Document of The World Bank
FOR OFFICIAL USE ONLY
Public Disclosure Authorized Report No. 5589
PROJECT PERFORMANCE AUDIT REPORT
JAMAICA SECOND POPULATION PROJECT
(LOAN 1284-JM) Public Disclosure Authorized
April 9, 1985 Public Disclosure Authorized Public Disclosure Authorized
Operations Evaluation Department
This document has a restricted distribution and may be used by recipients only in the perfonance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS
Currency Unit Jamaican Dollar (J$)
Appraisal Year Average: US$1.00 = J$0.91 Intervening Years: 1978 US$1.00 = J$1.70 1979-82 US$1.00 = J$1.78 1983 US$1.00 = J$3.28
GOVERNMENT FISCAL YEAR
April 1 to March 31
ABBREVIATIONS
CCRA Cornwall County Health Administration CHA Community Health Aide CHW Community Health Workers FP Family Planning GDP Gross Domestic Product GFR General Fertility Rate GOJ Government of Jamaica ICB International Competitive Bidding IEC Information, Education and Communication JPP Jamaica Population Project LCB Local Competitive Bidding MCH Maternal and Child Health MOHEC Ministry of Health and Environmental Control NDA National Development Agency NFPB National Family Planning Board PAHO Pan-American Health Organization PEU Planning and Evaluation Unit UNDP United Nations Development Agency USAID United States Agency for International Development WRAG Women of Reproductive Age Group FOR OMCIAL USE ONLY
POPULATIONIHEALTHINUTRITON STATUS AND TREND/a
1960 1982
Total Population (million) 1.6 2.4 Birth Rate (per thousand) 42 27 Death Rate (per thousand) 9 6 Rate of Natural Increase (Z) 3.3 2.1 Infant Mortality Rate (per thousand) 52 10 Total Fertility Rate 6.7 3.4 Z Population under 14 39 38 Z Population over 65 4 6 % Urban 34 48 Life Expectancy (Male/Female) 61/71 65/75 GNP Per Capita (US$dollars) 1,330 Population per physician 2,590 2,830 Population per nursing staff 420 630 Contraceptive Prevalence (%) 55 Daily Calorie Supply (Total) 2,643 as % of requirement 119
/a For definitions see next page.
Sources: World Development Report 1984. Population Reference Bureau, data sheet 1984.
This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. DEFINITIONS
Age-Specific Fertility Rate : Number of registered births per thousand women of a specific age group during the year.
Contraceptive Prevalence : Percentage of married women of reproductive age (15-49) using some method of contraception at a given time.
Crude Birth Rate (CBR) : Number of registered births per thousand at mid-year.
Crude Death Rate (CDR) : Number of registered deaths per thousand at mid-year.
Discontinuation (Attrition Rate) : Annual rate of suspended use by a cohort of acceptors. Specific for each method of coatraception.
General Fertility Rate : Number of registered births per thousand women between 15-44 years of age.
Gomez Scale : Grade 1 - 75-89Z of standard weight for age. Grade 2 - 60-74% of standard weight for age. Grade 3 - 59% of standard weight.
Gross Reproduction Rate : Computed similarly to the total fertility rate (see below) but based on family births only.
Infant Mortality Rate : Number of infant death (between 0-1 year of age) per thousand live births.
Maternal Mortality Rate (MMR) : Number of mother's deaths per thousand live births, as a result of complications of pregnancy, childbirth and the following ten-day period (puerperium).
Net Reproduction Rate (NRR) The total number of female births experienced by a woman from 15-44 years of age but taking into account their age-specific death rates. The net reproduction rate is significant in relation to a stable population. Rate of Natural Increase (RNI) : Crude birth rate minus crude death rate, usually expressed as a percentage.
Total Fertility Rate (TFR) : The average number of children that would be born per woman if she were to live to the end of her child- bearing years, and bear children according to a given set of age- specific fertility rates. The Total Fertility Rate often serves as an estimate of the average num- ber of children per family. PROJECT PERFORMANCE AUDIT REPORT
JAMAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
TABLE OF CONTENTS
Page No.
Preface ...... i Basic Data Sheet ...... ii Highlights ...... iii
PROJECT PERFORMANCE AUDIT MEMORANDUM
I. BACKGROUND AND SETTING ...... 1
National Context ...... 1 Jamaican Economy ...... 2 Sector Context ...... 3 Bank's Involvement ...... 5
II. PROJECT SUMMARY ...... 6
Project Formulation ...... 6 Project Implementation ...... 7 Project Impact ...... 8
III. PROJECT ISSUES ...... 9
A. Project Design ...... 9 B. Project Environment ...... 12 C. Bank Lending Policy and Supervision ...... 13 D. Institutional Development and Technical Assistance ... 14
IV. FOLLOW-ON AND SUSTAINABILITY ...... 15
Table 1 Net Recurrent and Capital Expenditure for the Ministry of Health ...... 17
ANNEXES:
1. Project Summary of First Population Project ...... 19 2. Clinics in Cornwall County ...... 23 3. Technical Assistance in Population Projects -...... 27 TABLE OF CONTENTS (cont'd)
Page No.
PROJECT COMPLETION REPORT
I. Introduction ...... 31 II. Project Implementation ...... 38 III. Project Cost and Financing ...... 50 IV. Outcome and Impact of the Project ...... 51 V. Bank Performance ...... 55 VI. Conclusions ...... 57
ANNEXES: 1 - 12
Map: IBRD 11939 Location of Health Facilities PROJECT PERFORMANCE AUDIT REPORT
JAMAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
PREFACE
This is a performance audit of the Second Population Project in Jamaica, for which a loan of US$6.8 million was approved in June 1976. The original loan closing date of December 31, 1980 was extended twice to December 31, 1982. The final disbursement was made in September 1983 and the remaining balance (US$0.77 million) was cancelled.
The audit report consists of an audit memorandum prepared by the Operations Evaluation Department (OED) and a Project Completion Report (PCR) prepared by the Population, Health and Nutrition (PHN) Department. The PCR was prepared following a mission to Jamaica in June 1983 and is based upon a completion report prepared by the Ministry of Health and Environmental Con- trol (MOHEC), available in OED. The audit memorandum is based on a review of the Appraisal Report (1040b-JM) dated May 27, 1976, the President's Report (P-1859-JM) dated May 27, 1976, the Loan Agreement dated June 17, 1976, and the PCR. Correspondence with the Borrower and internal Bank memoranda on project issues as contained in Bank files have been reviewed, and Bank staff associated with the project have been interviewed. The Project Performance Audit Report (PPAR) of the Jamaica First Population Project (Loan 690-JM), DED Report No. 2580 dated June 29, 1979 has also been consulted.
An OED mission visited Jamaica in September 1984 for the audit of this project. Discussions were held with officials in the MOREC, the Minis- try of Finance, the Planning Institute of Jamaica, the University of the West Indies, the regional Cornwall County Administration the National Development Agency (NDA) and the United States Agency for International Development (USAID). A field trip to Cornwall County to visit project clinics was under- taken. The information gathered during the mission was used to test the validity of the PCR's conclusions.
The audit finds that although the PCR covers the project's salient features it insufficiently highlights the main lessons learned and the real achievements made by the project. In addition to summprizing the objectives and results of the project, the audit memorandum expands upon certain issues because their importance to this as well as to other population projects - particularly the effects of project design on project performance. environmental effects, the Bank's lending style in population, institutional development and technical assistance. - ii -
The draft report was sent to the Borrower for comments on December 20, 1984; however, none have been received.
The valuable assistance provided during the preparation of this report by officials of the Government of Jamaica and executing agencies is gratefully acknowledged. PROJECT MERIORMANCK AUDIT RORT BASIC DATA BURT
JAMAECA SECDND 10PULAIN PROJECT (LOAN 123 4-JM)
KEY PAJCT DATA
Appraisal Actual or Actual as Z of Item Expectation Current Estimate Agerateal Etizate Total Project Cost (US$ million) 14.14 12.16 86 Loan/Credit Amount (US$ million) 6.80 6.03 89 Date Board Approval - 061176 Date Signing - 06/17/76 Date Effectiveness 09/15/76 B/30/76 83/a Date Physical Component Completed/b 06/30/80 12/31/81 1377 Proportion then completed (M) 100 102 Closing Date 12/31/S0 12/31/52/c 144/a Economic Rate of Return (Z%/d N.A. N.A. Financial Rate of Return (z%Td N.A. N.A. Institutional Performance good good/e Number of Direct Beneficiaries Not available Not avallable
Cumulative Estimated and Actual Dimbursements (US million) TY77 FT78 rY79 M80 MT31 FY82 M13
Appraisal estimate (US$ million) 0.3 3.2 4.6 6.4 6.6 6.8 6.8 Actual (USS million) -It 0.8 1.9 2.6 3.4 4.5 6.0 Actual as 2 of estimate -TF 25 41 41 50 66 8 Cancelled (09/13/83): USSO.77 million Principal repaid (08/31/84): US$0.43 million
MISSION DATA
Honth/ No. of Staff days Specializationm Performance Types of Mission Year Persons in Field Represented ! Ratiag /b Trend /i Problems l
Identification 04/74 4 20 - Preparation 07/74 - - - Appraisal 10-11/75 6 10B -
Supervision I /k 05/76 2 10 PR,A,C 1 Supervision II 11/76 1 2 A Supervision III/k 03/77 3 11 PH,A.C I Supervision IV T 0177 2 10 A.C 1 Supervision V Ik 04/78 1 5 A 1 2 Supervision VI7k 06/78 3 21 EO,A 3 3 F Supervision VII 07/79 2 10 A.10 2 1 P.m Supervision VIII 02/80 4 20 ED,A,C.PH 2 1 F Supervision IX 07/80 4 20 A.C,PH.PO 2 1 F Supervision X 04/81 2 14 A.PO - - - Supervision XI 02/82 3 21 PD.A,PR 2 1 F Supervision XI 10/82 2 10 PH,A 1 2 r Completion 06/83 2 20 PH
OTHER PROJECT DATA
Borrower Government of Jamaica (GDJ) Executing Agency Ministry of Health (10)
Preceding Project:/l Name First Population Project Loan Number 69 O-JH Loan Amount (USS million) 2.0 Date Board Approval 06/16/70
Follor-on Project Under Consideration
/a Percentage in third column to be calculated from date of signing. T Construction of Health Clinics. c The Closing Date was extended twice; first to 12/31/81 then to 12/31/82. Id Not applicable in population projectm. le Given the circumstances that I19O use operating under extreme financial constraints of of its control. 77 Negligible. E PH = physician/public health; 10 - population; A - architect; C - communication. 1 - problear-free or minor problems; 2 - moderate problems; and 3 - ajor problems. li 1 - improving; 2 - stationary; and 3 - deteriorating. F- financial; M - managerial; T - technical; P - political; and 0 - other. k Cambined mission to supervise First and Second Projects. ? PPIR OED Report No. 2580 dated June 29, 1979. - iv -
PROJECT PERFORMANCE AUDIT REPORT
JAMAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
HIGRLIGHTS
This was the Bank's second project supporting population activities in Jamaica. The loan was signed on June 1976, in the amount of US$6.8 million. The project included both hardware and software components. The focus of the hardware components consisted of the construction and support of 58 health centers in Cornwall County. At the national level, the project supported the development of human resources and the strengthening of the planning, research and health maintenance capacities of the Ministry of Health and Environmental Control (MOHEC).
Although the focus of the project was to strengthen integration of maternal and child health, population, and nutrition services within MOHEC's infrastructure, project objectives included reducing (i) fertility and (ii) malnourishment in children of 0-4 years of age. The project was successful in making important contributions towards strengthening the process of integration by improving the level of services available in the new clinics and institutionalizing a decentralized system of administration in Cornwall County. The project's impact on fertility trends and nutrition status, how- ever, could not be determined due to difficulty in isolating these effects from those of other program interventions (PPAM, para. 27).
Important lessons were learned in the process, and these and other points of special interest are:
- a clear hierarchy of project objectives should be established; these include: program objectives, strategy performance indica- tors, and physical implementation and utilization targets (PPAM, paras. 29-32);
- project environment invariably changes; thus, room for change should be built-in during preparation and monitored carefully during implementation to facilitate the actual process of modifica- tion (PPAM, paras. 39-41);
- institutional and bureaucratic arrangements need more attention; familiarity with the decision-making power structure is essential for both project design and implementation supervision (PPAM, para. 41); -v-
- supervision should pay attention not only to implementation symptoms but also to the underlying constraints (PPAM, paras. 42-43);
- lessons learned from the first two projects can now be utilized in the design of a third project (PPAM, paras. 47-50); and
- Government's capacity to implement a possible third project needs to be carefully assessed (PPAM, para. 50). -1-
PROJECT PERFORMANCE AUDIT MEORANDUK
JAMAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
I. BACKGROUND AND SETTING
National Context
1. The island of Jamaica occupies an area of 11,000 km2 and is one of the three largest islands in the Caribbean. The population is largely of African descent but has Chinese, Indian and European minorities as well.
2. Administratively, the country is divided into three counties and thirteen parishes. Each parish (local administrative unit) has a council which carries important local responsibilities but has limited power over policy-making and financing.
3. The political structure of Government is based on a parliamentary system where the majority partly is the effective Government. The Jamaica Labor Party (JLP), presently in power, and the People's National Party (PNP) are the two main parties. Of the two, the PNP is more socialistic in out- look; it was in power from 1972-80, thus overlapping with the execution of the Second Population Project for four years: 1976-80. The party supported the concept of improved health for all, and compared to the JLP, was more oriented towards free health services for the public.
4. The social system of Jamaica is unique in that marriage does not necessarily constitute a basis for a family union or -the licencing of pareathood-; socially, marriage is not automatically linked with parent- hood.1/ Sixty-eight percent of all unions are either "common la4" or visiting-, and are institutionalized within the societal system. The economic situation of the man defines whether he will enter into a more stable union or not. Census figures for 1970 indicate that children precede formal marriage by nearly eight years for a great many couples. Although parents eventually do get married, about 70% of the children are born out of common law and visiting unions. 2 / Evidence indicates that women entering legal marriages do so at a later age than those entering common law or visit- ing unions. Also, there appears to be more spacing between births among single than married mothers and, finally, fertility rates tend to be
1/ B. Malinowski, -Parenthood - the basis of social structure-, in V. F. Calverton and S. D. Schwalhausen's, The New Generation, New York, 1930.
2/ George W. Roberts and Sonia A. Sinclair, Women in Jamaica: Patterns of Reproduction and Family, New York, KTO Press, 1978. - 2 -
higher for legally married mothers as compared to mothers in common law and visiting unions.3/
5. Structurally, the Jamaican society is in a stage of transition from a society stratified on the basis of color and race where the economic and social institutions favored the white plantation owners, other expatriates and wealthy nationals towards a society where the divisions are based more on economic and occupational lines. 4 /
Jamaican Economy 5 /
6. The bauxite- and tourism-based strategy of economic development adopted by the Government since independence in 1962 was severely affected by external disturbances (induced by increases in energy costs; impact of reces- sion in the industrial world on sugar and aluminum demand; increase in interest rates in international capital markets), and by domestic policies. On the domestic end, Government efforts to provide employment, social bene- fits and redistribution of land coincided with these external conditions and finally led to an over-extended public sector and a disruption of the produc- tion sector. The economic crisis had a serious effect on unemployment, which peaked at 29% of the labor force in 1980 and most seriously affected youth and women. The signs of economic decline had begun to show by 1974 and increased considerably by 1976-77, when acute scarcity of foreign exchange became apparent and the budget deficit reached as high as 11% of GDP. This economic deterioration coincided with the start-up stages of the Second Popu- lation Project signed in June 1976.6/ By 1980, real GDP was 18% below the 1973 peak; investment expenditures declined from 22% of GDP in 1974 to 13% in 1980.
3/ Irene Green, -Effects of the Population Explosion on Jamaican Interna- tional Relations-, The South African Institute of International Affairs, 1966.
4/ Irving Kaplan, Howard Blutstein, K. T. Johnston, David S. McMorris, Area Handbook for Jamaica, American University, 1976.
5/ For details see the following World Bank reports: Jamaica: Development Issues and Economic Prospects, Report No. 3781-JM dated January 29, 1982; Jamaica: Structural Adjustment, Export Development and Private Investment, Report No. 3955-JM dated June 3, 1982; and Jamaica Recent Development and Economic Prospects, Report No. 4905-JM dated January 17, 1984.
6/ Concern over Government overextending itself and need for caution in keeping the project within Government's capacity to manage and support, was a regular theme in Bank internal documents. - 3 -
7. There has been some recovery in the 1980s.7/ Investment expendi- tures have increased and inflation fell to 6.5%in 1983 as compared to 29% in 1980. Nevertheless, unemployment remained high (27% in 1983).
Sector Context
8. A country's demographic patterns are significant in any efforts towards developing its economic situation.8 / In the past, largely due to high levels of emigration and reduced fertility in the mid-1960s and early 1970s, Jamaica's population growth has been maintained at 1.5% between 1970-82.9/ This rate of growth compares favorably to other Caribbean islands, and Jamaica can reach a net reproduction rate of one by the year 2005.10/ However, the rate of population growth can be affected by changes in the birth and death rates (which are influenced by the age structure of the popu- lation) and shifts in the scale of migration. In 1976, approximately 47% of the population was at reproductive age (15-49) and 35% in their teenate years (14.1% between 15-19) or close to entering them (21% between 10-14).1_/ This is a significant target group as teenage pregnancies are prevalent in Jamaica (PCR, Annex 2). Changes in emigration laws, making it more difficult for especially Jamaican professionals to leave, are also under consideration at the Government level.
9. In 1982, the population was estimated at approximately 2 million. Population density averages approximately 206 persons per km2 . In the urban parishes, such as Kingston and St. Andrews, it is as high as 1,600 persons per km 2 .
10. The Government of Jamaica leads other Latin American and Caribbean countries in adopting a policy position on population reduction. In January 1974, the -Ministry Paper No. 1: Family Planning" affirmed Government commitment. 12 / This has since been followed by the adoption of a national population policy by the Parliament in 1983. The population policy seeks to establish goals consistent with economic and social development of the coun- try.
7/ GDP is expected to grow at an average rate of 3% from 1983-90 with major emphasis on agriculture, manufacturing and tourism sectors.
8/ See World Development Report (WDR), World Bank, 1984, for macro- and micro-economic effects of rapid population growth, pp. 79-105.
9/ For further details on demographic status and trends, see PCR, paras. 1.03-1.10.
10/ WDR, 1984, table 19, page 254. ll/ Economic and Social Survey (GOJ), January 1976.
12/ This document waE the first policy directive of M0HEC calling for integration of fitmily planning with the regular health services, including the trar.sfer of 143 family planning workers from the NFPB into the MOHEC. 11. Prior to 1974, the strategy for population work was based on a single purpose -- "verticle approach" - where the National Family Planning Board (NFPB) was the agency responsible for the management and delivery of family planning services. Other programs by volunteer and private effort consisted of family life education, commercial distribution of pills and con- doms, counselling services and the workers' population education program, conducted by the trade unions.
