Documentof The World Bank Public Disclosure Authorized
Report No. 13025-CHA
STAFF APPRAISAL REPORT
Public Disclosure Authorized CHINA
COMPREHENSIVEMATERNAL AND CHILD HEALTH PROJECT
SEPTEMBER 21, 1994 Public Disclosure Authorized
Poverty, Population and Human Resources Division China and Mongolia Department Public Disclosure Authorized East Asia and Pacific Regional Office CURRENCY EQUIVALENTS (As of August 1994)
Currency Name = Renminbi (RMB) Currency Unit = Yuan (Y) Y 1.00 = $0.11 $1.00 = Y 8.7
WEIGHTS AND MEASURES
Metric System
FISCAL YEAR
January 1 to December 31
ABBREVIATIONS AND ACRONYMS
ARI - Acute Respiratory Infection EPI - Expanded Program for Immunization EPS - Epidemic Prevention Station FLO - Foreign Loan Office ICB - International Competitive Bidding IDA - International Development Association IMR - Infant Mortality Rate LCB - Local Competitive Bidding MCH - Maternal and Child Health MIS - Management Information System MMR - Maternal Mortality Rate MOF - Ministry of Finance MOPH - Ministry of Public Health ORT - Oral Rehydration Therapy PPO - Provincial Project Office SDR - Special Drawing Right SPC - State Planning Commission TCM - Traditional Chinese Medicine TFR - Total Fertility Rate UNFPA - United Nations Population Fund UNICEF - United Nations Children's Fund U-5 - Under-the-age of 5 U-5MR - Under-the-age of 5 Mortality Rate WDR - World Development Report WHO - World Health Organization - i -
STAFF APPRAISAL REPORT
CIIINA
COMPREHENSIVE MATERNAL AND CHILD HEALTH (MCI) PROJECT
CREDIT AND PROJECT SUMMARY
Borrower: People's Republic of China
Beneficiaries: Ministry of Public Health (MOPH) and Eight Provinces (Gansu, Guangxi, Jiangxi, Nei Mongol, Qinghai, Shaanxi, Sichuan and Yunnan)
Amount: SDR 61.9 ($90 million equivalent)
Terms: Standard, with 35 years' maturity
Project Description: The project's principal goal is to reduce maternal and child morbidity and mortality in the poorest areas of China. This would be achieved by: improvingthe qualityand effectivenessof MCH care at the primary and county levels; increasing equitable access to and utilization of the basic care; and improving MCH management. The project has four main components: basic health care delivery; health workers' training; management improvement; and a national-level component. Under the basic health care delivery component,the project would improveservices at the village, township, and county referral levels. At the village level, the project would provide basic equipment, in-service training and program support for obstetrics, infant/child care, health education, and improved nutrition. At the township level, it would finance essential equipment, in-service training, rehabilitation of physical facilities and program support to improveMCH care and the supervisionof the village staff. At the county level, the emphasis is on improving technical quality, referral capability, supervision and technical assistance, and health education. To this end, the project would provide the county MCH stations and the county hospitalswith essential equipment, limited rehabilitation of the physical facilities, staff training, and program support. The health workers' training component would support in- service training of all health workers concerned with MCH care at the village, township and county levels in basic MCH, clinical care, and management skills. The management improvement component would improve management of comprehensive MCH programs at different - ii -
levels through training, supervisory support and improved management information. The national-level component would oversee the overall managementand monitoringof the project, carry out interdepartmental and interprovincial coordination, provide technical support to the provinces, prepare and appraise the second phase of this project and disseminatethe project experiencesto nonproject areas.
Benefits: The proposed project is expected to benefit about 100 million of the poorest people from among China's economically most disadvantaged provinces and counties. The most direct beneficiaries are women of child bearing age, particularly during and after pregnancy, and children under five years of age. The number of pregnant women and newborn beneficiariesis expected to be about 1.5 million each per year or a total of 15 million during the five years of the project. In addition, some 15 million womenof child-bearingage would benefit from health education, improvedfamily planningadvice and other care, includingtetanus toxoid immunization.
The main benefits of the project would be the sustainable reduction in maternal, infant, and child mortality and morbidity in the country's poorest regions. The project would also support nutrition education and special programs to alleviate micronutrientdeficiencies that should lead to improved feeding practices and improved nutritional status of women and children. Furthermore, the project includes specific interventions designed to improve planning and managementcapacity of the Central, provincial and county Govemments to prepare and implement similar comprehensive projects and to replicate them in other parts of the country.
Risks: There are two main risks in this project. First, there is a risk that a part of the poorest segmentof the populationwill not be able to benefit from improved services. This risk has been greatly reduced as the participatingprovinces are required to implementspecially targeted plans to benefit the poor and the first batch of four provinces have already developed the plans to start implementation by January 1, 1995. Secondly, there is a risk that the central and provincial officials will not be able to oversee the implementationof the project activities. The institutional strengthening measures already taken at each level, the project's national component in MOPH to supervise and monitor the project and the IDA supervisionmissions should minimizethis risk. EstimatedCost LA: Local Foreign Total --- ($ million) ------
Basic Health Care Delivery 37.05 18.06 55.11 Health Workers' Training 21.49 1.17 22.66 ManagementImprovement 29.39 2.41 3180
Total Bas,elineCost 87 21.64 109.57
Physical contingencies 4.39 1.08 5.47 Price contingencies 23.00 0.63 23.63
Total Project Cost 115.32 23235 138.67
FinancingPlan:
Governmentof China, provinces and counties 48.67 0.00 48.67 IDA 66.65 23.35 90.00
ToQX 115.32 23.35 ,138.67
EstimatedDisbursement:
IDA Fiscal Year 1995 1996 1997 1998 1999 ------($ million) ------
Annual 11.97 28.26 20.76 13.52 15.49 Cumulative 11.97 40.23 60.99 74.51 90.00
Poverty Category: This Project is targeted to 100 million of China's poorest population. Special programs of targeted intervention are included to benefit the poor.
EconomicRate of Return: Not Applicable.
La The above estimated costs are based on the final costs of the four fully prepared and appraised provinces plus preliminary estimates of the remaining four provinces, which will be subject to further review and approval. Detailedcosts breakdownsfor both sets of provinces are in Annex 9.
- iv -
CONTENTS
1 Maternal and Child Health in China ...... 1
A. Population, Health and Nutrition Status ...... 1 B. Maternal and Child Health (MCH) ...... 1 C. Major Issues and Constraints...... 4 D. GovernmentPolicy and Programs ...... 5 E. Bank Group Involvementin the Sector ...... 5
2 Project Background ...... 7
A. Project Development ...... 7 B. Project Areas ...... 8
3 The Project .. 11
A. Project Objectives .11 B. Project Description.11 C. Project Costs and Financing .15
4 Project Organization and hnplementation ...... 17
A. Organizationand Management ...... 17 B. Procurement ...... 19 C. Disbursements...... 20 D. Accountsand Audits ...... 22 E. Project Monitoringand Evaluation ...... 23 F. Special Impacts ...... 24
This report is based on the findings of an appraisal mission which visited China in February/March 1994. Appraisal team members included: Mr. J. Upadhyay (Task Manager and Health Planner), Drs. M. E. Young (PHN), J. Hohnen (EA2HR), Mr. D. Hou (RMC), Drs. J. Quinley, J. Krister, V. Lin, and Mr. A. Lim (Consultants). Peer reviewers for the project were: Mmes C. Fogle and A. Tinker. Dr. A. Measham (PHN) and Drs. J. Marks and B. McCarthy (Centers for Disease Control and Prevention, Atlanta); R. Parker (UNICEF, Beijing);and a number of Chinese officials also helped in the design and preparation of this project. The Division Chief is Mr. Vinay K. Bhargava and the Director is Mr. Nicholas C. Hope. 5 Benefits and Risks ...... 25
A. Benefits...... 25 B. Sustainabilityand Replicability...... 25 C. Risks ...... 26
6 AgreementsReached and Recommendations ...... 27
ANNEXES
1. Maternal and Child Health in China .29 2. Basic Health Care Delivery Component .33 3. Health Workers' Training Component ...... 38 4. ManagementImprovement Component ...... 44 5. National Level Program ...... 48 6. Basic Health Services for the Poorest ...... 53 7. StandardizedProject Equipment ...... 55 8. Civil Works ...... 59 9. Project Cost Summary.62 10. Project OrganizationalChart .68 11. Project ImplementationSchedule .69 12. Estimated Credit DisbursementSchedule .70 13. Project PerformanceIndicators .71 14. Technical Assistanceand Overseas Studies .77 15. Proposed Project SupervisionPlan .82 16. Project Preparation and Appraisal in Additional Provinces.83
TABT:FSIN TEXr
1.1: Infant and Maternal Mortality Rates, 1991. 2 1.2: Infant and Maternal Mortality Rates for SelectedProvinces. 3
2.1: Basic Indicators of Project Areas ...... 10
3.1: Summaryof Cost Estimates ...... 15 3.2: Financing Plan ...... 16
4.1: ProcurementArrangements .21 - vi -
Selected Documentsin Project File
1. Project Proposals from Guangxi, Shaanxi, Sichuan and Yunnan 2. Project Costs: (a) Detailed Project Cost Tables (b) Detailed Cost tables for Each of the Four First-Phase Provinces (Guangxi, Shaanxi, Sichuan, and Yunnan) 3. Project ImplementationPlans and Guidelines
Map: IBRD No. 25783
1. MATERNAL AND CBILD HEALTH IN CHINA
A. POPULATION,HEALTH AND NUTRITIONSTATUS
1.1 DemographicStatus. China's populationwas estimated to be 1.13 billion in 1990. Since the Cultural Revolution,China has made serious efforts to limit population growth. As a result, throughout the 1980s, its crude birth and death rates remained at about 21 and 6 per thousand, respectively, stabilizingthe annual rate of natural increase at about 1.5 percent. The total fertility rate (TFR) has been held at 2.5 in the 1980s.
1.2 Health Status. Since 1949, China's achievements in health have been remarkable and her population has attained a health status comparable to middle-income countries. The country has been successfulin creating a comprehensivenetwork of health services covering all counties, townshipsand villages. Every county has a county general hospital, an epidemic prevention station (EPS) and a matemal and child health (MCH) station. Each township has a small hospital (average 15 beds) which provides both preventive and curative services to the population. Although many poorly qualified "barefootdoctors" have left the health field, by 1990, about 86 percent of the villages had a health clinic and the most of the remainder were covered under outreach programs. The World Development Report (WDR) 1993 indicates that, in 1991, China's average life expectancyat birth was 69 years, compared to 42 years for low-incomecountries and 69 years for upper-middle-incomecountries. Accordingto the WDR's measureof the overall burden of disease, China's per capita losses from disease are less than those of any region except the established market economies (EMEs) and the formerly socialist economies (FSEs) of Europe.
1.3 Nutritionalstatus. Averagefood consumptionin China compareswell with other developingcountries. The NationwideNutrition Survey of 1982 indicated that the average energy intake per capita was 2085 calories (102 percent of recommendeddaily allowance or RDA) and 67 grams of protein (92 percent of RDA). The average Chinese diet is not deficient althoughpockets of malnutritionexist in poorer areas. Micronutrient deficienciesare manifestedin the prevalenceof anemia (between30-80 percent of children under seven and about 50 percent of pregnant women in the rural areas), rickets (about 50 percent of the children in certain areas), and iodine deficiency disorder.
B. MATERNALAND CHILD HEALTH (MCE)
MCH Status
1.4 China's overall MCH status far exceeds that of most developing countries and compares well with middle income countries. Its infant mortality rate (IMR) and matenal mortality rate (MMR) compare well with countries with much higher per capita income, as indicated by the WDR data shown below in Table 1.1. China was able to attain these rates with fewer resources mainly because of the Govemment's policy to establish an extensivehealth service network and to emphasize preventive health care.
Table 1.1: INFANT AND MATERNAL MORTALrTY RATES, 1991
IMR per 1,000 MMR/100,000 live births live births
Low-incomecountries 71 308 Middle-incomecountries 38 107 Upper-middle-incomecountries 34 104 High-incomecountries 8 China La 35 88
La AlthoughChina's MCH status is undoubtedlybetter than most developing countries, it is hard to find reliable data on IMR and MMR. For consistency,China's IMR and MMR data in Table 1.1 were from official sources as used elsewhere in this report (see the source reference in Table 1.2).
