 77 60 MUMR (ve 100.000, 40 20 60 20 SO 20 CM. (per 1000) 41.2 >10 76 Annelx3 Intennediate Indicators to be used by each State Indicator Source | Validation Realth/FW Status & Serices % Coverage Matenal Immniaions HS Monty EPI Suvevs A.KR % Coverage Children nmmunizations HMS Moiwh EPI Surveys A. R . . ~ HM % Tempowrai conraetive use HMIS hknti Surveys_ % Permanent contraceptv use HIS Mon Sureys # Children ORT Treatment Surv Base-line Sunrgys # ANM Resident Suwvey Yearlv Sample Survey % ANM Resident -slY Yely Sample Survey A. K. R # Visits/Month by ANM HMMoS MY Sample Survey 14 R % SCs with own building baseline / Cell Mid-Term __ % Institional Births HMIS Monty EC Records A % Births at FRU HMS Monthly EC Records A % Births attended by health staff H?IS Moy Sample Survey K R % Pregnant with ANC care HMIS Monthly Sample Survy % Children Vit-a Sulements A % Pregnant Women getting Iron A Prolect/PronrM Manafemtent Indictors_____ __________ % Complete proect staffing (vacant positios PMIS I Six-Monthly A. KR / person months) Personnel % and $ Project Expenditure vs. Budget (by Project Six-Monthly A. K, R component ,I.llILIV, Innovative Schemes) Budget $ allocated in SAR / Sanctioned by GOI Project Six-Monthly A. KR Budfft % FW Prgram posts filled by level/Category PMI; / Six-Monthly Sample Surveys A Pesoel _ % Coverage of available Supplies Project Six.Monthly Imrentory Review Y. R Trainina Indicators % and # MO's Trained Survey t baseline I A, 4R TrDing Six-Monthly Records % and # ANMrs Trained (by Wm of traiiing) _ A,KR % and # LHV's Trained (bv type of training) _ _ _RA.K. % and # WHP's Trained (by type of traininR) ."' A,1R 77 Annx % and # Paramedical's Trained (by type of "" A. K. R training) % Skill level by (Category of staff/Skills to be Survey / baseline / Sample Surveys I specified) Skills test I annual Management Survey Evaluations IEC Indicators __ % of items in annual TEC plan completed Project Plans Six-Monthly % of $ expended against target for materials Project Plans Six-Monthly A % EEC message awareness by targeted groups Survey Base-Line / Sample Surveys A (per [EC Plan) annual % awareness Non-Tennina! Methods Surey Base-Line I Sample Surveys A.K.R annual % awareness Small Family Nonns Survey Base-Line / Sample Surveys A,kR annual % awareness Legal age of Marriage Survey Base-line / Sample Survqs A.Y.R annual _ ~~Sunrvey_ % awareness Non-Terminial Methods Survey Base-Line / Sample Surveys A. K. R annual _ _ __ ~~~~~~~~~Survey NGOllnnovative Schemes Number of innovative schemes implemented Project annual Management Information / Monitoring Survey # NGO's participating Project annual Management Information / Monitoring Survey Estimated NGO Population Coverage Project annual Management K. R Information / Monitoring Survey Infrastructure Indicators . # & % Facilities under construction & Constiruction Six-Monthly Quality Surveys I Completed (by category, % completed) Cell / Project Independent _____________________________Information _____ $ over/under budget (by type of faicilities) Project N _ _ __ _ Information ______ % facilities commissioned and completed _ A.KLR SC's PHC's Warehouses __________. Training Institutions Boat Clinics Mobile Clinics . % facilities up£aded to new categsry A. K. R CHC to FRU Disp. to PHC __ __ =__ % facilities rehabilltatedzpigraded. ._ A.KR 78 A SC 'IIII I PHC__ _ _ _ _ _ _ _ _ _ CHC _ Training Institutions _ _ _ % faciliies fully equipped, staffed and _ A}K%R functioning PHC .FRU _ _ _ _ _ _ CHC _ L_._._ Warehouses Mobile Clinics _ _ Boat clinics 79 AnICL3 Key Project Indicators Rajasthan Pn,lec imnat indicator B_aM-Line Target CBR (per 1000) 27.5 21 CPR % (Total) 29.3 60 CPR % Permnanent Methods CPR % Temporary mehods IMR (per 1000) 77.0 50 WAR (per 100,000) 40 20 CMR (per 1000) 41.2 >10 Assm Base-line Target at Project Number to be completed ____________________ S___________ Completion wider project PHCs _ _ _ _ _ _ _ _ _ _ _ _ _ Taining Instons _ Boat Clinics .. Mobile Clinics FRU 's_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ CHC to FRU _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dip isary to PHC _ _ _. _ SC, Rehabilitated _ PHCs R i CHCs REbiliated Intermediate Indicators to be used by Asam Indcator % comple proec safi ( pos ealthFWStatus &Seres P m nhs) % Covage 4aternal I % and S Proe Expenditure vs. Budget (by % Coverage Children Immunizations c_mponentIM_V, Innovative__ ) % Temporarv conraceptive use % FW Proam sts filled bsr leveUCate % Permanent contceptv use $ alloatd in SARI Saned by (01 % ANM Resident _______ Indicators % Instituiional Births % and # M0s Trained % Births at FRU % and # ANMs Trained (by type of tiNn) % Children Vit-A Supplements % and # LHV's Trained (by type of taining) % Pregant Women getling lion % and # WHPs Trained ( type of tuaining) Pre rem Mananemt Indicators % and # Paramedicars Trained (by type of t This form to be filled in afte bs line se is completd. Th numbe to be completd in th project is swn in the SAR 80 Anizzl % ]EC message awans by targeted groups (per EC Plan) % Awarens Non-Terminal Methods % Awaens Small Famly Norms % Awareness Leg age of Marriage % Awareness Non-Terminal Methods Infrastrure Indicators # & % Facilities under construcion & Completed (by category, %c c)mleted) S over/under budget (by type of acidiiles) % facilties emmisoned and completed SCs PHC's Warehouses Training Institiiions Boat Clinics Mobile Clinics % faduities upraded to new catory CHC to FRU Disp. to PHC % facilties rehabiltted/upgraded. SC PHC DCHC X ITaniing Instittions % faclites fuUly equipped, staffed and f%dosing SC PHC FRU CHC Warehoues Mobile Clinics Boat clinics 81 Annex 3 Key Project Indicators Karmataka Project Imnact Indkators Kamataka I_ l Base-Line Target CBR (per 1000) 28 20 CPR % (Total) 47 60 CPR % Permanent Methods CPR % Temporary Methods _ IMR (per 1000) 7 50 MMR (per 100,000) 60 20 CMR (per 1000) I Pbvsical Completion Tareets Karnataka Base-line Target at Project Number to be completed Completion under project S C 's _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ PHC's Training Institutions _ _ Boat Clinics ___ ___ _____ Mobile Clinics FRUs _____ _ CHC to FRU Dispensaiy to PHC SC. Rehabilitated _ ___ PHCs Rehabilitated CHCs Rehabilitated Intermediate Indicators to be used by Kamataka Indicator $ allocated in SAR / Sanctioned by 301 Health/FW States & Services % Coverage of Available Supplies % Coverage Maternal Immunizations Trauinir Indicators % Coverage Children Immunizations % and # MO's Trained # Visits/Month by ANM % and # ANMs Trained (by type of training) % Institutional Births % and # LHVs Trained (by type of training) % Births at FRU % and # WlPs Trained (by type of training) % ANM Resident % and # PanamedicalVs Trained (by type of % Births Attended by health staff tWaining) Proiecti/Prorm Manageme Indicators % Skdl level by (Categoty of stafSkills to be % Complete projea staffing (vacant positions specified) I person months) IEC ndicators % and S Projea Expenditure vs. Budget (by % Awareness Non-Teminal Methods component I,1I,I,IV, Innovative Schemes% Awareness Small Famiy Norms 82 Ann I % Awareness Legal age of Marriage % Awareness Non-Termtil Methods NGOJlnnovative Schemes Estimated NGO Population Coverage Infrastructure Indicators # & % Facilities under construction & Completed (by categor. % competed) % facilities commissioned and completed SC's PHC's Warehouses Training Institutions Boat Clinics Mobile Clinics % facilities upzraded to new category CHC to FRU Disp. to PHC % facilities rehabilitated/upgraded. SC PHC CHC Training Institutions % facilities fully equipped, staffed and functioning SC PHC FRU CHC Warehouses Mobile Clinics Boat clinics 83 Annex 3 Key Project Indicators Assam Proiect Imnact Indicators Assam Base-Line Target CBR(per 1000) 27.5 21 CPR % (Total) 29.3 60 CPR % Pemanent Methods ___ CPR % Temporay Methods . IMR (per 1000) 77.0 50 MMR (per 100,000) 40 20 CMR (pe: 1000) 41.2 >10 Physical Conmnletion Tareets Assam Base-line Target at Project Number to be completed .________________ _ Completion under project S C 's ___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ PHCs _ _ _ _ _ _ _ Tmining Institutions . Boat C lincs_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Mobile Clinics FRU's __ ___ _ CHC to FRU _ T Dispeny to PHC PHCs Rehabilitated __ ______ CHC's R ehabilitated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Internediate Indicators to be used by Assam I__d __ator | % and $ Project Expendite vs. Budget (by HealihWW Status & Senices component .IlIII, Innovative Schemes ) % Coverage Maternal Imm zatiom posts filled by 1eeCteg or % Coverage Children Immuniztions $ allocated in SAR / Sanctioned by GOI % Tempo__________wtiye_use_Training Indicators % Permanen contrceptive use % and # MO's Trained ______ANM __________________ % and # ANMs Trained (by type of training) % Institutionl Births % and # LHVs Trained (by tp of trai!ing) % Births at FRU of traning) % Children Vit-A Supplements % and # Paramedical's Trained (by typ of % Pregna Women getting iron _tmining) ProiectProrm Ma _AM t Indicators JEC Indicators % Complete project staffing (vacant positions % of items in annual IEC plan completed / person months) % of $ expended against target for materials 84 AglM 3 % IEC message awaeness by targeted ps (per IEC Plan) % Awareness Non-Tenminal Methods % Awarnes~s Smail Family Normns % Awaren Legal age of Mama % Awareness Non-Terminal Methods Infrastnwwre Indk8i10 # & % Facilities under consructi & Completed (by categorg. % completed) $ overAunder budget (by type of faities) % facilities commissioned and completed SCs PHCs Warehouses Training Insitutiions Boat Clinics Mobile Clinics % failtes upraded to new category CHC to FRU Disp. to PHC % facilities rhabietatb luparaded. SC PHC CHC Training InstiUttions % facilities fuly equipped, stafed and functioning SC PHC FRU cHC Warehouses Mobile Clinics Boat clinics 85 Annex 4 Sunmary Ist of Civil Works To be Undtake under th In AMi. Ralastn and KaRnataka ASSAM NAME OF UNIT NO OF UNrr UNIT AREA UNIT COST Sevice Delivery 1. Sub-Centers - New 800 78 sqm "64,000 2. Sub-Centers - renovation 50 50 3. Upgrading to PHCs of State Dpnsaries 100 100 sqm 310,000 4. ANM quaes at PHCs 88 43 sqm 135,000 5. GradeNVquartersatPHCs 75 35sqm 111,000 6. Upgrading (physical) to FRUs of CHCs and Civil Hospital 37 - 300,000 7. Renovations of existing buildings at all facilities to be upgrading to FRUs 39 Training 8. Extensions to SHFWTC, Khanapara, Guwahati 1 800 sqm 3,280,000 9. Extensions to RHTC, Chabua 1 637 sqm 2,230,000 86 Anx 4 NAME OF UNff NO OF UN1T UNIT AREA UNIT COST 10. Extensions to ANM/GNM Training Centers School building 17 500 sqm 1,750,000 100-Student Hostels 4 1,235 sqm 4,322,000 20-Student Hostels 5 375 1,312,000 Proje Mnent 11. Office Building 1 554 sqm 1,913,000 87 Annex KARNATAKA NAME OF UNIT NO OF UNIT UNfT AREA UNIT COST Seice Delivery 1. Sub-centers - new 1,039 64 sqm 243,200 PHCs - new 94 - 780,000 2. Rehabilitation of Health Centres sCs 2,212 - 16,000 PHCs 327 - 60,300 CHCs 48 - 99,000 3. Medical Officers' quarters at PHCs 271 71 sqm 268,280 4. Upgrading to FRUs of CHCs 72 - 75,000 Training 5. District Training Centers 19 575 sqm 2,185,000 6. H!FWTCs - Upgrading at S locations 1 - 6,365,000 7. LHV/ANM Schools in various locations 1 - 26,391,000 8. IHFW Office Building 1 500 sqm 1,900,000 88 Annex RtAJASTHAN NAME OF UN1T NTO Or UJJ1T UNIT COST TOTAL COST 1. Sub centers 600 2.50 750.00 (Project share) A. By DRDA (1.25 by DRDA) B. by N.G.Os & DRDA 260 2.50 195.00 (0.75 by the project and rest by NGO & 'nmmunity) 2. Const. of O.Ts at FRUs 48 4.00 192.00 3. Const. of SIHFW Building 1 250.00 250.00 4. Const. of New HFWTC at Jodhpur 1 165.00165.00 5. Const. of FPDA for New HFWTCI 4.00 4.00 6. Upgradation for two existing 2 6.60 13.20 HFWTC (Jaipur & Ajmer) 7. Const. of DTCs 2 65.25 130.50 8. Upgradation of DTC 13 25.35 329.55 9. Const. of FPDA for DTC 15 4.00 60.00 10. Computer site prep. Statistical unit 1 1.00 1.00 11. Computer site for prep. at Districd0 0.50 15.00 12. Computer site for prep. at Hqrs 1 0.50 0.50 13. Const. of Sub center t00 1.07 107.00 Delivery Room 14. UJpgrading of OTs and 100 0.20 20.00 Delivery Room at FRUs 15. Const. of new PHCs 25 20.00 500.00 89 A 4 NAME OF UNIT NO OF UNIT UNrI COST TOTAL COST 16. Upgrading of PHCs t CHCs 10 17.00 170.00 17. Const. of Drug 1 100.00 100.00 Warehouses at State level 18. Const. of Drug 10 25.00 250.00 Warehouses at Major Districts 19. Const. of Drug warehouses 20 12.50 250.00 at other Districts 20. Upgradation of Drug Test Lans 1 30.00 30.00 21. Installation and 10 10.00 100.00 Procurement of Hospital waste disposal (ncinerators etc.) TOTAL 3632. 90 Annex Model Plans for SubCentre Buildings 1 Assam. Rajasthan and Karnataka And Special Techniques and Procedures for Construton 1. This Annex shows model plans for sub-centre buildings. Though small and sim5ple in themselves, these buildings constitute by far the major component of the nroject's ciil works pogrm in all thuee states. Assam plans to construct 800 buildings for existing sub-centres now operating from rented premises, Rajasthan 860 buildings, and Ka-nataka 1,039 buildings. Notes are also atached on the special methods of construction that will be used in Assam and on the procedures by which construction will be carried out in Rajasthan through partnership between the Department of Health and Family Welfare, district DRDAs and selected NGOs. ASSAM Model Sketch Plan for Assam Sub-Cente Building 0 0 CL1 iC- Clt^tt bt^ 91 Details of Assam Sub-Centre Pl The Sub-Center will provide clinical facilities as well as quarters for the ANM. Plinth areas is 78 sqm. Clinical area - Waiting/IECverandah 12.5 sqm Consulting room 11 Examination room 7 Toilet 2 ANM quarters - Verandah (enclosed) 8 sqm Living room 12 Bed room 9 Kitchen 8 Toilet 2 A door will link the ANM quarters with the clinic. This enable supavisin of patients who may be held over night for observation without the ANM having to go outside. Note on Sub-Centre Construction Methods in Assam 2. Construction of sub-centre buildings will generally be based on a devalopaent of the traditional method of construction in Assam. Vertical posts, which have tritonaly been of timber, will be replaced by slender concrete posts (130x 130 mm). Above will be a post plate (wall plate) of timber. In-fill walls will be 115 mm brickwork. this construction, altough na as secure against earthquake movement nor providing as good an internal climatic environment as the entirely taditional form of construction, is considered acceptable. In remote areas, particularly in N.C. Hills District where costs will be high as a result of transport difficules, construction may be entirely traditional if necessary. 92 Annelx S MMadl ked Pl for Karnataka Sub-Cenrm Buid"p A~~~~~~NP The Sub-Center will provide clincal facilities as well as quarters for the ANM. Plinth sare is 78 sqm. Clincal area - Waiting/MEverandah 6.5 sqm Consulfti room 7 Examnination room 9.5 Toilet 2.5 ANGA quarter - Living room 7 sqm Bed room 7 Kitchen 5 Store I Toilet 2.5 Kitchen yard (open) 5 93 A Note ot, Sub-Centre Construction Methods in Karnataka 1. Construction will utilise local natual stone, wherever available. in order to keep maintenance needs and costs as low as possible, stone walls will neither be rendered or painted externally. Roofs will be pitched (sloping) to avoid risks of leakage of tapped rainwater. RAASTIHAN Model Sketch Plan for Ra3asthan SubCentre Building g-- = SLJBCENTRE FOR IPP IX ,ATOILET H W.C. Delivery Room and waiting %r7rT1 T/ i/ &,1 |as "hatchedc area are to be constructed only in selected Sub Centres. PLINTH AREA WITHOUT OPEN KITCHEN DELIVERY ROOM = 809 SqFt EXAMINATION COURTYARD PLINTH AREA WITH DELIVERY ROOM = 1019 SqFt F-7 [ | |ILIVING co00 I ROOM CLINIC BED ROOM VERANDAH VEANDAH | _ ..