12. In 1974, the Government made a strategic decision to integrate family planning and nutrition services within the health care system. Family planning clinics and related health staff, originally under the jurisdiction of NFPB, were brought within MOHEC's infrastructure and management frame- work. The decision to integrate services was influenced by: weakening lead- ership of NFPB; shifts in professional international thinking in favor of integration; 1/ and growing resistance by the public against population control, which made the issues politically sensitive with the PNP Government (PPAX, para. 3).
13. Integration required complete reorganization of MOHEC, a lengthy and difficult process, 1 4 / primarily due to a lack clarity in the roles and positions of staff, uncertain management mechanisms, salary and grading issues, and personality problems. In support of its strategy, in 1974 Government prepared a document, "Medicare for Jamaica: The Health of the Nation", which became the basis for the Second Population Project. In 1975, a task force was given the responsibility of developing a Plan of Action to carry out Government objectives towards meeting the health needs of the people within the Primary Health Care Framework.
14. The organizational infrastructure at the time of project appraisal involved multiple agencies and departments. Although the roles these agen- cies played in directly implementing the project varied, linkages between them were needed for effective operation. According to audit observations, the agencies and departments involved had different internal policies and procedures and administrative and accounting systems. In many instances, the linkages between the different agencies needed for effective coordination were either non-existent or operated on an ad hoc, informal basis.
15. Overall management responsibility for supervision and implementa- tion of health services (including family planning) rests with MOREC, which is divided into technical and administrative divisions. Family Planning (FP) is part of the Maternal and Child Health (MCH) division. At the operational level, the services are delivered and administered through staff at the county, district and parish levels. The Government is the main provide: of
13/ David Korten, "Organizing and Managing the Population Program in the Post-Bucharest Era*, prepared for the 10th Annual Meeting of the Associ- ation of Public Health 1976.
14/ The reorganization process which was initiated [n 1974 was not quite in place throughout the implementation of the Second Population Project, according to senior Government officials. - 5 - health care, and services are provided through 28 Government hospitals, one university hospital and 375 primary health care centers. In addition, there are private hospitals and clinics. Contraceptives are also available through commercial distribution.
16. Population work is financed largely through the public sector as part of MOHEC's budget. MOREC's recurrent and capital expenditures. as a percentage of the total Government budget, has been declining since the 1974-75 fiscal year (see PPAM, Table 1). The Government presently is in the process of introducing a fee system for the use of Government health facilities.15/
Bank Involvement
17. A Bank loan in the amount of US$2.0 million was made in 1970 for the First Population Project. 1 6 / The main components of the first project consisted of building a new wing on the Victoria Jubilee Hospital in Kingston, the construction of ten maternity centers, and technical assistance for NFPB. The basic project strategy was to expand delivery facilities to permit post-partum recruitment of acceptors who delivered in medical facili- ties. Although the first project was not successful in increasing family planning acceptors through the post-partum approach, it did lay a solid foundation for the the second project (for further details see PPAM, Annex I and PCR, para. 1.18).
18. The important lesson that was learned from the first project was that women in Jamaica were unwilling or reluctant to use single-purpose family planning service clinics. 1 7 ! This could be due to cultural factors, the inconvenient locations of the clinics, or preference for hospitals which provide multiple types of services. As a consequence, under the second proj- ect five of the ten maternity centers constructed under the first project were to be converted into centers providing MCH/FP/Nutrition services. Also, the pilot experience with Community Health Aids for outreach work was expand- ed under the second project. Furthermore, under the second project the post-partum approach was expanded from the one hospital covered under the first project to all the remaining hospitals in Jamaica. In the audit's view, the basis for this latter decision was questionable as there had been no increase in the number of post-partum acceptors under the first project.18/ Interviews with MOHEC's staff tend to confirm this viewpoint.
15/ Ministry paper on health services, as reported in The Daily Gleaner, September 18, 1984.
16/ Project Performance Audit Report, Jamaica First Population Project (Loan 690-JM), OED Report No. 2580 dated June 29, 1979 (hereafter referred to as PPAR First Project).
17/ PPAR First Project, paras. 19-24.
18/ PPAR First Project, para. 3.19. - 6 -
Finally, contracting experience under the first project resulted in a condition of disbursement for the second loan, namely that MOHEC was required to engage the National Development Agency (NDA) to take responsibility for the construction component and the procurement of furniture and equipment (PCR, para. 1.24), and this arrangement worked out well.
II. PROJECT SUMMARY
Project Formulation
19. Discussions about a second project began as early as 1974. The project, at an estimated cost of US$14.4 million, was to be executed over a four-year period. A Bank loan of US$6.8 million was approved in June 1976.
20. In the early project discussions, it became evident that MOHEC was primarily interested in the Bank project to: (a) strengthen its strategy of integration and establish a base for Primary Health Care (PHC) 1 9 /, and (b) to use Bank assistance as leverage in its dialogue with the Ministry of Finance (MOF). 2 0 / Government recognized the advantage of Bank involvement in the population, health and nutrition sector for instituting sectoral reforms (decentralization, budget administration and manpower development). Although the concept of -integration- was consistent with the current profes- sional ttiinking in the international arena at the time, it appears not to have been in accordance with what was then the Bank's lending policy for the sector.2 1 / This led to some problems in that there were differences in how the project objectives were perceived between the Bank and MOHEC.2 2 /
21. The project consisted of hardware and software components and had a regional and national scope (see also PCR, paras. 1.19-1.24). The focus of the project strategy was to contribute towards Government's plan for integra- tion of family planning, nutrition and health services. As noted above
19/ A task force to study this was established in 1975.
20/ The latter was confirmed in discussions with senior project staff in MOREC and Bank project officers.
21/ As amplified in internal guidelines in the Bank at that time, the Bank did not lead for health projects, and even if projects contained large health components, projects could only be called population projects and justified on the basis of demographic criteria.
22/ "The specific objectives of the four-year project are: (a) to reduce the general fertility rate from the 1974 level of 182/1000 to 150/1000 in 1980 by providing improved and integrated MCH/FP/nutrition services (formerly these services were segregated and unipurpose) and (b) to reduce malnutrition among children from 0 to 4 years of age and among pregnant and lactating women." (SAR summary and conclusions). The MCH objectives were to support the integration effort (PPAM, paras. 12-13). - 7 -
(PPAM, paras. 11-13), in 1974 the Government had made a decision to bring these services under the jurisdiction of MOHEC, which became responsible for the management of the Second Population Project.
22. At the regional level, in Cornwall County, located in the western part of the island, the Bank financed construction costs, vehicles and equip- ment for 57 health centers in the county's five parishes.
23. At the national level, the Bank's input (for a detailed list see PCR, para. 1.22) consisted of:
(a) technical assistance, fellowships and equipment for two midwifery training schools, demographic impact and research activities, other studies, and support for the planning and evaluation unit in MOKEC;
(b) technical assistance, equipment and vehicles for MOHEC inservice training and a nutrition education and communication components;
(c) technical assistance for a health facility maintenance unit and a building utilization study;
(d) equipment for Community Health Aid (CHA) training and expansion of the post-partum program; and
(e) funds for innovative activities.2 3!
Project Implementation
24. Considerable turnover in key project management positions within KOHEC as well as among Bank project officers, occurred from project identifi- cation through completion. This, combined with financial problems caused by the country's economic crisis in 1978, affected project implementation. In the end, the project was completed with a savings of about US$2.0 million, due to non-implementation of some components in the software area 2 4 / and to efficient procurement procedures (PCR, Chapter II provides the necessary project implementation details).
25. The hardware component of the project was effective (once the proj- ect resumed after implementation had been temporarily halted due to the economic situation) in that construction was completed on schedule, although
23/ US$400,000 was available under the project to support innovative activi- ties that may arise during the project years. The example given in the Appraisal Report was strengthening of the commercial distribution system of contraceptives.
24/ Demographic research activities were not carried out; technical assis- tance was ineffectively utilized for the planning and evaluation unit in MOHEC and its function and role are still unclear; training for CHAs and midwives fell short of targets; and only a few innovative activities were carried out. - 8 - site selection and acquisition problems caused some delay in project start- up. Once completed, however, roof leakage, plumbing and electrical problems persisted, primarily due to poor quality materials (see also PPAM, paras. 37-38). Procurement of vehicles and equipment was carried out smoothly. Bulk ordering contributed to project savings but created storage problems, as many of the components for which equipment and vehicles were ordered were not in place at time of the arrival of goods.
26. As also pointed out in the PCR (paras. 2.20-2.40), implementation of the software components was not as successful. A number of components were only partially implemented or not implemented at all. The audit is in agreement with the PCR that lack of financial support and shortages of staff were some of the problems, but is also of the opinion that there were design constraints which also affected the outcome of these components (PPAM, paras. 28-38).
Project Impact
27. When measured against project objectives 2 5 / the project did not, in the audit's view, have the intended impact. In addition, the causality of project impact on "macro" objectives cannot be established as the project cannot be isolated from effects of other ongoing projects or activities in the country or the region (for more details see PPAM, paras. 29-33). In the audit's view, however, the project did have an impact on:
(a) MOHEC's management capacitl to develop an effective administrative system in Cornwall County; 6/
(b) HOHEC's capacity to collect clinic level data in a systematized manner and to computerize it centrally, thus strengthening planning and evaluation;
(c) local capability in developing human resources for health services, especially training of community health workers (CHWs) and estab- lishing a decentralized system for training, which is being expand- ed to other regions; and
(d) expanded community access to health facilities through improved performance in the new clinics constructed under the project as compared to the older clinics in Cornwall County.2 7!
25/ As stated in the PCR (para. 1.19) these were: (a) to reduce fertility; (b) to reduce serious protein-calorie malnutrition among children from 0-4 years and eliminate anemia among pregnant and lactating women; and (c) to help reduce maternal and child mortality in Cornwall County.
26/ According to discussions with MOHEC's management staff, the Cornwall County model is being extended to two other counties of the island.
27/ There was both an increase in the total number of clinic visits and day services given from the second quarter of 1983 to the same perod in 1984. For details see PPAM, Annex 2. -9-
III. ISSUES
A. Project Design
28. OED's Annual Reviews have repeatedly shown that good project design is an essential ingredient to project success, as is flexibility during implementation. 2 8 / In this light, the performance of the Jamaica Second Population Project, in the audit's view, could have been enhanced by:
a) setting realistic objectives;
b) specifying performance indicators to assess the effectiveness of project strategy;
c) clearly defining management and administrative responsibilities; and
d) conducting an on-goiag review of physical design and construction.
29. Setting Realistic Objectives. During design of the Jamaica Second Population Project, project objectives were stated in terms of reduction of fertility and improvement of nutrition status (detailed in PPAM, footnotes 22 and 25). These objectives were derived from population and nutrition policy directives for the program as a whole as well as socio-economic development factors, whereas the project strategy (PCR, paras. 1.20-1.21) is more limited in that it would only have an impact on strengthening the integration system and services in Cornwall County, MOHEC's capability to develop human resources responsible for delivering services, and recruiting family planning acceptors in hospital settings.
30. Program objectives are unrealistic yardsticks for assessing proj- ects because program goals are achieved by multiple Government and non- Government interventions and efforts by other donor agencies, and are influenced by socio-economic development in general. The Second Population Project is only one component of the Government's (MOHEC's) efforts. Even if program objectives are being achieved, it would be difficult to establish the causal link between project results and program achievements.
31. Specification of Performance Indicators to Assess the Effectiveness of Project Strategy. During project design, quantifiable goals to measure the outcome of the various project strategies (PCR, paras. 1.20-1.21) were
28/ For example, see Tenth Annual Review of Project Performance Audit Results, OED Report No. 5248 dated August 30, 1984. "The importance of design, including detailed planning for successful project implementa- tion is recognized, although flexibility is also essential for adapting to changed circumstances;" (Volume III, Annex 3, para xi). Simularly, in the Ninth Annual Review of Project Performance Audit Results, OED Report No. 4720 dated September 16, 1983: "A conclusion which remains evident through the series of Annual Reviews is the importance of proj- ect design for successful project implementation" (Volume I, para. 4.09). - 10 - not stated. In the absence of such quantifiable targets and related indicators, real project achievement and impact could not be assessed. To what extent project strategies have been effectively implemented becomes a matter of subjective judgement, always open to debate. More objective measurement of strategy performance would be preferable.
32. Even if program objectives need to be specified as part of project justification, the audit suggests that during project preparation a clear hierarchy of project objectives be established: program objectives, strategy performance indicators and physical implementation and utilization targets. Indicators at the delivery and the institutional levels will both assist in linking project impact to the overall program goals as well as provide guidance as to what type of data need to be collected, processed and analyzed for purposes of management information and project impact evaluation.
33. With reference to institutional development, the objectives should be stated keeping in mind the time frame necessary for bringing about organi- zational changes, a point also made in the audit of the India Population Project 2 9 / and founded on experience with other Bank projects.3 0!
34. Clear Definition of Management and Administrative Responsibilities. In terms of project management the Government and the Bank had two choices: (i) to establish a separate implementation unit or (ii) to use existing MOREC staff and infrastructure.
35. The audit supports the decision to use existing MOHEC staff and departments for project management, which in this case appears to have been the most appropriate in terms of institutional development. However, while designing the project's institutional framework, it appears that two aspects did not receive enough attention. First, various Government officials in Jamaica mentioned the problems caused by dual responsibilities. As the amount of effort staff would devote to the project would depend upon how they perceived the priority of project work in relation to their other responsibilities which may be perceived to be more important for their own career development. Second, as designed, project management was to consist of existing MOHEC staff, namely a project director who was also the permanent secretary, and two deputy directors, one for technical supervision and one for construction supervision. But, the functions of administration and accounting were left undefined during the preparation process. 3 1!
29/ Project Performance Audit Report, India First Population Project (Credit 312-IN), OED Report No. 3748 dated December 31, 1981.
30/ Institutional Development in Africa: A Review of World Bank Project Experience (2 volumes), OED Report No. 5085 dated May 17, 1984.
31/ However, during project implementation, the situation improved consider- ably by the appointment of the project administrator and accountant, a good illustration of the point made above (para. 28) about flexibility in project design. - 11 -
36. Coordination and supervision linkages necessary for project execu- tion both within MOREC and with other agencies should have been determined during preparation. Problems of cash flow, accounting, staff recruitment, site acquisition, maintenance and supervision of different components, especially the post-partum and nutrition education components, can be attributed to poor linkages between different MOHEC departments, between the center and local counties, and among different agencies involved in project execution. Establishing coordinating committees does not appear to be the answer in the Jamaican context 3 2 / and thus a more structured system of clearly defined roles and functions was needed from the beginning.
37. Ongoing Review of Physical Design and Construction. The original clinic designs did not fully meet expectationsJJ/. It also showed a bias in favor of maximizing health center staff convenience. Clinic design was based on optimization by planning the doctors' movement through use of working sub-corridors. Doctors' performance is doubled if the doctor is able to move between already prepared patients. This produces a highly efficient use of skilled staff time although it tends to use more floor space. 3 4! However, it should be kept in mind that in Jamaica the majority of the health centers are not manned by full-time doctors and only provide doctor services on a refer- ral basis once or twice a week. Other staff, such as health inspectors and health educators, are in the field approximately 50% of the time. The audit observed that in the 20 clinics visited nearly half of the offices and exam- ination rooms were not being fully utilized. The working sub-corridors and multiple waiting areas only caused confusion for the patients. In the words of one doctor, patients often get lost as they tend to wander off and find a place to sit where there is least congestion.
38. The construction design called for four types of health centers changing in complexity in terms of staffing patterns and services provided (PCR, Annex 6). Because of financial constraints and the results of the Building Utilization Study (which was not done until most of the clinics were completed), there was some scaling down of the more complex centers (Types 3 and 4) in favor of more Type 2 clinics, 3 5 / and certain modifications were required in space allocations. Aluminum roof design has resulted in high temperatures inside the buildings, causing drug storage problems. Also, according to the Building Utilization Study, communication between clients and staff is often quite difficult when it rains.
32/ Experience with coordinating committees in general has been mixed; see for example, Seventh Annual Review of Project Performance Audit Results, OED Report No. 3640 dated October 9, 1981 (para. 3.44).
33/ In terms of efficiency of treatment area, record storage, supplementary food storage, waiting areas, and utilization of space. Building Utiliz- ation Study, GOJ, 1982, section VII.
34/ World Bank internal files, consultant advice, September 28, 1976.
35/ Function and characteristics of each type are detailed in PCR, Annex 6. - 12 -
B. Project Environment
39. Jamaica's population projects provided a good illustration of the changing environment within which projects have to be executed. Shifts in political leadership can mean differences in commitment; changes in social relationships such as formal or common law marriages may change the number of children people will have; changing sexual behavior of a certain group such as teenagers can have implications for family planning communication and delivery systems, in terms of identifying target groups; changes in economic conditions can disrupt financial support; and internal organizational changes induced by strategy shifts can cause lack of effective planning, management and supervision. These uncertainties have implications for project prepara- tion and appraisal. They call for a built-in warning system (can also be provided by supervision) and, as mentioned above (PPAM para. 28), some flexi- bility in project design to accommodate some of the requirements of the changing environment. For example, in the case of Jamaica there were fairly early signs that the economic situation was deteriorating. The proportion of actual total Government expenditure on health declined from 9.2% in 1972/73 to 6.8% in 1976/77. Jamaica was also facing difficult fiscal problems. In addition, MOHEC was being reorganized and functioni and relationships between the different units were unclear and undefined. Furthermore, problems of recruiting new staff were evident as early as 1975 (MOHEC letter to the Bank, March 1975), but the success of the second project depended to a large extent on recruitment of additional staff in most areas of project concern (Cornwall County administration, post-partum program, nutrition education, outreach work, training, planning and evaluation). In the audit's view, these factors should have been considered in the preparation stage of the project.
40. On the other hand, consultant provisions were used flexibly in that local instead of foreign consultants were used. Also, towards the end of the project, money left over was used for additional equipment.3 6 / However, not enough flexibility was used in reassessing problem components such as the post-partum program which faced serious staff problems, primarily due to poorly defined job descriptions of the health educators. Throughout the project, uncertainty existed concerning to whom the nurse educators were accountable, and further, their grading system alloved for no upward mobility and therefore no incentive to stay in the jobs. Also, the Planning and Evaluation Unit suffered from an unclear definition of its functions, making it difficult to decide what to plan for, what to evaluate, and what data to collect for evaluation purposes. Correcting the problems with the Health Facilities Maintenance Unit was outside MOHEC's control since the unit was under the Department of Public Works. But it was envisaged that the unit would be transferred to MOHEC. Such transfers from one ministry to another are often bureaucratically difficult to implement, and transfer arrangements should have been given more in-depth consideration. Similarly, the success of the demographic research component was dependent on establishing a new infrastructure in MOHEC. Primarily because the relationship between the
36/ Dental equipment for 10 clinics. - 13 -
Registrar General's Department (responsible for collecting basic data), the Department of Statistics (responsible for processing of data), and the Planning and Evaluation Unit in MOREC were not clearly established. The demographic research component infrastructure was never established. Again, the design should have been more sensitive to these institutional arrangements, and similarly, during implementation more efforts should have been made to understand these bureaucratic requirements.