Source: WDR, 1993.
1.5 Concealed behind the favorable national statistics, however, are serious differences in health status among regions of China. As seen in Table 1.2, IMRs (deaths per 1,000 live births) in Beijing, Jilin, and Shandong are 11, 27, and 17, respectively, comparedto 68, 50, and 74, respectively,for Guizhou, Guangxi,and Yunnan. Similarly, MMRs for the first group of provinces are 40, 47, and 40, respectively,for every 100,000 live births compared to an average of 170 for the second group. (For further detail, see Table A1.2 in Annex 1.)
MCH Institutions
1.6 Maternal and child health care is carried out by several different agencies in China. Under the Ministry of Public Health (MOPH), the Maternal and Child Health (MCI) Departmentis the main technicaldepartment responsible for establishingpolicy to safeguard women's and children's health. It has four divisions-women's health, children's health, family planning, and general administration-and a special project office to manage the 300-CountyProject,i/ supported by the United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA), and the World Health
1/ The official namoof the 300-CountyProject (a commonlyused phrase) is 'StrengtheningMCH-FP Servicesat the GrassrootsLevel Project." - 3 -
Table 1.2: INFANT AND MATERNAL MORTALrrY RATES FOR SELECED PROVINCES
Provinces IMR/1,000 live MMR/100,000 live births (1990) births (1989-91)
Beijing 11 40 Jilin 27 47 Shandong 17 40
Guizhou 68 170 Sichuan 50 170 Yunnan 74 170
NATIONAL 35 88
Source: IMR from the unadjusted 1990 census (first 6-months' deaths and births data). MMR for the 1989-91period derived from the National Surveillance System which produced only regional averages.
Organization(WHO) (see para. 1.14). The four divisions are small with few professional staff. The provincial MCH bureaus mirror this organization. The County MCH stations are responsiblefor coordinationand supervisionof all MCH activities within the counties, including townshipsand, through the townships, at the village levels.
1.7 The Medical AdministrationDepartment (MAD), of MOPH, is responsible for developing policy and providing technical guidance for clinical and hospital care, including MCH referral and emergency services at provincial, prefecture, county, and townshiplevels. County and township hospitalsprovide curative, obstetric, gynecological and pediatric services. Villageclinics provide these services at the lower level. Each level supervises the activities of the next level below. In addition, the State Bureau of Traditional Chinese Medicine(TCM) runs a parallel network with TCM hospitals in most countiesand at higher levels. Many TCM hospitalsalso offer Westem obstetric and child care services.
1.8 The Departmentof Disease Control of MOPH is the technical authority for immunization, including the extended program of immunization(EPI) for children and tetanus immunization of adults. This department is also responsible for policy and technical support of county-level epidemic prevention stations (EPS), county health education units, and epidemicprevention staff at lower levels. The Medical Science and EducationDepartment of MOPH is responsiblefor health workers' training, including the MCH subject areas. A separate Endemic Disease Office provides technical guidance for control of iodine deficiencydisorders at the nationallevel, but this program is incorporated into EPS at the county level. C. MAJOR ISSUES AND CONSRANTS
1.9 The regionaldisparity in health status is a serious problem in China (Table 1.2), and the quality of health services also varies greatly among the provinces and counties in China. While many rich provinces of the coastal east and the major urban areas offer sophisticatedservices to the population with health insurance provided by the organized sector, many in the poorest and remote areas of the southwest and northwest lack even preventive and basic curative services. As illustrated by Table 1.2 above, IMR and MMR in poorer provinces are far greater than the national average. Similarly, there are striking differencesin nutritionalstatus among provinces. For example, 33 percent to 45 percent of the rural children are underweight in Yunnan, Sichuan and Guangdong comparedto between 12 percent and 16 percent in Shandong, Zhejiang and Heilongjiang. The main problemsin the disadvantagedareas includeinadequate staff training, equipment and materials for prenatal and obstetric care; inadequate treatment of children with respiratory and diarrheal diseases; virtual absence of tetanus immunizationof pregnant women; and inadequateprograms to ameliorate micronutrientdeficiencies.
1.10 Reduced resources, along with increasedemphasis on cost recovery, have started to affect maternaland child health adversely. Since health services are being asked to recover an increasing part of their costs, there is a widespread tendency to emphasize lucrative, and often unnecessary tests, drugs and clinical services at the expense of preventive care. This problem is illustrated by the fact that, while the real per capita health spending (from all sources-budgets, fees and insurance) rose faster (11 percent) than economicgrowth (8.7 percent) between 1980 and 1988, budgetaryspending declined from 30 percent of the total health spending to 19 percent during the same period. Shortage of funds to pay village doctors has already led to decreased coverage of some essential programs, including EPI. Such budgetary limitations are considered to be an important factor responsiblefor the lack of significantreduction in national IMR and MMR in the 1980s despite high rates of economic growth experienced during this period.
1.11 Access to health services has become increasinglydifficult for many poor people since the introductionof financialreforms in the 1980s.Until the late 1970s,a rural cooperativeinsurance systemprovided low-cost and subsidizedhealth care to most of the rural families. After the abolitionof the cooperativehealth system, many rural families do not have health insurance and they must obtain care on a fee-for-service basis. As a result, even simple preventive and basic MCH care have now become out of reach for a large number of peasants.
1.12 Functional coordination among various MCH service providers is unsatisfactory,resulting in duplications and gaps. For example, in most counties, both county hospitals and MCH stations provide obstetric services, often in underutilized facilities locatedclose to each other. The current requirement that the health service units must generate revenue to cover increasing parts of their expenditure has aggravated the situation. This also distorts incentives, taking the service units away from preventive care and leading to "over servicing" with costly care. D. GOVERNmENT POLICY AND PROGRAMS
1.13 The Governmentis fully committed to improving the health status of the mothers and children of China. In 1991, China signed the Declaration and the Plan of Action of the World Summit for Children and in 1992 passed a National Program of Action (NPA). NPA targets for the year 2000, comparedto 1990, are to reduce infant and under-fivemortality by one third and maternal mortalityby one half. It aims at reducing moderateand severe malnutritionby one half. Its other goals include improved antenatal, delivery and postnatal care for women, elimination of neonatal tetanus and iodine deficiency disorders, eradication of polio, high breast-feeding rates, and improved managementof diarrhea and acute respiratory infectionsin children. While there is real progress in implementingmany of the programs initiated by the Government,the progress in improvingMCH has been significantlyhampered by the declining level of resources available for health care (see para. 1.10). The proposed project would significantly improve the resource situation in the project areas (see para. 5.2).
1.14 In support of the Government's own efforts, several projects and programs are being implemented under the sponsorship of a large group of external agencies, includingthe Bank (see para. 1.15). Most notable in the widespread implementationof MCH interventionsin China is the 300-CountyProject which is being implementedin 300 poor counties in 27 provinces assisted by UNICEF, UNFPA, and WHO. That project focusseson upgrading the technical skills of village and township staff as well as health education and managementimprovement. The proposed Bank project would allow the Government to achieve the NPA goals in about a further 300 counties of eight of the poorest provinces.
E. BANK GROUP INVOLVEMENTIN THE SECrOR
1.15 Past Experience. The Bank Group involvementin China's health sector began in the early 1980sand, to date, the Group has supportedfive projects and completed two sector studiesin health (in 1984 and 1990)and one in poverty alleviation (1992). The Rural Health and Medical Education Project (Credit 1472-CHA),approved in 1984, was completedin 1991 and a Project CompletionReport (No. SecM93-680)was prepared in July 7, 1993. The Rural Health and PreventiveMedicine Project (Credit 1713/Loan2723- CHA) approved by the Bank in June 19, 1986 has been completedexcept for the vaccine production component. Both these projects included activities to improve MCH care in limited areas. Under these two projects, a total of 96 counties in 8 provinces and one autonomous region were covered and both projects have been very successful. The IntegratedRegional Health DevelopmentProject (Credit 2009-CHA), started in 1990, also includes programs to improve MCH care in 30 counties of three provinces. It provides essential inputs but emphasizes improved regional planning and management. The project's progress has been satisfactory. In 1991, the Bank approved the Infectious and EndemicDisease Control Project (Credit 2317-CHA)to help control tuberculosisin twelve provinces and schistosomiasisin eight provinces. The project is also progressing well. A fifth project, the Rural Health Workers Development Project (Credit 2539-CHA), became effective in November 1993. In addition, two other projects, the Medium-sized Cities DevelopmentProject (Loan 3286-CHA/Credit 2201-CHA) and the Rural Water SupplyII Project (Credit 2336-CHA),also includesubstantial components to improve rural health.
1.16 Our experiencewith previousprojects has providedimportant lessons for the preparation of the proposed project. While experience with a number of projects in the sector has demonstrated that the Chinese agencies are fully capable of implementing complicated projects with several components, the lessons specified in the Project CompletionReport 2/ of the first health project are still very pertinent. Specifically,the design of the proposed project has paid particular attention to three major precautions mentioned in the Completion Report. First, it would have well-organized and staffed project managementoffices at all operation levels. Secondly, because of its innovative features, clear guidelines were developed for the preparation and implementationof the project. Thirdly, selectionof medical equipmentunder this project were made only after careful studies to determine their appropriateness.
1.17 Rationale for IDA Involvement. Consistentwith China's recent priorities and the Bank's emphasison poverty alleviation, the Bank Group seeks to focus its health sector activitiesmainly towards the poorest and most vulnerable sectionsof the population. This is in line with the recommendationsof the recent sector studies on health and poverty.a/ The recent poverty alleviation report makes a strong case for investment in matemal health. Also, the most recent health sector report recommendsthe restoration of adequatepublic funding for primary health services to the poor. The Associationis in a position to increase much needed financialresources for MCH care, through the Credit as well as through the increased domestic allocation for counterpart funding. Equally importantis the Association'srole in directingthe attentionof the Government,at different levels, to essential policy reforms. The main policy reforms expectedto be carried out under the project include improved access to health services for the poorest sections of the population; improved MCH management through better functional coordination; and increasedcommitment to preventive care.
2/ Project CompletionReport on CHINA-Rural Health and MedicalEducation Project (Credit 1472- CHA), SecM93-680,July 7, 1993.
3/ China.Long TermIssues and Optionsin the HealthTransition (No. 7965-CHA),1990; and China: Strategiesfor ReducingPoverty in the 1990s(No. 10409),1992. 2. PROJECT BACKGROUND
A. PRoJEcT DEVELoPMENT
Project Design
2.1 The proposed ComprehensiveMaternal and Child Health (MCH)Project was designed under two basic premises. First, the project should reduce maternal and child mortality and morbidityin the poorest areas of China, to the maximum extent and in the shortest time possible, applying techniques and methods that have proven effective for widespread application. Second, it should be economically and administratively manageableand be replicable, in whole or in part, in other provinces in China.
2.2 A large number of projects, includingresearch and demonstrationprojects, have addressedvarious health problemsof mothers and children in China and helped show the possibility for substantialreductions in maternal and child mortality and morbidity. The Bank's own experience under three previous projects (see para. 1.15) has demonstrated such possibilities in relatively small areas but under more intensive managementand with varying levels of inputs and resources. On the other hand, the 300- CountyProject (see para. 1.14) is being implementedsuccessfully in very large areas, but with more limited resources, focussing on upgrading the technical competenceof health workers at the grassroots, with emphasison preventivecare. In addition, multiyearstudies of childhood pneumonia and diarrhea in the late 1980s have shown that good case management can significantly reduce mortality in China. Another study in Henan Province, from 1990 to 1992, showed impressive results in reducing maternal mortality.
2.3 The design of the proposedproject has benefittedfrom these experiencesin China and from similar efforts elsewhere by focusing on priority health problems. A comprehensiveapproach waschosen for widespreadimplementation of completeMCH care mainly at the primary level but with active complementary support from higher levels which would include basic preventive care, cost-effective clinical care and referral services, upgrading of health workers' skills, improved MCH managementand specific measures to increase access of the poorest sections of the population.