~EE 94 AnRM 5 Proures..for Shared Sub-Centre Construction in Rajasthan 1. Under IPP IX, it is proposed to construct Health Sub Centers in 10 districts of the State covered by the aforesaid project. Construction of these sub-centers is proposed to be financed psity out of Jawahir Rojgar Yojna (JRY) funds available with the DRDAs of the districts cowered under the project. Construction cost of the one sub-center is Rs. 2.50 lakh out of which 50% amount i.e., Rs. 1.25 lakh per sub-center shall be provided by DRDA out of JRY funds and the rest amount would come from World Bank Project which would be entirely used for material component. The ratio of wage and material component of 60:40 shall be observed as regards the JRY funds i.e. at least Rs. 0.75 lakh would be spent against wage component and Rs. 0.50 lakh for material component. Some of the sub-centers are proposed to be constructed through NGOs; in such cases 30% of the construction cost would be contributed by the NGOs/viliage community as people's participation, 30% would be provided from World Bank Project and the rest 40% would be contribut-d from the JRY funds by the DRDAs. JAWARAR ROJGAR YOJANA: Main Features 2. Jawahar Rojgar Yojana is a Centrally Sponsored Scheme ard 80% of the expenditure under the Yojana is borne by the Central Government in the Ministry of Rural Development and 20% by the State Government. The Ministry of Rural Development, Government of India transfers its 80% share as Central share to the State Govemment and the State Government contributes 20% as State share and then the amount of Central as well as State shares is transferred to the concerned DRDAs for execution of various schemes and construction activities to be undertaken under JRY. 3. The main obijecive of the JRY is generation of additional gainful employment for the unemployed and the under-employed persons and also, creation of durable productive community assets. Works like Social Forestry, Soil and Water Conservation works, Minor Irrigation works such as construction of community irrigation wells, Drawings and Field Channels, Floods Protection works, Irrigation works, construction of Rural Roads, Land development and Reclamation of Wastelands, Construction of commumty worksheds, Dispensaries, Panchayat Ohars, Community Centers, Anganbaris, Primary School Buildings etc. can be taken up under this Yojana. 4. Out of the funds transferred to DRDAs under JRY, 28% funds used to be earmarked for individual beneficiary schemes like Indira Awaas, Million Wells and expnditure on establishment and administration. Of the remaining 72% , 80% was transferred to Gram. Panchayats by DRDAs for various construction activities listed above and 20% funds used to be retained at the DRDA level which was called as earmarked funds at the district level. This amount could be spent on inter Panchayat Samiti/inter Gram Panchayat works. From this year, the Government of India has slightly revised the guidelines and now 42% of the total annual allocation is to be earmarked for individual beneficiary programs like Indira Awaas Houses, Million Wells Scheme and expenditure on administraion and establishment. Of the remaining 95 Anne 5 58% amount, 80% is to be transferred to Gram Panchayats i.e., 46.40% of the entire annual allocation and 11.60% of the annual allocation is to be retained at the district level which can be spent on inter Panchayat Samiti and inter Gram Panchayat works. For the funds transferred to Gram Panchayats, the execution agency is Gram Panchayat and for the funds retained at the district level, the executive agency can be either the district level Heads of Departments of the concerned Nodal Department or the Panchayat Samitis. The contractor is not allowed and all the works under JRY are required to be executed as departmental works. The wage material component ration of 60:40 is required to be maintained and if funds are additionally required for material cbnmponent the same can be made available either from the State Plan funds or from other sources. AVAILABILITY OF FUNDS UNDER JRY: 5. In t1. 10 districts covered under IPP IX R4jasthan Project, the annual allocation of funds during the coming four years from financial year 1994-95 to 1997-98 as well as the funds available at Gram Panchayat and DRDA leveis for execution of works have been shown in the Annexure-I. From the Annexure-I, it be seen that the earmarked funds at the district level in the year 1994-95 ranges from 38.10 lakh for Sirohi district to 88.15 lakh for Barmer district. Presuming that there would be a cumulative increase of 10% in annual allocation under JRY in each year in the coming four years under the IPP IX Project period, the amount expected to be made avaiWl be to Gram Panchayats and at the district level as earmarked district level funds has been shown in al the 1Q districts. It would be seen from the perusal of Enclosure 1 that the minimum amount is available in district Jaisalmer as 25.82 lakh and the maximum amount would be mrade available with Barmer district to the tune of Rs. 88.15 lakh during the year 1994-95. 6. In the p oject report for IPP IX, 860 Health Sub-enters have been proposed to be constructed with 50% Lontribution by the DRDAs from JRY funds. Accordingly, it is proposed to construct 860 Sub-Centres in 10 Project Districts, by udlising JRY funds over a period of 5 years, starting from 1994-95. The cost of construction of each Sub-center would be Rs. 2.50 lakhs, of which 50% share will be paid by the respective DRDAs District. The details regarding the phasing of the proposed construction is at Annex-II. 7. Wage: Material component of 60:40 is required to be maintained under JRY guideLines for construction works. Out of Rs. 1.25 lakh proposed to be given from JRY, the wage component would be Rs. 75,000/- and material component would be Rs. 50,000/-. The entire amount of Rs. 1.25 lakh to be made available from World Bank funds for construction of Sub-centers would be available for material component. Thus, Material : Wage component ratio may go upto ,0:30 in which these buildings for housing the Sub-centers can easily be constructed. EXECUTING AGENCY FOR THE WORK: 8. The Gram Panchayats have been constructing various buildings under JRY program 96 Annex like Panchayat Llars, Health Sub-centers, Anganbaris etc and during last four years, a number of such buildings have been constructed in each district by the Gram Panchayats. The number of buildings constructed under JRY during last four years have been shown in the Enclosure 3. The local labour and local masons are enpged for the construction of the buildings by the Gram Panchayats and construction of proposed Health Sub-centers under IPP IX would also be undertaken by the Gram Panchayats as in case of construction of other buildings for which standards, model approved maps would be made available to the Gram Panchayats by the DRDAs. SUPERVISION AND MONITORING: 9. In each Panchayat Samiti, there is one post of Junior Engineer who supervises the construction works of the Gram Panchayats and provides all necessary technical guidance to these bodies. He is empowered to accord technical sanction of the works costing upto Rs. 1.00 lakh. There is one post of Assistant Engineer at each DRDA level who also supervises the construction works undertaken by the Gram Panchayats and also provides necessary technical assistance and guidance to the Junior Engineer and the Gram Panchayats. Besides the above mentioned functionaries, Project Director, DRDA and other officers of the Agency along with Vikas Adhikari at the Panchayat Samiti level also make the field visits and inspect the construction works from time to time and do necessary supervision and provide necessary gudance to the Gram Panchayats. Monitoring of the construction works would be done by Project Director at the district level and Vikas Adhicari at the Panchayat Samiti level. 10. Civil Works, the estimated cost of which exceeds Rs. 2.00 lakh are technically approved by the distrct level Heads of technical departments like Executive Engineer, P.W.D, Irrigation etc. In the present case, there would be a standard plan for each Sub-center the desig of which would be approved by the State Government and the cost estimates and technical sanction would be accorded by the district Executive Engineer of the concerned district. Site and location for construction of Sub-centers would be decided by PMO of the district in consultation with the authorities of DRDA including Project Directr of the DRDA. Flows of Funds to the Project 11. The financial assistance shall be received by the Government of India from World Bank under IPP IX. The Government of India shall credit this amount in the State Plan of Medical, Health and Family Welfare Department of Government of Rajasthan. Then on the advice of Special Schemes & Integrated Rural Development shall arrange the release of so received funds in the P.D. Accounts of the concerned District Rural Development Agencies. Thereafter the DRDAs shall further release the funds to the executing agencies in instalment which shall depend on the progress of works. 12. As regards JRY funds the amount is released by the Governmeat of India to DRDAs through State Government and it will continue to be done so. The DRDAs would sanction 97 Annex amount from JRY funds for making contribution towards 50% share for constructon of Haft Sub-centers and tis amount also along with share to be contributad from the project funds would be tUansferred to te concerned executive agencies who will be entrusted with the constuton of sub-center buidings. BrAIUIT UOW_O AVAIA3IX OF M Oa=RY *3FM 1994-M TOM79 8 Di t199.95 1996-97 1997- 9 No. 80% 20% TOW % 20% Toga 80% 20% Tota 60 20% TOW GOn DRDA Gum DRDA GIue DRDA rmC DRDA Pah Peac P*O*- P_ak &Yai aya *y at 1. BARMHR 335.9 .15 406.74 367.5 9696 44.1 426." 1066 533.3 469.30 117.32 536.4 2. DUCANBR I69.92 47.88 237.80 20.91 52A7 261. 229.80 57.93 27.73 25L27 65.7 S16.30 3. CIIRmU 191l2 47J9 239.41 210.67 52A66 26335 231.73 57.95 289A8 25490 60.74 SIL44 4. JOHPIJR 23L36 57PA3 289.19 254.49 63.61 318.10 279.93 69.97 349.90 307.92 76.97 3t4b9 S. NAGAUR 300132 75.07 37539 33035 82.58 41293 36338 90.33 454.21 399.1 99.91 4S9JS3 6. PAJ 277.5 69.36 346.93 305.30 76.32 381.62 3353.3 63.95 419.78 369.41 92.34 461.75 7. SIHXXI 152.42 38.10 190.52 167.66 41.91 209.57 18442 46.10 230.52 20286 50.71 253.57 L. JALORE 214.26 53.57 267J13 235.68 5.3 - 294.61 259.25 64.82 5207 25.17 71.30 56.47 9. (IANGAJIAGAR 29459 74.15 370.74 32625 81.56 407.1 356.57 89.71 4428 39S75 96.66 498.43 10. JAISALMBR 10333 25.82 129.15 1I1A6 28.40 142.06 12L02 31.24 15626 137.52 54.36 171.33 TOrAL: 2309.6 577.84 2855.70 2540.2 635.62 3176.44 2794.57 699.16 3493.73 3074.33 769.05 3S43* PIj . 22 * 2 R ° 2 j.} 2 2 2 o S 2 n ° 2 I J4 2 2: 2 2 - i ta at I ]4 i E: -IIq g|fl2 I~~ II § . 0 g lg | i gXE 99 An= 5 YAR-WISE DETAnBsO AMn =MAIU MUMS MM? IRO T ISOM S. Diauict No. P,:a7 h& B. IMih 8B14 OSm Tuu Puimtyl Pea. Bids. IWais SWhy Ode TaI Sw di ay l odW Lo. AMIs chat beenta LaL Blg. bbg. 1,. Sarm- t10 141 S111 2415 172 18 250 18 26 829 1313 2. Biner 67 S a 25 a n3 175 13 24 14 161 367 3. Cau 161 12 22 6 X 6aX 174 6 159 8 790 11 37 4. Iodput 243 1 IS - #9 533 160 - 49 - 209 S. Nagaw 293 67 179 1 Is1 m1 222 37 2 * * 100 706 8W 6.Pi' - - - 11l l9 12_6 - , 7. Sirhi . . . 7 7 - - 13 295 308 S. Jali - 320 U s 04 . 584 - . S" 9. G _aa- 231 34 135 124 27 731 104 - 239 1 35 360 739 Nagar 10 Jiai r - - 209 - 74 . -43 463 - *3 - 481 TOTAL 995 119 2113 141 40 S3 9242 822 39 1719 19 263 3141 6003 100 "NMI WR-WME ETL OF ASSI8 CRETED UNDER MR M I 14OTO 1t-* 8. Dist"t No. Ptim.y Pa- Bldg. Mabib Saimy O ToWa Pdsiaqy P. BWk. MAh Smib8y O0S Tdl M""dla ad Mmda LX. Mi dce Wadl LW. Bld8. UMg. t. Bsrnwt - - . 956 936 - - 834 834 2.11lmw 113 7 64 8 34 226 37 2 20 6 8 104 177 . cum 122 84 32 31 147 416 136 S 42 24 tt 144 362 4. JdApuw 11o - 1191 1301 40 - - * 40 S. Nag9 23 - 1509 1631 149 4 116 - t 598 n8 6.M - - - - 166 166 148 35 6M 45 362 1190 ?.Sibi - - - - - - - 197 197 S. 1dor 20 252 - - . 272 9 - 205 214 9. anga N4pr 89 - 40 257 386 51 - - - 452 s5 loJi_-ah - . - - 260 260 2 1 27 - 3 276 TUrAL: 553 71 371 31 46 4520 5614 572 45 778 so 80 3169 4076 101 Annexi Criteria for Selection of Comnunities and Sites To Receive Newly-Contructed Sub-Centre Building Assam. Rajasthan and Karmataka 1. A list of criteria drawn up by each state is given below. An example from Karnataka of the set of maps, including a village sketch map, which will be used to record the location and siting of each sub-centre building for the purposes of project records and supervision is also attached as a model. ASSAM 2. Locations and sites for construction of new Sub-Centers will be selected on the basis of the following criteria: (a) The location must be already have a sanctioned and functioning Sub-Center in rented accommodation or in a government owned building beyond repair i.e. New SCs will all be replacement of existing. (b) The existing SC must come under the supervision of a functioning PHC or FRUT. (c) The existing SC must be staffed with a female health worker (ANM) (d) There must be a need for the facility expressed by the community (e) Land must be shown to be available in within the village, to provide easy access for the community as well as security for the ANM (f) The community must be committed to ensuring that future maintenance of the buildings is carried out. KARNATAKA 3. Locations and sites for construction of new Sub-Centers will be selected on the basis of the following criteria: (a) Remoteness from the nearest PHC (b) Having low levels of child immunization and contraceptive prevalence (c) Availability of suitable site of at least 225 sqm within the village, providing easy access for the community and security for the ANM 102 Anex 6 (d) The site must be well drained and have suitable environmental conditions RAJA Locations and sites for construction of new Sub-Centers will be selected on the basis of the following critedra: (a) Need-based sub-centers already sanctioned as per ste level planning (b) Availability of suitable land in a village near village centre and major buildings, eg. near market place, panchayat headquarters, primary school, post office etc., where construction is technically feasible (c) Approachability and accessibility by community (d) Sub-center running in rented building (e) Adequate provision of water and electricity (t) Proximity to Anganwadi centres 103 Annex KARNATAKA Exampl of District Map Showing Location of Health and Family Welfare Facilities And Taluk (Block}Concemed * t * I ~ I a I;zi1 IgS I '' IgI * : I gti 141~~~~~~~~~~~$1 ~~~ ~~~ ! ~~~~~~ ~~~~i I ~ ~ n 2dd~~~~~~~~~~~~ £ * ~~~~~~~~~~~~~~~- co ~- g~~~~~~c 104 Annex 6 KARNAIAKA Ea.mple of TalukIBlo@ Mak Showing Locadon of PHCs and Villages r~~~~~ r ~ ; ' V - 4 gl X ~~~~~~~~~~~~~~~~~~~~~~~I {Je- W 41~~ 4^o 4480 ,x~~~~~~~~~~~~~~~~~~~7 t", K *Vzei °r z ~ ~ ~ ~~~*.t. W rvsion Yes Yes Yes Yes Jo~ Onetnation Yes San:ation - Yes Yes Conmniwucable diseases and their control Yes Yes Training iLsboraoIvtests I . Yes Vital Statistscs - Yes Yes _MES Yes Y cs Yes Y 'rainir; fo romoon I Yes Yes 1.9^. A workshop to discuss the survey data concluded that "there is an immediate need to retain all paramedical staff preferably at the district level. The group further recommended a government of Karnataka policy to offer in-service training for paamedical workers at least every three years for a duration of two weeks. 