41. Two lessons seem pertinent to this project experience and have wider application for other projects. First, project environments invariably change, and room for change should therefore be built-in from the beginning and monitored carefully during implementation to facilitate the actual process of modification. Second, institutional and bureaucratic arrangements need much more attention throughout. 37 / The traditional organigram is insufficient to capture actual lines of command and decision-making. Famil- iarity with the decision-making power structure in such areas as budgeting, funding, staffing and policy-making is essential for both project design and implementation supervision, and also to determine what data are required at what levels for proper project monitoring.3 8/ In this context, the methodology developed for the design of rural development projects39 /, which includes specifically the analysis of pcwer and control structures, might well have wider application for the design of population projects.
C. Bank's Lending Policy and Supervision
42. The population sector is undoubtedly one of the most sensitive sectors in the Bank's lending. Most countries are reluctant to borrow for population and prefer grant money available through other donor agencies. However, many countries do have investment needs for expanding their health delivery infrastructure. Available grant money is not sufficient to meet the size of the investments required, and in many cases grants cannot be used to finance such physical infrastructure. By contrast, the Bank is among donor agencies that do lend for infrastructural expansion. It also has a compara- tive advantage in that it can assist countries with such population or health projects against the much broader scope of its sector and economic know- ledge. In the audit's view, given Jamaica's economic situation, the Bank should have made greater effort to ensure that Government did not extend its
37/ Various task forces were established in Jamaica to provide background details for project design and appraisal (Human Resources, Physical Resources, Socio-Demographic Characteristics, and Nutrition/Food Produc- tion). In retrospect, a task force on institutional arrangements for project implementation would have been quite useful.
38/ On this subject, see "Built-In Project Monitoring and Evaluation: Rural Development in Northeast Brazil," OED Report No. 5078 dated May 11, 1984 (para- 4.11).
39/ "The Design of Organizations for Rural Development Projects--A Progress Report", World Bank Staff Working Paper No. 375, March 1980. - 14 - capacity beyond what was realistacally feasible, especially in terms of what could be financed locally during, and more importantly beyond, the project period. Alternatively, more options for cost recovery could have been considered. Regarding the latter, Government is presently planning to charge fees, which would offset at least part of the costs, for the use of health centers.40/
43. Although the PCR (paras. 5.01-5.07) recognizes that Bank supervi- sion should have been more definitive and to-the-point regarding the problem components, it does not suggest what should have been done. In the audit's opinion, there is a tendency in the PCR and the supervision reports to relate all problems to financial (lack of funds) or staff shortages. While correct, however, these are often only symptoms of more deeply rooted problems, and the appropriate solutions or problem-solving actions would have been to go beyond the symptoms and to examine planning, budgeting and project design to see how the impact of the underlying constraints could be minimized, perhaps through a wider sector and future operations dialogue. It would be useful during supervision to pay attention not only to symptoms but also to the underlying constraints. 4 1 / The audit is also of the view that supervision is often too much retrospective when reporting on problems; more anticipation of their occurrence would be helpful. For example, problems of commissioning health centers could, in the audit's view, have been anticipated ahead of time, given the lack of progress being made on the part of the Government in recruiting staff needed for the health centers.
D. Institutional Development and Technical Assistance
44. Institutional development is crucial for efficient transfer of resources and to ensure sustainability of completed projects. Under the project, five institutions were to be strengthened, sometimes by creation of new units within these institutions. These were the Cornwall County Health Administration, a Planning and Evaluation Unit in MOREC, a Research Unit in MOHEC, a Health Facility Maintenance Unit, and a Midwifery School at Cornwall Hospital. The audit assesses the success of institutional development to be mixed. The Cornwall County Administration and Midwifery School were found to be successful. Although both components took time to institutionalize, they had an impact on MOHEC's capacity to improve local level administration and training. In the case of other units mentioned above, institution building was of varying success, as stated in the PCR (paras. 2.01-2.05 and 4.07- 4.08). Lack of planning concerning the roles and functions of staff, problematic management and monitoring were the major obstacles observed by
40/ Ministry paper on health services as reported in The Daily Gleaner, September 18, 1984.
41/ in this context, project implementation reviews at the country level have been proven most useful. Another case where such country-wide reviews would have been useful is recorded in the PPAR on the Ivory Coast Second Cocoa Project (Loan 1069-IVC), OED Report No. 5190 dated June 19, 1984. - 15 - by the audit. Similar problems with institutional development were also experienced in other Bank population projects.4 2 /
45. Under the project, technical assistance and fellowships were the two main tools to support institutional development. Under this project, more investments in technical assistance were made in proportion to total project cost as compared with other Bank population projects (PPAM, Annex 3). This is also true for the population projects in the Latin America and the Caribbean Region as compared with other regions. There was a greater focus on research and evaluation under these projects, which obviously requires more technical assistance.
46. Out of 28 technical assistance positions envisaged, 23 were filled, and most of the fellowships were used. Government decided to hire local consultants where possible, and the decision to hire local consultants bene- fited the project in terms of cost and their familiarity with the Jamaican conditions. However, the impact of the work these consultants performed is unclear, as most of the institutional components which were dependent on technical assistance were not very successful, with the exception of training (PCR, paras. 2.20-2.40). This raises issues of Government's commitment to technical assistance, its implementation capacity to screen and select con- sultants, and the design of technical assistance (terms of reference).4 3 /
IV. FOLLOW-ON AND SUSTAINABILITY
47. To date two population projects have been financed by the Bank in Jamaica. The loan for the First Population Project (PPAM, paras. 17-18) was small, and the project strategy focused on recruiting family planning acceptors through the post-partum approach. During the project it became evident that this strategy was limited, and a broader focus was required to effectively strengthen the U3vernment's demographic program. The second project, therefore, while continuing support for the post-partum approach, also included components to strengthen MOHEC's institutional capacity and assist in extending the family planning services to the rural areas through the integrated approach that the Government had adopted (PPAM, paras. 10-16). Although the second project made a considerable contribution (PPAM, paras. 24-27), the appraisal and implementation of the project coincided with
42/ Project Performance Audit Reports on India First Population Project (Credit 312-IN), OED Report No. 3748 dated December 31, 1981; Indonesia Population Project (Loan 1373-IND), OED Report under preparation; Dominican Republic First Population and Family Welfare Project (Loan 1325-T-DO), OED Report under preparation; and Kenya First Population Project (Credit 468-KE), OED Report No. 3536 dated June 1981.
43/ Also highlighted in the Project Implementation Overview Paper produced by Project Advisory Staff in June 1983. - 16 - deteriorating economic conditions in the country, and MOHEC could not effectively implement and sustain many of the project components. There was a severe cut-back in staff with no new staff being hired, and construction inputs were reduced to modify the design, changing the more complex health centers to more modest ones.
48. In July 1983, a national population policy was approved by the Parliament, and NFPB was delegated the power to implement and promote family planning and population activities. The Government, as part of its health policy, proposed to extend access to health services and facilities in order to reduce regional inequalities. The three major priorities were to: (i) reduce the escalating high costs; (ii) expand and improve the integrated health system, and develop linkages between primary and secondary care; and (iii) strengthen MOHEC management.
49. Discussions concerning a possible Third Population and Health Proj- ect are underway between the Bank and the Government of Jamaica. As presently conceived, the main objectives of this project would be to generate demand for family planning services, particularly among target groups, and to improve access to and quality of family planning programs. The project would also help the Government to induce control measures to relieve the burden of cost in the health sector, and to improve efficiency of service delivery at primary and higher levels of health care. In the field of population, the following project components are being considered: (i) strengthening the planning and research capability of the National Planning Institute of Jamaica; (ii) institutional strengthening of NFPB through a strong IEC program and a community-based distribution program; and (iii) upgrading existing health facilities to become family planning delivery points. In the field of health, the following components are being considered: (i) strengthening the management capacity of MOHEC; (ii) strengthening the linkages between primary, secondary and tertiary levels of care; and (iii) alternative health care financing measures.
50. In designing the third population project, the audit recommends that the lessons of the first and second projects be given serious considera- tion, especially in assessing the institutional capacity of Government and its respective agencies to provide the necessary support to effectively implement the project. Project design of this third project takes place under somewhat unique circumstances. To avoid implementation or funding gaps, follow-up projects, in many cases, are prepared while their predeces- sors are still being executed. In this case, the two earlier projects have been completed and their experiences evaluated. This opportunity should be utilized to the fullest extent possible. - 17 - TABLE 1
PROJECT PERFORMANCE AUDIT MEMORANDUM
JAMAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
NET RECURRENT AND CAPITAL EXPENDITURE FOR THE MINISTRY OF HEALTH 1973/74 - 1979/80
Actual Net Percentage Percentage Year Recurrent of Capital of Expenditure all Expenditure all (J) Ministries (J$) Ministries
1973/74 35,108,780 10.6 4,321,199 3.7 1974/75 55,562,253 11.1 5,567,620 2.5 1975/76 65,678,663 10.6 5,084,060 1.5 1976/77 68,796,872 9.1 4,417,645 0.6 1977/78/a 79,642,549 9.6 3,602,469 1.0 1978/797 97,806,380 8.5 6,837,770 1.7 1979/80/c 96,624,434 8.1 9,900,000 0.9
Source: Estimates of Expenditure /a Actual Expenditure /b Revised Estimates /c Estimates
Statistical Yearbook of Jamaica (GOJ), 1979, page 187. -ti- -19 - ANNEX 1 Page 1
PROJECT PERFORMANCE AUDIT REPORT
JAMAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
PROJECT SUMMARY OF FIRST POPULATION PROJECT 1
1. The Project consisted of both construction and technical assistance elements designed to extend and improve the Government's national family planning program. Project funds were devoted primarily to the construction of key maternity facilities to provide expanded opportunities for educating and motivating women during their post-partum recovery period when they have high receptivity to FP information. Family p' -ning activities in the project facilities were part of a complex set of rP activities through out the island. The Bank's primary interest was in helping the Government develop an effective and economical national program. Therefore, the project also contained four technical assistance elements which, while small in amount, were intended to have an important impact on the success of the national program.
2. The project provided for the design, construction, and equipment of two types of facilities, both of which were to provide expanded opportunities for EP education:
(a) A new 175-bed wing at the Victoria Jubilee Hospital (VJH) in Kingston and the remodeling of parts of the present old structure. This building also contains space for the hospital's midwifery school. The expanded and remodeled hospital was intended to have a capacity of 332 beds as compared with 165 at appraisal. Ten Rural (b) Maternity Centers (RMCs) at various locations across the island, each with a capacity of 4 to 8 beds.
3. The project also included the following four technical assistance elements:
(a) A 3-6 month study of possibilities for rearranging some of the functions performed by doctors, nurses, auxiliary nurses, and clerks to relieve pressure on the time of the more highly-trained people, who are in short supply.
(b) A study of the service-delivery system in the Kingston-St. Andrew Corporation (KSAC) to see how to make the best use of professional staff and physical facilities.
(c) The provision of a training advisory to help the NFPB in planning and mounting an expanded training effort.
1/ Taken verbatim from Project Summary and Highlights of the audit report of the first project (OED Report No. 2580 dated June 24, 1979). - 20 - ANNEX 1 Page 2
(d) An annual review by a small external team of the progress of the Program during the disbursement period.
4. The project was the Bank's first in the population sector. It was designed to extend and improve the Government's National Family Planning Program. It was aimed particularly at enlarging the post-partum program of the Ministry of Health and Environmental Control (MOHEC) by expanding its maternity facilities, as well as assisting the Government in developing an effective and economical national program.
5. Under population pressure, in 1967 the Government adopted a national policy of slowing down population growth and started offering family planning services at public hospitals. In 1968, it created the National Family Planning Board (NFPB), a semi-autonomous bod responsible to the Ministry of Health but with no permanent legal status. / The initial target of the NFPB was to decrease the birth rate of 35 per 1,000 to 25 per 1,000 by 1975.
6. At the time of the Bank's program review mission in 1969, a vertical" family planning program3 / had already been set up by the Government, and there were tensions after the former Program Head had been replaced by the professional rival whose wife handed the private family planning program. The Ministry had serious reservations about the effectiveness of the senior health personnel in the Preventive and MCH side of the Ministry and of their capacity to implement the National Family Planning Program. The Bank Sector Mission (Jan-Feb. 1969) believed that integration of services with the Ministry of Health would be desirable but this was resisted on the basis of the Minister's reservations and a compromise was arrived at with the then-Minister of Health in August 1969. This was to work towards such family planning service integration as a long-term goal. The pace of integration of family planning services was accelerated in subsequent years as the subject of population control surfaced as political dynamite and the "Black Power" groups began to be critical of the program. This political setting was also reflected in attitudes to foreign advisors. The change of Government in 1972 led to the loss of effectiveness of the Chairman of the Board who "in effect" was a political appointee of the former Ministry; he, however, had contractual status and remained in office for several years and this led to the erosion of the effectiveness of the Board. The labor troubles, including physical attracts on Public Works staff and criminal investigations of corruption after the new Government came to power all had their impact on the performance of the
2/ The Bank mission recognized that the dubious legal status was not satisfactory; during preparation, it assisted with drafting of model legislation and required in the Project that the NFPB be given permanent legal status. This was done by the National Family Planning Act of 1970.
3/ The NFPB was to have its own separate staff of family planning workers, rather than integrating family planning activities with health services. - 21 - ANNEX 1 Page 3
Public Works Department (PND) and on physical development of the Victoria Jubilee Hospital (VJB). The even larger financial troubles of the Government and the general climate of instability, not foreseen at project approval, affected the overall performance of the Civil Service, including health and family planning staff.
7. During project generation, the Government was as much concerned with its health care system as with improving its family planning program. The Government, unlike many Third World Governments, was allocating reasonable amounts of local resources to the program and the external inputs were clearly additive to achieve improvements. Lengthy discussions within the Bank and between the Bank and the Government took into account Bank's current policies and the Government's own preference before agreement was reached on the project content. Given the putential areas of finance in population planning 1969, it is likely that without support to a major health/MCH investment, the Bank would not have had a sizable financial involvement to make it intervention meaningful. At the same time, the project strategy was consistent with current thinking. It is also to be noted that in the late sixties, post-partum programs were considered central elements of family planning programs and their extension from urban to rural settings was actively promoted by the Population Council. Project documents and particularly the appraisal report (paras. 5.13 and 5.16) recognize the risks involved in the rural maternity centers (RMCs).
8. Originally, the project was expected to be implemented over a four and one-half year period. It was initiated in November 1970, but at present (March, 1979), it has not been fully completed. Delays were caused mainly by the absence of adequate leadership and weaknesses in project management and by the integration of the NFPB into the MOHEC and the resulting uncertainties concerning lines of authority and responsibility. Some of the "software" components of the project, including a study concerning the reallocation of functions of medical personnel, and the first external review, were carried out and their recommendations incorporated into NFPB policy. However, the three subsequent external reviews required in the Loan Agreement were not done, and the training advisor stayed only for a few days.
9. Construction and equipping of the RMCs was completed in 1973 and they were commissioned and staffed in 1974. All are underutilized to a greater or lesser degree and one had to be closed down because the location was not considered appropriate. They are being converted to multi-purpose health centers. The main problems with project implementation were related to the construction of the VJH new maternity wing. After two years of delays in design and awarding of contract, the VJH construction was initiated in January 1973 but has not yet been completed. With the exception of its midwifery training school section, which began training sessons in April 1978, the VJH wing has not yet opened.
10. When construction of the VJH has been completed, the total capital cost of the project is expected to be US$4.6 million, in comparison to the original estimate of Us$3.3 million. The 39% overrun results mainly from construction costs which have doubled in spite of the fact that remodeling of ANNEX 1 - 22 - Page 4 the existing VJH building has not been done. The recurrent expenditures of the RMCs (about US$180,000 annually) are being met by the Government, but he Government may have difficulties in providing the VJH recurrent expenditures (about Us$1.0 million annually).
11. The project was the Bank's very first lending operation in the family planning field. Much experience has been gained from this and other similar projects begun with Bank/IDA assistance in the early seventies, and the lessons learned from that early experience are, for the most part, reflected in the Bank's current population lending policies. Many of the problems encountered in the implementation of this project arose from compromises between, on the one hand, the Bank's orthodox, "bricks and mortar" oriented financing methods at the time and, on the other hand, the special needs of family planning, particularly in the difficult Jamaican context.
12. Although much was learned from this first Bank effort in the field of family planning, and although Jamaica's crude birth rate, for reasons only partly related to the project, did fall slightly during the project period, the project did not fully succeed in attaining its primary objectives to extending and improving Jamaica's national family planning program.