Project Preparation Process
2.4 The preparation of this project was carried out with active involvementof the health staff at the village, township, and county levels, the relevant technical departmentsand bureaus at the center and provinces, and a number of external specialists. In April 1992, initial discussions were held in Beijing with most line departments of MOPH and the resident international agencies concerned with MCH. Following those - 8 - discussions, a project Identification Mission visited a number of villages, townships, and counties in three provinces in September 1992. This was followed by the selection of the first batch of four provinces (see para. 2.6) and the participating counties, field visits to the other two provinces, and the organization of a series of workshops to carry out the iterative process of project preparation. A Project Preparation Mission visited China in July 1993 followed by the Preappraisal Mission in November 1993.
2.5 At the outset, two pilot counties from each of the first four provinces were asked to prepare the first draft of the project proposals encompassing the needs of each village and township as well as the county level, within broad guidelines developed after the identification mission. The Bank missions, including several resident and visiting consultants reviewed the draft proposals with Chinese officials and by visits of the pilot counties. The project preparation process then expanded to cover all 155 counties in those four provinces. Each stage improved the earlier proposal and refined the project preparation guidelines, through document reviews, field visits, and workshops. Finally, MOPH officials and the Bank staff worked jointly in the finalization of this staff appraisal report.
2.6 The project was designed to be prepared and appraised in two batches of four provinces each from among eight of the poorest provinces of China (see para. 2.9). The first four provinces were Guangxi, Shaanxi, Sichuan, and Yunnan and covered 155 selected counties, with a total population of about 67 million. 1/ The Bank staff worked very closely with the national and provincial-level officials in the preparation and appraisal of the programs in the first phase. The preparation and appraisal of the programs in second four provinces-Gansu, Jiangxi, Nei Mongol, and Qinghai, with a total population of about 32 million in 127 counties-are being carried out under MOPH's supervision, following the procedures and guidelines developed in the first phase. The involvement of the Bank staff would consist of providing advice and support to MOPH when requested and reviewing and approving the project proposals. This process is consistent with IDA's objective of developing local capacity to prepare and appraise good quality health projects. Guidelines for project preparation and appraisal are summarized in Annex 16.
B. PRoJEcT AREAS
Selection of Project Areas
2.7 Selection Criteria. Since the main objective of the project is to improve maternal and child health in the poorest areas of China, the most important criteria used to select the project provinceswere their MCH indicators,as measuredby MMR and IMR, supplementedby informationon rural per capita income and the poverty level designation
1/ Two prefectures in Sichuanare counted as two counties although they are composedof 31 small counties. - 9 - by the Central and Provincial Govemments.Z/ Another important factor determining selection was the level of commitmentof the concemed provinces and their readiness to participate in the project. Finally, consideration was also given to the size of poor population which the project would affect. The selectionof counties followed the same principlesas those of the provinces but excluded those counties already covered under the 300-CountyProject or other MCH programs.
2.8 Project Size. Approximatelyone third of China's provinces exceed the adjustednational average IMR of 35 for every 1,000 live births and the average MMR of approximately88 for every 100,000 live births. Even these national averages represent unacceptably high figures if compared with those in the best third of the Chinese provinces. Therefore, initially, this raised a strong desire to implement the project in a large number of provinces. However, after careful consideration, it was determined that the project resources would be spread too thinly to create a significantimpact if it included more than eight suitable provinces. Similar considerations were used in deciding the number of counties, which were limited to about one third of the total number of counties in each province.
Project Areas
2.9 The project would cover 30 countiesin Guangxi; 35 countiesin Shaanxi;50 counties in Sichuan; 40 countiesin Yunnan; 31 countiesin Gansu; 31 counties in Jiangxi; 42 countiesin Nei Mongol; and 23 countiesin Qinghai. Comparedto the nationalaverage IMRof 35/1,000, MMR of 88/100,000,and householdincome of Y 709, the project areas represent the poorest sections of the population. Comparisonof the provincialand project areas basic indicators are presented in Table 2.1.
I/ There are 331 centrally and 368 provinciallydesignated poor counties in China which are eligible for Government assistance. Jiangxi, Guangxi and Gansu have the greatest proportion of their counties in the poor county list-67 percent, 58 percent and 57 percent, respectively. (Source: China: Strategiesfor Reducing Poverty in the 1990s, 1992) - 10 -
Table 2.1: BASICINDICATORS OF PROJECT AREAS
Nei Indicators Guangxi Shaanxi Sichuan Yunnan Gansu Jiangxi Mongol Qinghai
No. of counties: Province 83 107 219 127 85 99 100 43 Project area 30 35 50 40 31 31 42 23
Population (millions): Province 43.2 34.0 109.4 38.3 22.4 37.7 21.5 4.5 Project area 10.7 12.5 30.2 13.6 8.7 12.2 8.9 2.2 Percent/project 25% 37% 28% 36 % 39% 32% 41% 49%
Rural per capita Income: Province (Y) 658 534 590 573 552 495 641 395 Project area (Y) 388 419 437 347 503 424 507 384
IMR/1,000 live births L: Province 60 27 50 74 36 55 35 78 Project area 89 76 72 102 57 69 72 56
MMR/100,000 live births /b: Province 73 137 170 170 167 122 149 279 Project area 231 193 199 217 184 132 160 197
/a IMR data for the provinces are based on the unadjusted 1990 Census for the first six months of deaths and births. Project area IMR and MMR data are from a baseline survey for Phase One provinces, and are thought to be reliable, while the Phase Two data are from routine reports, which are often underreported.
/b MMR data for the provinces are based on the 1989-91 Summary by Region of the National Surveillance System. - 11 -
3. THE PROJECT
A. PRoJEcTOBJECTIVES
3.1 The principal goal of the project is to assist the Government in reducing maternal and child morbidity and mortality in the poorest areas of China. The specific objectivesare to:
(a) improve the qualityand effectivenessof maternal and child care, especially that provided by primary health workers at villages and townships and by referral levels;
(b) increase access, affordability, and utilization of basic maternal and child care; and
(c) improve the planning, resource allocation, coordination, and management of maternal and child care services.
B. PROJECT DEsCRWHON
3.2 The project would comprise four main components: (a) basic health care delivery; (b) health workers' training; (c) improvementsin MCH management;and (d) the national-levelcomponent. Detailed descriptionsof the project are in Annexes 2 to 5. A summary is given below.
Basic Health Care Delivery
3.3 The project would improve the basic MCH care services at the village, township, and county referral levels. Main activities would include maternal care, includingprimary, referral-level and emergencycare; child care, including immunization and nutrition, management of acute respiratory infections and diarrheal diseases; immunizationagainst neonatal tetanus; health education,including the promotionof breast- feeding and improved weaningpractices; and other area-specificprograms. The project would financeessential equipment,limited rehabilitationof facilities,and program support critical to improve the service delivery. Support for the improvementof basic health care delivery at different levels is described below. The provinces would institute special programs to help the poor increase their access to MCH care. Details of this component are provided in Annex 2. - 12 -
Health Workers' Training
3.4 The clinical skill level of the health staff is deficient in most of the project areas. Funds are inadequatefor regular in-servicetraining, especially for the lower level staff. There is also a need to review and upgrade the training programs. The project would improvethe technicaland managerialcompetence of all staff involvedin MCH care by establishinga system of regular refresher training which can be sustainedand replicated by the project provinces. Training activities are divided into short term (about one week) and longer-term (3 to 6 months) courses and focus on improving health service skills, especially MCH skills, and various aspects of management. Comprehensivepackages of teaching, learning, reference, and assessment materials would be developed, building on the experienceof earlier programs in China, notably the 300-CountyProject. The project would finance development,improvement and production of training materials, trainers' training, and also the cost of operating the training programs during the project period; limited rehabilitation and expansion of the county-level training facilities and training equipment. A detailed description of the health workers training program is in Annex 3.
ManagementImprovement
3.5 The project would improve MCH management at all levels, with three objectives: (a) to improve the mechanismand skills for better planning and coordination of MCH services; (b) to improve the quantity and quality of supervisory support between levels; and (c) to improve the functionand use of the existingmanagement information and surveillancesystems for MCH. The project would provide training for staff at provincial, prefectural, county and township levels in management skills relevant to their roles. Institutions responsible for MCH services would be strengthened and management procedures streamlined. Programs to improve the managementinformation system and operational research studies would be implementedat the central and provincial levels. The project will finance expansion of administrativeareas in MCH stations, supervision vehicles and management related equipment, and the operating costs of increased supervision,information system, evaluationand administrationactivities. (Further details are provided in Annex 4!.
National Level Program
3.6 The role of the Ministry of Public Health (MOPH) at the national level is very important in this project. Therefore, a financiallymodest National Level Program would be included in the project and located in MOPH (see paras. 4.1 and 4.2). This componentwould have the followingspecific responsibilities:
(a) Project managementand supervision,including implementation, monitoring and compliance with progress reporting, procurement and other requirements;
(b) Coordination of technical and operational tasks of various agencies at the national level and the provinces; - 13 -
(c) Preparatory activities concerning health workers' training, including the formulation of clinical protocols, development and quality assurance of training materials, and sponsoringmajor trainers' training.
(d) Technical support for the provinces, for managementimprovement, health education and operational research activities, and the implementation of studies in areas of common concerns (see para. 3.7);
(e) National level research and studies;
(f) Preparation and appraisal of the MCH programs in the remaining four provinces (see para. 2.6), including the formulation of the project managementmanual; and
(g) Disseminationof project experiencesto other areas.
A detailed description of this componentis in Annex 5.
3.7 Studies and OperationalResearch. MOPH is expected to organize and oversee the implementationof a limited number (possibly, four or five) studies during the whole project period. This includes a study aimed at improving functional coordination of MCH service providers that would be common to several provinces (see para. 1.12). Assurances were obtained at negotiationsthat MOPH would (a) not later than March 31, 1995, appoint consultantsin accordancewith IDA's procedures to carry out the study on functional coordinationof MCH services; (b) not later than March 31, 1996furnish to the Associationa time-boundaction plan for the implementationof the recommendations;and (c) thereafter, carry out the recommendationsand the actionplan, taking into account the Association's comments. Assurances were also obtained that the Borrower would carry out any other studies under the project only in accordance with proposals and terms of referenceapproved by the Association.
Project Support at Different Levels
3.8 At the village level, the project would improve the effectivenessof MCH services by providing equipment, training of village staff, and program support to carry out increased activities in preventive public health programs such as health education, nutrition,childhood immunization (including hepatitis B), tetanus toxoidimmunization, and iodine deficiencycontrol measures;and clinicalprogram such as care for pregnant women, mothers and sick children. Regular suppliesof drugs, vaccines and other consumableswill continue to be provided under existing arrangements.
3.9 At the township level, the project would finance limited rehabilitation of MCH facilities; essential equipment;basic transportation;training of health workers; and costs of implementingthe project activities includingMCH managementin the townships. At the referral (central) townships, the project would also provide additional equipment, including operation facilities and equipment for newborn care, additional training and - 14 - emergencyvehicles in selectedcases. These inputs will support both direct health services and managementof the village level programs.
3.10 At the county level, the projectwould strengthenthe technicalassistance and supervisoryrole of the MCH stations through training, limited improvementsof physical facilities, equipment necessary to improve their ongoing MCH care, and operating costs for supervision and health education. The project would improve the MCH work of the county general and TCM hospitals through limited repairs of physical facilities, provision of essential MCH equipment,training (includingtrainers' training), and operatingcosts to improve supervision. For the epidemic prevention stations (EPS), the project would fill any shortages in the cold chain equipment and provide training and program support to carry out tetanus immunization.
3.11 The province andprefecture levels would coordinate all project activities in the province, including supervisionand monitoring of project implementation,providing technical guidance and, in some cases, clinical training to the lower levels. The project would provide program support to help in the increased managementactivities, technical assistance, training, and a limited amount of equipmentand civil works where necessary.
3.12 Access to the Poorest. As stated above (see para. 1.11), inadequateand declining access of poor families to essential clinical services has been a very alarming problem in most parts of rural China. The inability of current programs to assist families who cannot pay for these services contributesto high mortality and morbidity. To ensure that benefits under the proposed project are also shared by the poorest, each project province would establish a "MCH poverty relief fund" which would fully or partially subsidize the health care for essential obstetric and pediatric inpatient and outpatient services (see Annex 6!. The fund is expected to improve access and MCH service coverage to at least the poorest five percent of each county's population and is expected to provide a demonstrationof the cost-effectivenessof such access to health services in reducing maternal and under-five mortality and morbidity. The basic standards of the poverty relief fund have been discussed and confirmed with each of the first-phase province. Assuranceswere obtainedat negotiationsthat eachparticipating province would establisha poverty relieffund designedto fully or partially subsidizeessential obstetric and pediatric services to the poorestfamilies under arrangementsand time scheduleacceptable to IDA. At least four provinces are expectedto establish this fund by January 1, 1995.