165 A x16 Training Institutions HFWTC 20. The State has five HFWTCs providing in-service and pre-service training for medical officers, training faculty, supervisory workers and paramedical staff. The facilities are adequate with the exception of the facilities at Mandya and Ramanagaram. In Mandya, training is conducted at a temporary facility which is to be replaced by a permanent facility and relocated in Mysore. The Ramanagaram centre requires additional teaching space. ANM Tmining Schools 21. There is one training centre with hostel facilities in each of the 19 districts. Eleven of the 19 have their own buildings with hostel facilities, the remaining witht are function in district hospitals and using the hostel accommodation provided in the general nursing hostel. There is a need to construct seven training facilities in the districts of Bellary, Dakshin, Kannad, Hassan, Kodagu, Mandya, Mysore and Uttar Kannad. LHV Promotional Taining Schools 22. There are four training centres functional at Bangalore, Belgaum, Gulbarga and Mangalore but three schools have no training or hostel facilities. Construction of a school at Gulbarga is nearing completion and the proposal includes a provision for a facility at Bangalore. The Belgaum and Mangalore schools will be closed and the two remaining schools will be capable of raining sufficient LHVs to meet staffing requirements until the year 2000. Traiing Materials 23. Library materials including reference books, journals, and student manuals are needed for all ANM, LHV and HFWTC training facilities. 24. No taining needs assessment was carried out for Rajasthan, since one had recently been completed under UNFPA funding. Its results were used to prepare the training component of the project in Rajasthan. COMMUNICATIONS NEEDS ASSESSMENTS Am 25. The assessment of communication needs for this state has been completed. The state was divided into four geographical zones: lower Assam, upper Assam, Barak valley and the hill 166 Annex16 districts. 14 districts were included: Dhubri, Kamrup, Nalbari, Sonitpur, Naogaon, Jorhat, Golaghat, Dibrugarh, Lahimpur, Tinsukia, Cachar, Karimgani, N.C. Hills and Karbi Anglong. The final report has not been received from the agency given this task, but a preliminary presentation indicates the following: (a) Women, as a group, are likely to show less resistance to family welfare communication. This is because, compared to many other states, their status is higher, as are their aspirations - educational and economic. Muslims, particularly on the Chars, are an exception. (b) Reflecting this status is the finding that husband as well as wives are decision makers with respect to family planning choices, although elders are consulted. (c) Elders, in fact, are also recognized as "knowing best' when to get boys and girls married; hence, despite the status of women and the relative autonomy of the husband-wife unit, elders constitute as important target group. (d) Doctors, while being acknowledged as a credit source on MCH and PP issues, are not cited as the first point of reference by young men and women seeking information. (e) As in the case of Rajasthan, analysis of data based on attitudes reveals that target group segmentation based on preisoition to fimily welfre issues will be useful. MOMSg S==eg (f) Data on age of manriage are quite encouraging. Except for the hills population, all segments agree that the girl's age at marriage should be at least 20. This compares with the actual figure (1991) of 19.92 years. (g) Knowledge of the fact that there is a legal provision on this or what the legally correct age should be is, however, low. But given the earlier finding, it may not be necessary to push a legal message. (h) The data suggest that it will be easier to promote spacing after the first child. While the "need" to produce a child immediately after marriage is more pronounced among tribals and the Char Muslims, all segments show this attitude. This is despite the fact that the benefits of spacing are well known. (i) Similarly, the benefits of a small family are klown, but the ideal family size is considered to be more than two children. Expectedly, the discrepancy is accounted 167 Anx16 for by fears that one child may die and the need for more hands to help with the family's earning capacity. (j) There is some indication that the belief persists ta family planning is "bad" and associated with killing. (k) The preference for at least one son is widespread. (1) Only 30% of the population appears to have "ever tried" a family planning method. Intentions to adopt a method in the future are even lower. (m) With respect to MCH, less than 505 of the women reported having taken Ir for the last pregnancy, the figures for tribals and Muslims being much lower. Coverage indicated by EFA intake and ANC checkups is also low. (n) In general, awareness of MCHI services is low, especially in the Hills. Not only are services not seen as critical among those who do know about them, but s high as 40% feel that availing such services may result in the child having to be aborted. (o) Only 17% of children were reported as having been covered completely. This is clearly a problem that needs special focus, especially in the Char area. (p) Besides awareness being a problem, especially among mother'sn-law and men, there are also attitdinal points of resistance expressed in beliefs such as that the health is in "god's hands" and that immunization is 'not necessary." Media &tra (q) The most surprising finding in this area is that home visits by ANMs have been to less than 10% of households. This would clearly restrict the impact of interpsonal communication through her. (r) At the same time, the reach of mass media - TV, radio, outdoor and even press - is found to be high. (s) There is great dependence on government institutions for treatment, so on-premise communications could be focused on this audience. 26. In Karnataka, communications needs were already well understood through the studies and activities carried out under the very strong IEC component implemented under IPP m, which had closed not long before preparation for EPP IX began. Nothing beyond a rapid 168A assessment was therefore needed for preparing the IEC stategy for IPP IX. However the IEC management team plar.s to caTry out a special preparatory study of mass media coverage at the begiing of the project, since this is the one area in which they feel more detailed information is needed for implementing the strategy. Raastban 27. The Rajasthan CNA, conducted in 1991, was carried out in five districts, selected from each of five geographical zones. The disticts chosen were Bharatput, Jodhpur, Churu, Bundi and Banswara. In addition, two urban centers, Nasirbad and Kota, selected purposely to represent population strata of less than 100,000 and more than 500,000, respectively, were included. Using a mix of qualitative and quantitive techniques, the following findings were obtained: ITage gm (a) A two-step analysis revealed that there was scope to segment the population into attitudinal groups within demographic categories. For example, unmarried males compared to unmamed females, showed a more favorable attitude toward female age of marriage being more than 18 years. Similarly, (male) heads of household were more hikely than mothers-in-law to agree that the ideal number of children was "up to 2." gb) In general, younger groups were found to be more progressive and men showed a 'better attitude" than women. MesWaff strte (c) Resistance points were identified and the attitude-based segmentation used to arrive at profile of groups on the resistance points. For example, the resistant group was more likely to believe that "god gives children" and that "wtradition should be followed." (d) Message stategy should, it was recommended, convert reislance points by using thiem to motivate desired behavior. For exmple, messages based on the uaditions, custms and history of the people could be used to inject a sense of prde conceming the women of Rajastan. (e) Among the younger groups, it was found that appeals hinging on modernity were likely to work better. (f) The thrust areas that emerged were: delay mariage, delay the first child, space subsequent births, limit overall family size; among MCHI issues, the ones that would 169 Annexl need emphasis are: colostrum, safe delivery and immunization. wdia natgy (g) while the study did not probe media behavior in depth, it did conclude that interpersonal communication by health functionaries was low for all groups and discussion of family even lower. BENEFICIARY NEEIDS ASSESSMENTS 28. In order to determine whether the tribal and other special groups in Rajasthan, Karnataka and Assam would require specific strategies to cater to them, a services of studies was conducted in these states as part of project preparation. The major findings pertaining to difference between tribals and non-tribals obtained from these investigations are summarised below: 29. A two-phase study of tribal (Bhil, Meena, Garassiya, Gameti and others) and non- tribal men and women in the reproductive age band of 15-45 years was carried out by a professional research agency during the period June to October 1993. The first phase was a qualitative, exploratory series of group discussions and depth interviews, while the second consisted of structured interviews on a much larger sample, Lata from which were collected from Sirohi, Udaipur and Dungarpur districts. 30. Similar data on the migratory populations of the state are expected early in the first year of the project; because of the migratory behavior of these groups, data collection has to be extended over several months. Key findings reflecting differences between tribals and non- tribals are described. Marruae and Child Birth (a) Tribal women marry at a younger age than non-tribals: 16.7 compared to 18 years; (b) tribal men appear to be helping in the delivery of children, unlike non-triabl, for whom the role is assigned to female relatives and local dais; (c) some tribals reported that no medicine was applied to the cord after delivery. Child Ca (a) Non-tribals showed a higher level of awareness of immunisation, with some tribes showing levels that were particularly low; 170 Anne 1 (b) a higher proportion of non-tribals had had their youngest child immunised; (c) the duration for which a child was exclusively breastfed was slightly longer for tribals than for non-tribals, although there were no differences with respect to giving the child colostrum or solid food. (a) despite experiencing the problems resulting from large families, tribals did not recognize the need for limiting family size as much as non-tribals did; (b) more non-tribals were aware of sterilization, although the proportions in both groups were high (94% and 88%, respectively); Health seeldn behavior (a) Given the availability of allopathic, homeopathic and the indigenous system, a higher proportion of non-tribals were aware of the availability of allopathic ueatment; 0b) for some types of illnesses, such as epilepsy and convulsions, tribals are likely to always prefer the indigenous doctor as the first recourse, while non-tnbals may try aliopathy as much as the 'bhopa"; (c) 54 per cent of the respondents expessed the view that aPHC was not easily accessible and that long distances and long waiting periods had to be suffered to avail of their services. Given that tribals live in isolated hamlets off the main road, the responses are more likely to be indicating their views; (d) probably because of the problem of accessibility, a significantly higher proporton of tribal respondents had consulted a doctor outside the village than non-tribals. Ass= 31. An investigation similar to that carried out in Rajasthan has been under way in Assam during the latter part of 1993. Ten districts (Kokrajhar, 3oalpara, Xmrup, Darang, Marigaon, Kaibi Anglong, North Cchar Hills, Lahimpur, Jorhat and Dhemaji) with tib population have been covered. The final report is expected by the end of January 1994; findings based on preliminary analysis are described. 171 Annex 16 Gmkbgrog e (a) the incidence of encephalitis was found to be higher in the tribal population in two districts; (b) traditional herbal medicines are used to a greater extent by tribals in hiUly areas, where accessibility to health centers is poor; (c) the attribution of chicken pox, measles and psychiatric problems to supernatural powers is more prevalent among tribals; (d) cure for problems such as snake and dog bites is sought from ISM by tribals; (e) use of alcohol appeared to be greater among tribals. EBL_an lm (t) female sterilisation appears to be more popular among tribals than non-tribals; 32. The data available for Kamatala come from the studies conducted by two different organisations, the State Family Welfare Bureau of the Directorate of Health and Family Welfare Serices and a private consultancy firm (STE). Because of the very different methodologies employed, comparison and consolidation of the findings is difficult, particularly since STEM's results are presented without cuiaparison of tribal and non-tribal response, and there is variation in the unit of analysis from respondents to villages. They covered a sample of tribal population in four districts (Chitradurga, Dakshin Kannada, Kodagu and Mysore) and non-triLals in these and six additional districts (Bellary, Chikmagaur, Hassan, Mandiya, Shimoga and Uttar KaMnad). The DHFWS carried out a qualitative study in the four districts of Uttar Kannad, Dakdhin Kannad, Kodagu and Mysore dunng September - October 1993. Against the limitations mentioned earlier, the following picture has been extraued from these studies. En*rom da (a) The percentage of non-tnbal communities with borewells is substantially higher than that in tribal villages. The latter rely more on open wells; (b) while almost all non-tribal respondents reported their villages as having electricity, "four out of ten" tribal vfllages were described as not being electrified; (c) a higher proportion of non-tribal villages were reported to be connected by tar road, while the prcentage was substantially higher for tribal villages when the connection 172 Agex 16 was a mud road. (d) about 80 ,er cent of tribals stated that their villages were not covered by ICDS, while the corresponding figure for non-tribals was only 20 per cent. Availablfty of health and FP services (e) The TBA appears to be more available in non-tribal villages, while tribals seem to report a greater presence of the health guide; (f) while half the non-tribal resndents reported that their village was 'covered' by a sub-center, the percentage of tribal village reporting this was substaniy smaller; (g) mobile tribal health units, operated by government and NGOs, provide service in a manner not available in non-tribal area, but frequent breakdowns awid seasonal disruptions do not enable sustined service delivery; h) the geographical area to be covered by an ANM seems to be far greater for tibal areas: one example reported an average of 5.4 sq.kms area for a non-tribal sub- center compared to 45 sq.kms for a tribal one. (i) usage of IUDs and pills appeared to be lower among tribals, while that of 'herbal contraceptives' was more widespread, although this could not be confirmed; (j) awareness of vasectomy among thibals was lower. MCisLisues (k) ANC visits by ANMs appeared to be more common for tribals; O) tribals resort to prayers in the belief that pain during delivery will be lessened; (m) the traditional position for delivery, squatting, is prefenred by tribals; (n) while there were no differences found in the use of colostrum, trbals were motivated by an age-old tradition in this regard; (o) tribals believe that 'milk in the breast of the mother is always meant for the offspring." 