13. Points of special interest are:
- sociological factors needed greater attention in project design;
- single-purpose RMCs were an inefficient use of resources and were improperly located;
- the switch from a "vertical" family planning program to the integration of family planning with health services created many difficulties;
- the construction of a new maternity wing at the VJH represented two thirds of total project cost; although badly needed to relieve hospital overcrowding, its contribution to Jamaica's family planning program is marginal; and
- serious problems were encountered in implementation of the construction program the Bank's wealth of experience and long-established policies and procedures in dealing with construction projects were never fully brought to bear on these problems. ANNEX 2 Table 1
- 23 -
PROJECT PERFORMANCE AUDIT MEMORANDUM
JAMAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
Clinics in Cornwall County
Number of Old and New Clinics in Cornwall County
Parishes New Old
Trelawny 7 14 St. James 16 13 St. Elizabeth 11 21 Hanover 10 12 Westmorland 14 11
Total 58 71 % of total no. of clinics 45% 55% ANNEX 2 Table 2
- 24 -
PROJECT PERFORMANCE AUDIT MEMORANDUM
JANAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
Clinics in Cornwall County
No. of Clinics per km2 and average population per clinic in Cornwall County
Area Estimated Average (kn2 ) Total 1982 Area Population per Parishes No. Clinics Population km2 per clinic 1 clinic
Trelawny 21 65,038 567.7 3097 27 St. James 29 127,994 387.4 4414 13 St. Elizabeth 32 132,353 763.9 4136 24 Hanover 22 60,420 285.1 2746 13 Westmorland 25 116,163 515.8 4647 21 ANNEX 2 Table 3
- 25 -
PROJECT PERFORMANCE AUDIT REPORT
JAMAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
Clinics in Cornwall County
Days of Service in Cornwall County by Type of Service in Nev and Old Clinics
1984 Second Quarter (days of service)
Total Old New
All Services 17,523 8,969 8,554 MCH 1,354 679 675 Child Health 1,310 664 646 FP 4,404 2,373 2,031 Home Visits 3,750 1,847 1,903 Other 3,750 3,406 3,299
1983 Second Quarter (days of service)
Total Old New
All Services 16,109 8,500 7,609 MCH 1,352 729 623 Child Health 1,571 759 812 FP 3,411 1,784 L,627 Home Visits 3,941 2,084 1,857 Other 5,834 3,144 2,690 ANNEX 2 Table 4
- 26 -
PROJECT PERFORMANCE AUDIT REPORT
JAMAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
Clinics in Cornwall County
Clinic Visits in Cornwall County by Type of Service in New and Old Clinics
1984 Second Quarter (clinic visits)
Total Old New
All Visits 222,106 117,993 104,113 MCR 15,167 7,012 8,155 Child Health 25,378 12,965 12,413 FP 15,551 7,857 7,694 Rome Visits 46,800 23,823 22,977 Other 119,210 66,336 52,874
1983 Second quarter (clinic visits)
Total Old New
All Visits 197,880 100,560 97,320 MCH 15,907 7,637 8,270 Child Health 27,927 12,955 14,972 FP 15,422 7,783 7,632 Home Visits 40,923 24,345 16,578 Other 97,701 54,532 43,169 Annex 3 Table 1
- 27 -
PROJECT PERFORMANCE AUDIT MEMORANDUM
JAMAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
Technical Assistance in Population Projects
Technical Assistance (TA) as Percentage of Total Project Cost, Completed Projects, By Region (US$ millions)
TA as Ln/Cr Total TA % of Total Region Project Amount Project Cost Project Cost Cost
LAC Dominican Republic (P) 5.0 7.53 0.38 5.0 Jamaica I (P) 2.0 3.50 0.09 2.6 Trinidad & Tobago (P) 3.0 4.55 0.18 4.0 Jamaica II (P) 6.8 14.16 1.44 9.9
Subtotal 16.8 30.1 2.09 6.9
EMENA Egypt I (P) 5.0 10.50 0.25 2.4 Tunisia I (P) 4.8 7.72 0.26 3.4
Subtotal 9.8 18.22 0.51 2.8
S. Asia India I (P) 21.2 31.80 0.73 2.2
E. Africa Kenya I (P) 12.0 38.80 0.27 0.7
E. Asia Indonesia I (P) 13.2 33.00 2.20 /a 6.7 Malaysia I (P) 5.0 14.50 0.30 2.1 Philippines I (P) 25.0 50.00 0.19 0.4
Subtotal 43.2 97.50 2.69 2.8
Total 103.0 216.42 6.29 2.9
/a Includes fellowships. Annex 3 Table 2
- 28 -
PROJECT PERFORMANCE AUDIT MEMORANDUM
JAMAICA SECOND POPULATION PROJECT (LOAN 1284-JM)
Technical Assistance in Population Projects
Total Man-months of Technical Assistance (TA) by Region and by Function for Projects Completed and Under Supervision /a
South East East West TA Category LAC EMENA Asia Africa Asia Africa Total
Service Delivery 60 - 18 12 286 36 412
Manag ement/ Administration/b 340 224 36 150 576 -- 1,326
Training 156 48 42 12 270 - 528
Research & Evaluation 411 84 24 U/a !97 24 740
Studies 126 42 60 -- 132 - 360
IEC 195 99 151 -- '40 24 809
Total 11288 497 331 174 1 801 84 4P175
/a As of February 1983. 7b- Includes technical assistance to strengthen the planning, managerial, statistical, and financial capacity of MOR and/or the agency responsible for project implementation.
Note: information on India Population I and India Population I not included because TA was provided by local institutions and staff time in manmonths was therefore not available. - 29 -
JAMAICA - SECOND POPULATION PROJECT
PROJECT COMPLETION REPORT
Loan 1284-JM
February 9, 1984
Population, Health and Nutrition Department - 30-- - 31 -
I. INTRODUCTION
A. Socio-Economic Political Setting
1.01 Jamaica is one of the larger Caribbean islands with an area of around 11,000 km2, a population of 2,265,000 1/ in 1982 and a population density of 206 people per km 2 .
1.02 In 1981, unemployment was about 26%, more than double the 1974 rate of 11%; 60% of the unemployed were in the 14-24 year-old age group. Young females experienced an unemployment rate of 69% and comprised 39% of the unemployed labor force. Jamaica's per capita income is estimated at US$1,180 (1981). This compares favorably with a fair proportion of Latin American and Caribbean countries. Wages are much higher in the manufacturing and mining sector than in agriculture and services. Nearly three-fourths of all farm units have less than 5 acres and account for only 15.5% of the cultivated area, while 2% of the farms account for 44% of the arable land. Emigration has taken out of the country a large number of unemployed skilled labor and of farmers with no prospects.
B. Demographic Profile
1.03 The population of Jamaica is predominantly of African descent but has Indian, Chinese and European components as well. Up to the 1920's population growth was slow because high fertility was offset by high mortality. In the 1920's mortality began to decline and consequently the rate of growth of population began to increase. In the mid-1960's, fertility too began to decline; this decline, in conjunction with a high level of emigration, has kept population growth within relatively manageable bounds in recent years. Specifically, the rate of natural increase of 3.1% in 1960-70 (22 years doubling time) dropped in 1970-82 to 2.2% (31 years doubling time).
1.04 With emigration, the average rate of growth in the 1960-70 period was only 1.6% per annum, dropping slightly again between 1970-82 to 1.5%. The rate of net emigration has slowed recently; in the period 1960-70 it totaled 290,000 people compared with only 95,000 in the period 1975-80.
1.05 The low rate of population growth has been retained despite a continued fall in mortality rates: crude death rates (CDR), the annual number of deaths per thousand population, decreased from 8.8 in 1960 to 6.9 in 1975 and to 5.6 in 1982; and infant mortality rates (IMR) dropped from
1/ This compares with the Bank estimate of 2,172,000 for 1980. The 2,265,000 figure was compiled from data provided by the Registrar General, Department of Statistics and Immigration Department. The preliminary census data is given as approximately 2.1 million and the discrepancy may be due to underestimation of emigrants. A detailed analysis by GOJ which will attempt to reconcile the existing discre- pancy between the population totals is not expected to be available before Spring 1984. - 32 -
50.9 deaths per 1000 live births in 1960 to 23.5 in 1975 and to 12.4 in 1979 2/.
1.06 In 1980 a long steady downward trend in annual births was re- versed, with the number of births per year and the Crude Birth Rate (CBR), or number of annual births per thousand population, beginning once again to climb. The number of births per year, which had dropped significantly from a high of 71.5 thousand in 1966 to 62.0 thousand in 1974 (the lowest figure since 1958), and then to a new low of 58.0 thousand in 1980, started to climb in 1981 (59.0 thousand) and had reached 61.0 thousand in 1982. Likewise, the CBR, which had peaked in 1960 at 42, dropped almost 29% to 30 in 1975, declined a further 10.3% to a low of 26.9 in 1980 but since then has begun once again to climb (27.3 in 1982). The data available does not permit to ascertain the causes for this increase or even if it is real or due to differentials in reporting of births.
1.07 The dramatic increase in the number of girls 15-19 may have contributed in a small part to the upswing in the birth rate. That increase has begun to offset the high level of emigration among women in their 20's, the age at which women are normally at their reproductive peak. Emigration among women in this age group in Jamaica is extremely high. Between 1970 and 1982, the number of women 20-29 years of age actually fell 7%, bringing the rate of increase of all women of reproductive age to only 14%. This compares with increase in males in the 15-49 age category of 44% (Annex 4). Nonetheless, nationally, women still outnumber men (1.2 million females in 1982 compared to 1.1 million males) and the total number of women grew 30% between 1970-82 compared to a total male increase of 25% (Annex 4). Even with the recent decline in the rate of out-migration (para. 1.04), women emigrants still predominate: between 1975 and 1980, 60% of all emigrants were women, of whom 53% were between the ages of 15-24.
1.08 It is unlikely that an increase in fertility played a part in the recent upturn in the number of births. The General Fertility Rate (GFR) fell from 182 births per 1,000 women of childbearing age in 1974 to L50 in 1980 and again to 121 in 1981, better than the project target of 150. Analyses of total fertility rates (TFR) and age-specific fertility rates, made as part of the second population project, also show a steady decline. TFR fell from 6.26 children per woman in 1964-66 to 4.0 in 1975-80 (Annex 1). The drop was greatest between the 1970-72 period and the 1973-75 period (20%). It slowed to 9% from 1973-75 to 1975-80, matching the rate achieved from 1964-66 to 1967-69 and substantially better than the rate achieved from 1967-69 to 1970-72 (3%) (Annex 1). Regarding age-specific fertility rates, the rate of the 15-19 year old cohort has dropped more rapidly than the rate for women in their 20's. The younger cohort dropped 36% between 1964-66 and 1975-80, compared to 30% for women 20-24 and 25-29. In the shorter time span, 1964-66 to 1973-75, the 15-19 age cohort dropped 30% compared to 20% for 20-24 year-olds and 29% for 25-29 year olds. Even during the 1973-75 to 1975-80 period, when the
2/ The World Developinent Report gives a figure of 16/1000 in 1981. The figure of 12.4/1000 may reflect problems of under-registration of deaths. - 33 - decline of TFR slowed considerably from the period immediately preceding, the decline for the 15-19 year-old age group remained rapid, equal to the national rate of 9% and better than all other rates except the 13% decline in the 20-24 year-old cohort. Notwithstanding this progress, teenage pregnancy is still a problem as shown by the high number of deliveries by mothers less than twenty years old at the Victoria Jubilee Hospital in Kingston (Annex 2).
1.09 Despite the above changes, over the long term, the population seems to be in a period of transition from one of expansion to one of lower rates of growth. Since 1970, the population under 14 years of age decreased from 45.9% to 38.2%; the population of 65 years increased from 5.6% to 7.7%, the median age of the population currently is around 20 years, and the life expectancy has been stable since 1975 at 69 years.
1.10 Even the relatively low rate of growth, however, puts heavy pressure on already densely populated lands. Between 1970 when the population was 1,848,500 and the present, the total population had grown by 22.6% or by 418,000 persons. This translated into an increase of 1.8 persons per km2 yearly, better than the 1970 rate of 2.4 people/km2 per year but still high when compared, for example, with Mexico's 1970 rate of only 1.1 additional persons/km 2.
C. Government Policies
Family Planning
1.11 The Government of Jamaica was one of the first in the Latin American Caribbean region to adopt a policy of family planning. After about 30 years of modest private efforts, official family planning services were inaugurated in 1964 and institutionalized in the National Family Plan- ning Board (NFPB) created by the National Family Planning Act of 1970. That year a CBR target of 25/1000 was proposed for achievement by 1975.
1.12 As of 1974, a total of only 67,000 women of reproductive age had tien recruited as active family planning clients. Although there were some 22,000 annual new acceptors, there was also a high level of failure to continue use. Data from November 1968 to June 1971 showed that over 25% of new acceptcrs never made a second visit. A rising trend in the use of the "Depo-Provera- injection method (it reached 20-25% in 1972), in preference to the Pill and the IUD, appeared to have a positive impact in reducing the number of births.
1.13 The continued high CBR in 1974 (30/1000 instead of the goal of 25/1000) convinced the Government that a new type of approach was needed if it was to succeed in its efforts to institute a successful family planning effort. It issued Ministry Paper No. 1, Family Planning, which reaffirmed its commitment to family planning and called for integration of family planning into the regular health services of the Ministry of Health and Environmental Control (MOHEC). Achievement of the goal of a CBR of 25/1000 was postponed to 1978, in anticipation of success of the new approach. - 34 -
Nutrition
1.14 In 1974, in a companion move to broaden the scope of its ongoing health programs, the GOJ established a Nutrition Advisory Council, chaired by MOHEC's principal medical officer. The Council was operated under the Ministry of Commerce and Marketing and had members representing health, agriculture, education and other ministries and agencies. Its first major undertaking was to develop a nutrition policy designed inter alia:
(a) to eliminate malnutrition among most vulnerable groups (serious protein calorie malnutrition and anemia in children 0-4 years of age and nutritional deficiencies in pregnant and lactating women); and
(b) to encourage breast-feeding of infants.
1.15 Improvement of nutrition was seen as an important ingredient in the effort to control population growth. Experience elsewhere had demon- strated that reduction of infant and child mortality through improved nutrition among other health measures, had translated into the reduction of family size. In addition to its primary impact on infant health, breast-feeding also has resulted in lengthening the period of postpartum infecundity through lactation amenorrhea and thus contributes to an overall reduction in fertility.
Institutional Reorganization
1.16 The new emphasis on integrating family planning and nutrition component into its ongoing health programs was translated into an institu- tional reorganization in April 1974. Specifically, the NFPB lost its autonomy and became instead a part of MOHEC. Delivery of services became the responsibility of MOREC and NFPB retained the job of administering, motivating and supervising the delivery systems. Thus, operations in the existing 161 family planning clinics came within the purview of MOHEC and 43 family planning field educators were transferred from NFPB to the Bureau of Health Education in MOHEC.
1.17 In concert with the integration of nutrition and family planning activities into its regular health services delivery system, MOHEC itself was reorganized. At the national level, medical officers previously responsible separately for MCE/FP/Nutrition, hospital, and public health were assembled in one unit. As a pilot area, Cornwall County Health Administration was to utilize community health aides (CHAs) and district midwives, responsible for delivery of primary health care services and with priority on MCH/FP/Rutrition services, essentially through a home visiting program. - 35 -
D. Bank Efforts
The First Jamaica Population Project
1.18 The first Jamaica Population Project (Loan 690-JM), approved in June 1970, was the Bank's first in the population sector. The central strategy was to expand delivery facilities to encourage the recruitment of new family planning acceptors through the postpartum approach, among the relative', large population (50Z) of women who delivered in medical facilities. Its main components were:
(a) building of a new wing at the Victoria Jubilee Hospital in Kingston, and
(b) construction of ten 4-bed rural maternity centers.
These centers were a new untried facility. The project also included development of a home visiting program and provision for review of family planning in Jamaica to provide a basis for modifying and strengthening the National Family Planning Program. Other than construction delays (the project took seven instead of four years to complete), the experiences of the project proved instructive. Low utilization of the rural maternity facilities, inadequacy of the single-purpose home visiting program, limitations of the postpartum approach, and a disappointing level of new acceptors all contributed to the Government's 1974 decision to integrate FP into the regular public health delivery system (para. 1.13). Inadequately trained family planning workers in delivery centers have led to MDHEC efforts to improve in-service training in 4CH/FP/Nutrition for medical officers, midwives, nurses and other staff.
Second Population Project
1.19 The Bank's second project in the population sector (Loan 1284-JM) was approved in June 1976. It had an estimated cost of $14.14 million, including a Bank loan of $6.8 million. It was to be executed over a four-year period. It was essentially an outgrowth of government moves to integrate family planning within the new model developed for primary health care services in Jamaica and to incorporate a nutrition element into those services, primarily as a method to influence families to reduce family size. The project had three prime goals:
(a) to reduce fertility as measured by a variety of indicators;
(b) to reduce serious protein-calorie malnutrition among children from 0-4 years of age and eliminate anemia among pregnant and lactating women; and
(c) to help reduce maternal and child mortality in Cornwall County.
1.20 These strategies were proposed to achieve the project goals:
(a) training and equipping of new midwives, CHAs, and existing medical personnel, all of whom would be responsible for delivery of integrated health services; - 36 -
(b) extension of the postpartum project started under the first Population Project to the 17 additional hospitals in the country with maternity beds;
(c) development of a pilot integrated MCH/FP/nutrition program in Cornwall County, which represented about one-fourth of the nation's population, to L able the potential for delivery of all health services in this area. This component consisted primarily of creating a decentralized Cornwall County Health Administration and of constructing 57 health centers, which the Government would be expected to staff appropriately. The program would be replicated nationally following evaluation.
1.21 The strategy to achieve nutrition improvement was to mount an educational and communication campaign, and would include a feasibility study regarding ways to improve availability of nutritional foods to target population groups. The project also included various research projects designed to help judge the effectiveness of the national FP Program, in- cluding studies on FP client attrition rates, socio-economic characteris- tics of PP acceptors, building utilization, registration of vital events, and regular publication of age-specific fertility rates. Institution support to MOHEC was also to be provided in the development of a planning and evaluation unit, management information system and health facility maintenance unit.
Project Components
1.22 Specifically, the project contained 11 components:
(a) Cornwall Country Program: vehicles, equipment, construction of 57 health centers;
(b) Equipment for the training of about 1,000 CHAs (including their supervisors) and audiovisual aids for 2,000 CHAs to be used in their educational/motivational work;
(c) Midwifery Training: Equipment, technical assistance and fellow- ships for a new midwifery school to be located in Cornwall County and for one existing school in Spanish Town;
(d) In-Service Training: Technical assistance, equipment and vehicles to strengthen MOHEC's in-service training program in MCH/FP/ Nutrition for medical officers, midwives, nurses and other staff;
(e) Postpartum Program: Equipment needed to expand postpartum family planning services to 17 additional hospitals;
(f) Nutrition Education and Communication (to promote breast-feeding and improve child and maternal nutrition): Equipment, vehicles and technical assistance for national and local campaigns, train- ing, production of audiovisual aids, research and evaluation, and fellowships; - 37 -
(g) A Feasibility Study for local production and processing of sup- plementary food, including training fellowships;
(h) Technical Assistance and fellowships for the Planning and Evalua- tion Unit in MOREC;
(i) Technical Assistance, fellowships and equipment for evaluation of the demographic impact of the National Family Planning Program, including program-oriented research studies;
(j) Technical Assistance to support a Health Facility Maintenance Unit to be created by the GOJ and for a building utilization study;
(k) Innovative Activities: Funds to support innovative activities that may arise during project years.
Project Management
1.23 The project was to be managed through MOHEC. The Permanent Secretary of MOREC was to be project director. Two deputy project directors were appointed within MOHEC, one responsible for coordinating construction and procurement and the other for supervising MCH/FP/Nutrition activities. A project coordinator in the Cornwall County Health Admin- istration was appointed to coordinate the Cornwall County component of the project. The Government also agreed to additional support staffing, including:
(a) filling vacancies in the MCR/FP/Nutrition delivery system in Cornwall County;
(b) sanctioning positions for at least 60 midwives starting in 1978 to ensure a minimum number of jobs for graduates from the two midwifery schools;
(c) sanctioning about 1,000 additional positions for CHAs to permit deployment of CHAs at the ratio of one CHA/1000 population;
(d) three research assistants in the Planning and Evaluation Unit;
(e) a media and commerce assistant to a newly appointed education and communication officer.
1.24 As a condition of loan disbursement, MOHEC was required to engage the National Development Agency (NDA) to take responsibility for the construction component and the procurement of furniture and equipment. NDA is a government-owned company which performs the function of a management agency for the implementation of development projects, acting as technical coordinator for contractors engaged on the Government's behalf. - 38 -
Site Selection
1.25 Criteria for site selection were outlined during project prepara- tion, and by appraisal, locations had all been selected and 31 sites had been acquired. GOJ agreed to complete site acquisition by Dec. 31, 1977.