3.13 OperationalResearch. Each province is expected to carry out a limited number (two or three) of operational studies during the project period to test different MCH interventions, such as those in epidemiologicalor health finance areas, or to test certain initiative in small pilot areas. Methodologiesto select the topics, to prepare the terms of reference, and to choosethe consultantshave been broadly discussedwith MOPH and the provincial officials. Assurances were obtained at negotiations that the participating provinces would carry out operational studies in accordance with the proposals and the terms of referenceapproved by the Association. - 15 -
C. PROjECr COSTS AND FINANCING
3.14 Project Costs. The total cost of the project is estimated at $139 million. This is based upon detailed estimatesof the costs in the four first batch provinces and the provisional estimates of the remaining four provinces. Detailed cost estimates are in Annex 9. A summary is given in Table 3. 1.
Table 3.1: SUMMARYOF CosT ESTIMATES
Y million $ rnillion Foreign Total Local Foreign Total Local Foreign Total Exchange Base Cost
Civil works 117.59 - 117.59 13.52 - 13.52 - 12 Equipment 46.44 139.31 185.75 5.34 16.01 21.35 75 19 Vehicles Ambulances - 39.00 39.00 - 4.49 4.49 100 4 Supervision car 53.80 - 53.80 6.18 - 6.18 - 6 Training Long term 42.53 - 42.53 4.89 - 4.89 - 4 Short term 137.62 - 137.62 15.82 - 15.82 - 14 Overseas studies - 6.05 6.05 - 0.70 0.70 100 1 Technical Assistance: Local specialists 12.52 - 12.52 1.44 - 1.44 - 1 Foreign specialists - 3.82 3.82 - 0.44 0.44 100 - Operation research 7.25 - 7.25 0.83 - 0.83 1
Total Investment Cost 417.75 188.18 605.93 48.02 21.64 69.66 31 64
Program support /a 314.21 - 314.21 36.11 - 36.11 - 33 Maintenance 33.00 - 33.00 3.80 - 3.80 - 3
Total Recurrent Cost 347.21 _ 347.21 39.91 _ 39.91 - 36
TotalBase Cost 764.96 188.18 953.14 87.93 21.64 109.57 20 100
Physical contingency 38.25 9.41 47.66 4.39 1.08 5.47 2 5 Price contingency 200.04 5.44 205.48 23.00 0.63 23.63 2 22
Total Proiect Cost 1.003.25 203.03 1.206.28 115.32 23.35 138.67 17 127
LaDescribed in the Development Credit Agreement as 'incremental recurrent costs."
3.15 The projectcosts are based on December 1993prices. The civil works costs are derived from the space estimates and unit costs provided by the provinces. The physical contingenciesof 5 percent have been applied to base costs for all components. To provide for inflation during project implementation,the following annual escalation - 16 - rates have been applied: for local expenditures(excluding civil works), 12.0 percent for 1994, 9.0 percent for 1995, 8.0 percent for 1996, 7.2 percent for 1997 and 6.5 percent for 1998 and 1999; for civil works, 20 percent for 1994, 12 percent for 1995, and 10 percent in 1996; for foreign expenditures, 1.2 percent for 1994, 2.4 percent for 1995, 3.2 percent for 1996, 3.4 percent for 1997, and 3.2 percent for 1998.
3.16 Project Financing. The proposed credit of $90 million equivalent would finance about 65 percent of the total project cost, includingabout $23.35 million in foreign exchange. The participating provinces and counties would finance the balance of the project cost. The financingplan is shown in Table 3.2.
Table 3.2: FINANCING PLAN ($ million)
Local Foreign Total Percent
Governmentof China, Provinces and Counties 48.67 0.00 48.67 35% IDA 66.65 23.35 90.00 65%
Total 115.32 23.35 138.67 100%0
3.17 The Government would allocate $1.69 million equivalent to the National Level Program and $88.31 million equivalentof the proceeds of the DevelopmentCredit to the provincialprograms for 20 years, includinga 5 year grace period, at a fixed annual interest rate of 1.1 percent. The provinces would further allocate part of their proceeds of the credit to the countiesunder similar terms. Project provinces would bear the foreign exchangerisk. Assuranceswere obtained at negotiationsthat the Borrower would onlend the creditproceeds to the provinces at not more than 1.1 percent per annum, for at least 20 years, including a grace period of 5 years; each province would make the proceeds available to its counties on a grant basis or other terms whereby the counties would pay interest at not more than 1.1 percent per annumfor at least 20 years (includingfive years' grace) and would not bear the foreign exchange risks; and each province would provide adequatefunding for project activities to be carried out both at the provincial and local levels within the province. - 17 -
4. PROJECT ORGANIZATION AND IMPLEMENTATION
A. ORGANIZATION AND MANAGEMENT
National Level
4.1 Management and Coordination. The Ministry of Public Health (MOPH) would be responsible for the overall direction, coordination and oversight of the implementationof the project. To carry out these responsibilities, the Government has established a Project Leading Group under the Chairmanshipof the Minister of Public Health and including the directors of MOPH departmentsof Maternal and Child Health (MCH), Medical Administration, Disease Control, and Medical Science and Education, the Endemic Disease Office, the Center for Health Statistics and Information and the Foreign Loan Office (FLO). FLO, which was establishedspecifically to help implement other World Bank supported health projects, would act as the secretariat of the Leading Group. FLO is well-equippedto coordinate and oversee the implementation of Bank- assisted projects. FLO would be responsible for all operational aspects of project coordination, including progress monitoring and complying with procurement, disbursement, audit, and other requirements. Assurances were obtained at negotiations that the Borrower would maintain the Project Leading Group, with membership, terms of referenceand resources acceptable to the Association, throughout the project period.
4.2 The MCH Department is the most important participant in the proposed project as most of the project activities fall under its responsibility. However, because of its comprehensivenature, this project would also require active involvementof a number of other line departmentsand offices at the Center as well as in the provinces. Therefore, under the Leading Group, a Project Coordination Group has been established which is chaired by the Director of FLO, with the Director of the MCH departmentas deputy, and includes the heads of the Maternal Health and Child Health Divisions of the MCH Department, and division chiefs from other relevant departmentsand offices of the MOPH. To carry out the national level programs the Project CoordinationGroup would establish a Technical Unit of 3 or 4 full-time staff. The Unit would also establish expert groups from time to time to carry out specific tasks as assigned by the Project Coordination Group. Assurances were obtained during negotiations that the Borrower would (a) maintainthroughout the project period the Project CoordinationGroup with membership, terms of referenceand resourcesacceptable to the Association;and (b) establishnot later than January 31, 1995, and thereaftermaintain, a Technical Unit, to assist the Project Coordination Group, with terms of reference, staffing and resources acceptable to the Association. - 18 -
4.3 Project Preparation and Appraisal. As discussed earlier (see para. 2.6), the MOPH would prepare and appraise the maternal and child health programs in the remaining four of the eight project provinces. The Bank's role would be quality control and advisory support as well as to review and approve the project proposals prepared and appraisedby MOPH. The procedures to be followedto prepare and appraise the programs in these four remainingprovinces have been discussed fully with MOPH and are described in Annex 16. Assurances were obtained at negotiations that the provinces would be eligible to participate in the project only when the Association has notified the Borrower of its approval of the proposed programs. Assurances were also obtained on Project ImplementationProvisions under which the provinces would participate in and carry out the project. Written commitmentto those Project ImplementationProvisions by at least four provinces would be a condition of credit effectiveness.
Provincial and Prefecture Levels
4.4 Management and Coordination. The provincialorganizations mirror those of the Center. Each province has already established a Leading Group under a Vice Governor and comprising senior representatives of the provincial finance and planning bureaus and the heads of the departmentsand bureaus dealing with health. Each province has a Foreign Loan Officein the Bureau of Public Health, and has established a Provincial Project Office (PPO) headed by a project director, and a Technical Advisory Group. Officialsat the prefecture level will also participatein project coordinationand supervision. Assuranceswere obtainedat negotiationsthat each participatingprovince would maintain the Leading Group, the PPO and the TechnicalAdvisory Group throughout the project period with membership, staffing and terms of referencesatisfactory to the Association.
County Level
4.5 Present MCH Responsibilities. At the county level, MCH care is provided by the MCH Station and other health service facilities. The Station is responsiblefor the overallplanning and supervisionof MCH activitiesin the county; training of townshipand village level MCH staff; health education;nutrition-related activities; handling of MCH managementinformation; and carrying out preventive activities and some clinical work. County EpidemicPrevention Stations are responsiblefor immunizationprograms. County hospitals provide full obstetric, emergency and pediatric cares, usually dealing with a relatively high volume of high-risk deliveries. County TCM hospitals also offer MCH care.
4.6 Project Coordination and Implementation. The bulk of proposed project implementationis expected to take place at the county level and below. Each county would establish a Project Leading Group of senior officials, including the county-level planning, finance and health officials, under the chairmanshipof the head or deputy head of the county. Each county would also establisha TechnicalAdvisory Group and a project office. Assurances were obtained at negotiationsthat the participating provinces would cause each project county to maintain a Leading Group, a TechnicalLeading Group, a - 19 -
Project Office headed by a project management officer and a training officer, with membership, staffing and terms of referencesatisfactory to IDA.
B. PROCUREmENT
4.7 Items to be procured and financed partly or wholly with credit proceeds includecivil works, equipment,vehicles, training, technicalassistance, operationresearch and program support. Civil works ($17.27 million) include new construction and rehabilitation. Virtually all constructionwill be small, simple and inexpensive, scattered over a very large area, mostlyin remote counties, and carried out over a three-yearperiod. Therefore, all civil works estimated to cost $50,000 per contract or less, up to an aggregate of $14 million will be procured on the basis of comparing quotationsobtained from at least three local contractors and communityorganization groups. Force account procedures may be used for the construction and repair of township level facilities for works estimated to cost less than $25,000 up to an aggregate amount not exceeding $1 million. All other civil works, approximatelytotaling $2.27 million, would follow local competitivebidding (LCB) proceduresacceptable to the Association. IDA review prior to inviting bids, contract award wouldbe required for each contract estimatedto cost more than $300,000. The rest would be subject to random sample review by supervision missions. Constructionsupervision will be organizedby the constructionengineering units where constructionis taking place. Standard bid documentsprepared for China will be used for LCB.
4.8 Equipment and Medical Vehicles ($28.62 million) would largely consist of medical and teaching items. Most individualequipment items will be inexpensivebut in fairly large quantities while some items will be relativelyadvanced medical diagnostic equipmentbut in limited quantities. Office equipment,including computers, will also be acquired to support project managementand offices to support improved MCH program management. Goods procurementby the provinceswill be consolidatedcentrally to allow for LCB and ICB followingIDA's ProcurementGuidelines. Contracts estimated to cost between $25,000 and $300,000 equivalent, in aggregate not exceeding $15 million, may be procured through LCB procedures acceptable to the Association. Goods estimated to cost less than $25,000 per contract, and in aggregate not exceeding $5.0 million, may be procured through local shopping procedures under contracts awarded on the basis of comparison of price quotations obtained from at least three eligible foreign or local suppliers. International suppliers may compete in these procedures. Contracts for proprietary items and items required for the purposes of standardization, subject to the approval of the Association on a case-by-case basis, may be awarded after direct negotiationswith suppliers, in accordance with procedures acceptableto the Association. Under ICB, local manufacturers would be eligible for a margin of preference in bid evaluationof 15 percent or the prevailing rate of custom duty, whicheveris lower.