173 Annx 1 lIues concernng health delivery (p) while there are no differences concerning when help is sought, tnbals tend to come to the government system a bit later because they have been seeking treatment from their own indigenous system first; (q) preference for home remedies is much higher among tnbals; UtiUsation of health facilities (r) tnbals were reported as relying more on a pnvate doctor than non-tnbals, regadless of whether it was sickness, immunisation or FP services; (s) corespondingly, utilisation of the sub-center by tribals was less than for non-tribals, although this was not as marked in the case of PHC utilisation; (t) compared to non-tribals, tnbals were much more likely to be seeling services for TB, malaria, diarrhoeal disease, scabies and worms; (u) there was, not surprisingly, a marked difference in the amount tribals were willing to pay every month for 'complete health coverage for their families' compared to non-tribals - Rs. 5 against Rs. 25. However, while all tribals were willing to pay, almost half the non-tribals were against it. 174 Annx 17 Strategies For Improving Family Welfare Services to Tribal and Migratory Groups Assam. Rajasthan and Karnataka 1. Although specific programs aimed at improving the conditions of tribals and other groups have been adopted by the Government of India and various states since the 1950s, their special needs persist. It is, therefore, necessary to identify responses to address these special needs in the delivery of family welfare services. It is this set of responses that constitutes a tribal strategy in each state. The strategies in all states will be continually refined and revised as more and more information and feedback comes in, but their main outlines are clear and unlikely to change significantly. 2. As revealed by the findings of the assessment studies (Annex 14) the overall health and family planning status of these groups is generally worse, though usually in a global, non- focused way, with no special and unusual health conditions that demand major changes in the normal range and content of Family Welfare services. Beliefs and practices related to health and fertility behavior are usually also more dominated by traditional views and customs than in the non-tribal population, though *._;e appears to be general acceptance of the principles of MCH and family planning. Relatedly, access to health and Family Welfare services, including IEC, tends systematically to be worse for population than non-tribal groups. 3. There are two key reasons underlying these tribal - non-tribal differences. First, tribal groups tend almost invariably to live in scattered hamlets in geographically remote places. Whether it is the rocky, hilly terrain of Udaipur, or the densely forested areas of Koday, or the hills of North Cachar, poor general accessibility is a miajor reason for the poorer health and Family Welfare status of tribal populations and their less modernized beliefs and practices in these areas. Thus the foundation of all the state strategies is a special effort to improve access by tribal groups to Family Welfare services. The second reason is cultural identity - the collective sense of self among these groups and their determination that it should be preserved. As population outside tribal areas has grown, so has the pressure on their land and the real or perceived threat of loss of identity. This, in conjunction with the emergence of political leadership in several areas of the country, has strengthened the need to maintain the way of life that they see as 'our own.' These tendencies have been reinforced by the isolation and inaccessibility of tribal groups referred to above, which has helped to preserve their disthict culture and ancient beliefs and practices. Thus another element of all strategies is the development and implementation of Family Welfare IEC programs which are customized to tribal cultural conditions. 4. Thus, although tnbal strategies may vary across states according to their individual characteristics, there are three common strands running through the responses formulated by them. These are: (a) the introduction of greater mobility into the health delivery system to cope with the 175 AnnexR17 accessibility issue; this will include service delivery (mobile vans, boats), enhanced outreach capacity (camps, mobility for the ANM in the form of bicycles, mopeds, extra travel allowance etc.) and IEC (all the above plus video vans and camel carts); (b) the implementation of IEC strategies based on the beliefs and practices of these groups (including the use of the indigenous bhopa or ..aditional healer, sensitization of ground-level functionaries for more effective interpersonal communication); and (c) the use of community-based systems (women's groups, health promotersllink workers, and NMOs) to establish gater rapport between the health delivery system and these communities. 5. Specific aspects of sttegies in each state are now described. RAJATH 6. Tribal groups form 12 percent of Rajasthan's population, and are mainly located in the hilly and forested southern districts of the state. Migratory groups, who make up around two percent of the population, live in the westernmost desert districts. The state's strategy for migratory groups is still to be finalised following completion of the longitudinal baseline study over the annual migratory cycles. However the strategy for both groups must necessarily be based on the recognition that the hostile terrain inhabited by the migratory populations of the western districts, and the inaccessibility of tribal hamlets in southem districts, call for special attention. Pending the availability of data on migratory groups, the following elements have been formulated by the state for a strategy covering both groups: (a) an operations research study in the inaccessible areas of two westem districts to examine the costs and benefits of mobile clinics. Based on detailed planning at the local level, four mobile clinics, operated by NGOs, each staffed by a doctor and nurse and adequately equipped, will be deployed over the first two years of the project The vans will travel on a twice - a - month fixed-visit schedule and will also conduct IEC activities; (b) hired camel carts will be used to cover scattered hamlets along the route of the mobile clinic, visiting them a few days before the van to give advance publicity and to carry out other IEC campaigns; (c) a 3camp approach" will be adopted on an experimental basis in two districts to reach remote areas or to fill gaps in subcenters where no staff have been available. These one-day camps will provide a comprehensive range of preventive and some curative services, as well as IEC; (d) innovative IEC measures will be used, including the cooption of the tribal 'ojha 176 Annex 17 into understanding, interpreting and transmitting to the community appropriate family welfare messages; (e) for the migratory populations, on a experimental basis, a joint effort with animal husbandry agencies will be undertaken to provide EEC to these groups in animal markets and where fodder and veterinary services are normally provided along their migratory routes; 7. Tribal groups make up 16 percent of Assam's population, and predominate in many areas. Their political influence in the state is significant, much more so than in any other state. Indeed, Assam is in the unique position of having established autonomous elected goveming councils in the two dominantly tribal hill districts of Karbi Anglong, North Cachar Hills and is in the process of creating a third in the still-insecure district of Bodoland. These District Development Councils are almost entirely tribal in membership. 8. Consequently, the state has developed and implemented an unusually comprehensive tribal development plan with special earmarked funds, and this includes a substantial Family Welfare infrasucue with coverage norms adapted to more scattered settlement patterns. Tribal groups living in the plains are generally very little disadvantaged in this respect relative to the non-tribal neighbours among whom they are dispersed, and do not suffer from extreme isolation or inaccessibility. Assam's tribal strategy therefore concentrates on improving access to Family Welfare to tribal hill populations in Karbi-Anglong and North Cachar Hills districts, which live in scattered and shifting hamlets in forested and hilly terrain with very poor road and transport networks, plus tailormade IEC efforts for all tribal populations. Major elements of the strategy, which in places overlaps with the general project strategy for the whole state, include: (a) provision of additional sub-centers and other facilities such as FRUs in any underserved tribal areas (as for underserved areas throughout the state under the project), possibly using traditional construction methods for sub-centres in particularly inaccessible areas and establishing community maintenance systems (b) provision of mobile van clinics offering Family Welfare services and out-patient care, operating out of CHCs or hospitals with regular schedules and itineraries, to cover particularly remote areas in Karbi-Anglong and N.C. Hills districts (c) increased mobility for FW field workers who have to travel long distances through the revolving loan fund for vehicles. (d) use of NGOs in tribal areas, where available, to supplement FW program efforts irt service delivery and IEC 177 Anne 17 (e) experimentation with innovative approaches to service delivery in remote areas, in full partnership with the District Development Councils, through formation of district plans drawn up after consultation and participation from community leaderships and local FW workers; these could include experimentation with sub- center siting in spots where large populations gather, such as marketplaces, adaptation, after study of current constraints on recruitment and retention of local tribal girls as ANMs, of ANM qualifications, training and living and working conditions to improve recruitment and retention rates, similar study of how to attract and hold locally-born doctors, construction and maintenance of access paths to sub- centres by communities etc. (t) heavy use of community linkage schemes, including the WHP and MSS schemes (Annex 10) and links with traditional healers, particularly in the remotest areas where sub-centers may be difficult to reach and the WHPs or traditional healers might be traned to take on extra duties (g) development of IEC messages, materials and activities which are tailored to the culture and conditions of the tribal groups, and make full use of their social and leadership networks, including the District Development Councils. KARNATAK Tribal groups make up about 4 percent of Karnataka's population, dispersed all over the state in a large number of disparate groups. They fall into two rather different categories. The first category consists of more modernised groups who, as in the Assam plains, have to a Large extent integrated themselves into the general populaton and do not differ greatly in their health and Family Welfare stus and access. The second is made up mainly of non-modemised tibes classified as primitive tribes, many of whom are hill forest-dwellers who have now been resetted by the state outside the forest areas. Health and Family Welfare con.ditions tend to be poor among this category of tribal group, again due in large part to their isolation and low socio- economic status. Efforts have been made by the state, under its Tribal Sub-Plan and a set of tribal development projects, to set up a network of social services for these groups, including a health and Family Welfare infrastructure. The state has worked effectively with NGOs in this area, utilising them as agents to deliver health and Family Welfare services. Karnataka's tribal stategy under the project, like the Tribal Sub-Plan and tribal development projects focuses largely on these worse-off groups. Due to the multiplicity of groups and the recency of the new data on them collected in the 1991 census, the Beneficiary Needs Assessment described in Annex 14 is considered only as a first step allowing an outline of the strategy to be prepared. The first step under the strategy will therefore be: (a) on the basis of disaggregated 1991 census data, expected to be available shortly, identify tribal pockets in every district and cover them adequately in the project 178 Annex 17 baseline survey, plus detailed beneficiary and communication needs assessment. this information will be used to prepare a finalised, detailed and comprehensive tribal strategy In the meantime, the outline strategy includes the following elements, which again focus on improving access to services and customised IEC: (b) establishment of mobile health teams, based at PHCs, CHCs or hospitals, which will make regular visits to areas identified as having the worst health conditions and provide Family Welfare and outpatient services (c) increased coverage of inaccessible hamlets by selecting and training 100 tribal girls (20 per year) as ANMs on a ratio of one per area of 500 population, under supervision and management by NGO groups; to accommodate local cultural conditions, the emphasis at first would be more on health and nutrition than family planning (d) development of IEC messages, materials and activities which are tailored to the culture and conditions of each tribal groups (e) development of further innovative approaches to service delivery and IEC for individual tribal pockets on the basis of the detailed census and survey data described above. In addition, it is expected that the provision of greater mobility tu FW field staff through the revolving loan fund for vehicles would also be of particular benefit to FW staff woridng in these tribal areas, and that the project's program for involving NGOs more in Family Welfare service delivery and IEC would include support to additional efforts by NGOs in tribal areas, since this has been their area of greatest involvement to date. 179 ANNEX 18 DedW Cost TAbles Table 4.1 - Cost By Component at=" Mu ) v. % %rtOa COPN Fak Bw Ladl Fnam Ttdal LO1 FLen Towl ExChane Cas Stenthen Health & F.W. SWer Deliy 1,559.83 139.15 1,698.98 46.0 4.1 50.1 8% s% lmpove QualityofF.W. Serices 714.06 30.78 744.84 21.1 .9 22.0 4% 23% lncreagDemandfor F.W. Servces 339.19 8.83 341.02 10.0 .3 10.3 3% 11% Management I n276.92 21.00 297.92 8.2 .6 8. 7% 9% lnnovazive Scheme 134.55 2.76 137.31 4.0 .1 4.1 2% 4% Totad BASELIE COSTS 31024.55 202.52 3,227.07 89.2 6.0 95.2 6% 100I Physical Contingencies 244.43 20.25 264.68 7.2 .6 7.l 8% 8% Price Contnene 835.52 825 918.06 .2 .7 .8 78% 1% TOIWPROJECf CO1 4,104.49 305.32 ' .'.81 96.6 7.2 103.6 7% 109% Table 4.2 - Cost by Categories of Expenditure (Rapt. MIie. (JMIUl % % TOal Foteg Bar Loa Frdga Teal Local Feala TOWl Exhange cow Inyslsen Coats Civil Wab (New) 920.40 102.27 1,022.67 27.2 3.0 30.2 1O% 32% Civi Works (Itehb & UPgra) 256.31 28.48 284.79 7.6 .8 8.4 I0% 9% Furnu 102.78 10.17 112.95 3.0 .3 3.3 9% 3X Equipmen 201.60 27.49 229.09 5.9 .8 6.8 12% 7% Vehild 119.97 11.33 133.0 3.5 .4 3.9 10% 4% Boos 10.86U 1.21 12.09 .3 .0 .4 10% - Traniegh Ml 49.53 - 49.53 1.5 1.5 2% [EC Mateil & Ativire 144.88 - 144.88. 4.3 4.3 - 4% efalth Kits 43.65 4.85 48.0 1.3 .1 1.4 10% 2% Local TM&nin Servi 254.69 - 254.69 7.5 - 7.5 8% ILocI ConlaInts 33.30 - 33.30 1.0 - 1.0 - 1% Innvative Schemes 111.39 - 111.39 3.3 3.3 3% Vehiclb r Field Staff (PART 2c) 167.80 167.80 4.9 4.9 - 5% GramsntoNGOs 70.003 70.00 2.1 2.1 2% GramtstoPhartmv ituttn 3.00 3.00 1 .1 - .