Provision of Counterpart Funding
1.26 The Government agreed to provide in the annual MOHEC budget ade- quate and specifically allocated funds for the MCH/FP/Nutrition programs.
II. PROJECT IMPLEMENTATION
A. Project Management
2.01 Although political instability resulted in considerable turnover in key project management positions, the jobs remained filled and the various occupants carried out project responsibilities as well as could be expected under the circumstances. Nonetheless, the turnover did contribute to delays in project completion.
2.02 The turnover affected all key central government positions: the Project Director, who was also the Permanent Secretary of MOHEC, changed four times over the course of the project as the Permanent Secretary posi- tion was filled by four successive occupants, including in one case, the chief Medical Officer. The Deputy Project Director for Civil Works and Procurement also was changed several times, but with the assistance of the NDA (paras. 1.24 and 2.07), these changes did not disrupt project execution. The position of Deputy Project Director for Health (Maternal and Child Care, Family Planning and Nutrition) was filled by the Chief Medical Officer, who was changed five times. As the project management became more stabilized, the project director and his deputy for health in particular began to provide a strong positive leadership role.
2.03 The appointment of a full-time project administrator for the project in 1976 added strength and stability to project management. Although the post fell vacant for a period after the first six months, it has since been occupied by a single incumbent who has remained in place through project completion.
2.04 A key aspect of the project was testing of the viability of decentralization and integration of the health delivery system at the county level. The program strategy was to establish a Cornwall County Health Administration (CCHA) and to delegate to it full responsibility for delivery of FP/MCH/Nutrition services. On balance, the CCHA has operated successfully. There was a two-year delay before its establishment due to lack of funds in the GOP budget for 1976/77 and 1977/78. The position of Project Coordinator was first filled by an expatriate. At the end of 1980, he was replaced by a Jamaican. As Senior Medical Officer of CCRA and project coordinator, he devotes full time to the project and appears to be - 39 -
performing satisfactorily. A variety of other staff positions remain either to be filled or established although CCHA can be considered a reasonably organized decentralized branch of MOHEC; particularly transport supervisor, engineer and audio-visual maintenance engineer. The decentralized budgetary and financial management systems are working well. CCHA currently has its own budget and administers it separately and independently. On the other hand, decentralization has placed a heavy administrative burden on the coordinator; as a result, supervision has been inadequate in such important areas as monitoring the logistics of supplies and equipment for health centers.
2.05 Overall the level of monitoring, supervision and reporting has gradually improved as implementation has proceeded. Project management has cooperated with Bank missions and responded well to missions' advice and comment.
B. Physical Implementation of the Project
Summary
2.06 In spite of political instability, physical implementation of the project was generally satisfactory though completed about two years later than originally scheduled. Construction of the 57 health centers called for the project to be undertaken in two overlapping phases. The first phase, during which 31 centers were built, ran from mid-1977 to mid-1980 and the second phase, during which the remaining 26 (increased to 27) centers were constructed, ran from the end of 1978 to the end of 1981. In 1978-79, due to severe financial constraints, the Government proposed a delay of project implementation and the Bank subsequently agreed to this. In 1980, after project implementation had resumed, devaluation of the Jamaican dollar eased the financial situation and the Government not only completed all the centers but founded a variety of additional minor civil works, including addition of a 58 th center in New Market to replace one which had been destroyed by flood; installation of incinerators in all centers; installation of 16 water tanks; and, construction of four additional staff houses. The Government was also authorized to refurbish, with project funds, 19 existing health centers which had been scheduled for renovation with Government funds during the project period (Annex 5).
2.07 The basically smooth execution of the construction works was due primarily to the satisfactory performance of the NDA (paras. 1.24 and 2.03) which became fully responsible for construction and procurement under the leadership of the project coordinator and the project administrator paras. 2.02 and 2.04). Under the guidance of the two project managers, NDA (a) selected and supervised the consulting architects, engineers, quantity surveyors and other necessary consultants; (b) ensured the selection and acquisition of the sites; (c) pre-selected the contractors and organized the bidding operation; (d) supervised the construction or refurbishing of the project facilities; (e) finalized the furniture and equipment lists and related bidding documents; and (f) organized and supervised the procurement and installation of the furniture. Until 1981, NDA did an excellent job of supervising and monitoring construction and - 40 -
procurement activities. That year, many of its qualified personnel had to be dismissed in the wake of financial difficulties. Fortunately, by then, its job with JPP II was almost completed and the project suffered almost no problems as a consequence.
Site Selection
2.08 The site selection process which was completed during appraisal took into account the existing health infrastructure, population distribu- tion and projections, and accessibility. Very few of the selected sites were government property, some were donated, but most of them had to be acquired. At negotiations, the NDA had surveyed the already 31 acquired sites and began the process of acquiring the remaining 26. A number of difficulties arose in the process. Many pre-selected sites were uneven and not suitable for construction; some were owned by more than one person, and some had uncertain ownership. Unexpected population migration also made it advisable to relocate several sites. The original agreement had called for site acquisition to be completed by December 31, 1977, but in fact eight sites were acquired after that date, the latest in May 1981 (Annex 7).
Design of the Project Facilities
2.09 The schedules of accommodation for four different types of health centers were developed during project preparation and appraisal based on the size of the population to be served. At the beginning of project implementation the schedules for types II, III and IV were amended to provide additional specialized rooms, for example, dental units. Annex 6 details the characteristics of each type of center, and Annex 7 indicates that 35 type I centers, 17 type II, 4 type III and 2 type IV centers were actually built.
2.10 The design brief was prepared by a consulting firm in June 1976. NDA then selected three private consulting architects to prepare blue- prints. The architect in charge of the design for type I left Jamaica and NDA had to complete the design. The resulting designs called for larger facilities than specified in the design brief: 18% larger for type I, 70% larger for type II and 25% for types III and IV. These proposals were revised further, and the resulting blue prints were found acceptable by the MOH and the Bank even though the type II area was still larger than proposed initially, but it had the advantage that it could accommodate additional services. The design was generally good, economical and well-adapted to local climatic conditions. The Building Utilization Study, which the COJ agreed to carry out after project facilities had been in operation for a certain period (paras. 1.23, 2.40 and 2.42), has shown that: (a) a larger type II center instead of types III and IV could have allowed for a more efficient use of personnel; (b) most type I centers should have been larger to provide more services; (c) more attention should have been given to insulation and maintenance problems; and (d) as most of the sites were uneven, the design for the large centers should have permitted more flexibility for site adaptation. - 41 -
Construction of the Project Facilities.
2.11 Construction procurement was made through local competitive bidding (LCB). Foreign contractors were permitted to bid but none showed interest in small contracts. Annex 7 details the location and type of centers for each phase together with the biddings and contract awards that took place.
2.12 During preparation of the second phase (1978), severe financial problems forced the GOJ to request suspension of all construction activi- ties. The result was a major dislocation of the work program with accom- panying escalation of costs of material and labor causing an increase in final costs. To reduce costs, the decision was made to substitute two smaller type II centers for one type IV and one type III centers.
2.13 Delays were also experienced due to a number of practical prob- lems which arose during project implementation including: (a) poor perfor- mance of four contractors who had to be replaced (in Askenish, New Works, Bounty Hall and Georges Plain); (b) difficult site conditions (Somerton and Aberdeen); (c) shortages of building materials, particularly cement, steel bars and lumber; (d) lack of water near the sites; (e) poor road access in the most remote locations and (f) difficulty in finishing some works, particularly plumbing installations and roofs.
Furniture, Equipment and Vehicles
2.14 The preliminary lists of furniture and equipment for each type of health center were prepared by the MOR and agreed upon with the Bank during project appraisal. They were then revised and finalized by a group of selected physicia-as and nurses and representatives of the OHEC and NDA departments of supply. The lists proved to be adequate although additional equipment and furniture were purchased during the most recent period of project implementation.
2.15 Procurement of Furniture. The procurement of furniture, with the exception of imported medical furniture, was made through local competitive bidding organized by NDA. Foreign firms were allowed to bid but none responded. Furniture was procured in accordance with the construction schedule and no delay occurred in their delivery and installation. Most of the furniture was not of very good quality mainly because of shortages and lack of good imported timber. Some furniture had to be either repaired or replaced by contractors.
2.16 Procurement of Equipment (including medical furniture). Under the supervision of the MOHEC and NDA departments of supply, the procurement of equipment and vehicles was made by a specialized procurement agency, Crown Agents of United Kingdom, which was selected after some delay in July 1977 and ensured procurement under international competitive bidding (ICB) in accordance with Schedule 4 of the Loan Agreement. The delays were occa- sioned by the initial reluctance of GOJ to hire a foreign firm specialized in procurement. - 42 -
2.17 All equipment, including medical furniture not produced in Jamaica, were delivered in Kingston in 1978 and 1979 and then stored by the KOHEC in a warehouse that was constructed for this purpose in Montego Bay. NDA proceeded with the installation of furniture and equipment on comple- tion of construction of the project facilities. With the exception of ini- tial errors, later corrected, the distribution and installation of equip- ment were carried out successfully and there was no problem or delay. Some audio-visual equipment was mistakenly delivered to the Ministry of Educa- tion and had to be replaced; the cost implications were minor and the equipment was re-procured from loan proceeds. All equipment and medical furniture proved to be well-adapted to the users' needs and were of good quality. On the whole, early procurement produced large savings (para. 3.02).
2.18 Procurement of Vehicles. The 63 vehicles included in the project were procured under ICB through Crown Agents and delivered in Kingston early in 1978, where they were stored until center construction had progressed further. After a severe flood in June 1979, however, MOREC appropriated most of the project vehicles for emergency needs, the under- standing being that the vehicles would be returned to Cornwall County as soon as possible. Currently, however, only 46 vehicles have been returned while the remaining 17 have either been accidentally destroyed or are still being utilized by the MOHEC in Middlesex and Surrey counties. An additional 11 vehicles were purchased, but nonetheless, home visiting program staff have complained of lack of vehicles. Establishment of a vehicle management system, including inventorization and logistical computation, might alleviate the problem and ensure the most cost-effective use of the vehicles in the years ahead.
2.19 Additional Equipment, Furniture and Vehicles. Additional equip- ment, furniture and vehicles were procured at the end of the implementation period to respond to the need of: (a) the additional facilities; (b) the new MOREC departments developed under the project; and (c) the additional, services to be delivered in the health centers. Thn additional vans and one maintenance vehicle were also procured for Cornwall County after consultation among suppliers locally represented (see para. 2.18). Most of the additional equipment was procured under ICB by Crown Agents. The furniture was procured under LCB. However, some requested additional equipment could not be procured under the project by the time of closing because of delays in the preparation of the bidding documents.
C. Implementation of Software Components
Summary
2.20 Implementation of the software components of the project were not as smooth or successful as that of the hardware components. Due to budget constraints and various jurisdictional disputes, the Government fell short in its commitment to provide staff for all three programs through which family planning services were to have been delivered (para. 1.20); it provided only about two-thirds of the staff required for the new Cornwall - 43 -
County health centers; it fell far short of training goals for both CHAs and midwives who were to deliver family planning advice nationwide; and it fell short of coverage goals for the postpartum advisory programs, though the program was extended to all the hospitals intended. The research component was also weak. With the role of the Planning and Evaluation Unit (PEU) of MDHEC still in doubt, the studies on family planning were not executed as planned; the failure to utilize Technical Assistance Consultancies for the PEU and demographic research contributed to the problem. Finally, only a few innovative activities were carried out. On the other hand, the nutrition component was carried out successfully. The in-service training efforts exceeded their goals. Eighteen out of 23 Technical Assistant consultants were appointed, and most fellowships were used. The Health Facility Maintenance Unit was organized and the Building Utilization Study was completed.
Health Centers
2.21 Commissioning and Staffing of Facilities. A total of 49 centers, out of 58, had been commissioned at the end of 1982 to provide primary health care services; MOEC expected the remaining nine to be commissioned some time in 1983. Often, the rate of commissioning appeared slower than necessary, due primarily to unavailability of staff. Only 66% of staffing goals had been achieved by 1982; instead of 1,016 personnel in place, there were only 673, which was only 163 above the pre-project level (Annex 8).
2.22 Utilization of Health Centers. The expected average number of visits to a health center was 360 visits per month. Type I centers aver- aged 190 visits per month; type II centers 530 per month; and type III centers averaged 725 per month. Figures for type IV centers were not given. MOHEC maintains that patient visits showed a marked improvement over utilization of the 71 centers which existed in Cornwall County prior to the project. However, there are no pre-project figures available to verify this estimate. There was some disappointment expressed during mission visits regarding the momentum of the family planning component of services provided at the centers. It was estimated that 90% of all service were curative in nature and that of the 75% of the total which were for maternal and child care, only 16% were for family planning. The family planning aspect was described as suffering from weak direction and lack of supervision. The frequency of demand for FP was estimated to have fallen and the information retrieval of drop-outs was found poorly organized. Despite these shortcomings, there was a large increase in available health services at the county level with, presumably, improvement in health conditions.
Comm!iity Health Aide (CHA) Program
2.23 The project provided for training of 1,000 CHAs to bring the total number to 2,000 and achieve a target ratio of 1/1000 population. The training would be carried out in home communities by public health nurses. In 1976 there were approximately 450 CHAs in the program. Training was scheduled for completion by 1978, but was suspended during the last two years of the project due to differences between the Nursing Association and the Covernment regarding the establishment of the CHA cadre. The Nursing - 44 -
Association felt its position threatened by this new cadre of workers. By 1982 only 1,507 'HAs had been trained, giving a ratio of only 1/1757 population.
District Midwives Training Program
2.24 The purpose of the midwifery training program was to increase the number of district midwives and nurse midwives from 295 to 550 and provide a ratio of 1/4000 population. The midwives would receive training to fit them for an expanded role in the delivery of maternal and chil.0 health, family planning and nutrition services under a primary health care service. This was to be achieved by:
(a) extension of the midwifery training school at Victoria Jubilee Hospital (VJR) to the temporary school at Spanish Town Hospital in St. Cather'ne. This school would train an additional 20 midwives per year;
(b) establishing a permanent midwifery school at the Cornwall Regional Hospital in St. James which by 1980 was expected to graduate 20 midwives a year. These areas were selected as they offered an unusual opportunity for training midwives in a rural setting where an integrated health care system was being developed; and
(c) development of a new curriculum.
2.25 The midwifery training school in Spanish Town commenced work in October 1976, had the services of a consultant and tutors throughout and maintained the desired level of intakes and graduates. The start-up of the Cornwall Midwifery Training School was delayed until 1978. There were two problems. Funds were not budgeted and MOREC failed to fulfill requirements of the Nursing Council to ensure that the hospital was suitable for craining, (i.e. provision of appropriate improvements in obstetrical services, separation of gynecological patients from obstetrical ones and acquisition of various types of equipment). Once underway, training achieved desired levels of intakes and graduates. During the last year of the project, midwifery training was suspended due to the Government's failure, mostly from lack of funds, to sanction the additional midwife positions to which it had agreed under the project (para. 1.23). The midwifery training consultant to the project, who served from 1976-81, noted in her final report to MOREC that it should have collaborated with the local Government Ministry to ensure it created the additional positions required. In total, only 82 midwives were trained, instead of 255, bringing the total number to 377 midwives, 38% short of the total goal, with a distribution of only 1/5695 population. The new curriculum for basic midwifery training was completed and published in 1978 after pre-testing.
In-Service Training
2.26 The project appraisal estimated that a total of 1,480 health workers would be given in-service training over the four-year period, including 300 midwives, 120 public health nurses, 1,000 CHAs, 30 nursing - 45 -
supervisors and 30 medical health officers. The objective was to orient these personnel towards delivery of the new integrated health services.
2.27 The Pan-American Health Organization (PAHO), USAID and MOHEC's Training Division assisted in developing the programs for in-service training. A series of training of trainers' workshops were organized. A total of 1,705 participants (some 225 over the target) received in-service training between 1977 and 1979. Failure to appoint two consultants (one training coordinator and one training consultant) did not seem to have an adverse affect on the program, thanks to PAHO and USAID assistance. On the other hand, lack of funds for counterparts led to uneven application of the program in different parishes.
Postpartum Program
2.28 The postpartum program was supported initially under the Bank's First Population Project (1970) at the Victoria Jubilee Hospital (VJH), Kingston, and in ten rural maternity centers (para. 1.18). The second Population Project was designed to extend the postpartum project to all the nation's 22 hospitals, with maternity facilities.
2.29 The program was implemented in a total of 20 hospitals, only two hospitals short of the goal. The program, however, has provided only 50% coverage of postpartum mothers, rather than the target of 80% coverage. Due to budgetary constraints, MDHEC created only 26 instead of the 28 posts agreed upon at appraisal and had filled only 15 as of December, 1982. The posts were to have been filled by nurse educators, but they dropped out of the program at a high rate. MOHEC could have trained and substituted district midwives, with hardly any attrition, but failed to do so. USAID assisted with extra funding during two of the project years.
Nutrition Education/Communication Program
2.30 The purpose of the program was to improve the nutritional status of children under 5 years of age, improve breast-feeding practices and eliminate anemia in pregnant and lactating women. The goals were to be carried out mainly through mass media campaigns. Due to budgetary constraints all activities were suspended for a year and several aspects of the program had to be revised at additional expense. Nonetheless, overall, results were good.
2.31 The Agency for Public Information was responsible for production of films and slides and of radio and television programs and spots. MOHEC's Bureau of Health Education was responsible for producing printed materials to be distributed through health centers. While on the whole, the Agency for Public Information produced good mass media materials which were widely used, there was a major problem in regard to film production. Budgetary provisions had been made for production of six films. The Agency of Public Information did not have the capacity for the job, and consultant producers were hired for the assignments. A variety of disagreements over film content delayed production, with costs escalating in the process. By the end of the project, only one film - Carlene - had been produced. At the local level health centers were amply supplied with educational - 46 -
materials procured through the project. The local production of educational materials, however, was hampered by failure of MDHEC to consolidate and upgrade the operations of its Bureau of Health Education. In addition, the project had provided funds for upgrading its printing capacity, but the printery was not developed and the related equipment not procured although project funds were utilized to procure paper for the production of educational mat-rials. Fellowships to upgrade Bureau employees were not utilized.
2.32 The component was to have been coordinated by an education and communication officer in MOHEC, assisted by a commerce and media assistant and by three specialists in the Nutrition Unit. The coordinator was appointed as ascheduled, but in 1978, responsibility for the activity was shifted from IKOEC's Bureau of Education to the Nutrition Unit where it remains.