4.9 Equipmentand medicalvehicles will be procured in phases spread over three years with the bulk of the medical equipment procured during the first two years of implementation. During the first year of implementation,20 percent of the equipmentwill be procured. The next phase of equipment procurement will occur at about the time of - 20 - completion of the civil works, at which time 60 percent will be acquired. In the third year, all the remainingequipment will be procured. Equipmentwould be grouped, to the extent possible, to form packagesin excess of $300,000 for each contract. Proposals from the provinces would be forwarded to FLO for bulk purchases by the China Machine Corporation which has experience with ICB procedures using the Association's ProcurementGuidelines. FLO will be responsiblefor procurement under LCB procedures acceptable to IDA and use other procurement procedures including local shopping. For contracts exceeding $300,000 each, prior IDA review of bid evaluation reports and "no objection" would be required before contracts could be awarded and signed. For other contracts, random sample review of bid evaluationreports and contracts would be carried out by supervisionmissions.
4.10 Equipment lists have been prepared by the participating provinces and reviewed by MOPH and the Association. The standardizedequipment list according to health service levels is detailed in Annex 7.
4.11 Technical Assistance ($3.47 million). Technical assistance under the project includesboth consultantservices at the national and provincial levels and contracts for carrying out operational research. Employment of local consultants, to the extent possible, will be encouraged, whenever such expertise exists in China. Consultantswill be hired in accordance with principles and procedures satisfactory to the Associationon the basis of the ConsultantGuidelines published by the Bank in August 1981. Contracts with firms of $100,000 equivalent or more and contracts with individuals of $50,000 equivalent or more will require prior Association review or approval of budgets, short lists, selection procedures, letters of invitation, proposals, evaluation reports, and contracts.
4.12 Training ($27.43 million local and $0.78 million overseas). Local training activities will be carried out by existing institutionson the basis of the training program as described in Annex 3. Approximately90 percent of the local training costs will be financed by IDA and the remaining will come from counterpart financing. Overseas training plans are described in Annex 14 and will be reimbursed at 100 percent by IDA.
4.13 Program Support ($47.98 million). Based on the MCH service package, 65 percent of the program support will be providedby IDA subject to standardAssociation reimbursement requirements. Program support includes medical and other supplies, transportation,accommodations, meals and allowances for nongovernmentemployees.
C. DISBURSEMENTS
4.14 The proposed Credit of SDR 61.9 million ($90 million equivalent) would be disbursed over a five-year period as follows:
(a) 30 percent of the costs of civil works; - 21 -
Table 4.1: PROCuREMENT ARRANGEMENTs ($ million)
Project element Procurement method Consulting ICB LCB Others services NIF Total
A. Civil works - 2.27 15.00 - - 17.27 (0.68) (4.50) (5.18)
B. Equipment and 8.62 15.00 5.00 - - 28.62 medical vehicles (7.44) (12.94) (4.32) (24.70)
C. Supervision vehicles - - - - 7.92 7.92
D. Training:
Long-term training - - 5.99 - - 5.99 (5.39) (5.39) Short-term training - - 21.44 - - 21.44 (19.29) (19.29) Overseas Studies - - 0.78 - - 0.78 (0.78) (0.78) E. Technical Assistance:
Local specialists - - - 1.91 - 1.91 (1.91) (1.91)
Foreign specialists - - - 0.49 - 0.49 (0.49) (0.49) F. Operation Research - - - 1.07 - 1.07 (1.07) (1.07) G. Program Support La - - 47.98 - - 47.98 (31.19) (31.19) H. Maintenance 5.19 5.19
Total 8.62 17.27 96.19 3.47 13.11 138.67 of which (IDA) f7.44) (13.62) (65472) L.47) (9000)
Note: (1) Figures in parenthesis are the amounts financed by IDA. (2) Others - includes force account, shopping, and direct contracting. (3) NIF - Not IDA financed
La Includes medical and other supplies, allowances for nongovernmentalemployees, transportation,accommodations and meals required for project implementation. - 22 -
(b) 100 percent of CIF expenditures of imported equipment, 100 percent of local expenditures(ex-factory cost) and 40 percent of local expendituresfor other items procured locally;
(c) 90 percent of expendituresfor local training and 100percent of expenditures for overseas training;
(d) 100 percent of consultingservices and of operation research studies, and;
(e) 65 percent of incrementalrecurrent expenditures.
4.15 Statementof expenditures(SOEs) would be used for reimbursementsof less than $300,000 equivalentagainst contracts for civil works and equipment,and for training and incrementalrecurrent expenditures;this limit is justified based upon experience, and the nature and complexity of the project. Consultants' contracts of $100,000 equivalent or less for firms and $50,000 equivalentor less for individualswould also be made on the basis of SOEs. Documentationsupporting the SOEs would be retained by FLO in MOPH and the PPOs in the provinces and made available for random sample review by IDA supervisionmissions.
4.16 The estimateddisbursement forecasts closely follow the disbursementprofile for human resource projects in China (Annex 12).
4.17 Special Account. A Special Account with authorized allocation of $6 million, based on four months' average expenditures, would be established in a bank satisfactory to the Association. Applicationsfor replenishment of the Special Account would be submitted monthly or whenever the Account has been drawn down by about 50 percent of the initial deposit, whicheveroccurs first.
4.18 Retroactive Financing. To ensure the timely start of the project, retroactive financingof up to SDR 5.5 million would be available for eligible expenditures,incurred after March 1, 1994, covering consulting services, training and incremental recurrent expenditures.
D. AccouNTs ANDAuDrrS
4.19 Separate accounts showing expenditures for project activities would be maintainedby each province. Assisted by the MOF, a total project account would be maintainedby the FLO in two books, one for project expendituresfor each province and the other by category of expenditures for the whole project. MOF would maintain a separate account showing amountsexpended under SOEs for each fiscal year and would maintain the Special Account. Project accounts would be audited by the State Audit Administration (SAA) and/or its local offices in accordance with standard practices in China which have been found acceptable to IDA. Assurances were obtained that the Borrower would submit to the Association, within six months after the end of eachfiscal - 23 - year, an annual audit report, by independent auditors acceptable to the Association, includingan audit of the Special Account and a separate opinion on the SOEs.
E. PROJECr MONITORINGAND EVALUATION
4.20 ImplementationSchedule. The proposed project would be implemented over a five year period with an additionalone year for the completionof payments and full withdrawalof Credit proceeds. The project is expectedto be completedin June 2000 and closed on June 30, 2001. A project completionreport would be submittedby FLO to IDA within six months of the closing date. A chart showingthe implementationschedule is in Annex 11.
4.21 PerformanceMonitoring. Baseline surveys in all project counties have been carried out during the project preparation which has provided reliable basic indicators. To monitor the progress of the project and to evaluate the project outcome, three sets of performanceindicators have been prepared, as explained in Annex 13. They are (a) input indicators; (b) process/output indicators, which would measure project activities;and (c) outcomeindicators (health status). The provincesand FLO would ensure that these indicators are analyzedat the agreed frequency.
4.22 ProgressMonitoring and Reporting. The MOPH wouldcoordinate project implementationand monitor its progress. Each province would be required to provide semi-annualprogress reports to the MOPH, includingthe performanceindicators (see para. 4.21) as appropriate. Assuranceswere obtainedduring negotiationsthat the MOPH would prepare andfurnish to the Association semi-annualprogress reports, including national- level and provincial activities, in accordancewith the performance indicatorssatisfactory to IDA.
4.23 Project Evaluation. Evaluation of the project progress and adopting necessarycorrective actions are importantelements of the project. Therefore, in addition to the regular project and progress evaluation activities, a special mid-term evaluation would be carried out after two and two-and-halfyears of project implementation,jointly by the Borrower and IDA to review the objectives, design, and implementationof the project and to recommendany necessary modifications. Assurances were obtained that, by June 30, 1997, the Borrower would submit to IDA the project's mid-term evaluation report, carriedout jointly with the participatingprovinces, indicatingthe project's progress from the inception and proposing any measures to further the objectives of the project.
4.24 SupervisionSchedule. Project supervision would be a joint responsibility of MOPH and IDA. Regular supervision of all aspects of the project is an important functionof the Project CoordinationCommittee. Becauseof the complexityand the large area covered by the project, IDA's supervision requirement is also expected to be higher than most health projects in China. A supervision plan is given in Annex 15. - 24 -
F. SPECIALIMPACTs
4.25 Impact on Environment. The project would have no significantimpact on the environment. It would, however, train health workers to promote health education, to improve sanitation, and to protect the health of the villagers from any local environmentaleffects.
4.26 Impact on Women. Since the project's main objective is to improve the health of women and children, its impact on the populationof the project areas is expected to be very high. As described in para. 5.1, the project would directly benefit 1.5 million women each of the five years of the project with maternal care with substantialimpact on maternal mortality and morbidity. In addition, 15 million women would benefit from the projects activities. The net effect would be better health, increasedproductivity and other benefits to the whole family. The project is also expected to benefit disproportionately large number of women health workers through training and improved job performance since more women are in MCH work.
4.27 Poverty Impact. The project is specifically directed towards 100 million of the poorest population of China. Approximately seven and a half million each of pregnant women and children would be the most direct beneficiaries, through their increased coverage by improved quality essential preventive and curative services. This would directly improve their quality of life by reducing mortality and morbidity, which would in turn provide an improved setting for increasedproductivity and living standards. - 25 -
5. BENEFITS AND RISKS
A. BENEFS
5.1 The proposed project is expected to benefit about 100 million of the poorest people from among the economically most disadvantaged counties of some of China's poorest provinces. The most direct beneficiaries are women during and after pregnancy, children under five years of age, and women of child-bearing age. The number of pregnant women and newborn beneficiaries is expected to be about 1.5 million each per year or a total of 15 million during the five years of the project. In addition, some 15 million women of child-bearing age would benefit from health education, improved family planning advice and other care, including tetanus toxoid immunization.
5.2 The main benefits of the project would be the sustainable reduction in the very high maternal and infant/child mortality and morbidity in the country's poorest regions. The project would also support improved feeding practices, that should lead to improved nutritional status of women and children, and special programs to alleviate micronutrient deficiencies. The project also includes specific interventions designed to improve planning and management capacity of the national, provincial, and county governments to prepare and implement similar comprehensive projects and to replicate them in other parts of the country. Furthermore, the project addresses the problem of recurrent cost, periodic in-service training, operational costs of preventive programs and program management and, at least in part, the problem of inability to pay for essential clinical services, all of which are expected to demonstrate to government the value of maintaining such recurrent costs.
B. SUSTAINABHITY AND REPLIcABIxrIy
5.3 Sustainability. The proposed project would require an additional allocation of approximately $0.18 million over five years in each county as counterpart financing, or about $0.1 (Y 0.8) per capita per year. Total project base costs come to about Y 1.9 per capita per year, including the longer-term investment costs such as civil works and equipment. This compares to Y 36 per capita of total health expenditures in China in 1988. Although the government health expenditures in 1989 totaled Y 6.4 per capita or only 2.5 percent of total government expenditures, the government's primary health care objectives for the year 2000 would raise the health expenditures to 8 percent of government budgets. Therefore, the recurrent costs of the project are well within the government's targets, even for poor counties.
5.4 Replicability. The proposed project is built upon experience gained in a large number of different projects implemented in various parts of China with which - 26 -
Chinese officials are well acquainted. The training programs under the proposed project are patterned after the ongoing 300-County Project which is implemented in different parts of each province participating in the proposed project. Additional expenditures required for replication are not excessively high as indicated in para. 5.3. Two likely constraints are inadequate technical and managerial capacity; and the lack of political will to allocate the critical minimum amount of resources required for the improvement. The project would significantly improve the technical and managerial capacity at all levels and this should adequately strengthen the capacity to replicate the program in other counties. Considering the additional resources, as stated in para. 5.3 above, the additional burden is not very large and, it is expected, that the positive effects of the proposed project would provide important impetus to persuade the provinces to allocate the resources necessary to replicate the project elsewhere. The annual per capita project cost will be equal to 24 percent of the 1989 per capita government health budget or 0.6 percent of the 1989 total government budget.