- _ Fdloh bps 15.06 * 15.04 .4 - .4 * TOtWl Invutmnet Costs 2,505.2 187.8 2,693.0 73.90 5.54 79.44 7% 83% Roennre Cob Salari of Additn Staff 146.29 146.29 4.3 4 4.3 - 5% Honowrium to Coammnity Volues 95.33 95.33 2.6 - 2.6 - 3% T.A./D.A. of Staff 8.35 8 8.35 .2 * .2 Contaahles 50.00 5.56 55.56 1.5 .2 1.6 10% 2% Civi Works Malt 55.14 55.14 1.6 1.6 2% Equipmen & Fleet Operdin and Mais 81.63 1- 8.63 2.4 - 2.4 3% Medictnes& Medical Maal 82.58 9.18 91.76 2.4 .3 2.7 10% 3% Tot Reenrant Co 519.3 14.7 534.1 15.32 0.43 15.75 3% 17S Toad BASLINE COS18 3,024.55 202.52 3,227.07 89.2 6.0 95.2 6% IGO% Phyial Contgnc 244.43 20.25 264.68 7.2 .6 7.8 8% 8% Prti Cnnecles 8U35.52 82.54 918.06 .2 .7 .8 76% IS Ttw PROIECTCOSIS 4,104.49 305.32 4,409.8l 96.6 7.2 103.8 7% IO9% 180 Annex 18 Details of Expenditures - Assam State Expenditure Accounts by Years - Base Costs (Costs in Rs. Millions) Foreign Dasm Colst Exhnge 1995 1996 1997 1998 1999 2000 200l Tota % Amount Civil Works (New) 16.2 38.9 55.1 64.8 58.3 45.3 45.3 323.8 10% 32.4 Civil Works (Rehab & Upgrade) 7.4 17.8 25.2 29.7 26.7 20.8 20.8 148.4 10% 14.8 Furniture 1.8 4.4 6.2 7.3 6.6 5.1 5.1 36.5 9% 3.3 Equipmnt 5.2 12.6 17.8 21.0 18.9 14.7 14.7 105.0 12% 12.6 Vehicles 7.6 15.1 22.7 15.1 7.6 7.6 - 75.6 10% 7.6 Books 0.2 0.5 1.0 1.5 1.8 1.8 1.8 8.7 I0% 0.9 Trainin Material 0.1 0.2 OA 0.6 0.7 0.7 0.7 3.3 - - JBC Material & Activities 0.8 2.4 4.8 6.8 8.4 8.4 8.4 39.9 - Health Kits 0.1 0.2 0.5 0.7 0.8 0.8 0.8 3.9 10% 0.4 LocalTrain4Services 2.0 5.9 11.9 16.8 20.8 20.8 20.8 98.9 - Local ConsAultans 0.1 0.2 0.5 0.7 0.8 0.8 0.8 4.0 ave hemes 0.1 0.2 OA 0.5 0.6 0.6 0.6 3.0 - - Vd fesobr FeldStaff(PART2c) 1.1 3.2 6.3 9.0 11.1 11.1 11.1 52.8 GrantatoNMOs 0.1 0.4 0.8 1.2 1.5 1.5 1.5 7.0 - - Granta to Phannacy nstinnes 0.1 0.2 0.4 0.5 0.6 0.6 0.6 3.0 - - elowships 0.1 0.3 0.6 0.9 1.1 1.1 1.1 5.0 - - Total_ vstment Coss 42.8 102.5 154.5 176.9 166.2 141.7 134.1 918.8 8% 71.9 RenmTent Cost - - - - ' - Salaries of Additional Staff 0.6 2.4 3.9 5.1 6.0 6.0 6.0 30.0 HonoramiuntoCommunityVolumners 0.1 0.6 1.0 1.2 1.5 1.5 1.5 7.3 T.A./D.A. of Staff 0.1 0.2 0.3 OA 0.5 0.5 0.5 2.5 Consumables 0.7 2.0 4.0 5.7 7.1 7.1 7 1 33.7 10% 3.4 Civil Works Maim - 0.9 1.8 2.6 4.0 4.0 4.2 17.6 - Equipme & Fleet Operation and Maim 0.5 1.4 2.8 4.0 5.0 5.0 5.0 23.7 Medicnes & Medical Material 0.0 0.1 0.2 0.3 0.4 0.4 0.4 1.9 10% 0.2 Ttl R dcurat Costs 2.0 7.6 14.0 19.5 24.4 24.4 24.6 116.6 3% 3.6 TdoalDSUW COSTS 44.8 110.1 168.6 196A 190.7 166.1 158.7 1,035.4 7% 75.5 Physal Contingncies 4.3 10.3 15.5 17.7 16.7 14.3 13.5 92.3 8% 7.5 Pricomingencies 1.8 12.6 31.1 49.2 60.3 63.8 72.4 291.3 10% 30.4 Tol PROJECT COSTS 50.9 133.0 215.2 263.3 267.7 244.2 244.7 1,419.0 8% 113.4 Taes 3.3 8.2 12.8 15.1 14.3 12.4 12.1 78.3 - - ForignExchange 4.8 12.2 19.0 22.2 20.7 17.5 17.1 113.4 181 Annex 18 Details of E=pedithures - Karnsatnk Sta Expendit Accounts by Years - Base Costs (Costs in Rs. Millions) - 5 199 19S7 199 1999 2900 2001 Toal % Amount hCwdutenCub Civ Works (New) 19.7 47.2 66.9 787 70.8 55.1 55.1 393.5 10% 39.3 Civi Work (Rdub & Upgrade) 3.9 9.4 13.3 15.7 14.1 11.0 11.0 78A 10% 7.8 Furniure 3.0 7.3 10.3 12.2 11.0 8.5 8.5 60.9 9% 53 Equizmcut 3.8 9.1 12.9 1.2 13.7 10.6 10.6 75.9 12% 9.1 Vehicles 0.9 1.8 2.6 1.8 0.9 0.9 - 8.8 10% 0.9 books 0.0 0.0 0.1 0.1 0.1 0.1 0.1 0.5 10% 0.1 TaIiong Matl 0.2 0.5 1.0 1.A 1i 1.8 1.8 8.5 - IEC Matei & Acdvtids 0.8 2.3 4.5 f.4 7.9 7.9 7.9 37.6 - - Healft Kis 0.4 1.2 2.3 3.3 4.1 4.1 4.1 19.3 10% 1.9 Local TraiingSevices 0.9 2.6 5.2 7.3 9.0 9.0 9.0 43.0 - lcal Conslat 0.3 0.9 1.8 2.5 3.1 3.1 3.1 14.7 hnwvativc Sch4e 1.5 4.6 9.1 12.9 15.9 15.9 15.9 75.9 - VdidcesforFieldStaff(PART2c) 2.1 6.3 12.6 17.9 22.1 22.1 22.1 105.0 - - Gran to NOOs - - orants to Pharmacy hb es- - - - - - - - - Pellowdhp 0.1 0.3 0.6 0.9 1.1 1.1 1.1 5.0 - - Tdoalisment cobs 37.5 93A 143.3 176.1 175A 151.1 1502 927.0 7% 64.6 Reawret Cod ' ' Salaries of Addiinal Steff 0.9 3.5 5.7 7.5 8.8 8.8 8.8 44.2 - HonorarnumtoConmunity Vouaes 1.8 7.0 IIA 15.0 17.6 11.6 17.6 88.0 T.A./D.A. of Staff - - - - - Covsmables 0.4 1.2 2.3 3.3 4.1 4.1 4.1 19.5 10% 1.9 Civl Works Mam - 1.4 2.8 4.2 6.4 6A 6.7 27.9 - - EqulPMe & Pfl operaaoanimd O 0.8 2.5 5.0 7.1 8.7 8.7 8.7 41.5 Medcm Mical Mal - - - - - - - - - Ttda Reamrnt Coa 3.9 15.6 27.3 37.0 45.7 45.7 45.9 221.1 1% 1.9 TotaBASEL=INCOSTS 41.4 109.0 170.6 213.1 221.1 196.8 196.2 1,148.1 6% 66.6 Physc Co _igcies 3.7 9.2 13.9 17.0 16.8 14.4 14.3 89.4 8% 6.7 Prce Contendce 1.6 12.2 30.8 52.3 68.5 73.9 87.8 327.1 8% 27.3 TOWt PROECT COSIS 46.7 130.3 215.2 282.5 306.4 285.1 298.3 1,564.5 6% 100.5 Taxes 2.8 7.3 11.4 14.4 14.4 12.4 12.9 75.5 - - ForPig Excaw 3.9 10.2 15.7 19.6 18.9 15.8 16.5 100.5 182 Anntex l8 Details of Expeditvres - Ra'siethsn State Expediture Accounts by Years - Base Costs (Costs in Rs. Milons) Fai DmeCnd Ebngem 1995 196 159? 1996 199L9 2 U6 Tdal % Amou_t 1h mm Costs civU Wors (Now) 15.3 36.6 51.9 61.1 55.0 42.7 42.7 305.4 10% 30.5 CivlWouksReb&Upgack) 2.9 7.0 9.8 11.6 10.4 8. 8.1 S7.9 10% 5.8 P.mduare 0.8 1.9 2.6 3.1 2.8 2.2 2.2 IS.5 9% IA Fquipment 2.4 5.8 8.2 9.6 8.7 6.7 6.7 48.2 12% 5.8 Vcildes 4.9 9.8 14.7 9.8 4.9 4.9 - 49.0 10% 4.9 Docks 0.1 0.2 0.3 0.5 0.6 0.6 0.6 2.9 10% 0.3 Taii Maal 0.8 2.3 4.5 6.4 7.9 7.9 7.9 37.7 - [ECMazerlah&Acclic * 1.3 4.0 8.1 11A 14.1 14.1 14.1 67.3 - ieal 1Us 0.5 1. 3.0 4.3 5.3 5.3 5.3 25.3 10% 2.5 Loeal Tainng Sevi 2.3 6.8 13.5 19.2 23.7 23.7 23.7 112.8 - - La Cosultants 0.3 0.9 1.8 2.5 3.1 3.1 3.1 14.7 - - I Smovadv_Sdiemas 0.7 2.0 3.9 5.5 6.8 6.8 6.8 32.5 Veu Ar Field Saff(PART2c) 0.2 0.6 1.2 1.7 2.1 2.1 2.1 10.0 GrantsroNGOs 1.3 3.8 7.6 10.7 13.2 13.2 13.2 63.0 Gra to Phumay lutumo - - - - Felbwsp 0.1 0.3 0.6 0.9 1.1 1.1 1.1 5.0 - Tal4ld bnawm tu C 33.7 83.3 131.8 158.3 1597 142.6 137.7 847.2 6% 51.2 Rewnot Cotds - - - - Sala eotAddikmlStdf IA 5.8 9.4 12.3 14.4 14.4 14.4 72.2 - - Ionrm to Commmity Volnr -- T.AJD.A. o0Stff 0.1 0.5 0.8 1.0 1.2 1.2 1.2 5.8 - - C _mumnble 0.0 0.1 0.3 0.4 0.5 0.5 0.5 2.4 10% 0.2 Cii Work maw - 0.5 1.0 IA 2.2 2.2 2.3 9.6 - - equp m & Feet Operation ad Maint 0.3 1.0 2.0 2.8 35 3.5 3.5 16.4 - Medices & Medial Mrl 1.8 5.4 10.8 15.3 18.9 18.9 18.9 89.9 10% 9.0 TW Re1mWU Cub 3.7 13.2 24.2 33.2 40.7 40.7 40.8 196.4 5% 9.2 Tdd UASEE COSTS 37A 96.6 156.0 191.5 20D.4 183.3 178.5 t.043.6 6% 60.4 Phyi Continges 3.3 83 13.0 15.3 15.6 13.9 13.4 83.0 7% 6.0 PriceContingaies 1.5 10.8 28.2 47.2 62.3 69.3 80.3 299.7 8% 24.9 TCmpRO SIECST06 42.2 115.7 197.2 254.2 278.3 266.5 2.2 1.426.2 6% 91.4 Tams 2.4 6.3 10.1 123 12.3 11.1 11.0 65.4 - Fog Exchane 3.5 9.0 14.4 17A 17.1 15.1 15.0 91A - 183 Annexl DonI o andtrs & D Expenditure Accounts by Years - Base Costs (Coss in Rs. Mllons) ~~~~~~~~~~~~~~~Vdgp s995 1996 1N97 I9 1999 2009 2S Ta % Amma kvabimt coa Civil Wats (New) 51.1 122.7 173.9 204.5 184.1 143.2 143.2 1,022.7 10% 102.3 Civil Wotk5 (Reinb Upgrade) 14.2 34.2 48.4 57.0 51.3 39.9 39.9 284.8 10% 283 FIture 5.6 13.6 19.2 22.6 20.3 1I.8 15.8 112.9 9% 10.2 Bqupme I1. 27.5 38.9 45.8 41.2 32.1 32.1 229.1 12% 27.5 Veicelsa 13.3 26.7 40.0 26.7 13.3 13.3 - 133.3 10% 13.3 Vdtlclfor lFd9 Staff(PAiRT2c) 3.4 10.1 20.1 28.5 35.2 35.2 35.2 167.8 Dock 0.2 0.7 1.5 2.1 2.5 2.5 2.5 12.1 10% 1.2 T g aterwIl 1.0 3.0 5.9 84 10.4 10.4 10.4 49.S IBC Mataria & Actvies 2.9 8.7 17.4 24.6 30.4 30.4 30A 144.9 - Realib KIts 1.0 2.9 5.8 8.2 10.2 10.2 10.2 48.5 10% 4.8 LocalTTtablnlSavices 5.1 15.3 30.6 43.3 S3.5 S3.5 53.5 254.7 Lol Comula 0.7 2.0 4.0 5.7 7.0 7.0 7.0 33.3 Iovative Schms 2.2 6.7 13A 18.9 23A 23A 23A 111.4 Gtams to NGOs IA 4.2 8.4 11.9 14.7 14.7 14.7 70.0 - - anumto Pbm alm aum 0.1 02 0.4 0.5 0.6 0.6 0.6 3.0 Fiowdbp 0.3 0.9 1.8 2.6 3.2 3.2 3.2 15.0 * 11ala.rn cinia 114.0 279.2 429.6 511.3 SOIA 435.4 422.1 2,693.0 7% 187.8 Recrnw Code SablrieaofAddonalStaff 2.9 11.7 19.0 24.9 29.3 29.3 29.3 146.3 Hon axlum to Coaan ty Volutrs 1.9 7.6 12.4 16.2 19.1 19.1 19.1 93.3 T.A.D.A. of Staff 0.2 0.7 1.1 IA 1.7 1.7 1.7 8.3 Comwnbles 1.1 3.3 6.7 9A 11.7 11.7 11.7 55.6 10% 5.6 Civil Works Maim - 2.8 5.5 8.3 12.7 12.7 13.2 55.1 Equpamm&PentOperatoaandMai 1.6 4.9 9.8 13.9 17.1 17.1 17.1 81.6 Medcie&MedIclMadrial 1.8 5.5 11.0 15.6 19.3 19.3 19.3 91.8 10% 9.2 TOW a*luz t com 9.6 36.5 65.5 89.7 110.8 110.8 111.3 534.1 3% 14.7 TdcdAseBCOSS 123.6 315.7 495.1 6D1.0 612.1 546.2 533A 3W7.1 6% 202S Phydal Cend_ -18,11.3 27.8 42.4 50.3 49.1 42.5 41.2 264.7 8% 20.3 PricCongicies 5.0 35.6 90.1 148.8 191.1 207.1 240.5 918.1 9% 2 Totl RojUCTOSIS 139.8 379.0 627.6 800.0 852.4 79S.8 815.2 4,409.8 7% 305.3 Tas 85 21.8 34.3 41.8 41.1 35.9 36.0 219.2 PFreip Uxcmg 12.1 31A 49.1 59.1 56.7 48.4 48.5 305.3 184 Annex 19 Disbursement Accounts by Fhianciers (Total Cost In US$ Mlion) GOI iDD TOW Fer. (IL Dow & Amount lb A,_m f Am_ S Et l Td.N) 1I CIvl Woks 4.28 10% 38.50 90% 4278 41% 4.67 35.12 2.9 Gran, IlPeas.F ip &LoculCamltam 0.75 5% 14.17 95%. 14.92 14% - 14.92 Punur 0.74 20% 2.9 WS 3.69 4% 036 3.07 0.26 Eqpm &Heftblts 1.82 20% 7.29 SD% 9.12 9% 1.16 7.32 064 TllnIMarhIa& Boka 0.10 5% 1.92 95% 2.02 2% 0.04 1. 0.10 v'da 0.86 20% 3.43 SDS 4.29 4% .46 3.52 0.30 MC mai & Acavil 0.95 20% 3.79 80% 4.74 5% - 4.50 0.24 Hoewarluuto CuumultyVoutous 0.74 26% 2.09 74% 2.13 3% - 2.83 SalArofMAddoalo Staff 1.19 26% 3.37 74% 4.56 4% - 4.56 VdeiJoImw PANdStaff(PART2c) 1.10 20% 4.39 80% 5S 5% - 5.21 0.21 Camamabh 0.49 27% 1.35 7j% 1.84 2% 0.20 1.51 .33 MedIcu& MbdeI Mterials 0.81 27% 2.22 73% 3.04 3s 0.33 2.49 0.21 Equ1i_ilaFIetb opdoaMaint 0.68 27% 1.87 73% 2.55 3% 2.42 0.13 Clvi Wob maintnance 0.49 2S% 1.24 72% 1.73 2% I.64 0.09 T.AJD.A. o(Stiff 0.27 100% - - 0.27 0% - 0.27 Totdal 15.26 15% 8.58 83% 103I84 100% 7.23 91.26 5.35 185 ANNEX 19 Expenditure Accounts by Project Compoments (Coss in US$ Millions) Hea& _mo Iwaiq Swm F.W. QuRy D_md for F.W. Wqd.l Seric olF.W. J.W. Prop. areaC __ Dlwy Sevi sServi Me Selumed ToTda S hm_ Cds CIvU Wek (New) 22.38 3.59 - 3.88 0.32 30.17 10.0C 3. CIvi Waft tRobb & Upgrade) 4.88 3.34 0.18 8.40 10.00 06 Furnue 2.66 0.62 0.6 - 333 10.00 0M qulpzue.t 3.11 0.30 1.77 1.33 02S 6.76 10.00 0.S Vehiles 2.79 0.44 0.46 0.04 020 3.93 10.00 039 Books _ 0.36 - ' 0.36 10.00 0.08 Talne MaeI - 1.46 - - - 1.46 10.00 0.15 MC Mala & AcdviWes - - 4.27 - 4.27 10.00 A43 Heft Kis 1.41 0.02 - 1.43 10.00 0.14 Locd Tinin Savices - 7.32 0.19 - 751 5.00 0.38 1 Comatn_ - 0.13 0.05 0.80 0.93 5.00 0.A _a e S-e - - 329 3.29 Vdddiesb fo d Staff(PART 2) 4.95 - * - - 4.95 10.60 0.49 Grans toNGOs - - 2.06 2.06 - Grams to Pharmacy lsdt _ 0.09 - 0.09 Felwshps - 0.44 . - 0.44 WIeta Iedimn 0C0e 42.18 18.11 8.62 6.48 4.05 79.44 8.70 6.93 3.mCOt - . . Slaies of AddJidal Staff 0.10 2.45 033 1.43 - 4.32 5.00 0.22 Honeoarium to C anly Vouers 2.30 0.01 - - 2.81 T.AJID.A of Staff 0.S 0.02 0.07 - 0.25 10. 0.02 Com _asbes 0.75 0.42 0.02 0.45 - I.o4 10.00 0.16 Civi WoYk main 1.13 0.50 - - 1.63 5.00 0.08 Eipme & FleetOpeMn aMadIm 0.45 0.33 1.28 0.36 - 2.41 5.00 0.12 Mecms & Media Mateal 2.71 - - - 2.71 10.00 0.27 Tldd Reeirnat Coe 7.94 3.86 1.65 2.31 - 15.75 5.60 0.88 TdeBlASUNCOSIM 50.12 21.97 10.27 83.9 4.65 95.19 .20 7.1 hyica Co _ngncIe 4.65 1.61 0.74 0.74 0.Q8 7.81 - Price Cont _cIes 0.46 0.19 0.08 0.08 0.63 0.84 7.70 0.6 Tdal lOJEf COSTI 55.23 23.76 11.08 9.61 4.16 103.84 7.60 7.87 186 Anne 12 Project Components by Year (Base Costs in Rs. Million) 1995 1996 1997 1996 1999 200 2001 TOWal SIt Im Humh& F.W. Srvice Divery 74.4 183.9 277.1 324.5 312.6 267.8 258.7 1.699.0 ulrw Qtaity offP.W. Servkis 23.7 64.3 105.9 134.7 146.3 135.6 134.3 744.8 hreaslirft Deaa4 for F.W. Srvices 10.0 26.9 47.7 61.4 69.4 67.0 65.5 S48.0 Mlanagemntpf rent 11.6 30.2 45.8 56.2 56.4 49.0 48.8 297.9 Innovative Schemes 3.9 10.3 18.7 24.1 27.5 26.7 26.1 137.3 Totdl ASUEINK COSTS 123.6 315.7 495.1 601.0 612.1 546.2 533.4 3;2,.1 lysldacairagalews 11.3 27.8 42.4 50.3 49.1 42.5 41.2 264.7 PrIce ComningendIs 5.0 35.6 9G.1 148.8 191.1 207.1 240.5 918.1 Totld PROIKCT CoS 139.8 379.0 627.6 800.0 852.4 795.8 815.2 4.409.8 187 Annex12 Project Components by Finciers (Tot Costs in US$ Million) GOI RlD TOal For. (xd. Dies & Amou_ l Amoent % Aumt % hL Taxes) Taxes 0 Sugengd Healt & F.W. Service DDveqy 8.59 15.6% 46.64 84.4% 55.23 53.2% 4.97 46.74 3.52 bmprove Qualiy of F.W. Services 2.80 11.8% 20.96 88.2% 23.76 22.9% 1.10 21.84 0.82 bnrasn Demand for F.W. Services 2.03 18.3% 9.05 81.7% 11.08 10.7% 0.31 10.29 0.48 Managm n mprovement 1.53 15.9% 8.08 84.1% 9.61 9.3% 0.75 8.38 ).48 hmovative SchQm 0.30 7.2% 3.86 92.8% 4.16 4.0% 0.10 4.00 0.06 To-al Dlb _rsaut 1S.26 14.7% 88.58 85.3% 103.84 100.0% 7.23 91.26 5.35 188 Annex I Procurement Arrangements C(otal Costs In US$ Mfllions) .~ ~ ~ hun ,gbo W*_ llArd VOWpSUUT cdueuth. Local Direr Fore swan Bg Aeog C d _ N.S.F. Tetal CIVIL WORIKS CivD Works - 36.19 - - 6.60 - 42.78 (S2.S7) (5.94) (38.50) GOODS Veidces 3.99 - 0.30 4.29 '3.19) (0.24) (3.43) M?opos. Bkycles for Feld Staff - - 5.48 5.48 (4.39) (4.39) FPuau 2.71 0.98 - - 3.69 (217) (0.79) (2.9 Eqipmt & Healh Kits - 6.69 2.43 - - 9.12 (5.35) (1.94) (7.29) Ttrsnl Matcrtl & Booc - - 1.51 0.15 - - 1.67 (1.44) (0.13) (1.57) Cosbles - - 1.4 - - - 1.84 (1-35) (1.35) Mde & Medis Matral 3.04 - - 3.04 (2.22) TECHNCAL ASSJANCE Projec Prpatt & laplmni. 15.67 15.67 S-o clue Gram, Inatv Schm) (14.92) (14.92) Pr*CePMPKram &lmplemeo . 1.30 - - 1.30 St-,opM (Publy Seve) (1.04) (1.04) lstzloa Do nat incd . - - 3.04 - - 3.04 IEC & tain) 2.3S) (2.35) MISCELLANEUS Saaries of Additonal Staff - - - 4.56 - - 4.56 (337) (3.37) Hloorain to Commm_ty Voue - - 2.83 - - 2.83 (2.09) (2.09) T.A./D.A. of Staff - - - 027 0.27 Civi WorkaOpenasl&Mahi 1.73 - - 1.3 (1.24) (1.24) Eqp & Flet Opmtien & Maint - - - 2.55 - - 2.55 (187) (1sn Total 3.99 45.S8 15.58 31.82 6.60 0.27 103.84 (3.19) (40.0 (12.36) (27.01) (5.94) (88.58) Naot: FWig n parentes me repect eawm fhneed by MDA (b)iw ofCMMenu) 189 AmEX 19 DA FSaW Year Semester CSmmulatie $US Milon-- FY95 Ist (Jul94 - Dec 94) 1.93 1.93 3.00 3.00 2nd (Jan 95 - Jun 95) 1.93 3.86 0.37 3.37 FY96 Ist (Jul95 - Dec 95) 4.91 8.78 4.30 7.66 2nd(Jan96-Jun96) 4.91 13.69 4.30 11.96 FY97 Ist (Jul96 - Dec 96) 7.76 21.44 6.49 18.45 2nd (Jan 97 - Jun 3a) 7.76 29.20 6.49 24.94 FY98 lst (Jul97 - Dec 97) 9.56 38.76 7.96 32.90 2nd (Jan 98- Jun 98) 9.56 48.32 7.96 40.87 FY99 Ist (Jul 98- Dec 98) 9.84 58.16 8.20 49.07 2nd (Jan 99 - Jun 99) 9.84 68.00 8.20 57.27 FY200 lst (Ju 99 - Dec 99) 8.96 76.96 7.08 64.35 2nd(Jan2000-Jun2000) 8.96 85.92 7.08 71.43 FY2001 1st (Jul 2000 - Dec 2000) 8.96 94.88 7.08 78.51 2nd (Jan 2001 - Jun 2001) 8.96 103.84 7.08 85.58 FY2002 Ist (Jul 2001 - Dec 2001) 0.00 103.84 3.00 88.58 a ~ ~ ~ 5 3 liii If f l||| - 9 2v;;{ 3'0~~~~ ~~~~~ 3BS3tj2 lt t = k > 0 0 S S 9 f t~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ iX _' _$ | _ | | _ iE ; _ ; 3;~ _ _ slsf *jg __ I!~~ ~~ Ii---- E 191 Annex 19 CS ASSAM Cil W- W. New cmkmw ~ ~ ~~mumdCs MA 37 C1% - 2%CiW WaftR 3%~~~~~~~~~~~~~~~~~~~O Mc 1, .. .. __ ___. _V/80o 192 Annex12 Recufrrt Costs: ASSAM TA/DA & WHP 19/ Staf Consmuables/ Drep 2W,8%adMan 26% \~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 193 AnwrJLi IwMestnt Costs: ASSAM (Rupee Millions) 200 ------- .............. ...............-.---....................................................... 180 *Civil Wors New 0 ~~ ~ ~~~~~~ Civil Work 160 . Re..ab. /\ -- ¢ Furn./EquipiKits 140 /~~~~~~~> Vehicls 120 ......... -*---- Trn gjBoks / .JEC haterial 100 0..... - 80 *-----/ L i 7 § + X ¢ve-< * X h+* * in+e 40 ............. 0 1 2 3 4 5 6 7 L 9 S £ Z I 0 ................................ . . .001 .._=...- . ..... ...... .... o_ ................................... - . . . . ...................... ...... . .. WS ot ................................................................... .......................... of ~~~~~~~~~~~~~~*qpqo *w -j--- 081m ........................ o. ........ ............ ............ ..L0 (uo!1np uodnF nsss :slo )n IWSAUJ ............................. .......................... . . . . ..... . . .., . . . .. . O ....................................................... ............ ........ ......... .............. . . ........... ........................... ;jOOt . ....... ....................... MOZI ........... ...... . . . ...... .. ... .. .................... 09 ..........I...............................---.---- qm- -pA --- - - - - -j-IWD) 0 1 (uot, SS :swo3 Yuusasvul 61 xu"v 195 An= 12 Recurrent Costs: ASSAM (Rupee Million) Staff 35 ............ ................... .........................--........................... 3 0 Build./Maint. 2 5 .. ...... .......................... ........,3 * Consumables/Drugs _ 25 .... ; 20 TI TADA & WHP 10 .w .. ........... ........................................-.................................................... ................................... I .... .... .. ................... ....... ................................................................. ,; 1 2 3 4 5 6 7 Total Costs: ASSAM 600- . 