2.33 The component had provided for the Institute of Mass Commu- nication to carry out a variety of studies to test the effectiveness of the mass media campaign. The Institute successfully carried out the initial baseline survey to determine the knowledge and attitudes, practices and beliefs of the population with respect to nutrition with special relation to children and pregnant and lactating women. With USAID funding and the support of MOHEC's Nutrition Unit, it conducted a mid-term evaluation in 1979/80 of the nutrition education campaign under the project. This established that there was a high level of breast-feeding practice, but that it was accompanied by a relatively low understanding of the nutritional implications. It also revealed a need for more emphasis on family planning messages. The Institute, however, failed to complete the final evaluation which would have updated the information in the base line survey on the nutritional status of target groups. In health centers, however, field data indicate that reduction of Grades II and III malnutrition came close to project targets; Grade II was reduced by 52% and Grade III by 56% as compared with a project goal of 60% reduction. Moreover, the dissemination of nutrition messages in the media and health centers was thorough, with an estimated 100% coverage of mothers in health centers having been achieved.
2.34 A Feasibility Study to explore alternate strategies for cost-etfective methods to reduce infant and child malnutrition, however, was cancelled by MOHEC on the recommendation of a fact-finding team from the Jamaica Industrial Development Corporation. Its recommendation was that GOJ would do better to utilize such loan funds as initial capital in setting up a pilot plan for the commercial production of a weaning food. The Canadian International Development Agency had provided US$389,000 financing for this component. A scheme for the pilot plant to produce supplementary foods, was also shelved with resultIng savings of over $350,000 in project funds.
Planning and Evaluation Unit
2.35 The project was to support the new Planning and Evaluation Unit (PEU) to be established in MHOEC. The Unit was expected to advise the Permanent Secretary and to establish a health management/information system - 47 -
for MOHEC. The Unit was established on schedule. Three research assistants were appointed, but well behind schedule. As of 1982 the Unit was still considered short of skilled staff. Appointment of five consultants during the project helped fill the gap. These included a consultant to establish the Unit, a consultant to chart progress, one to handle future planning, an economist and a 'Rtistician. An advisor for health planning, however, was not appointeO 7hat the exact role of the PEU in MOHEC still seems to be an issue as. e a result of the failure to appoint this advisor.
2.36 Three studies were completed in 1982, namely, a final design for the health nutrition information system, a final report on a vital registration survey, and papers summarizing key issues in the population, health and nutrition sectors; a health manpower inventory was partially completed. The studies were all useful and comprehensive.
Demographic Research components
2.37 The project provided support for the following research projects: (a) processing age-specific fertility rates between 1976-80; (b) follow-up studies on attrition rates for contraceptive users; (c) analysis of data on factors which affect contraceptive use (i.e. public health, manpower, family planning, prices, etc.); (d) sample surveys to generate household information on present and past fertility, income, employment, contra- ceptive use and their relationships. The infrastructure for these areas in MOHEC was not established and therefore the research consultant and the associate staff called for in the project were not appointed and the special equipment was not procured. The research studies on fertility statistics, contraceptive continuation rates and relationship of household behavior were not carried out. However, the Ministry's Statistics Division had provided demographic indicators, including fertility rates for 1970-82.
Health Facilities Maintenance Unit
2.38 The establishment of a Health Facilities Maintenance Unit was carried out as planned although with some delay (para. 1.23). The Unit was transferred from the Department of Public Works to MDHEC, was reorganized with staff reduced from about 300 to about 120, and its annual budget for material and spare parts was increased to an acceptable level. The services of a UNDP consultant were secured in 1981 and in 1982, MOHEC signed a contract, financed under the project, with Project Hope to assist the maintenance unit through: (i) staff training in maintenance of bio- medical equipment; (ii) establishing and equipping maintenance teams; and (iii) assisting the teams in their initial operations. In 1982 the Bank also agreed to finance under the project a maintenance officer for the Cornwall County maintenance team. Four MOHEC employees have received in-country fellowships and one overseas fellowship. An unspecified number of employees have also undergone local training.
Building Utilization Study
2.39 Three consultants were appointed and the study was completed and published in December 1982 (para. 2.10). - 48 -
Innovative Activities
2.40 The component was to support innovative activities which might emerge during the implementation of the project and US$400,000 was allocated for such activities. Only $52,000 were disbursed, a disappointingly low level. The Bank approved three activities: (a) operational research on the use of radio for continuing education of peripheral health workers in Jamaica; (b) assessment of under-registration of vital events in Clarendon parish; and (c) development of a primary/ secondary care referral system, and emergency medical services. Boston University was contracted to carry out the third activity.
2.41 Implementation of the first two programs was fully carried out and the results were satisfactory; MOKEC's evaluation of the first indicated a good research program. The third was only partially completed by project termination due to difficulty in completing the system's designs, a slow start-up and problems in processing procurement of special equipment.
D. Technical Assistance
2.42 Implementation of five of the project components depended primarily on the utilization of technical assistance and fellowships. These included: (1) the Planning and Evaluation Unit in MOHEC; (2) the demographic impact studies; (3) the Health Maintenance Unit; (4) the Building Utilization Study; and (5) Innovative Activities. To a lesser degree, consultants were expected to play a part in implementation of (1) midwifery training; (2) in-service training; (3) the nutrition education and communication program and (4) project management. A total of 23 consultancies out of 28 were utilized for technical assistance in eight areas of service to the project and a total of 34 officers benefited through fellowships provided in overseas institutions. On the whole, the consultants carried out their duties in a responsible and efficient manner; their reports were timely and clear, and the respective areas of consultancies have given a positive contribution to MOHEC's service delivery program.
2.43 The consultants appointed are listed in Annex 9. They include:
(a) 7 for nutrition education/communication (two audio-visual; two for film production; two for research; and one for commu- nication);
(b) 5 for the PEU (para. 2.36);
(c) 3 for the Building Utilization Study: health planner, economist and architect);
(d) 2 each for in-service training; health facilities maintenance unit (one to establish and one to evaluate) and midwifery; - 49 -
(e) 1 each for innovative activities and for project administration (controllers).
The consultants not appointed included two for in-service training (para. 2.28) and one each for the PEU (para. 2.36) and the Zemographic research component (para. 2.38).
2.44 The high percentage of consultancies used (82%) is particularly impressive considering the failure of the GOJ to implement a number of project components dependent, in part, on consultancies. Specifically, the MOHEC did not create a demographic research unit (para. 2.38); was not able to upgrade operations in its Bureau of Health Education (para. 2.32); and was unable to staff the PEU in a timely and complete manner. Other project components which could have utilized more consultant time, had they been implemented as planned, were the feasibility study (para. 2.35) and the innovative activities (para. 2.41).
2.45 Eighteen fellowships were utilized, including:
(a) 5 for midwifery, all of whom are currently at post;
(b) 4 persons received fellowships at Cornell University, U.S.A., in communication strategy, as part of the nutrition education/communication program;
(c) 4 fellowships for the Planning and Evaluation Unit, including two utilized by staff members of the Unit (only one returned) and two medical officers (one from the Cornwall County Health Administration and one from Bellevue Psychiatric Hospital);
(d) 5 fellowships for the health maintenance facility, including one overseas and the rest in-country.
In only one case did fellowships not materialize: that for members of the MOHEC's Bureau of Health Education, since the officers who had been identified could not accept the appointments.
E. Fulfillment of Special Covenants and Supplementary Conditions
2.46 Alchough the implementation of several program components was delayed, the Government eventually fulfilled most of the covenants in the Loan Agreement (Annex 10). The delays, while perhaps unavoidable in the context of Jamaica's financial situation, also had an adverse affect on the project outcome. Costs of building health centers increased somewhat due to postponement of works. Coupled with delays in construction of health centers and failure to provide adequate staff, the slowness in establishing the CCHA in staffing and hiring of consultants for the PEU and in providing age-specific fertility rates, have made difficult an accurate assessment of the institution of the primary health care program.
2.47 Section 3.03, calling for employment of consultants to assist in implementation of the project, was satisfied only in part. Five consultants were not appointed. - 50 -
2.48 Section 3.04(b), which called for all goods financed out of project funds to be used exclusively for the project, was violated insofar as the Government diverted 17 vehicles for emergency use in other counties.
2.49 Section 4.03(b) which called for establishment and staffing of the CCHA was basically complied with, other than the GOJ's failure to fill a few staff vacancies.
2.50 Section 4.05 (a)(iv) and (v) pertained to provision of midwives and CHAs. The GOJ fell short in both these areas.
III. PROJECT COSTS AND FINANCING
3.01 The total project cost is US$12.4 million equivalent or about US$2.0 million less than appraisal estimates of $14.14. A cost summary by category is contained in Annex 11.
3.02 Almost half of the savings (US$952,000) were due to MOHEC's inability to use all technical assistance and fellowships (para. 2.43), while failure to implement fully the innovative activities component resulted in savings of another US$348,000 (paras. 2.38-2.39). Efficient and early procurement was also very important in the project savings. Some $867,000 was saved, primarily for furniture and equipment for health centers, special equipment and vehicles. The vehicles savings resulted from early procurement and changes in specifications and were achieved despite an increase in the number (from 63 to 74) and inflation. A favorable rate of exchange during the last two years of the project also contributed to the savings.
3.03 The estimated final cost (US$8,7 million) of the civil works component compared favorably with project estimates of costs including contingencies (US$8.0). The unallocated sum of US$3,7 million covered the cost overruns and despite costly delays in implementation, there were sufficient funds available to cover US$630,000 for additional civil works (Annex 5).
3.04 The rate of disbursement lagged behind project estimates for a number of reasons, both programmatic and fiscal (Annex 11, page 3). Due to the deliberate decision of the Government to halt expenditures during the financially troubled period in FY78-79, project spending was at least US$3 million behind schedule by late FY79. Program problems contributing to slow disbursement included: high staff turnover (para. 2.02), slow commissioning of health centers due to staff shortages (para. 2.22), and bureaucratic problems in the postpartum, nutrition and midwifery programs (paras. 2.30, 2.32 and 2.26). Initially a technical problem, the Ministry of Finance's tardiness in clearing applications for dispatch by MOHEC to the Bank, also delayed disbursement, but this was remedied upon the appointment of a project accountant. - 51 -
3.05 The total amount disbursed on this Loan was US$6.0 million or 88% of the original amount of US$6.8. In accordance with the Loan Agreement, the Loan has financed the interest and commitment charges during implementation to the value of US$1.1 million (nearly $0.1 million more than estimated) while the total amount of foreign exchange was slightly over US$4.9 ($1 million less than the originally forecast US$5.9 million). The Government financed total local cost of US$6.2 mi'.1ion, as opposed to the estimate of US$7.34 million equivalent.
IV. OUTCOME AND IMPACT OF THE PROJECT
A. Demographic Impact Nationwide
4.01 The demographic profile in paras. 1.03-1.10 showed a progressive decline in the rate of population growth and fertility indicators over the past twenty years. Table 1 below shows that, while the project targets for the Gross Reproduction Rate and the General Fertility Rate were exceeded during the project period, the rate of natural increase and the crude birth rate fell short of goals.
TABLE 1 Demographic Indicators 1981 Figures Compared with Pre-Project Figures and Project Goals
Pre-project Percentage of 1970 1974 1981 Goal achievement
Rate of Natural Increase () - 2.4 2.1 2 75
Gross Reproduction Rate (per woman) 2.7 - 1.7 2.1 167
General Fertility Rate (per 1000 WRAG) - 182 122 150 187
Crude Birth Rate - 30.4 27.3 1/ 25 57
1/ Figure for 1982.
4.02 Failure to achieve the goal for the birth rate automatically determined that the goal for the rate of natural increase could not be achieved. Achievement of the goals of fertility reduction is, however, more important from the point of view of population growth. I: addition, the reduction in the rate of natural increase had been predicated on a continuation of the emigration rate; in fact, the emigration rate declined between 1975 and 1980 and this affected especially women in reproductive ages and may have contributed to the upswing in the CBR observed in 1982. - 52 -
B. Family Planning japact Nationwide
4.03 The national family planning program had aimed at recruiting 140,000 new acceptors equivalent to 40% of women of reproductive age group (15-44) (WRAG) over the four-year period (1976-80) at the rate of 35,000 new acceptors annually. The target for contraceptive prevalence rate among WRAG was 33%. Table 2 below indicates that none of these goals was achieved. The number of new acceptors came closest to the goal, reaching 32,000 annually in 1981 or 64% of the goal; but as a percentage of WRAG, however, achievement was about -9% indicating a fall from the pre-project level (13.7% compared with 16.4%), reflecting the unexpected growth of WRAG in the 15-19 year cohort (para. 1.08). The overall contraceptive prevalence rate improved significantly from 11% to 24% - or about 60% of the target of 33%.
TABLE 2 Family Planning Acceptance Actual 1981 Figures Compared with Pre-Project Figures and Project Goals
Pre-project Project Percentage of (1974) 1981 Goals Achievement
Number of Annual New Acceptors 30,300 32,000 35,000 64.0
New Acceptors as % of WRAG 1/ 16.4 13.7 45.0 -9.0
Contraceptive Preva- lence Rate for WRAG 11.0% 24.0% 33.0% 40.0
Contraceptive Preva- lence Rate for Women in Union 2/ 38.0% 58.0% n.a.
Number of Active Family Planning Clients 67,000 83,000 n.a.
New Acceptors as % of WRAG - Cornwall County n.a. 21.4 n.a.
I/ Women of Reproductive Age (15-44) 2/ Women in union are those who are married, in consensual union; visiting in union or common-law marriage. Most teenagers are outside this group.
4.04 The pill (38.7%) and injection (45.6%) account for the main methods of contraception used by clients. Injection has been gaining in popularity. It had become the preferred method of 20-25% new acceptors by - 53 -
1972, and has gained considerably since then. Since injection is more effective than the pill or the IUD, its increased use has had a positive impact in reducing the number of births. The percentage of IUD users remains insignificant while other conventional methods like condoms and spermicidals (10%) receive fair support. Female sterilizations have been negligible throughout the years of the project but have received a boost recently with 3,062 clients recorded for 1981/82; vasectomies for male clients are negligible and unrecorded. There is no available information on differential continuation rates in contraceptive mix, thus differences in method-composition of new acceptors and active users cannot be assessed. The Statistical Report of the NFPB for 1981 and 1982 did not carry an analysis of characteristics of women accepting family planning services (Annex 3).
4.05 An apparent anomaly in the national fertility picture is that, while the program did not recruit its targeted 35,000 new acceptors, both the Gross Reproduction Rate and the General Fertility Rates fell well below their targets (Table 1). The probable explanation is that the private sector is serving a large and growing number of the female population. GOJ has no current information either of supply or utilization of contraceptive services in the private sector. There is a need to assess not only availability but also the reasons for the apparent success.
C. Cornwall County Impact
4.06 The second Population Project was designed to create in Cornwall County a microcosm where a total MCH service through health centers would prove an important contributing factor to reduction of family size. Although in no case were targets achieved, all aspects of MCR care improved dramatically to a point where well over two thirds of the population was being served and there were secondary benefits which accrued in terms of the successful institution and operation of a primary health care program as part of project activity. Table 3 provides specific data.
TABLE 3 Provision of MCH Services in Cornwall County (Percentage of Population Covered)
Percentage of Pre-project Achievement Goal Achievement
Ante-natal Care (%) 55 70 90 43 Attendance of Deliveries by Trained Personnel (%) 75 80 100 20 Provisioning Post-natal services (%) 25 70 1/ 70 100 Immunization of Children age 0-5 (%) 50 Ratio 65 80 50 DPT-lst-80% DPT complete-55%
IT_ 56% achieved through home visits. - 54 -
Annex 3 shows that 21.4% of WRAG in Cornwall County were new acceptors of family planning, 56% better than the national figure of 13.7%. This relatively good record, despite lack of full staff complement, is a strong indication of the success of the integrated approach in Cornwall County.
D. Institutional Impact
4.07 The program was designed to create or revamp five institutions: the Cornwall County Health Administration, a Planning and Evaluation Unit and a Research Unit in MOHEC, a Health Facilities Maintenance Unit, and a Midwifery School at Cornwall Regional Hospital. As indicated in paras. 2.03, 2.14, 2.36, 2.37 and 2.26, these institutional innovations met with varying degrees of success.
4.08 The most important institutional change, however, was the integration of NFPB into MOHVEC, and although this would have occurred with or without the project, the provision of training, supplies, equipment and health centers through the project, were all designed to facilitate the merger, and more important, to ensure that family planning would constitute a strong component within the health services being offered. In fact, the integration of NFPB has proved to be an uneasy alliance, with the family planning element having lost some of its momentum partly as a result of more competing demands of health services. Commitment to integration by either body has been in question and primary health care had appeared to take precedence over family planning. Family planning officials cited some problem areas among which were, absorption of NFPB staff into the regular MOHEC staff which reduced their effectiveness for motivating family planning clients (para. 1.16); and a less effective outreach with loss of autonomy over selected uni-purpose family planning service delivery facilities. MOREC and NFPB officials admitted that training and super- vision for regular MOHEC staff in family planning have been inadequate; that delivery of family planning supplies and equipment to existing and new health centers has often been uncertain; and that there was failure to identify adequately the 15-19 year-old age groups as a prime target for family planning advice and did not direct an effective demand creation/ motivational and service program for that group. MOHEC, on the other hand, has not matched its perception of family needs with effective management and direction of the services and has not utilized NFPB personnel and expertise effectively. Integration has not succeeded too well judging by the outcomes. This, however, should not detract from the fact that the step was a logical one for Jamaica. The Government, however, failed to institute an appropriate and effective management system within the structure and to promote an orientation of all staff to population and family planning. Had this been done, the results would have been more positive. - 55 -
V. BANK PERFORMANCE
5.01 The second Population Project was identified by a four-person Bank mission in April 1974, about mid-point in implementation of the first Population Project and coincident with the integration of the NFPB into MOREC and the establishment of a Nutrition Advisory Council. A Primary Health Care Plan of Action prepared by a Government Task Force, which focused on integrated family planning and nutrition services, provided the basis for further Bank discussion with the Government. These discussions took place over the course of several preparation and pre-appraisal missions (129 staff/days) from mid 1974-late 1975, when the appraisal mission took place. (See mission data (c) p.ii).
5.02 Between loan signing on June 17, 1976, and the closing date of December 31, 1982, the project was supervised in the field by 12 Bank missions involving 127 staff days, or about 10 1/2 man-days per mission. Following the closing date, one supervision mission visited the project to assist in the preparation of the project completion report. The missions were weighted more to hardware than software activities, with a total of 12 architects' visits compared with only five visits of information, education and communication specialists, five of sociologists, four of population specialists and three of public health specialists (Annex 12). There was no record of visits by management, and intervals between visits and frequency of missions were irregular and sometimes long; all these factors may have failed to give the support needed by the project in software implementation during the project's critical phases. The MOHEC, however, felt that supervision missions were supportive and useful and that it benefited from discussions held. Periodically, Government officials also visited the Bank.