C. RISKS
5.5 There are two main risks in this project. Firstly, there is a risk that the provinces will not take special steps to ensure that the poorest population benefits from improved services. While the proposed project is not expected to fully resolve the present health financing problems in China, each project province will be required to institute a plan to support the poor in a manner satisfactory to the Association (para. 3.12). Secondly, there is a risk that the central and provincial officials will not be able to oversee the implementation and coordination of the project activities. The institutional strengthening already made at each level, closer monitoring by IDA supervision missions, and the strengthened Unit in FLO (MOPH) should minimize this risks. - 27 -
6. AGREEMENTS REACHED AND RECOMMENDATIONS
6.1 At Credit negotiations,assurances were received that the Borrower would:
(a) (i) not later than March 31, 1995, appoint consultantsto carry out the study on functional coordinationof MCH services; (ii) not later than March 31, 1996, furnish to the Associationa time-boundaction plan to implementthe recommendations of the study; and (iii) thereafter, carry out the recommendationsand action plan, taking into account the Association's comments (para. 3.7);
(b) carry out other operationalresearch studiesunder the project in accordance with proposals and the terms of reference approved by the Association (para. 3.7);
(c) make the proceeds of the Credit available to the provinces at not more than 1.1 percent per annum and repayable in not less than 20 years, includinga grace period of 5 years with the provincesbearing the foreign exchangerisk (para. 3.17);
(d) maintain the Project Leading Group and the Project Coordination Group with membership, terms of reference and resources acceptable to the Association(paras. 4.1 and 4.2);
(e) not later than January 31, 1995, establish a Technical Unit to assist the Project Coordination Group with terms of reference, staffing and other resources acceptable to the Association(para. 4.2);
(f) permit provinces to participate in the project only after the Associationhas notified the Borrower of its approvalof their proposed programs (para. 4.3);
(g) submit to the Association, within six months after the end of each fiscal year, an annual audit report, by independent auditors acceptable to the Association, including an audit of the Special Account and a separate opinion on the SOEs (para. 4.19);
(h) prepare and furnish to the Association semi-annual progress reports, includingthe national-leveland provincialactivities, in accordancewith the performance indicators acceptable to the Association(para. 4.22); and - 28 -
(i) not later than June 30, 1997, furnish to the Associationa report of mid-termn evaluation, carried out by the Borrower and each participating province, together with any measures to further the objectives of the project (para. 4.23).
6.2 At Credit negotiations,assurances were received from the Borrower that it would cause each participatingprovince to:
(a) establish a poverty relief fund designed to fully or partially subsidize essential obstetric and pediatric services to the poorest families under arrangementsand time scheduleacceptable to the Association(para. 3.12);
(b) carry out the operationalresearch studiesin accordancewith such proposals and the terms of reference approved by the Association(para. 3.13);
(c) makethe proceedsof the Credit available to its countieson terms that would be at least as concessionaryas it receives from the Borrower (para. 3.17);
(d) maintain the Leading Group and the Provincial Project Office, and TechnicalAdvisory Group throughoutthe project period with membership, staffing and terms of reference satisfactory to the Association(para. 4.4); and
(e) cause each participating county to maintain a Project Leading Group, a Technical Leading Group and a Project Office headed by a project managementofficer and a training officer, with membership, staffing and terms of reference satisfactory to the Association (para. 4.6).
6.3 Written commitment to the Project ImplementationProvisions by at least four participating provinces (para. 4.3) and State Council approval of the Development Credit Agreement would be conditionsof credit effectiveness.
6.4 Subject to the above agreements,the proposedproject is suitablefor an IDA credit of SDR 61.9 million (equivalentto $90 million) on standard IDA terms, with 35 years' maturity, to the People's Republic of China. - 29 - ANNEX I
MATERNAL AND CHILD ]HEALTH IN CHINA
A. HEALTHSECTOR IN CEHNA1/
DemographicTransition
1. DemographicAspect. China's populationwas estimated at 1.13 billion in 1990 in which 27 percent are under 15 years old while 9 percent are over 60 years old. The country's population is projected to grow annually at 1.3 percent till the end of the century. In 1991, crude birth rate (CBR)was estimatedat 22 per 1,000 populationwhile crude death rate was estimated at 7 per 1,000 population.
2. Role of Family Planning. The dramatic decline in China's population growth is reflected in the projected stabilizationof the net reproduction rate (NNR) to a level of one by 1995. This will have been achieved despite an increase in the proportion of women in child bearing age from 45 percent in 1965 to 56 percent in 1991. Contraceptiveprevalence rate among married women of childbearing age was estimated to be 72 percent in 1989, one of the highest rates in the world, and achievedthrough very strong state commitment.
3. Health Status. Given the level of China's development,the health status has improved remarkably in the last 30 years. Life expectancyat birth, one indicator of a country's health status, was estimated at 43 years in 1960, and by 1990 it was 69 years. In comparison, life expectancy in 1991 among high and middle-incomeeconomies were 77 years and 68 years, respectively,while among low-incomeeconomies it was 62 years. In 1975 China's mortality rate for children under 5 years was 85 per 1,000 and this was halved to 43 in 1990. This 1990 rate was slightly better than the combinedrates for the established market economies (EME) and formerly socialist economies (FSE) of Europe in the 1960s. Another health indicator, loss of disability-adjustedlife years (DALYs) reflects a society's overall burden of illness and premature deaths. For 1990 it was estimatedthat China lost 178 DALYsper 1,000 populationcompared with 117 for EMEs, 168 for FSEs, 574 for sub-SaharanAfrica, 240 for other Asia and islands, and the world average of 259 per 1,000 population.
4. Health Strategy. China's exceptional accomplishmentsin health were achieved to a large extent through developmentof a comprehensive network of health services and an emphasis on prevention through mass campaigns. Every county has a
1/ Most of the data in this section come from the World Development Report 1993: Inesting in Health. - 30 - ANNEX 1 general hospital, an epidemicprevention station (EPS), a maternaland child health (MCH) station, and often a county health school and a traditional Chinese medicine (TCM) hospital. Each township has a small hospital of about 15 beds which provides preventive and curative services to the population. Although many inadequately trained "barefoot doctors" left health work in the early 1980s, as of 1990, about 86 percent of the villages had a health clinic and many of the remainder were covered by different health outreach programs.
5. Problems and Constraints.2/ In spite of great success in the past years in the health sector, there are still problemsto be addressedin order for China to complete the first health care revolution. The total "medicallyvulnerable" population (below age five and over age 50) is expected to increase from a ratio of 38 percent to 60 percent of the working age populationby the year 2025. Apart from the growing size of this group, health benefits must be realized in the poor areas of the country. The ongoing economic restructuring, the escalationof health costs and the growingemphasis on curative medicine have made the poor more vulnerable through reduced access to quality basic health services. Health financing will have to be reformed to avoid reduction in the health coverage of the most disadvantagedgroups and to ensure that the present achievementsare maintained and spread equitably throughoutChina.
Nutrition
6. Average food consumptionin China compares well with other developing countries. The NationalNutrition Survey of 1982 found that the average energy intake per capita was 2085 calories (102 percent of the recommendeddaily allowanceor RDA) and 67 grams of protein (92 percent of RDA). In general, therefore, the average Chinese diet is not deficient although pockets of malnutritionexist in poorer areas, especially among women and children. Available data indicate that the proportion of infants with low birth weight (LBW) in the period 1985-87ranged between 6 and 9 percent.j/ Estimates from the decade 1980-90give the prevalence of stunting (low height-for-age)among children aged 2-4 years as 41 percent while wasting (low weight-for-height)for children between 12 and 23 months was 8 percent. A sample survey in nine provinces in 1987 found over 24 percent of children between ages four and five years were underweight based on the WHO standards for this age while 39 percent of the same age group were stunted. The survey results by province also indicatechildren in rural areas were nutritionallyworse off than their urban cohorts. The data suggestthat the nutrition problems are related to poor weaning practices and possibly to reduction in growth caused by infectious disease. Micronutrientdeficiencies affect certain sections of the population. The prevalence of anemia in pregnant women until the 1980swas estimatedat about 25 percent while iodine deficiency is known to affect a significantportion of the rural population.
2/ China. Long-TermIssues and Options in the Health Transition,1992.
/ 'Thehigher percentage comes from a national survey done in 1987 cited in a forthcoming UNICEF publication. - 31- ANNEX 1
B. MATERNAL AND CIL HEALTH STATUS
7. China's MCH status far exceeds that of most developing countries and compares favorably with middle income countries shown in Table Al.l below. These rates were attained with much lower expenditures on health than the richer countries. China's health expenditurein 1990 was only 3.5 percent of her GDP while the EMEs were spending on the average 9.2 percent of GDP in the same period.
Table AM.l: INFANT AND MATERNAL MORTALxrY RATES
1991 1988 IMR/1,000 MMR/100,000 Live Births Live Births
Upper-middleincome economies 34 104 Middle income economies 38 107 Lower-middleincome economies 42 111
Low-incomeeconomies 71 308 High-incomeeconomies 8
China 35 88
Source: World DevelopmentIndicators, Tables 28 and 32, World Development Report 1993, except for the figures for China which come from the official sources.
8. The favorable national MCH statistics obscure serious regional disparities as indicated in Table A1.2. In 1990, available estimates for IMR ranged from a low of 11 per 1,000 live births in Beijingto a high of 94 in Tibet. MMR in 1989-91ranged from a low of 40 per 100,000 live births in Beijing to as much as 170 in several southwest provinces. - 32 - ANNEX 1
Table A1.2: ESTMATEDINFANT AND MATERNALMORTALITY
Region/ 1990 1989-91 Region/ 1990 1989-91 province IMR MMR/100,000 province IMR MMR/100,000
NORTH YANGTZERIVER Beijing 11 40 Shanghai 14 40 Tianjin 15 40 Jiangsu 19 40 Hebei 13 77 Zhejiang 22 40 Henan 24 73 Anhui 32 40 Shandong 17 40 Jiangxi 55 40 Hubei 34 73 NORTHEAST Hunan 49 73 Liaoning 20 47 Jilin 27 47 SOUTH Heilongjiang 24 47 Fujian 30 40 Guangdong 21 73 NORTHWEST Hainan 34 73 Nei Mongol 35 77 Shanxi 23 77 SOUTHWEST Shaanxi 27 137 Guangxi 60 73 Ningxia Hui 42 137 Sichuan 50 170 Gansu 36 137 Guizhou 68 170 Qinghai 78 137 Yunnan 74 170 Xinjiang 62 137 Tibet 94 170
Notes: (1) IMR is from the unadjusted1990 Census-first six-months'births and deaths. (2) Maternal mortality rates estimated from the 1989-91National Maternal Mortality Surveillancesummary by region. - 33 - ANNEX 2
BASIC HEALTH CARE DELIVERY COMPONENT
Introduction
1. The project would improve the basic maternal and child health (MCH) services at the village, township, and county referral levels by supporting a number of program activities under this component. The main objective of the component is to improve efficiencyand effectivenessof the current MCH care delivery systemin poor rural counties of China and to reduce maternal and under-five mortality and morbidity. The project would finance health workers' training (Annex 3), equipment (Annex ), civil works (Annex 8), and program support to carry out the program activities. The program support would include incremental budgetary supplementsto carry out health services in the areas of health education,promotion of breast-feedingand improved supplementaland weaningfood practices, tetanus immunizationfor neonataltetanus control, and supportfor iodine deficiencycontrol. At present, funds are inadequateto carry out these basic MCH service activities effectively.
Program Activities
2. The followingprogram activities will be improved in the project provinces and counties:
(a) Health education
(b) Primary level maternal care
(c) Emergency communicationsand transport
(d) Referral level maternal care
(e) Managementof common perinatal problems
(f) Management of acute respiratory infections (ARI) in children
(g) Managementof diarrheal diseases in children
(h) Tetanus toxoid for neonatal tetanus control
(i) Promotion of breast-feedingand improved supplementaland weaning food practices -34- ANNEX 2
(j) Support for routine childhood immunizations
(k) Support for iodine deiiciecncycontrol
(1) Others-Province specific or to be developed
3. Health Education. Well planned and targeted health education is a cost effective strategyin preventive care, leading to improved knowledgeof families to prevent and manageillnesses at home and better use of local health services. With the high level of contact between families and health providers either already achievedor planned under the project, the main health education approach will be through interpersonal communicationduring these contacts, with additional special activities, such as meetings, campaigns, and mass communicationfor specific programs listed in para. 2 above. The project will finance the developmentand production of health education materials at the national and provincial levels.
4. Primary Level Maternal Care. This includesprenatal, labor and delivery and postnatal care for normal pregnancies. The project will emphasize the use of iron supplements to prevent and treat anemia in pregnancy, the use of high risk criteria for early identification of women needing special care or referral level deliveries, careful monitoringof labor to identify complicationsneeding emergencyreferral, and improved primary level managementof common complications.