400- / s- 300- -_ 200/- 100 Recunrnt Cos6 1995 1996 1997 1998 1999 2000 2001 196 Annex 19 RAJASTHAN fnvesentn Cosu: Rajas5ha Civil Works New 36% Civil Works Rehab. 2% 7% IW S _ __ _ 5% Tm&iBooks I - | 11 - I |1 I I- 7 0 197 Annex 19 Rcurrent Costs: Rajasdian TA/DA & WHP 3% Consumables/ Drugs 47%0/ L 9 S t 01 MU~~IjO9 ~UTq ~~ * - - .-*-- 0£ _ ~~~~~~~~~~~~~~~~~............................................ _ ............... .............. -OZ i~~111 .4o X- XI wao p .......... o . .. .......... ......... ......... ... i~~~~~~~~~~~~~~~~~. X. ....................................................................... ................. .. . .. ....... s| w dm arPP ........... ....... . ... .. ............. ... .......... .......... -- .- -OS m 4BatlY4 s n ._ ........... ....... ......................... ............ - 09 (uoqw d)UmB :sMD wuAIw UUUUv 961 L 9 S £ Z F I____ -UiW -fi -0I--_-- 01 ........................... .... _.. ....................... Sl a................................. ..... ..................................... -^ - -- ; _ sw OZ .................................. ........... ................---------:----'WD........ ...................................... * m s V - ...... OZ .................. ................. ........ ....... .......... ....... ... .... ...... ............. S ....... O£ .............................. .................... . . ...... 1~~~~ (UObtM usqlse.tekT :slso3 suaunsa u L 9 S E _ 0 .......... . .... ................... ...................... ..... ..... .... .. ... . .... ..... oz ................................ .............................................................................. .. .. . ...... .-. ............... . ..... . ... ...... . ....... .. ....... /:.O£ .................................................................... .................. ........ ................ ...... ......... . t MNrq-MPAiD--- O .............. ..........-.....................-.. . ..... ... 0S ...................... ..................................... ,,z_.... .......... v H -A W 09 ...................... .....................I.................... ................................ ............ ... ... . .. N P°l!D . OL (uot.!1 **&dl) ueqmeh :S)soa l uounsmul I1 in"U 661 ^1~~~~~~~~~~~~~~~~~~66 166 9~~~~~~~~~~~~~~~~~6 .~.. ..... ... ... . . .... ...."".'-."..... 1 .* . .... . ....9. .....~~~...... ... . ... ... 00g~~~~~~~~~~~ ......... ........... .......... . ..................... . ................... .~~~~~~~~............... . . . . .. . . .. . . .. . . . .. . . . . . .. . . .. . . .. . . . 201 Annex 19 KARNATAKA IwsnoCos. Kamtk Civil Woks Now 42r 2% Civil WoabRehab. 21% 16% 62oo V0% 202 Annex 12 Recunt Costs: Kamataka Staff 40%o Consumables/ Drugs 9% 203 Annex 19 Illvestment Costs: Karnataka (Rtupee Million) so0 .......... ......................................................................... ..... ............... It\\ F - * Civil Works New 70-- y . }Civil Works Rehab. 60 -------------- .................................... Furn./Equip./Kits ----Vehicles SO - ----- ------ ....................................................... - i'mg.A3ooks / EEC Material 40 -....................................................... .,1....... -*/---t- Grants/Fellowship 30 .-........ ........ .................... Inn. Scheme -X- Conswtants 120 -- .......................__... 0. 1 2 3 4 5 6 7 204 Annex I Investment Costs: Kamataka (Rupee Million) 80 - C l Works Now ..... ................................... - - -...........- 70 0- Cvi Wor Rehab. .....-............................... ---- ~~FumfiEquwpAIlts 6 0 ......................... ................................. ............................... ..... ....: 40 - ;..Ve7cl/ 30 ,____ ==_______=_ 40 1 . g cC .................- 20 1 2 3 4 5 6 7 Imtestme ,Costs: Kamnataka (Rupee Million) -Ue----- TrnBoks ,S ~ -IZI--- IEC Material -- 30 . $ Grants/Fellowls ................................... . . 25 - -- = S l e..................................................................... 2,0 ]- * osu 10 :3= 1 2 3 4 S 6 7 205 AnIne Recurrent Costs: Karnataka (Rupee Million) 18 *Staff ..... - - .-.--..--..-.._ =A ....... ...... ....... ......... 16 { 0 Build/Maint. ............ .... .... 14 ...... .. ..... .- -.......... .... .............. 12 Co s m D u s ........ ........... .. .. ...... ..........I......-..-............ 10 0 TAIDA & WHP ............. ....... ...I.......... .... . .-........ ......-............ ......... 6 .................. .. ........ .. ........... .... . ...... ... .... .... 4 / ............. .. ... ..... - . . . .....,........ 2 ------ ........... ..... .... ... .. ............. .. ... . ................. ........... ..... O 1 2 3 4 S67 Total Costs: Kamnatak:a (Rupee Mfillion) 100 Recuffet Costs 10 .199S 1996 1997 1998 1999 2000 2001 206 A n Smmv Analyse of Sustatnabiliy of Poect Iynyto," And Recumnt Cost fmpilcatlons Assam. Ranasthan and Kanataka A summary of the results of the sustainability analysis is shown in Table A.20.1. Table A.20.1 Recurrent Recurret Cost Total Tota RB Recurrent Costs Cost after after Completon Non-Plan Roecart Project Costs Completion w/Contiwgues H&FW Budget Cost as 1 (Rn. Million) Total As % (Per Annm) (Per Amum) by Yr 2000 of Budt AIssam 1,035.4 116.6 1 11.2% 24.6 34.3 1,306.0 2A% XlKarnataka 1,148.1 221.1 19.2% 45.9 63.9 3,700.0 1.7% l asthn 1,043.6 L 196.4_j 18.8% 40.8 56.8 1,418.0/a 4.0% /a VIM aid Non-Plan FW Budget 1. The project foresees total project cost witlhout contingencies of Rs 1,035.4 million of which approx. Rs 117 million or 11.2 percent ar recurrent costs. During its final year in 2000, it would require Rs 24.6 million annua}ly in recurrent costs at present values; if contingencies are computed, recurrent costs after project completion by the year 2000 will amount to Rs 34.3 million annually. 2. The efforts to sustain project activities after completion are worth special mentoning in Assam. Maintenance of buildings below the PHC level will be ensured through community contributions and through programmes which are part of the development plan of the state, as well as utilistation of untied funds at the disr qsal of the Deputy Commissioners. Main of other buildings are computed at 2 percenL of construction cost (or Rs 35 milion for up gradation of state dispensaries into PHCs) and reach a level of Rs 0.7 million anually only. Personnel of the construction cell will be borroved from Public Works Departmeit and after project completion, staff would be reverted back leaving only skeleton staff to be absorbed by the Health department This holds also true for other personnel in the project directoat which is to be constituted for the duration of the project on the basis of deputation from the main health deprtt. At the end of the project they would go back to their parent organistion. 3. Rs. 0.65 million annually have been quantified to cater for staff created by the project after completion. As far as taining and IEC are concemned, annual recurrent costs will amount to Rs 10 million to make sure that acdvities can be sustained at high levels beyond the 207 Annex20 project life. 4. Rs 24.6 million would also accommodate the additional recurrent cost incurred for the improvement of logistics. Still, annual recurrent costs are at a comparatively low level, thas to the special and innovative efforts to sustain project activities. S. It is impossible to tell at this time whether (01 will continue to maintain Fanily Welfi as a 100 percent centrally-financed program. It is possible that part or all of the progam's financing may be transferred to become a state responsibility, even if that is highly improbable for the State of Assam which is a special category state enjoying special dispention as far as plan funds are concmned. 6. In order to assess the future financial burden on the State of Assam and thus, the s_sanability of the recurrent costs generated by the project after its completion, the annual recrt costs will be held against the non-plan state budget of Health and Family Welfare in compatibility with other states covered by IPP IX. However, a more realistic sustainabiity analysis would also have to take into account the centrally-sponsored Family Welfare schemes within the plan Health Budget where about 45 percent or Rs 270 million of the total budget for 1993/94 of Rs 601 million is set aside for Family Welfare. It should also be mentioned that Assam enjoys special attention for the hill areas for which an additional provision is made in the plan and non-plan health budgets of approx. Rs 50 million (Rs 18 million for Family Welfre) and Rs 41 million (Rs 0.4 million for Family Welfare) p.a. respectively. 7. The State of Assam's combined Health and Family Welfre budget amounts to non- plan expenditures of approx. Rs 670 million in the year 1993/94 of which approx. Rs. 13 million go to Family Welfare. It is claimed that the expenditure on Health and Family Welfare bas reached a more than 12 percent real growth over the last 7 years. For the present analysis, a more consevative real growth rate of 10 percent annually will be computed. Accordingly, non- plan exenditures under the combined Health and Family Welfare budget would amount to Rs 1306 miUion by the year 2000, and expenditures for Family Welfare to Rs 26 million. 8. In the project proposal, the recurrent cost implication of the project after completion would be 2.6 percent of the total combined non-plan Health and Family Welfare budget of Assam (without taking into account the additional resources of Rs 42 million in 1993/94 for hill areas). If recurrent costs are only held against the non-plan Family Welfare budget, the recurrent cost implications would lie in the order of more than 100 percent. An increase of 2.6 percent can be considered as insignificant and the burden created by the project as minor. But an increase of more than 100 percent of the non-plan Family Welfre budget - or more than doubling - seems difficult to reach and therefore it might be concluded that only if funds from the general health budget could be transferred for Family Welfare activities, would the State of Assam be able to sustain project activities beyond the project's life without taldng into account centrally financed schemes. 208 Anug.20 9. The project foresees total project cost without contingencies of Rs 1,043.6 million of which approx. Rs 196.4 million or 18.8 percent are recurrent costs. During its final year in 2000, it would requie approx. Rs 40.8 million annually in recurent costs at present values; if condngencies are computed, recnt costs after project completion after the year 2000 will amount to approx. RS 56.8 million anually. (Recurrent cost after project completion are computed as follows: 1. State Institute of Health and Family Welfare: Rs 3.12 miliion, 2. New H.F.W.T.C.: Rs 2.0 million, 3. Two existing H.F.W.T.C.: 0.64 mifflion, 4. DTC: Rs 14.38 milion, 5. HMIS: Rs 0.86 million, 6. IEC: Rs 1.5S mon annually). 10. If part or all of the program's financing may be transferred to become a state responsibility, the future financial burden on the State of Rajasthan has to be assessed and thus, the susainability of the recurrent costs created by the project beyond the prqect's life. Therefore, the annual recrt expenditure will have to be held against the estmated state's budget resources available for Family Welfare in the State's FW budget as weUll as within the Stte's health budget. However, realstically, centrally-sponsored schemes should also be tae int account to assess fitmre sustinabilit. iI. For the year 1993/94, the budget esdmates on Family Welfare reached Rs 711 million on plan expenditures and Rs 49 million on non-plan expenditures. Assuming a future annual nominal growth rate of 10 percent, non-plan expenditures by the year 2000 will reach Rs 95 million. The total Family Welfare budget including centally-financed resources will amount to Rs 1418 million. 12. The recurent cost implication of the project after completion would be 60 percent of the total non-plan expenditure for Family Welfire. This means that if the annual recurrent costs would have to be covered by the state non-plan budget alone, the impact would be consderable. If recuret costs are held against the combined plan and non-plan Family Welfre expenditures, the impct would be in the order of 4.0 pent This burden is relatively insificant and the project can be considered as sustinable. KMRN&TAM 13. The proect proposal foresees total project cost without contingencies of Rs 1148. 1 million of which 19.2 percent or Rs 221 million are recuret costs. When the project will be completed by the year 2000, it would require Rs 45.9 million annually in recuent costs at present values; if contngencies are computed, recunent costs after project completion by the year 2000 will amount to Rs 63.9 million. 14. It is impossible to tell at this time whether GOI will continue to maintain Family Welfare as an almost 100 percent centrally-financed progam. It is possible that part or all of the program's financing may be transfed to become a state responsibility. In order to assess the future financial burden on the State of Kamataka and thus thie sustinability of the recurent AAO9 An=2 costs geneated by the project beyond the project's life, the annual recurring exediture will have to be held against the estimated non-plan state budget resources available for Family Welfae in the Stae's Family Welfare budget as well as within tfie State's Health budget. Two thirds of the State's non-plan Health budget arn claimed to be spent on Family Welfe expenditures acoording to the Secretay of Health. 15. For the year 1992/93, the expenditure on Family Welfare reached Rs 563 million on plan exenditures and Rs 38 miion on non-plan e tures over Rs 508 million and Rs 29 million respectively for the previous year representing an increase of 12 and 13 percent respecively. Assuming a future annual growth rate of 10 pecent, non-plan expendius by the year 2000 will reach Rs 74 million. The total Family Welfare budget will amount to Rs 1171 milion. Strictly, the sustainability analysis would have to limit itself to the implications on state budgets and disregard centrally-funded progams; however, it should be assumed, as in the case of Assam and Rajasthan, tat at least patt of the burden will be carmied by 001 and therefore, plan expenditures will be kn into account. 16. The Stabt of Karnatass combned Health and FW Budget amounts to Plan expenditures of Rs 1,478 million and non-plan expenditure of Rs 2,848 million or a total of Rs 4326 milion for the year 1993/94 which repents 4.66 percent of total state expediue. It is claimed that the expenditure on Health and Family Wehe has been growing at a compound rate of 14.4 percent since 1983. For the present analysis, a more consevative growth rate of 10 pert p.a. will be computed. Accodiny, non-plan expenditures would amount to Rs 5550 million by the year 2000. If two thirds of this amount are spent on Family Welfae expenditures, an amount of apprx. Rs 3,630 would be available by the year 2000 for Family WeLfare within the Health and FW Budget of Kanataka. The total resources of the Family Wfre budget of Rs 74 million and of the Family Welfae component of the Health Budget amount to Rs 3,700 miion by the year 2000. 17. The recont cost impHcation of the project after completion would be approx. 1.7 percent of the total non-plan cxpenditure for Family Welfare, provided two thirds of the Health Budget are acbually available for Family Welare. Ihis increase is rlatively insignificant and the burden created by the prqect can be considered as sustainable. However, if the annual recrent cost after project completion had to be financed by the non-plan state budget for Family Welfare solely, the impact of over 100 percent would be drmatic, as resources would have to be more than doubled. 