5.03 The question arises as to why the Bank did not take a more definitive position in regard to implementation of the various manpower inputs where the Government was falling behind schedule. It is understandable that the Bank would not force compliance during the financially troubled period in 1978. Thereafter, however, when the Government continued the delay in posting the CHAs, midwives, nursing educators and staff for the Cornwall County health centers, the Bank might have exerted more pressure or at least made a more serious effort to identify reasons for the delays. Because manpower was not in place, it has become difficult to judge the effectiveness of any of the strategies designed to improve family planning - the extension of the postpartum project, the new integrated approach nationwide, or the intensified approach in Cornwall County.
5.04 The Bank and the Government had originally conceived this project as an experimental expansion of the original postpartum approach which had been used in the Bank's first three population projects worldwide - Jamaica, Trinidad and Tobago, and Tunisia. In JPP II, the Bank and the Government were seeking to learn (a) whether the Government's new - 56 -
integrated approach to delivering family planning services would be more effective than the uni-delivery system; and (b) to what degree improved breast-feeding might contribute to fertility reduction. The creation of a Planning and Evaluation Unit, which would establish a health management system to help measure the efficiency and effectiveness of the MCH/FP/Nutrition services, was deemed central to the research effort. The demographic and research studies on fertility, contraceptive continuation rates, and on socio-economic variables were to provide additional Light on progress in family planning. Neither of these components was properly executed, with the result that the project leaves as many questions unanswered as before. The Bank should have been aware at an early date of the bureaucratic difficulties which were inhibiting ataffing of the PEU and the creation of a demographic and research unit within MOHEC, and should have provided guidance to help solve the problems. It should also have reviewed the function of the PEU to see if it was meeting the informational needs of MOHEC.
5.05 The Bank was aware throughout the project of management difficulties besetting the new integrated FPIHCH/Nutrition health care system, particularly through extensive feedback from family planning advocates. The Bank, however, appeared not to wish to become embroiled in this bureaucratic issue. While perhaps taking sides would not have been politic, the Bank could certainly have played a more prominent role in defining the issues among all parties and in attempting to seek an equitable solution.
5.06 The construction component would have moved more rapidly if close attention had been given at appraisal to reviewing the system for acquisition and location of sites. It is probable that, because over half the sites had been successtully acquired before appraisal, no one anticipated that problems would arise with the remaining sites. The failure to anticipate these difficulties led to unnecessary escalation of costs.
5.07 The diversion of 17 vehicles to other counties was a clear violation of the loan agreement and even though it arose in the context of an emergency, the Bank should have been firm in insisting that MOHEC turn the vehicles over to Cornwall County once the emergency had passed. There was no provision in the project agreement for creation of a system for vehicle management. Probably even now one should be created; although it could not affect a transfer at this Late date of the 17 vehicles, it might ensure proper utilization of the remaining 43 vehicles during their lifetime. - 57 -
VI. CONCLUSIONS
6.01 In 1974, at the time of project identification, there were several compelling reasons for the Bank to assist the GOJ in a second effort to control population. The Jamaican Government had had a long history of attempting to curb its population growth. Despite good intentions, however, its efforts had seemed to lose impetus. Its intention to develop a new strategy of integrating family planning and nutrition education dovetailed with the Bank's own interest in testing formats other than mere postpartum counseling. More important, however, the Bank wished to capitalize on the apparent sincere intention of the GOJ to make a serious effort to improve its family planning program. Thus, Bank officials felt there was ample justification to consolidate the efforts of JPP I by embarking on JPP II.
6.02 The Bank and GOJ agreed that the effectiveness of the new strategy needed to be tested, and the program was designed to that end. The goal had been to deem whether the pilot integrated delivery system in Cornwall County was an effective enough method for promoting family planning to replicate nationwide. An excellent opportunity existed to test its effectiveness including the postpartum counseling method against the less intense integrated effort in health centers elsewhere in the country. Unfortunately, adequate testing instruments were not built into the program design, and clear-cut conclusions did not emerge. Thus, judgement in replicating nationwide the Cornwall County design is being made primarily on a presumptive basis. The results in terms of health services in the County appear to be impressive.
6.03 Without precise data on relative effectiveness of the various program interventions, it seems natural to turn to demographic goals and the degree to which they were met to judge program success. This approach too is only partially satisfactory. Family planning programs are only one of several factors which affect a country's demographic profile; moreover, at best, targets are merely educated guesses; more often, they are the product of wishful thinking. Usually, the accuracy of the target says more about the acumen of the planners than it does about the success of various program interventions. Significantly, JPP II goals were wide off the mark on two important demographic areas. Fertility rates apparently fell faster and farther than predicted while, seemingly paradoxically, the crude birth rate did not reflect this fall but in fact started to rise again as the project concluded. In making predictions, planners had apparently overlooked two important competing forces, the effectiveness of the private sector as a factor in lowering fertility rates and the effect the bulge in the 15-19 year-old cohort and emigration would have on the number of births each year. The miscalculations carry important lessons for future programming efforts in family planning.
6.04 In the future, the number of females in the childbearing ages will certainly continue to increase, and thus the conclusion is that it is imperative for the Government to seek ways to reach them. The first step in devising a program strategy must be to learn more about fertility - 58 -
determinants affecting teenage cohorts. Given its success among older women, the private sector should be enlisted in this effort. Eventually, a cooperative strategy should be devised including shared costs, commercial marketing of contraceptives and the development of innovative programs. These two elements should be the cornerstones of any upc sing family planning program in Jamaica.
6.05 Despite the limitations of targets as a measure of program success, it cannot be overlooked that in all areas, improvement of family planning acceptance fell below the program goals. The poor showing brings into question the effectiveness of the nerger of NFPB and MOHEC. Spot checks and comments from family planning advocates raised a variety of questions regarding the effectiveness of district midwives and community health aides as the front-line providers of family planning advice and supplies; there seems to be more than professional jealousy to the charges that staff whose sole training and purpose it is to promote family planning should be in the field performing that rask rather than be absorbed with the bureaucracy in more generalized roles.
6.06 An important lesson learnt, in the institutionalization of family planning and health in an integrated medium, is that there should be a strong base for supervision and monitoring of family planning activities which, as experience shows, are in competing demand with health services.
6.07 Experience elsewhere has shown that the success or failure of family planning depends, as perhaps in no other sector, on government commitment. It is not just MOHEC's commitment which is in question, although this is certainly an important issue. It is the commitment of the Government as a whole. While in Jamaica, there has been a long tradition of interest in population control, out-migration has always provided a safety valve which has made the problem less urgent than in such countries as China and Indonesia. In recent years, however, even as the level of out-migration has declined, financial difficulties have arisen which now put in question Jamaica's ability to fully fund future family planning efforts. In short, lack of Government commitment may well be the major reason that JPP I was not able to attract more Jamaicans to the family planning program. Consequently, the degree of commitment which the GOJ is prepared to exhibit in future should be the major determinant in whether a third population project should be undertaken. W
JAMAICA - SECOND POPULATION PROJECT (LN. 1284-JM) Age-Speciftc Fertility Rates and Total Fertility Rates, 1964-75
Age-Specific Fertility Rates Rate of Change (in 2)
Age 1964-66 1967-69 1970-72 1973-75 1964-66 1964-66 Group 1964-66 1967-69 1970-72 1973-75 1975-80 to to to to to to 1967-69 1970-72 1973-75 1975-80 1973-75 1975-80
15-19 196 165. 182 137 125 -16 10 -25 -9 -30 -36 20-24 295 271 272 236 205 -8 0 -13 -13 -20 -30 25-29 284 257. 253 201 197 -10 -2 -21 -2 -29 -30 30-34 235 223 204 150 137 -5 -9 -26 -8 -36 -42 35-39 183 158 129 94 90 -14 -18 -27 -4 -49 -51 40-44 52 52 56 54 31 n.n. n.a. n.a. -42 n.a. -40 45-49 9 9 9 9 5 n.a. n.a. n.a. n.a.
TFR 6.26 5.68 5.52 4.40 4.0 -9 -3 -20 -9 -30 -36 La
Source: Jamaica Fertility Survey, 1980 -60 - ANNEX 2
JAMAICA - SECOND POPULATION PROJECT (LN. 1284-JM) Victoria Jubilee Hospital Deliveries by Mothers 19 years and under
Percentage Babies of all deliveries
1974 4,212 30 1975 4,137 31 1976 4,294 31.5 1977 4,202 31.2 1978 4,054 30.9 1979 4,080 32 1980 3,832 30.6 1981 3,774 29.6 1982 3,872 28.5
Total Approx. Number of Deliveries Babies Born Each Day
1974 13,618 37.5 1975 13,212 36.2 1976 13,423 36.7 1977 13,356 36.6 1978 13,121 35.9 1979 12,784 35.3 1980 12,745 35 1981 12,747 35 1982 13,644 37 JAMAICA - SECOND POPULATION PROJECT (LN. 1284-JM) Critical Demographic and FP Data
1974 1975 1976 1977 1978 1979 1980 1981 1982
Population (million) 2.10 - 2.11 2.14 - 2.19 2.23 2.265 1 CBR/1000 30.6 30.1 - 28.9 27.4 27.5 26.9 26.9 27.3 CDR/1000 6.9 - 6.8 5.7 6.2 5.8 6.0 5.6 RNI % 2.3 - 2.2 2.2 2.1 2.1 2.1 2.2 IMR 23.5 - 15.1 14.9 12.4 N.A. N.A. - WRAG (15-49 years) % 45 - 42 2/ GRR - 1.8 1.7 1.6 1.7 - TFR 4.4 - - - - 4.0 -
Contraceptive Mix (%) . Pill - - - - - 38.7 - - . Injection - - - - - 45.6 - - . IUD - - - - - 1.3 - - . Sterilization - - - - - 0.5 - - . Diaphragm - - - - - 0.2 - - . Condom/Spermicidals - - - - - 10.0 - - . None - - - - - 3.8 - - . Total Nbr. of Users - - 154,236 - -
Contraceptive Prevalence (2) . Women in Union 38.1 ------58 . WRAc ------33
Acceptors . New as % of WRAG (National) - - 16.4 - - - 13.7 - - Cornwall Co. JPP II ------21.4 - . Active Users as % of WRAG (National) - - 11.0 - - - 24.0 - Nbr. Estimated of Clients in FP Program (1974-67,000) 73,000 62,000 72,000 - 66,000 62,000 83,000 84,000 (16%) - (14%) (13%) (17%) (17%) Nbr. of Annual New Acceptors - - 30,300 - 23,000 24,000 32,000 35,000 (5%) (5%) (7%) (8%) % Change New Acceptors - - - - (-8.0) (5.7) (34.5) (1.4) - % Coverage Postpartum Mothers - - 37 - - - 50 -
1/ Mid-1982 provisional figure. Compare with 1.85 million (1970 census). 2/ Compare with 48% (1970 census). JAMAICA - SECOND POPULATION PROJECT (LN. 1284-JM) Population b Age and Sex: 1970, 1982 1/ (in '000s)
Age 1970 Census Estimate April 1982 Group Male Female Total % Male Female Total Z
0-4 144.7 142.4 287.1 15.8 134.9 127.2 262.1 11.8 5-14 273.8 271.2 545.0 30.1 309.6 280.5 590.1 26.4 15-19 81.2 84.7 165.9 9.1 132.5 137.8 270.3 12.1 20-29 108.3 199.4 227.7 12.6 177.0 184.5 361.4 16.2 30-39 76.0 85.6 151.6 8.9 96.7 101.5 198.2 8.9 40-49 70.3 76.3 146.6 8.1 77.4 84.0 161.4 7.2 50-59 61.5 64.6 126.2 7.0 72.8 77.1 149.9 6.7 60-64 25.3 27.3 52.6 2.9 27.0 39.2 66.3 3.0 65 + 44.7 56.2 100.9 5.6 81.2 90.6 171.9 7.7
Total 885.5 927.7 1,813.6* 100.0 1,109.1 1,212.4 2,231.5 100.0
* The 1970 Census total 1,816,600 excludes 34,600 persons for whom incomplete data were obtained.
1/ Source: Economic and Social Survey (Jamaica) compilation from the Census, April 1970, and Labor Force Survey, April 1982. -63- ANNEX 5
JAMAICA - SECOND POPULATION PROJECT - Loan 1984-JM
Additional Civil Works Undertaken and Proposed during Project Implementation
The following civil works were undertaken in 1980 and 1981 in addition to those approved under the Project:
a) installation of incinerators in all centers;
b) installation of water tanks in 16 centers in locality in which water shortages were expected: Lowe River, Bellevue, Berkshire, Granville, New Works, Cornwall Mountain, Darliston, New Market, Beeston Spring, Tower Hill, Townhead, Delveland, Albert Town, Bounty Hall, Garlands and Southfield;
c) construction of an additional center in New Market;
d) construction of additional staff houses in Montpellier, Cornwall Mountain, Bellevue and Garland; and
e) refurbishing of 19 existing health centers which were in bad need of repairs. These repair works were expected to be carried out on the government's own resources but had been delayed because of severe financial constraints. All repair works were carried out successfully by local contractors after local competitive bidding under the supervision of NDA.
The following civil works were considered for financing under the project but not undertaken:
a) construction of offices for the Cornwall County Health Administration; and
b) the remodeling of the MOHEC warehouse in Montego Bay into a regional medical store for drugs, medical supply and material. 64- ANNEX 6
JAMAICA - SECOND POPULATION PROJECT (LN. 1284-JM)
FUNCTION AND CHARACTERISTIC OF TYPE CENTERS
1) Type I
This Center will serve a population of approximately 4,000 persons. The services to be offered will include ante-natal, post-natal, family planning, child health, nutrition, etc. The facilities will be staffed by midwives and community health aides and visited regularly by other health personnel. Housing accommodation provided at some of these centers.
2) Type II
This service will serve a population of approximatey 12,000 persons. In addition to the services to be provided by Type I Center, this Center will cater to immunizations and the treatment of minor illnesses, etc. The staff will include midwives, Public Health Personnel, community health aides, etc. The Center will also accommodate visits of consultants, doctors, pharmacists, dentists, etc.
3) Types III and IV
This Center will serve a population of approximately 20,000 persons. In addition to the services to be provided by Type II Center, this Center will function as District Headquarters.
Staff will include medical officers, dentist, public health personnel, etc.
The Type IV Center, in addition to all the services and the facilities of the Type III, will house offices for the Parish Medical Officers of Health. JAMAICA - SECOND POPULATION PROJECT - LOAN 1284-JH
NATIONAL DEVELOPMENT AGENCY LTD.
SUMMARY OF TIME & COST OF HEALTH CENTRES
BUILT IN THE COUNTY OF CORNWALL
in Jamaican Dollars JUNE 1983
HEALTH CENTRE DATE OF DATE OF DATE OF PROJECT'D ACTUAL DATE OF DATE OF ORIGINAL CONTRACT FINAL SITE TENDER CONTRACT CONSTRUC. CONSTRUC. COMPLE- COMMIS- ESTIMATED SUM COST L1 Type I ACQUISI- RETURN AWARD PERIOD PERIOD TION SIONING COST TION MONTH(s) MONTH(s)
Creat Valley 101 May 76 7.7.77 24.8.77 4 11 July 78 May 79 50,000 42,083 49,800 Montpelier 102 May 76 30.5.77 24.6.77 4 13 Sept. 78 Mar. 80 36,539 25,509 35,047 Copse 103 May 76 2.9.77 2.11.77 4 13 Dec. 78 May 79 66,950 46,332 62,363 Askerish 104 Nov. 77 19.10.77 25.4.78 4 14 July 79 Feb. 80 67,359 44,401 63,359 Logwood 105 Nov. 77 16.2.79 1.5.79 4 7 Dec. 79 Apr. 80 46,346 45,999 54,940 Green Pond 106 Oct. 80 14.8.80 11.11.80 4 12 Nov. 82 106,000 81,580 121,859 Glendevon 107 May 76 12.7.77 24.8.77 4 12 Aug. 78 Nov. 78 56,229 52,838 51,767 Barrett Twn 108 May 76 12.7.77 24.8.77 4 8 Apr. 78 Nov. 78 66,906 50,944 62,319 John's Hall 109 May 76 2.9.77 2.11.77 4 9 Aug. 78 Nov. 79 53,343 27,394 47,730 Carlands 110 May 76 2.9.77 2.11.77 4 7 June 78 Feb. 80 73,320 35,501 70,599 I Springfield 111 May 76 2.9.77 2.11.77 4 13 Dec. 78 Jan. 80 46,271 31,015 46,429 p Lottery 112 Aug. 77 30.5.77 24.6.77 4 11 May 78 Oct. 78 53,287 43,745 51,704 Somerton 113 Apr. 81 1.7.81 14.9.81 4 12 Oct. 82 281,502 Goodwill 114 May 77 6.10.77 29.11.77 4 6 May 78 Oct. 78 36,888 30,079 34,504 JAMAICA - SECOND POPULATION PROJECT - LOAN 1284-JM
NATIONAL DEVELOPMENT AGENCY LTD.
SUMMARY OF TIHE 6 COST OF HEALTH CENTRES
BUILT IN THE COUNTY OF CORNWALL
in Jamaican Dollars JUNE 1983
HEALTH CENTRE DATE OF DATE OF DATE OF PROJECT'D ACTUAL DATE OF DATE OF ORIGINAL CONTRACT FINAL SITE TENDER CONTRACT CONSTRUC. CONSTRUC. COMPLE- COMIS- ESTIMATED SUM COST Type I ACQUISI- RETURN AWARD PERIOD PERIOD TION SIONING COST TION MONTH(s) MONTH(s)
S $ $ Power Hill 115 210,000 179,000 207,462 Deeside 116 May 76 7.7.77 24.8.77 4 16 Dec. 78 Feb. 81 73,367 36,476 72,994 Rio Bueno 117 May 76 7.7.77 24.8.77 4 5 Jan. 78 Oct. 79 77,738 46,905 76,304 Bounty Hall 118 Dec. 77 1.11.79 11.1.80 4 21 Sept. 81 Oct. 82 173,402 Troy 119 May 76 30.5.77 10.8.77 4 16 Dec. 78 Apr. 80 70,514 43,380 77,179 Lowe River 120 Dec. 77 26.2.80 18.6.80 4 9 Mar. 81 Jan. 82 143,752 105,162 222,598 Braes River 121 May 76 30.5.77 24.6.77 4 7 Jan. 78 Sept. 79 69,000 46,186 66,475 Fyffes Pen 122 Aug. 78 21.6.69 20.9.79 4 5 Mar. 80 Sept. 80 61,528 54,964 74,620 Springfield 123 Apr. 79 21.6.79 28.4.80 4 7 Nov. 80 Oct. 81 113,988 86,468 125,752 Bellevue 124 Dec. 77 17.1.80 18.6.80 4 7 Jan. 81 June 82 83,271 61,214 87,130 Prospect 125 Dec. 77 11.1.79 18.6.80 4 5 Dec. 80 Apr. 82 145,517 106,578 158,056 Delveland 126 Apr. 77 2.9.77 2.11.77 4 10 Sept. 78 Aug. 79 54,412 49,350 53,273 Jerusalem Mtn 127 Dec. 77 16.2.79 1.5.79 4 13 June 80 Mar. 81 93,124 79,927 110,884 Baulk/ 128 June 77 2.9.77 2.11.77 4 11 Sept. 78 May. 80 62,652 48,400 65,134 Town Head JAMAICA - SECOND POPULATION PROJECT - LOAN 1284-JM
NATIONAL DEVELOPMENT AGENCY LTD.