5. EmergencyCommunications and Transport. In addition to transferring high risk pregnant women for delivery at the referral level, reductionin maternalmortality will require timely managementof unexpectedcomplications in all women.
6. Referral Level Maternal Care. WHO has identified key "first referral level" obstetrical interventions (such as operative deliveries and blood transfusion capability)that are crucial as a backup to primary services in the case of complicationsthat require a higher level of resources and skills. Based on the WHO guidelines, the project counties have selected referral level facilities, balancing needed capability and proximity to the population. All county hospitals, and the few county MCH stations which already provide this level of service will be strengthened. Where needed according to the guidelines, one or more central township hospitals per county were selected to provide referral level services but in many cases they will require improvement in facilities, equipment and staff training before they can function in this capacity. On average, one referral level facility will be available for each 200,000 population under the project.
7. Management of Common Perinatal Problems. Prematurity, neonatal asphyxiaand birth trauma account for a high percentage of under five deaths. Improved managementof labor, delivery and care of the newborn, both at the householdand hospital level can greatly reduce the mortality from these conditions.
8. Managementof Acute RespiratoryInfections (ARI) in Children. ARI is the major cause of death in infants and children under five. Improved recognitionand - 35 - ANNEX 2
standardcase managementprotocols can reduce mortality from these conditions. Standard WHO case managementguidelines for both primary and small hospitallevels have already been adapted for use in China and will be used in this project.
9. Managementof DiarrhealDiseases in Children. Diarrheal diseases are still a leading cause of under five mortality in project counties. Standard WHO case managementguidelines which are simple and highly cost-effectivetreatments that have been introduced in several previous projects will be used in this project.
10. Tetanus Toxoid for Neonatal Tetanus Control. Up to now, China has used training of village birth attendantsin clean delivery as the sole method for control of neonatal tetanus. However the rate of clean delivery remains low and tetanus, formerly thought to be uncommon, is a major cause of neonatal death. The project will promote improved delivery practices, but also provided tetanus immunization of all eligible reproductive age women in all counties with neonatal tetanus rates of one or more per thousandas determinedby the baselinesurvey. This activity is in accordancewith China's national plan of action for elimination of neonatal tetanus. The two approaches are expected to reduce neonatal tetanus mortality to less than one per 1000 live births. In addition to the regular funding, project funds will specifically finance: (a) all the preparatory activities for the tetanus toxoid campaign, including the cost of planning and advocacy meetings; (b) the registration of eligible women; (c) the cost of vaccine, supplies (needles, syringes, sterilizations);and (d) the labor cost of the village vaccinators during the mass immunizationand the subsequent "mop-up"immunizations.
11. Promotionof Breast-Feedingand ImprovedSupplemental and Weaning Food Practices. Although breast-feedingrates in rural areas are high, inappropriate weaningpractices lead to a rapid declinein the rate of growth falteringin Chinesechildren between six and 24 months of age. The project will focus on programs to educate parents regarding the need for exclusivebreast-feeding for at least four to six months followedby appropriate supplementalfoods. Specialattention will be given to education on foods and practicesto reduce childhoodanemia and rickets and supplementationprograms for vitamin A may be introduced. In addition, funds will be used for activities to establish "Baby Friendly Hospital" status in the obstetricalunits at all county and township levels.
12. Support for Childhood Immunization. The expanded program on immunization(EPI), whichprotects against six commonchildhood diseases in the first year of life, has been one of the most successfulprimary health care programs in China, due to a high level of political commitment and funding support of transport and storage of vaccine, and payments to village doctors to immunize children. Althoughhigh levels of immunizationwere reached by 1990 even in poor counties, the program has since suffered from decreased attention and financial commitment. Under the project, the county governmentis required to maintainor restore financialsupport for EPI at least to 1990/91 levels, enough to maintain high immunizationrates. Project funds will only be used to purchase cold chain equipment if present supplies are inadequate. - 36 - ANNEX 2
13. The government has initiated routine use of hepatitis B immunizationin newborns, but families must pay for the vaccine, limitingits availabilityto the poor. The project encouragesprovincial and local governmentsto make this immunizationavailable at reduced price or free to those who cannot pay.
14. Support for IodineDeficiency Control. China is committedto elimination of iodine deficiencydisorders by the year 2000. This project will build on the work of a UNDP/UNICEF supportediodine deficiency project that provides training and technical support to the county level in salt and iodine deficiency monitoring and in promotion of family use of iodized salt. The project will also fund the routine annual surveillanceof salt iodination and iodine deficiency in those counties without a surveillance system, in accordance with the revised national program.
15. Other Health Services. All provinces plan to include support for better family planning counsellingunder the project. Yunnan and Sichuan provinces have also specified the treatment of common gynecological infections and the correction of late complicationsof delivery (uterine prolapse and obstetric fistulas) as health services to be supportedby the project. There is provision for additionalhealth service interventionsto be added during the implementationof the project, subject to agreement during progress reviews.
Essential Services Package
16. Each county in the project is expectedto work to achievehigh levels of good quality coverage for each of the following health services. This means that all health facilities and health workers at each level in the county will follow standard case- managementguidelines for their level (as indicated in project training materials), and that services will be organized to achieve the highest possible coverage of the entire county population. The essential services package includes:
(a) Maternal Care
(i) Prenatal care with special emphasis on health and nutrition education, iron/folate supplementationto prevent and treat anemia, tetanus toxoid immunization, and improved identification and managementof high risk and complications.
(ii) Labor and delivery care with special emphasis on improved management referral of complications to reduce maternal and perinatal morbidityand mortality.
(iii) Postnatalcare
(iv) Tetanus toxoid for child-bearing age women following the National Plan of Action guidelinespromulgated by the government. - 37 - ANNEX 2
(b) Sick Child Care
(i) Managementof acute respiratoryinfections in children (para. 8).
(ii) Management of diarrheal diseases in children with special emphasison ORT and feeding (para. 9).
(iii) Newborn resuscitationand managementof sick neonates (para. 7).
(c) Well Child Care
(i) Nutrition interventions through nutrition education on breast- feeding and weaningfoods. Countiesare strongly urged to include routine vitamin A supplementation and periodic deworming, especially for children being seen for other reasons (para. 11).
(ii) Routine childhood immunizationthrough the Expanded Program of Immunization(para. 12).
(iii) Iodine deficiency control through iodine status monitoring (para. 14).
17. During project implementation,other priority health services may be added to the above list if suitable strategiesand materials are developed. Two possible areas are 'clinical diagnosis and presumptive treatment of gynecological infections, including sexually transmitted diseases" and "health education for the prevention of childhood injury". - 38 - ANNEX 3
HEALTH WORKERS' TRAINING COMPONENT
Introduction
1. Issues in health workers' training. In most rural areas of China there is a fairly complete network of small hospitals for each township and most administrative villages have one or more village health staff (either village doctors, health workers, or birth attendants). The number of staff at referral level (central township and county) facilities for clinical care and for managementsupport are also usually adequate.
2. The health care practices and skills of health staff at all levels are problematic. Treatment of common illnesses such as pneumonia or diarrhea, is often inappropriate. Complicationsand high risk conditionsin pregnancy, such as anemia, are often not managedcorrectly, monitoringof labor is rarely done in township hospitals and referral of emergenciesis not planned in advance. Health education skills and knowledge of correct messagesare poor. The managerial skills of township, county and higher level supervisorsand managers are limited.
3. Planning and funding of regular in-servicetraining is inadequate, especially of lower level staff. Suitable training courses and materials at all levels are seldom available. The most common training method is lectures, often based on simplifications of universitytexts, which are usually inappropriatefor lower level trainees and often out of date. Training is generally not closely linked to actual work performance and training for the trainers and supervisorsis rarely carried out.
Objectives
4. The objectivesof the training componentare (a) to improve the competence of health workers at each level in their tasks and responsibilitiesfor maternal and child health; (b) to strengthen the capacity of the provinces to plan, organize and deliver appropriatetraining; (c) to establisha systemof in-serviceand refresher training which is sustainable by the provinces after completion of the project; and (d) to identify and strengthenmechanisms for disseminationof lessons from the project experiencein training to nonproject areas.
Strategies
5. The componentwill focus primarily on in-service training, building on the experiences of earlier projects in China, particularly that of the "300 County" Project which is currently being implementedby MOPH in 27 provinceswith supportof UNICEF, UNFPA, and WHO. Training will be provided for all health workers with MCH - 39 - ANNEX 3
responsibilitiescovering clinical, preventive, communicationand decision-makingskills, and for supervisors, managers and other support staff in the appropriate skills for their particulawroles. The largest groups of traineeeswill be villageworkers, and the MCH, out- patient clinic, obstetric and pediatric staff of township, central township, county and traditionalChinese medicine(TCM) hospitalsand the county MCH station. Other smaller categoriesinclude the staff of epidemicprevention stations (EPS) who are responsible for immunization,control of iodine deficiencyand health education, the teachers of county health schools and the staff responsible for statistics and information management.
6. The trainers will be trained to use modem training methods, stressing competency-based,problem-oriented, and participativelearning. Comprehensivepackages of teaching, learning, reference, and assessment materials will be developed by selected working groups to enhance training effectiveness. Close links between in-servicetraining and supervisionof the workers will be established,through involvementof the supervisors as trainers, through team training for workers in geographicareas, and through assessment of staff competenceand service improvementin the work situationby the supervisorafter training. Training content and methods will be adjusted and improved according to this assessment.
Training Program Activities
7. The project's training activitiesare divided into short term (about one week) and longer-term (3 to 6 months) courses. Training content is divided between health service skills and various aspects of management. For health service skills, the short courses, for groups of 15-20 staff, will cover village, out-patient and out-reach work, disease control, and health education. This training will be organized on an annual basis throughoutthe project, reaching on average all village workers and about half of concerned higher level workers each year. (It has been estimated that this is the proportion of workers with MCH responsibilities.)
8. Within the short course stream, much of the training will be delivered to mixed groups of health workers from a particular facility (such as township hospital) or geographic area, in order to improve understandingof each other's roles and build team cohesionin service delivery and problem solving. This type of training is very important where service effectivenessdepends on referral betweenlevels and feedbackof information for patient follow-up, or on division of work to improve service coverage.
9. The longer-term health service courses will be clinical placementsof 3-6 months in designatedhospitals, for improvingcompetence in clinical procedures and the care of inpatient and emergencycases. This training will be taken by 4-6 staff (doctors and nurses) from each township, central township, county and TCM hospital, and 6-10 from each county MCH station, once each during the project. Some provinces will also give longer term basic training to new village MCH workers. -40 - ANNEX 3
10. The training for management improvement, both short term and longer-term, will cover different aspects of program management and supervision for staff with these responsibilities (see Annex 4!.
11. Training of Trainers (TOT). Training of trainers will be organized on a two or three step basis, originating from a peak group of master trainers for each of the major training activities, drawn from the province and prefecture levels. These master trainers will be responsible for training the second tier at county level and for helping county staff to train township level trainers.
12. The project design stresses the overlapping nature of training from level to level, with shared or team teaching between the levels. Trainers from province or prefecture will assist county staff in training at the township. Since the training ability of the township staff is usually very low, county level trainers must go to the townships to help teach at every courses given to village workers. This requires that the township to village training courses be spread over time, instead of all townships giving the same village training all at once. It also requires that sufficient county level staff receive TOT so they can help with this work.
13. Content of Training. About 20 topics have been identified for the training program in the three major areas of child care, obstetrics and gynecology (including family planning) and communication and management. The high priority topics in each area were selected by a workshop of provincial staff and regional university representatives in September 1993 and cover the prevention and management of the common causes of serious illness and death in mothers and children, as well as health education, and interpersonal communication (Table A3. 1). The topic list may be enlarged or priorities changed according to experience during the project.
14. Development and Production of Training Materials. The package for each major subject area will comprise learning objectives, (based on expected job performance and standard case management protocols for each level), curriculum, training guidelines, essential content, reference materials, assignments and worksheets, print and audio-visual training aids, evaluation and assessment tools, criteria for certified competence and guidelines for supervision. Suitable materials from other projects, with revision or supplementation as indicated, or new materials to be developed in the first two years of the project will also be incorporated in the training packages.