210 Annex 21 Lists of Staff/Comnittee Members and Orfanigrams Of Project Management Structure Assam. Ralasthan and Karnataka Assam Empowered Committee * Minister of Health * Additional Chief Secremty & Special Comnussioner & Special Secretay (Health & Family WeLfare Deparment) * Additional Chief Sertary, P & D Department * Commissione, Finance * Commissioner, PWD * Secretary, Health & Family WeLfare * Representative of GOT. MOH&FW * Project Director Project Management Committee (PMC) * Additional Chief Secrety & Special Commissioner & Special Secretaty Health & Family Welfare Dqertm * Secretay, Health & Family Welfare • Director, Health Services * Director, Health Services (Family Welfare) * Project Director Project Directorate * Medical Officers and Nurse Trainers x Project Director * AU para-medical & Community Constrction Cell Health Workers * Superintending Engineer * Architect Monitoring & Evaluation Cell * Executive Engineer * Deputized pet'sonnel from * Assistant Engineer Dqeament * Section Officer * Drafts man IEC Cell * UD Assistant * Senior Consultant * LD Assistant cum Typist * Steno-Typist Materials Management Cell * Grade IV staff * Deputized personnel from * Diver Depant Consucion Ceol - Field office District Level Project Management * Executive Engineer District Project Coordination * Assnt Engineer Committee * Section Officer * Deputy Commissioner * LD Assistant cum Typist * Project Director, DRDA * Grade IV staff * Additional Deputy Commissioner * Driver (Dev.) * Executive Engineer (CiviliWater CM&HO) Healh Manpower Development Coil * Additional, CM&HO Public Health * Senior Consultant Enginering (Water Supply) * Tutor Consulants 211 Anmex2 IPP-IX Project Management A S S A M Empowered Project Cowmmi ttee Management CC tniettee Project Director I Project D irectorate Construction ealth Manpower| Monitoring & Materials Cell DeveloPment Evaluation IEC Cell Management c Cel Cell Dist. Proj. Construction District HMIS Mgmt. .- Field Trng. Centre Information Committee office _ ~~~~~& Hlh .. SDM&NO U!P Officer D Heat 212 Annex 21 Karnataka Project Governing Board (PGB) * The Chief Secrtary to the Gowernment * Representative of the Government of India * The Secretary to Government. Finance Depaumen * The Secretary to Go aermet Health & Family Welfare Dqeatm * The Director of Health & Family Welfire Seavices * The Additional Director (Family Welfiae & MCH) * The Project Coordinator PGB Steerng Committee * Secretary to Govement. Health & Family Welfare Departmnt * Secretay to Govenment, Finance Depatment * Additional Secrtary Health & Family Welfire * Director of Health & Famiy Welfare Services * Additional Director (Family Welfare & MCH) * Additional Director, Projects Intra Departmental Committee * Secrr, Health & Family Welfire * Additional Secretary, Health & Family Welfre * Ditector, Health & Family Welfire Services * Director, Population Centre * Additional Director, Family Welfare & MCH * Additional Director, Projeas Institute for Health & Family Welfare * Deputy Director Information * Director * Deputy Director Field Operations 3 Joint Director * Deputy Director Publicity * Deputy Director * First Division Assistant * Second Division Assistants Drivs * class IV Engineering Wing * Superintding Engineer * Assislant Executive Engineer * Assistant Engineer * Draughts man * Traces JAIES * Deputy Director * Senior Systems Analyst * Hardware Engineer * FDA * District - FDA IEC Cell * Joint Director IEC 213 Annex 21 IPP-IX Kamataka Project steering Governing Committee Board bry 81 IntrM Health & D epartmental FW Commfflee {:Addl. Sec.8 ;'Director ILH8FW J Add. Dir Adi D jXr.A 214 AUL= 21 IWaasthan Empowered Commite (EC) Monitorn Committee (MC) Disrict Coordination Committee (DCC) Secretariat: * Health Sccetary > Chief Coordinator * Specia Secry> Additional Chief Codiator * Deput Se ay Proje Coonato Straegc Maagement Unit (SMU) Directorate: * iror Medical Health Services -> Additional Project Dirtor Disict: * Chief Medcl Health Officer -> Distict project officer Human Resoures Development Commiftee (HRDC) -Diector Family Welfare * Additional Director HRD * Pnpal, SOWW * Prject Director Zonal Level Training Coordinating Committee - Jot Director District Traning Coordinato -Principals of District Training Centers Integated Statistiacal Unit * Medica Lecturer - Joint Dirctor Statistics * Management Lectu ProgramImer * Behavioral Science Lecturer *DaftaEntry * Health ComnctonLecturer * Statstica Officer State Institute of Health & Family Welfare * Social Science Instructor (S771HF) PHN1 Instructor *Principal Staff CMB) *Extension and Publicity Officer *Accounts Officer *Research Assistant *COMPUte Programmer *Field Investigtor *Library-cum-Docunientation Office *OffieSueitedn * Officer Sprnedn *Accountant * Clark-sum-Accountant-cunm-Store Keeper * ographer *~~~~~~~ Steno-Typist *UDC * Laboratory technician *Driver * Artist-cumi.draftsman *Class-IV' * Clerk-cum-typist * Laboratory Assistan Healt & Family Welfare Training Cenftrs * Projectionist * Principal (Deputy Director level Pleon 215 Annex 21 * Driver-cum-mechanic * Health Communications Instructor * Sweer * Mnagement Istructor * Cleaner * Nursing Tutor * Chowkidar-cum-mali * Soca Science Instructor * LDC * PHN Instrcors * Librarian Assistant * UDC * Driver * Junior Accounts Officer * Record Keper * LDCrrypist *Class IV Dirict Training Centers (DTC) * Driver * Senior Medical Officer IPP-IX Project Management Rajasthan E_owe_ ed monitoring NEel Comittee Committee Secretarat Secretary Str _lgic SOeputayr Spca i Unitw (sm Coordinator f - > ~~Hunan Resources| integrated |Zonal Trafning Health & Familyt District welfare Tr ining Trainino Center Centers 216 Annex 22 LIst of Additional Posts Created under the Project Ams Raaa and ka SUJbDARY OF ADDMlONAL POSTS POOE FOR CREATIQN UNDE13R JIPP ISK PROJECT STATES TOTAL NO. OF POSTS 1. Assam 90 2. Kamnataka 163 3. Rajastha 228 4. Department of 5 Family We1tr TOTAL NUMBER OF POSTS 486 217 LIS OF ADDMO-NAL STF PROPOED L A% HA Or NI DlBSIONATON NOF POltS A. Projea Directos 1. Projea diret 1 Offico 2. Steno-typist 1 3. U.D. Asstt. I 4. Grade IV 1 4 B. Financial Mansan 1. Sr. Fmnancial Adviser 1 2. Accountant 3. Cashir 4. L.D.A. cum typist I 4 C. Constrcati CCU 1. Supdt. Engineer I 2. Exective Engineer 5 3. Asistant Engincer 5 4. Archict 5. Section Oficer 1 6. Drdtasman 7. Steo-typist I S. LD. Asst.-cumypirt 6 9. Grade IV 6 35 D. Moaitosing Cea 1. Sr. Remearch Officer 2. Research Officer I 3. Reserch Asstt. I 3 L. Heath Manpower 1. Sr. Consultant I Development CeU 2. Sr. Consult 2 3. Stno-typist I 4. Grde IV I P. Mc Cll 1. Sr. Consulant 2. Astt. Edtor I 3. Steo-typist 1 4. Gade IV I 4 G. MatalManagem 1. Store Offier I Cdl 2. U.D. cum sto keaper 1 3. Paker 2 4. Grade IV I 5. Night Chowkidar I 6 218 A 2L N or UNIT D13SIGNMTON N, OFSl H. HMIS CAMl 1. Pm mer 2. Prrmme AtL 2 3 Tlaun Dim for nw voes 26 TOTAL NO. OF POST6S AdmIaliratlon 1.Jit Drect 1 2. Iq.aeumas A br ~~~~~~~~~~~~~~~~~~1 AsM Enginee Daann 2 Trams 2 3. MIIs Dy. Direor I St. Sy_ alyst 2 HNrdwm Eogioe Coputer Opea (FDA) 23 27 4. MIc Dy. direcor (dd Operation) I sooW S alia Dy. D.H.E.O. 2 AitI First Dhim Aa& I Onop D i Group D 9 S. ImW Dirr I IL Drecr I Dy. Dieco 10 Anti Dior 1 Fr Dhii Ase. 2 Second Division Asf. 2 Drven 4 Group D 2 23 6. DiM Troiog 'ock 19 Ceatr 19 CAM Group D 76 'S An tibd ita 219 Amna 2 m -.A NI_ofl DUati No. ofPos A. S.I.N,P.W. 1. Principal 2. Accouts Officor 1 3. Analyst cutt Porammer 4. Lbarin I S. OfMice Supdt. 6. Accountant 7. Stawo. S. UDC 3 9. LDC 2 1O.Drivcr 2 1I.ClasaslV 4 I2.Sodot Faculty 3 13.Faculty 3 14Ju1nior Faculty 4 1S.ReserchOffice 2 16.Research Investigator 2 7.Stenoghaper 2 34 D. HFWTC 1. Pdncipa 1 2. M.L.D.C. I 3. Communication Officer 1 4. Lectrer 1 S. E.P.O. 2 6. Soc. Sc. Instructor 1 7. Stat Offtcer I S. P.H.N. Insuctor 1 9. Office Supd. I 10. aekAcc/senghr 1 II. Stno-typist 12. Lab. Tochnicin I 13. Computer 1 14. Ar/Draftsman is. aerTypist 16. Lab. AsaaI 17. Class IV 3 18. Driver-cum-Moch. I 19. Chowia dar-cum-Mali I 20. Lecrer in Management 3 21. Lect. in Behaviourd Sc. 3 22. Resarch AsstL 3 23. Field veigaor 3 24. LDC 3 25. LbaianAAstn. 3 26. Record Keeper 3 43 220 AnKhL Name of Unit Deal m of Pam C. D.T.C. 1. Sr. Modica Offcer IS 2. HUalth Communlctou ht W 3. LDCtrypist 1 4. ManSement Instructor IS 5. Udo/Jr. Accounts 75 D. PROjECT MANAGEMENT 1. Mananenicut Utins 1. ProJect Director-cum Depuy SectY I 2. kt. Director I 3. Section Officer 1 4. Aslt. Accounts Offcer I S. Addl. Director (Proet) 1 6. Jt. Direcor (Servieo Ddeveay) I 7. Dy. Diretor (Project) I 8. Accounts Officer I 9. Accountant I 10. Stenograpber 3 1 1. Stat. Asiant I 12. Stat. inspetr 1 13. U.D.C. 4 14. L.D.C. 4 1S. aaa IV 2 16. Drvr 4 28 H. 1aji3n 1. Jt. Director 1 2. Snogapher 1 3. Driver 1 4. Caa IV I 4 M.HMIS Section 1. Dy. Dirctor (Mon.) 1 2. StaL Officer 3. Stat AamuL 2 4. Aalyi-cum-Ptogrlr 2 S. Programmer 2 6. Data Enty Opeaor (In. Coenatn 2) 4 11 IV. Construction Wina 1. Ex5ective Eaginsr 1 2. Dy. Arcict 1 3. AMs. Arcliect 2 4. Draftsm 2 5. LDC 1 6. Driver 7 221 2 2 P.M of Unit 12slonmo.o B. I.EC. 1. Dkor ([AS) 2. Jt. Direcor I 3. Dy. Dirctor I 4. Ast Dirctor 3 S. DocumentecoOffier I 6. D ibutian Ocer 1 7. Jr. Accountant I S. Sutopher 3 9. UDC 2 10. Eecrician I 11. A.V. Tecnician 1 12. LDC 2 13. Sound Recordef I 14. Driver 2 15. CIaaIV 4 16. Packer I 26 TOTAL POST S IV. Dentt.f F&mUX Wda&e 1. Desk OffcerI 2. Stenogapher (Gr.1) I 3. Progaer 1 4. DMtaEntry Operato s. Peon S Tota No. of Pes oo the dw "a: U+1a+22+S dU 222 AnnexL3 utline of &ope and Metbodology For BaseUne Suvneys and Other Evaluative Survens and Studies 1. Theprogess and impact of the project will be measured in tenrs of the agreed key proct indicators, as well as other indicators contained in the full indicator matrix (Annex 3). Routine implementation of the project will be monitored through: (a) MIS tracling (Annex 14); (b) six-monthly progress reports prepared by the state project management units (Annexes 26 and 27); (c) the Midterm Review (Annex 25). Evaluation of the project's effectiveness and impact will be canried out through a series of studies and surveys, namely a set of baseline surveys, mid-term studies and surveys, and various evaluative studies surveys including end- project surveys. This Annex outlines the scope and methodology required for the base-line, mid- term and end-project and other evaluative surveys and studies. Baseline Surveys and Studies 2. Population-based sample Baseline Surveys are required for all three states, to provide a set of baseline values for the project indicators of health and Family Welfare status, cens and uptake of services, and quality of services. In Assam, t& o results of the National Health and Family Welfare Survey held in 1993 will be used as the statelevel baseline survey if available, but a matching separate new baseline survey for the tribal poplion would then be carried out within the first year of the project. If the NFWS results are not available to the ate, en a new baseline survey for the entire state would have to be held within the same time- fiame. New baseline surveys should be carried out in Rajasthan and Karnataka within the first sx months of the proect. For the migratory population in Rajasthan, a special longitudinal study Is in progress Xt will track migratory groups through the annual migration cycle; because of dhe logistcal difficulties of surveying this population adequately, it will serve as both baseline suey and beneficiary needs assessment. For all states, a fuU analysis and final report of the baseline survey should be ready by the end of the project's first year. 3. Detailed design of the corntent and methodology of the Baseline Surveys will be the responsibility of each state, and shouid incorporate local concerns and conditions to the extent posible. However, it is recomm.ended that the NFWS design in each state be used as a model fo the basline survey, since it reflects state-of-the-art survey methodology and has been ucssfuly applied world-wide. The basis would be interviews of a sample of households and individual women witiin the households, with a sample size large enough to be disaggregated in analysis down to whatever level is chosen as suitable and feasible for the purpose of evaluating progress in the project and in the Family Welfare program. The district, or clusters of districts, might be suitable analytic units. However the design must also permit the evaluation of progress in tribal populations vis-a-vis non-tribal populations in each state, which will probably entail over-sampling of tribal groups in all states in order to yield sufficiently large tibal samples. 4. The Baseline Survey questionnaire, again following the NFWS model, would cover 223 Annyx 23 such topics as: fertility histories including child survival; knowledge, attitudes and prctce of all types of family planning method; place of last delivery and type of attendance at delivery; source and scope of antenatal care, including tetanus toxoid immunisation and iron supplementation; breastfeeding and infant feeding practices; incidence and treatment of diarrhoea, fever and acute respiratory infections among children; immunisation status of children; height and weight of children; treatment of children with vitamin A; etc. 5. To these core questions could be added modules dealing with access to and quality of Family Welfare services, such as: distance and travel time to nearest FW and health facilities; waiting times at facilities; services, staff and supplies available at facilities; attitudes of and towards FW staff; home visits from FW staff; use of private medical practitioners; etc. Such questions can be put to individual households and women, and also asked of community representatives under a separate Access to Services module. Additional modules could also be added as desired, to deal with such topics as: male attitudes and practices regarding Family Welfare services, particularly family planning; knowledge, attitudes, practices and available services for MTP; maternal mortality and morbidity; exposure to various IEC channels and messages; etc. 6. The analysis and report of the Baseline Surveys would aim to present a coherent picture of current levels, past trends and current differentials in: -the health and Family Welfare status of each state's population -access to health and Family Welfare services, including FW IEC -quality of FW services, including FW IEC 7. Values for as many as possible of key project impact indicators would be estimated, as well as for other indicators in the entire matrix of indicators. These would serve as benchmarks to measure subsequent project impact. Particular attention would also be paid to differenils between tribal and non-tribal populations and to trends in districts covered by the prect's civil works program (in Rajasthan and Karnataka). 8. In addition to the Baseline Surveys, other initial studies will be carried out as needed to establish baselines and benchmarks for the project. Examples would be further in-depth studies of tribal groups where the initial beneficiary assessments have indicated a need for them, and supplementary studies of training or IEC program needs. End-iftject livaluative Studies 9. In the final year of the project, population-based Final Evaluation Surveys would be caried out in all three states. These would consist of a repeat of each state's Baseline Survey. In Assam, this might entail a two-part survey, one covering the non-tribal population and one the trbal population, if this is needed to match the original baselines. In Rajasthan, it would include a repeat of the longitudinal migratory group study. The analysis of the final evaluative surveys would repeat the analysis for the Baseline Surveys, but add an analysis of trends in 224 ADD23 health and fmily planing status and service access, based on values for key indicators, which would seek to establish the impact of the project on them. Particular attention will be paid to trends in tribal and migratory areas, in differentials between tribal and non-tribal groups, and in project civil works districts (in Rajasthan and Karnataka). 