SUMMARY OF TIME & COST OF HEALTH CENTRES
BUILT IN THE COUNTY OF CORNWALL
in Jamaican Dollars JUNE 1983
HEALTH CENTRE DATE OF DATE OF DATE OF PROJECT'D ACTUAL DATE OF DATE OF ORIGINAL CONTRACT FINAL SITE TENDER CONTRACT CONSTRUC. CONSTRUC. COMPLE- COMMIS- ESTIMATED SUm COST Type I ACQUISI- RETURN AWARD PERIOD PERIOD TION SIONING COST TION MONTH(s) MONTH(s) $ S$ Belmont (Cave) 129 Nov. 77 6.10.77 29.11.77 4 7 June 78 Dec. 78 60,310 47,029 56,056 Bershire 130 Oct. 80 14.8.80 11.11.80 4 10 Sept. 81 Jan. 83 172,000 132,600 167,180 New Works 131 Dec. 77 17.1.80 18.6.80 4 22 Apr. 82 Dec. 82 160,962 119,191 254,470 I Cornwall Mnt. 132 Feb. 79 5.2.79 1.5.79 4 4 Sept. 79 Oct. 79 49,746 43,512 121,270 0% Freeston Spring 133 May 81 1.7.81 8.9.81 4 11 Aug. 82 180,000 163,530 186,553 * St. Leonards 134 Oct. 80 26.2.80 18.6.80 4 16 Oct. 81 138,709 116,501 173,255 1 Georges Plain 160 Nov. 78 21.9.79 20.9.79 4 13 Oct. 80 Aug. 81 70,623 55,691 71,015
'U1 JAMAICA - SECOND POPULATION PROJECT - LOAN 1284-JM
NATIONAL DEVELOPMENT AGENCY LTD.
SUMMARY OF TIME & COST OF HEALTH CENTRES
BUILT IN THE COUNTY OF CORNWALL
in Jamaican Dollars JUNE 1983
HEALTH CENTRE DATE OF DATE OF DATE OF PROJECT'D ACTUAL DATE OF DATE OF ORIGINAL CONTRACT FINAL SITE TENDER CONTRACT CONSTRUC. CONSTRUC. COMPLE- COMMIS- ESTIMATED SUm COST C% Type II ACQUISI- RETURN AWARD PERIOD PERIOD TION SIONING COST o TION MONTH(s) MONTH(s) S S S Sandy Bay 235 June 77 29.9.77 29.1.77 6 16 Mar. 79 Apr. 79 211,138 141,055 179,425 Grange/Kendal 236 Dec. 78 24.1.80 3.9.80 6 15 Mar. 82 May 82 227,485 151,065 433,103 Cascade 237 Dec. 77 8.11.79 28.4.80 6 18 Oct. 81 Feb. 82 341,031 254,265 380,434 Cave Valley 23C July 81 24.1.80 Sept. 81 6 12 Sept. 82 Jan. 83 385,947 290,332 550,358 Catadupa 239 May 76 13.10.77 6.2.78 6 15 May. 79 Jan. 80 150,064 219,103 Mt. Salem 240 Dec. 77 16.2.79 5.10.79 6 July 81 248,5777 188,147 346,315 Mt. Carey 241 May 78 6.12.78 28.6.80 6 13 July 81 Oct. 81 292,237 198,923 437,161 New Market 242 Jan. 82 15.5.81 Mar. 82 6 12 Feb. 83 424,000 430,257 550,000 Aberdeen 243 Dec. 78 21.8.80 Feb. 81 6 21 Nov. 82 519,875 438,125 1,100.000 Maggotty 244 Apr. 77 19.9.77 16.11.77 6 19 June 79 Jan. 81 213,183 138,271 217,726 Southfield 245 Dec. 78 7.2.79 6.6.79 6 12 June 80 May 81 239,176 190,937 308,453 Negril Peterefield 248 Dec. 77 31.3.78 14.6.78 6 12 June 79 May 80 215,000 152,627 204,894 Cranville 249 May 76 3.4.79 5.10.79 6 24 Oct. 81 May 82 322,692 249,480 345,834 JAMAICA - SECOND POPULATION PROJECT - LOAN 1284-JM
NATIONAL DEVELOPMENT AGENCY LTD.
SUMMARY OF TIME & COST OF HEALTH CENTRES
BUILT IN THE COUNTY OF CORNWALL
in Jamaican Dollars JUNE 1983
HEALTH CENTRE DATE OF DATE OF DATE OF PROJECT'D ACTUAL DATE OF DATE OF ORIGINAL CONTRACT FINAL SITE TENDER CONTRACT CONSTRUC. CONSTRUC. COMPLE- COMMIS- ESTIMATED SUm COST ACQUISI- RETURN AWARD PERIOD PERIOD TION SIONING COST TION MONTH(s) MONTH(s)
Type I
Albert Town 252 May 76 10.4.81 12.10.81 6 13 Nov. 82 520.000 470,000 439,464 Say-la-mar 256 May 78 9.3.79 5.10.79 6 14 Dec. 80 Dec. 81 230,000 217,145 279,755 Black River 257 Dec. 78 20.4.79 11.1.80 6 12 Jan. 81 Apr. 82 278,000 230,189 380,922
Type IIII
Santa Cruz 258 Feb. 81 20.6.80 21.11.80 6 13 Dec. 81 May 82 480,000 426,242 837,178 Catherine Hall 350 May 76 4.8.77 20.10.77 9 13 Nov. 78 Jan. 80 216,684 239,331 209,461 Cambridge 351 Dec. 77 6.1.78 20.3.78 9 16 July 79 Jan. 80 309,176 225,000 301,002 Darliston 353 June 77 18.11.77 27.1.78 9 10 Nov. 78 Oct. 79 276,574 195,828 272,237
Type IV
Lucea 454 May 76 22.7.77 20.10.77 9 21 July 79 Oct. 79 266,500 196,246 260,748 Falmouth 455 May 76 28.10.77 20.10.77 9 13 Nov. 78 Jan. 80 283,412 199,848 286,063 -70 ANNEX7 Page 6
JAMAICA - SECOND POPULATION PROJECT (LN. 1284-JM) Refurbishing Health Centers
Site Contractor Contract Final Figure Figure
1. White House L.A. Parchment 6,400.00 . 8,000.00 2. Hopewell Hanover Road Const. 8,265.45. 19,757.55 3. Duncans Alpha Construction 21,776.00. 21,776.00 4. Grange Hill George Barnaby 8,307.10 16,136.90 5. Balaclava Lonsdale Longmore 10,500.00 22,000.00 6. Green Island Ashok Construction 12,94.07 13,500.00 7. Exeter Leslie Williams 12,150.00 17,040.00 8. Wait-A-Bit Wright's Construction 32,545.17 40,204.17 9. Lacovia Maxwell's Construction 32,402.65 38,000.00 10. Maroon Town Ernest Aljoe 14,000.00 14,000.00 11. Salt Spring Archibald Morris 16,997.00 21,354.65 12. Adelphi Melbourne Allen 11,692.00 14,692.00 13. Luanvale Leslie Samuels 11,927.75 19,437.75 14. Warsop Marjorie White 34,315.00 37,890.00 15. Williamsfield W.S. Scott 26,096.67 32,000.00 16. Wakefield John Sterling 17,953.20 9,500.00 17. Portsea Henry Miller 12,378.00 14,378.00 18. Roehampton Kenneth Windross 6,798.76 7,534.75 19. Malvern Percival McLeod 15,977.00 15,977.00
TOTAL $312,675.82 $383,178.78 -71- ANNEX 8
JAMAICA - SECOND POPULATION PROJECT (LN. 1284-JM) Comparison of Number of Staff in Cornwall County Health Administration
Projected Actual 1976 1980 1982
Physician Full-Time 3 27 13 Physician Part-Time 11 11 1 Public Health Nurses 33 86 32 Senior Public Health Nurses 8 14 8 Nurse Practitioners 0 32 15 District Midwives 89 138 117 Community Health Aides 366 708 487 Nutritionists
TOTAL 510 1,016 673 ANNEX 9 - 72 - Page 1 of 2
JAMAICA - SECOND POPULATION PROJECT (LN. 1284-JM) Use of Technical Assistance and List of Consultants Employed with Costs (US$)
Period Name Service Component Foreign Local
1/10/76-30/9/81 Mrs. Beryl Chevannes Midwifery Delivery Midwifery $33,718 $18,539 5 years University Hospital Services & Curri- Training West Indies, Jamaica culum Development
1/2/77-31/10/77 Dr. Everald Hosein Baseline Survey Nutrition - $5,618 1/6/78-31/08/78 Inst. Mass. Comm. Nutrition Education/ U.W.I. Jamaica Education Communication
January 1977 Messrs. Siegel, Eden, Establishment of Planning & $3,093 Girder Plannian and Evaluation Chapel Hill, Evaluation Unit Unit N. Carolina, USA
1/2/77-31/1/78 Fredie Wilmot Film Production: Nutrition $12,359 $4,214 Toronto, Canada Producer/Editor Education/ Communication
1/2/77-31/1/78 Tony March Film Production - do - S9,719 $1,318 Kingston, Jamaica (Photography)
3/6/77-31/8/81 Denis Ranston Audio-Visual - do - $16,714 - Ranston, Jamaica Producer
3/6/77-31/1/79 Mrs. Jacqueline Audio-Visual Aids - do - $11,236 $5,056 Ranston Kingston, Jamaica
1/9/77-31/8/78 Mrs. Pearl Gammon Health Planning Planning & $6,742 $3,667 National Planning Evaluation Agency: Jamaica Unit
1/3/78-31/3/80 Mrs. T.G. Taylor Midwifery Tutor Midwifery thruugh USAID Training
1/11/78 Mr. 0.W. Knott Financial Project S22,542 Kingston, Jamaica Controller Administration
1/11/78-31/3/82 Osmond C. Gordon Statistician Planning & $23,034 $13,820 Kingston, Jamaica Evaluation Unit Health Information System -73 - ANNEX 9 Page 2 of 2
ZAMAICA - SECOND POPULATION PROJECT (LN. 1284-Jm) Use of Technical Assistance and List of Consultants Employed with Costs (US$)
Period Name Service Component Foreign Local
October 1979 Institute of Mass Mid-term Evaluation Nutrition February 1980 Comms. UWI and USAID Nutrition Campaign Education/ Communication
1977-1979 Mr. Mark Gross & Trainers In-service - 1/6/78-31/08/78 Mrs. U.M. Clay Nutrition training through USAID from Education Johns Hopkins Univ.
9/3/81 MJS Associates Documentation of Planning & $40,000 - Boston, Mass. USA Implementation Evaluation Progress of Project Unit
1/6/81-31/12/81 Arthur Walton Setting up Health Health $48,630 - c/o UNDP Facility Hainte- Maintenance nance Unit Unit
1/11/81-31/1/82 Dr. G.E. Camper Economist Planning & $10,000 - Ross Institute Evaluation London, England Unit
1/11/81-31/10(82 Mrs. Daphne Kelly Communication Nutrition $7,865 $2,697 Kingston, Jamaica Education/Com.
5/7/82-31/10182 Dr. G.E. Cumper E-nno ist Building Uti- $10,000 - lization Study
5/7/82-31/10/82 MJS Associates Health Planning Building Uti- $10,000 - Boston, Mass. USA lization Study
5/7/82-31/10/82 Lloyd G. Robinson Architect - do - $10,000 Kingston, Jamaica
31/10/82 Boston University Linkages PHC/Emer- Innovative $30,000 through USAID gency Medical Training Services
15/2/82-31/12/82 Project Hope Biomedical Health Faci- $91,000 Foundation USA Engineering lity Mainte- Statistician nance Unit Evaluation Unit Health ANNEX 10 -74 - Page 1 of 2
JAlmICA - SECOND POPULATION PROJECT (LN. 1284-JK) Fulfillmt of Special Covenants and Supplementary Conditions
Action Pending Covenant Condition Met and Status Remarks
Section 3.01.
Section 3.02. (a) The Borrower Yes. except for delays in shall appoint a Project Director, two processing. persons as Deputy Project Directors, one to coordinate construction and pro- curement and the other to supervise maternal and child health. family plan- ning and nutrition activities under the Project.
(b) National Development Agency to Tes, except for some delays assist in the implementation of cons- in processing disbursement truction and the carrying out of applications on part of procurement. Ministry of Finance.
(c) and the qualified and Tes. experienced person shall be appointed Project Coordinator for the Cornwall County Health Administration.
Section 3.03. The Borrower shall 23 out of 28 consultancies 5 consultants not employ consultants and advisors. utilized. appointed: 2 for in- service training; I advisor for Plan- ning Evaluation Unit: I for demo- research. Section 3.04. (a) The Borrower Yes. graphic undertakes to insure the imported goods against hazards.
(b) Except as the Sank shall other- Yes. 17 vehicles out of wise agree, the Borrower shall ensure 63 were diverted that all goods and services financed out for MEC emergency of the proceeds of the Loan will be used in Middlesex and exclusively for the Project. Surrey Counties.
Section 3.05. (a) The Borrower shall Yes. furnish to the Bank, the plans, speci- fications, reports, contract documents and construction and procurement sched- ules for the Project.
(b) The Borrower: (i) shall asin- Yes. tain records; (iI) shall enable the Bank's accredited representatives to visit the facilities and construction sites, and (iii) shall furrLsh informa- tion to the Bank on the expenditure of the proceeds of the Loan and the goods and services financed out of such pro- ceede.
Section 3.06. (a) The Borrower shall Yes, except that 8 sites acquire all land required for carrying were acquired after out the Project. Dec. 31, 1977: 2 in 1978; 2 in 1979; 2 in 1980: and 2 in 1981.
(b) the Borrower shall acquire the 26 sites required for Phase 2 of the ProJect by December 31, 1977.
Section 4.02. -he Borrower shall Yes, NDA kept accounts up maintain records -ifresources and ex- to date after appointment penditures. of accountant in Jan.. 1978 -75 - ANNX 10 Page 2 of 2
JAAICA - SECOND 1OPULATION PROJECT (t. 1284-JM) Fulfillmnc of Special Covenants and Supplemtary Conditions (cont,d)
Action Pending Covenant Condition Met and State asmarks
Section 4.03. (a) The Borrower shall No. Fonds were either provide in its annual budgets suns ade- delayed or inadequate quate to meet the needs of the maternal for: and child health, family planning and Staffing: nutrition programs of the Borrower. (a) Health Centers was only 673 personnel in 1982 compared to project goal level of 1016.
(b) Postpartum only 15 new posts satfed compared to goal of 28.
Training a CiA - only 507 trained compared with goal of 1,000 (b) Midwives - only 82 trained com- pared with goal of 255
(b) The Borrower shall establish Yea, except for two-year A few scaff vacen- and maintain a Cornwall County Health delay. cies reasin. Administratioo; no later than ay 31, 1979, appoint persons in all vacant positions; no later than July 31, 1977, assign such other staff.
Section 4.04. The Borrower shall by Yes. A planning advisor December 31, 1976. establish a Planning not appointed; and Evaluation Unit. staffing weak and role unclear. Section 4.05. (a) The Borrower shall: (1) within air months, a person Yes. shall be appointed to assist the Borrower's Principal Medical Officer in charge of maternal and child health, family planning and nutrition program. (ii) appoint by December 31, 1976, No. a ComnicAtions Officer and a Comserce and Media Assistant responsible for the nutrition component. (III) appoint by December 31. 1976. Yes. at least three suitably quali- fied persons to work as Research Assistants in the Planning and Evaluation Unit mentioned. Civ) employ about 60 additional mid- $o. A total of only 82 wives each year during the aidwives trained period 1978 through 1982. (v) by December 31, 1978, provi- No. A total of only son of about 800 additional about 500 new CHAs comunity health aides and employed about 200 community health sides' supervisors.
Section 4.06. The Borrower shall No. Made only one publish in 1977, and thereafter, publication in regular annual records of age-specific 1980. fertility rates to Jamaica. -76 - ANNEX 11 Page 1 of 3
JAMAICA - SECOND POPULATION PROJECT (LN. 1284-JM) Comparative Cost Summary per Category of Expenditure (US$ & J$'000)
Appraisal Estimates Estimated Final Cost Balance
Category J$ US$ J$ US$ J$ US$
1) Civil Work 5,100 5,611 14,684 8,700 9,584 3,089 including professional fees
2) Furniture & 939 1,030 2,068 540 +1,129 -490 equipment for health centers
3) Vehicles 603 663 612 587 +9 -76
4) Special 362 399 516 700 +154 -301 Equipment
5) Technical 1,306 1,437 1,307 485 +1 -952 Assistance & Fellowship
6) Innovative 364 400 364 52 0 -348 population sub-projects
7) Interest and 858 944 1,576 1,076 +718 +132 other charges on the Loan
8) Unallocated 3,326 3,659
TOTAL 12,857 14,144 21,127 12,140 8,270 -2,004 - 77 - ANNEX 11 Page 2 of 3
JAMAICA - SECOND POPULATION PROJECT (Ln. 1284-JM)
Disbursements per category of expenditure (US$)
Category Forecast Actual Balance
1) Civil Works including 1,862,000 2,856,977 + 994,977 professional fees
2) Furniture & equipment 511,000 269,262 - 241,738 for health centers
3) Vehicles 663,000 587,126 - 75,874
4) Special equipment 337,000 699,402 - 362,402
5) Technical assistance 908,000 484,483 - 423,517 and fellowship
6) Innovative population 200,000 25,607 - 174,393 sub-projects
7) Interests and other 944,000 1,076,351 + 132,351 charges on the Loan
8) Unallocated 1,375,000 - 1,375,000
TOTAL 6,800,000 5,999,208 - 800,792 ANNEX 11 - 78 - Page 3 of 3
JAMAICA - SECOND POPULATION PROJECT - LOAN 1284-JM
M9£
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e * - * ------79 - ANEX 12
JAMAICA - SECOND POPULATION PROJECT
Composition of Missions
04 4 Su 4J v-44i Ii ø ce ø 0ø 4 4J UW. -J'ri ..4 &C riU -r4 4 0m d
"c, -4ICu0 mæ 0 Sue o VI m a E 4.'. a~~ Q V0C.~ ~ ~~/ciJ2C .W
Supervision I i i
SupervisionSueriio,V4 IX 11J 1-Oq. 1 L
Supervision X1 1 1
Supervisioni IV Superisio ii CII gn11
Supervision V 1
Supervision VI i i
Supervision VII ii
Supervision VIII i i i i
Supervisioni IX iii i
Supervision Xii
Supervision XIii I
Supervision XII i i 一 不