10. In addition, f;nal evaluative studies of all new programs and aprroaches ploeered under the project will be carried out towards the close of the project, in order to determine their value and effectiveness. These would include any innovadve programs or approaches covered under the four main components of the project and any innovative schemes that have survived their initial testing and evaluation period. No model design or methodology can be laid down for this type of study, since each will need to be tailored to individual circumstances and requirements. The Mid-term Review 11. ITe Mid-tenn Review of the project will be carried out by the states appoximately half way through the project period, and is described in Annex 25 which lays out the superviion plan for the project. Its main objective will be to determine whether the project is on course or not, and whether any major adjustments need to be made in order to ensure that project funds will be fully utilised within the project period and the major goals of the proect will be achieved. Its core content, described in Annex 25, includes no studies or surveys. 12. However, in addition to the core content of the Review various studies and surveys may be carried out, if IDA and the states agree that it could usefully be done at that point (see Annex 25). These could include a repeat of the Baseline surveys, which could always at a minimum provide a useful picture of background trends in key indicators, even if proiect progress has been too slow to expect any specific impact of project activities on them. If progress has been fast, such a repeat might also give early indications of project impact. Repeats of the taining and communication needs assessments conducted as part of project preparton may also be carried out at this point. These would be used to assess the effectiveness and impact of the project in improving training and IEC programs. In addition, spcial in-depth evauative studies of any new and innovative prograns, approaches or schemes that appear particularly promising or problematic from field reports or their regular evaluation may be carried out. The design and methodology for these will again be tailored to the individual requirements of each study. 225 Am= Outline of Layout and Content for Si-MOlnthl lm enorta Sample IPP-IX Six-Monthly Project Report This sample report is provided to gie pojeCtS an outine to follow in the preparation of six-monthly repos fo submission to the World Bank and for use in inerl project rview ad evaluaui Executive Summary: InstJUCQIons: Proide a general ovevew of projea activities within the last six months; iclud * Summuary of activities * Budget * Project successes * Probms encountered Project Activities (Last six months) nstructions: Provide a geneal overview of acities completed. Aci'tiles Completed Instuctions: Provide a bief ovemew of the major actvities completed during the past period. Problems Encountered Instructions: All problems encounterod by the project during the past period should be outlined in dhiL lswes to be addnssed dwing review Inst tions: Specific isses which need to be addsessed by the project and suron minsons should be outined. Paoned Activities (Next six months) Insructions: Provide a geneal overw of activites to be completed duing the next period. This section should also ecplain how the planned activities directly eblte to goals of the project Project Budget: Ins_uctions: The goal of the prject budget summary is to asses the curt le of fandig for difrent categones of actives, and to evauate the mtes of spendig vs budgtd iems For each of the items the budget figumes should be provided. Addonal commen regarng under and over speing should be provied and discussed in the itl section Comments on Budgnt ntucons: Specific comments readg the budget and epedtur should be povided (ie. 1imds VWre not released for certin activaies eady enough for aoa). 226 AM= 2it Ptojed Expeditures by Category item Total Total Amount Amount Differe Amount Budget Budget Spent Budgeted Spent Last next 6 months Est PIT PFM last 6 6 Months .__________ months Civl Work Furniture _ . Computers . - Trinin _ ___ _____ _____ ______ _, ____ __ _ etc_ . __ . ___'_____ _________-__ etc. (0) Project To Date (PTD) Graphs of BadgertExpend%res 1) (Bar Chart) Total Budgeted for category to date Total Spent for category to date 2) (Bar Chart) Total Budgeted this period Total Spent this period Budget for next penod 3) (Pie Chart) Expdiurs this period by catey Specific Achievements/Activities (This period) Ilstructions: Complete a matrix of all activities which w ere planned for the previous six monkt and the staus of the activity. Training MO Traiuing for new group of Complted New materials wre officers under proect dveloped for taining _ ____course. HMIS Trining for District bealth On.Gon New forms were gnen to personnel CHMO at training __ __ __ ___ ___ _ _ _ _ _ __ _ _ _ _ __ sessions_ Constucio 10 new PHC's to be sted 8 PHCs stated Unable to locate adeqte duringperiod site in vilIge for two .________ .________________ _ ___ PHCs Complete 20 PHCs 17 Completed Three PHCs are waiutg for materials prior to ._ _ __ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ com pletion Projct Complete prject staffing AUl P _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ been filled ETC. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 227 Az24 Activities Planned (Next Period) Instructions: A worksheet should be prepared outlining all activities that are to be compleWd in the next 6 months. This plan should be developed to specify activities, and other project related information as a blueprint for action. Categories can be any gruping of activities the project wishes to iden*. The categories should match those used for reporting completed activities as shown in the prvious worksheet Construction Complete proposal Contuction Rainy Season Inldude revised review of NGO design Cel, Architect, starts in two blueprints for all for SCs NGO months SCs being cr IEC KAP Survey for new EEC Cell, local Personnel not Covea of suvey radio campaign radio station, available for should indude IlHMR sui tribal populations as _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___ _ _ _ _ _ _ _ _ _ _ _ _a sub-s Quick survey of Tribal EEC Cel TrPjals are Ideni specific Needs Assessment migiatozy factors relaed to __________ _______________ duwing period heath cue access. ETC. I_ + - Key Indicators Insuctions: Inoron on key indicators should be provided based on available information. The physical completon targes should be reported on a six-monty basis. Additdonaly, any appropite project process indicators should be included m the report A full analysis of indicator status should be maintained and presented witiin the annmal reporl # planned to be # completed % of Number to be # to Total completed ths thisperiod Target completed next complete Completed pperiod period- in project SC's .___ _ __ ___L PHC's__ _ _ _ _ _ _ _ _ Training institutions Boat Clinics L Mobile Clinics Etc.. _ 228 Annex 24 Compliance with Major Covenants Section Type of Status Original Revised Description of Covenant Comment Covenant Date Date 7.1 Assurances from 001 GOI provided an assurance that it would: 7.1(a) F Carry out with IDA in December of each year a review of the actual expenditures incurred under the project during that fiscal year, azid by March 31 of each year a review of the resources required for the project for the following fiscal year, in order to determine that there will be full provision for that year's planned project activities. 7.1(b) T Implement the Action Plan for Revamping the Family Welfare Program. 7.2 F Joint Assurance from 001 and the States of Assam. Raiasthan and Karataka During negotiations, 001 and the States of Assam, Rajasthan and Karnataka provided assurances that they would: prepare and have audited by independent auditors acceptable to IDA, accounts and financial statements for the project for each fiscal year; maintain statements of expenditure according to sound accounting practices, retain them for at least one year after completion of the audit for the fiscal year in which the last withdrawal was made, and include a separate opinion on them in the annual audit; and furnish copies of these accounts to IDA as soon as possible, but not later than nine months after the end of each fiscal year. 7.3 M Assurances from the States of Assam. Raiasthan and Karnataka The States of Assam, Rajasthan and Karnataka also provided assurances that they would: 7.3(a) Establish the full project management structure, including all Comminttees and technical units by October 30, 1994. 7.3(b) Engage all other key additional personnel to be recruited under the project by December 31, 1994. 229 Annex 24 7.3(c) Ensure that the Empowered Project Committees hold regular meetings at a frequency adequate for effective project direction and supervision, but in any case at least twice a year. 7.3(d) Prepare and submit to IDA for approval by January 31 of each year, annual civil works, training, IEC, MIS and service delivery plans for the following fiscal year substantially in accordance with content and timetables embodied in Annex 26. 7.3(e) Six-monthly progress reports to IDA in conformity With the format and timetable laid out in Annex 24. 7.3(f) Carry out, in each state, a baseline survey, a Midterm Review, and final evaluative studies and surveys according to the protocols, methodologies and timetables laid out in Annex 23. 7.3(g) Adhere to the selection criteria for location and siting of sub-centre buildings laid out in Annex 6 in the construction of all sub- centres during the project period under either l_________ _______ _________ _________ project or non-project funding. 7.3(h) Ensure that adequate resources are provided on a timely basis, through a series of measures agreed with the Association, for the maintenance of Family Welfare facilities and will ensure that the facilities are l _______ _______ ________ ________ adequately maintained. 7.3(i) Ensure that adequate supplies of drugs and other medical materials are made available to sub-centres, PHCs and FRUs on a timely basis, by, inter alia: (a) establishing an essential drugs list for Family Welfare program drug purchases by December 31, 1994; (b) from January 1, 1995 onwards, purchasing all drugs for the Family Welfare program, under either project or non-project funding, solely from among items on the essential drugs list; and (c) mobilising incremental resources for drugs and other medical supplies for Family Welfare facilities. 7.3) _ Implement the State Action Plans. 230 Amm 24 7.3(k) Utilise the key project indicators laid out in Annex 3, and related to national and state Action Plan goals and objectives, for project monitoring and evaluation of project __________ implementation and imapact. 7.3Q) Implement fully their tribal strategies as laid out in Annex 17. 7.3(m) Select NGOs for participation in the project in accordance with criteria and procedures - - ________ ________ ~~~~~~agreed with the Associationi.- 7.3(n) Obtain approval from the Association for selection of innovative schemes to be carried out under the project. 7.4 State of The State of Karnataa also provided an assurance during negotiations that it would: Begin by July 1, 1995 implemertation of a progam, to be funded out of state non- project funds, of adequate rehabilitation of Family Welfare facilit. s constructed prior to the project, whicb wiil be carried out according to a timetable agreed with the Association; and furnish to the Association evidence of satisfactory implementation of the rebabilitation program. -ype or Covennt OK: Covenat complied with Soon: Compliance expected in reasonably short time NYD: Not yet due ACT: Needs use of formal remedies to bring about compliance RVS: Needs to be tevised M: Mamaga F: Financial T: Technical E: Economic 231 Annex Annexes: (Materials for Report) Contacts and Physicl Progress Provide informaton on construion contcs and progress of work on contracts. Consrucion Saus Workheet Guwahati PHC Comrletd 100% I Jan. 95 on "" |SC Foundation 30% SJue 95 comiletd .JEt Lcf- = 1 Penonne Staflng Workshe aing programs in _thesummer. Etc. IC Worksee Film shows Health Posts Awareness of Services 126 27,733 available at SC% and Etc. PHCIS Traning Planing Worksee 232 Other Materials to be Induded: * Special Reports * Survey Studies * HMIS Summaty Rqps * IEC Mateials Produced * Detailed budgt PReports * Etc. Sample Budget Report (Six-Monthly) Civil Works 5000 4000 -1000 1000 800 -200 400 Fumiture 1000 800 -200 200 200 0 200 Equipment 2000 1000 -1000 600 500 -100 600 Computers 500 300 -200 100 100 0t 100 Vehides 1000 700 -300 200 100 -100 200 materials 500 200 -300 100 75 -25 100 Training 2000 1500 -500 1000 900 -100 1000 Grants to NGOs 500 200 -300 100 :80 -20 100 Totals: 12500 8700 -3800 3300 2755 -545 3700 233 AnneiL24 Sample Poject To Date (PTD) Graph Grants to NGO's - . * ~~~~~Towa Spent FM Training _ . ATouta Budgete ne Materas L__ Vehides_L Com0uteost Equipment Furnturen Civil Works 0 500 4ooo 1520060250 800 3000 3500 4000 5000 Sample Graph: This Period Grants to NG'sm__ Training - M.t al Amount Budgete next6 Vehicles months| Computers w Amount Spent last 6 Months| Equipment ~~~~ 's Amount Budgeted last 6 Equiprnent e . 8 =j ~Months Fumiture | Civil Works 0 200 400 600 800 10,00 12,00 140 234 Annex 24 Sample Graph: Expenditures this Period Amount Spent last 6 Months Fumiur Civil Wors r/O 290% Equipm_ 18% Gfants to NGOes l ces 4% , ) illl 11111 i _ M*ineals 3% Trining 3I% 235 Annex 2S Supeision Plan General Rouffne Sunervison 1. The core of the routine supervision process will be the six-monthly Bank supevsion missions. An indispensable basis for this will be the six-monthly progrss reports to be submitted by each state project directorate (see below for an outine of their format and content). In addition, the large, costly and complex civil works component will be covered by a specidal extra system of locally-based supervision. 2. Mission Frequency. Scheduling. Programs: Regular Bank supervision missions wil visit the project approximately every six months. Thus if the project is launched in mid-1994, supervision missions would be scheduled between November, 1994 and January, 1995 and between May and July, 1995; and so on for each year of the project. 3. On each supervision mission there will be a joint meeting of all three state project teams either in Delhi or in one of the state capitals (on a rotation basis). At this meeting, the three project directors will present their six-monthly progress reports for review and discussion. This meeting will also serve the purpose of disseminating and sharing experience between the three states on a regular basis. 4. On each supervision mission one of the project states will also be visited by the mission, again on a rotation basis. The general meeting would normally be held in that state if it is not held in Delhi. The visit would include field trips for the mission architect (see below) and for other missions members as appropriate. Trbal or nomadic areas in every state will be visited at least once every two years. In Assam, the distncts with autonomous district development councils will be visited at least twice during the life of the project, at least once in the first half and at least once in the second half; the councils will also be invited to participate in any general project meeting held in Assam. 5. Composition of Missions: The missions will be led by the Bank task manager and will always include an architect (see below). In prnciple, the mission teams will also always include specialists in public health, training, IEC and relate