15. Pre-requisites for Training Activities.
(a) Drafting of Service Protocols and Standards. The project will support development of standard case management protocols for the management of common health problems at both the primary and referral level. Training materials and programs, and evaluation of service quality will be based on these protocols. Protocolswill be prepared by national/provincialteams and incorporated into training materials. Similar guidelines will be developed for MCH program management. - 41- ANNEX 3
Table A3.1: PROPOSEDTRAiNG PACKAGES By Service Level
Village Township County
PEDIATRICS 1. Neonatal care * N R N 2. Respiratory infection * R R N 3. Diarrhea * R R N 4. Breast-feeding & Infant nutrition R R N 5. Immunization R R R
OBSTETRICS & GYNECOLOGY 1. Normal maternity care * R R 2. High risk management N R N 3. Obstetric bleeding (before and after delivery) R R N 4. Hypertension N R N 5. Septicemia & shock N R N 6. Medical complications N N N 7. Abnormal & obstructed labor R R N 8. FP counselling R R PP procedures incl. IUD - R R PP management of complications - N N 9. STD and other infections N N N
COMMUNICATION & MANAGEMENT 1. Training of Trainers * - R N 2. Interpersonal communication N R N 3. Management & supervision - N N 4. Information management N N N 5. Health education - - N (included in IPC and other topics for village and township
OTHER 1. Rational use of drugs (may be included in each topic area or form a separate package)
Note: R = Existing material for China identified, but needs revision or supplementation N = New material required (some English materials available) * = Priority for first year - 42 - ANNEX 3
(b) Preparation of Clinical Training Bases. For the 3-6 months clinical upgrade training, suitablehospitals at the county or prefecture level will be identified as clinical training bases and then p--pcr^l to Prsm-e t½t thlwt meet agreed criteria to conduct this type of training. In each province one or more provinciallevel institutionswill be selected, and special training in clinical teaching techniques will be provided to a core of master clinical trainers. They will in turn provide this training to the staff of the training bases. The curriculum, training materials and assessment methods for clinical upgrade training will be based on those prepared under the 300- County project, with modificationsas needed.
(c) ManagementTraining. For training in MCH program manag',ment,the same elements of course development, materials developmentand training of trainers (TOT) will be carried out, using a suitable institutionalbase, to design a practical, relevant training experience for the county, prefectural and provincial managersconcerned, and aimingfor capacityto continue this training beyond the project period and in other parts of the country.
(d) Prior to full-scale project implementation, short orientation and review workshopswill be arranged for governmentand communityleaders and for heads of the health agencies at township, county, and province levels.
Organizationand Implementation
16. National Level. National support for the provincial training initiativeswill be provided, particularly to assist the developmentof provincial capacity, with training of the provincial master trainers, writing of clinical protocols, curriculum and materials development, quality control and overall supervision, monitoring and evaluation. The national level will also take part in analysis of the training experience and dissemination of results and guidelinesto non-project provinces. This support will be provided through suitable universities and other professional institutions, supplemented with external technical assistance, particularly in the initial stages. The national support will be coordinatedthrough the project's proposed technical unit (Annex 5)
17. Below National Level. Management of the training program at the provincial, prefectural, and county levels, will be the responsibilityof designatedfull time staff of the MCH bureau in cooperationwith the project office (PPO). Annual training plans will be made. Indicators for assessingprogress and outcomes of the training have been decided (see Annex 13) and the MIS of the MCH program will be modified to ensure that the required data is collected, and routinely collatedand analyzedat county level, with summaries forwarded to prefecture and province. Assessment of the effectiveness of training of individual workers will be the responsibilityof line supervisors (who will be trained for this). Special investigationsof particular aspects of the training program will be conducted from time to time, when problems arise and at the mid-term stage of the project. In the secondhalf of the project, cost-effectivenessstudies will be carried out to - 43 - ANNEX 3
assist in definingthe budget implicationsfor sustaininga systemof in-service trainingafter project completion.
18. Program Inputs. The project would finance (a) the development and standardizationof the clinical protocols as a prerequisite of the training activities; (b) revision or new developmentand productionof training materials; (c) operationalcosts of the training courses; (d) cost of management,monitoring, and evaluationrequirements; (e) some institutionalimprovement for designatedclinical training bases includinglimited civil works construction for classrooms; (f) limited classroom audio-visual equipment for training; and (g) training of trainers (TOT). -44 - ANNEX 4
MANAGEMENT IMPROVEMENT COMPONENT
1. The project will address the shortcomings in management expertise and procedureswhich are an important constraintto improvingMCH service delivery in China. This intervention recognizes that the major approaches for improving health status of mothers and children do not require expensive, sophisticated technology or highly specializedstaff. Rather the need is to implement key basic strategies that already exist and are known to be effective.
2. Issues in MCH Health Service Management:
(a) Lack of Coordination. At the county level and above, responsibility for preventive and curative health services for women and children are shared betweenMCH stations, epidemicprevention stations, and general and TCM hospitals. Planning tends to be work unit-oriented rather than health problem- or population-oriented, often with little communication or coordination between units having complementary or overlapping roles. Similar coordinationproblems occur among staff of different categories at the township hospital and even at the village level. No higher level unit takes full responsibilityfor comprehensiveplanning of the MCH program.
(b) Lack of Management Skills. Managers and supervisors often lack the skills needed to improve their programs within the resources they have or could obtain. Most have not undertaken managementtraining of relevant content and methodology for their work. Many are unfamiliar with procedures for quality assurance, for assessing service coverage, for evaluating the health knowledge or attitudes of the population, or for estimatingthe resource and productivity implicationsof alternative service arrangements. They may be inexperiencedin critical aspects of personnel management such as supervision, performance appraisal and on-the-job training.
(c) Deficiencies in Collection, Presentation and Use of Information. The current managementinformation and surveillancesystems do not provide all the information needed, in appropriate format or frequency, to support managers in their problem identification and resource allocation tasks. Managers often do not know how to recognizeerrors in or to interpret data that is available. Reporting and feedback of informationis often not done, or not presented for easy interpretationand use by the managers. -45- ANNEX 4
(d) Insufficient Resources for Management. Although the numbers of managementlevel staff are usually adequate, their level of activity is often very low due to lack of funds for supervision and monitoring visits, for meetings or for other operationalneeds. Equipmentneeds for management include transportationand basic office equipment.
3. Objectives. The overall purpose of the management improvement componentis to strengthenmanagerial support for the MCH program in order to contribute to improved coverage, quality and utilization of MCH services, and thus reductions in maternal and under five mortality and morbidity. The component objectives are:
(a) to improve mechanismsand skills for the better planning and coordination of health services related to mothers and children;
(b) to improve the quantity and quality of supervisory support between levels, and;
(c) to improve the function and use of existing managementinformation and surveillance systemsfor MCH.
4. Managementimprovement activities: In order to achieve the objectives, MCH managementimprovements will be targeted at two levels. At the highest level, a National component(Annex 5) will carry out the technicaland operationalcoordination of the project. This will include formation of managementexpert groups under the project technical unit, who will investigate management issues at all levels, design improved methods, and introduce these to the project provinces by training or other means. At the provincial and lower levels, the project will support the following activities:
(a) Trainingwill be provided for staff at provincial, prefectural, county, and township levels in management skills relevant to their roles. The three broad areas of managementto be coveredare skills in planning/coordination (including program coordination, resource allocation, financial planning, etc.), supportive supervision (both of direct service health workers and of lower level managers), and the managementinformation system (focusing on better use of available informationand collectionof what is most needed for program management).This training will be developedwith appropriate national and international technical assistance, using workshop and field based experiential learning methods, drawing on the past experience of MOPH and core health managementtraining institutionsin the country.
(b) Improved Coordinationof MCH Services. Multi-sectoralleading groups and technical groups set up under the project, with representation from planning, finance, MCH, medicaladministration, and epidemicprevention institutions, will coordinate those programs providing services for mothers and children. County MCH stations will be responsiblefor monitoring the overall health status of women and children in the county, reporting to the - 46 - ANNEX 4
health bureau and leading and technical groups and coordinating the planning for improved services.
(c) Strengthening of existing management procedures within the MCH program, including planning, implementation and review of services, procedures for management of personnel, finances and information, procedures for communityliaison and the introduction of mechanismsand processes to monitor and improve service quality(also referred to as quality assurance, total quality management (TQM) or continuous quality improvement(CQI)). The developmentof these procedures and associated standards and guidelines will be closely linked to the managementtraining initiatives.
Supervisionand review of activities of lower service levels by higher levels will be one means in which MCH management can be strengthened. Regular interactionsamong the staffs of different service levels will allow experiential learning and enhance managerial capacities in MCH health managementand coordination.
(d) Increasing the Area Orientation of MCH Services. At each level, especially township hospitals, health service managers will be encouraged to take responsibilityfor all persons living in their catchmentarea, not only those presenting for service, to measure service quality and effectiveness accordingto coverage of and use by the families in the area, and to reorient service activities and adjust staff duties on this basis.
(e) OperationResearch. Specialstudies at the provinciallevels with assistance from qualified institutions and specialists in the areas of epidemiology, health services utilization, and health financing. All of these are geared towards improvinghealth service managementin China.
Each province will carry out 2 or 3 studies during the project period. The first phase provinceshave selected a number of possibletopics but they need further definition. Details of each operational research studies, including the qualificationof the specialistsand the institutions who would carry out the studies, would be submittedto IDA for its "no objection."
5. Program Inputs. The limited constructionat the county MCH station, and all constructionat prefecture and provincial levels will be to support their administrative and supervisory functions (Annex 8). Equipment for administration and information management,such as typewritersand computers, will be provided and each county MCH station will receive a vehicle for supervisory work (Annex 7). Furthermore, since recurrent budgets under the current system are almost exclusivelyfor salaries, funds are inadequate for management activities. The project, under the "program support" expenditurecategory, will support the followingrecurrent costs. - 47 - ANNEX 4
(a) The cost of regular supervisoryactivities from province, prefectural, county and township levels to lower levels, including labor, transport, meals and accommodationscosts where appropriate.
(b) Periodic meetings for village staff at township level and for township staff at county level for managementpurposes. Costs of management meetings at higher levels.
(c) The costs of special studies, meant to supplement routine information reports.
(d) Consumable supplies for the operation of the information system, such as data forms and computerdisks.
(e) The costs of project evaluationsand project administration. - 48 - ANNEX5
NATIONAL LEVEL PROGRAM
Introduction
1. Three major project points require special attention from the National level. Firstly, the project will be implementedby a large number of provinces at several service levels. Secondly,the comprehensivenature of the project necessitatesthe involvementof many departmentsand bureaus at different levels of government. Finally, the Ministry of Public Health (MOPH) must have the capacity to carry out the preparation and appraisal of the project in four remaining provinces as well as to ensure replication of successful experienceto nonprojectareas. Therefore, a financiallymodest national-levelcomponent is included in the project to establish and strengthencapacity of the central governmentto carry out the following specific functions:
(a) Project managementand monitoring;
(b) Coordination, includinginterdepartment and interprovince;
(c) Health workers' training program;
(d) Technical support to the provinces;
(e) National level operational research and studies;
(f) Preparation and appraisal of the project's second phase; and
(g) Disseminationof project experiences.
Organization of National Level Program
2. Overall direction of the project is the responsibility of a Leading Group chaired by Honorable Minister of Public Health and comprising directors of the MOPH departments of Maternal and Child Health (MCH), Medical Administration, Disease Control, and Medical Science and Education, the EndemicDisease Office, the Center for Health Statistics and Information, and the Foreign Loan Office (FLO). FLO will provide the secretariat to the Leading Group. Below the Leading Group, a Project Coordination Group will be responsible for overall planning and implementationof the national-level projectactivities, including the commontraining activities, consolidation, interpretation and feedbackof managementinformation, managementof specialoperational research studies, and technical assistance for the provinces. The Group is chaired by the director of FLO with the Director of MCH Department as its Deputy Chief, and consistingof the division -49- ANNEX5
chiefs of Maternal Health and Child Health Divisions of the MCH Department, and division chiefs from other MOPH departmentsand offices.
3. The Project CoordinationGroup will establisha small technical unit of 3 or 4 professional staff who will be recruited from an institution (probably a University)that will be contracted to carry out the detailed planning and day-to-day managementof the training activities [para. 6(c)]. The Technical Unit will receive institutionalsupport from the contracting agency as well as from outside as required. They will be responsiblefor preparation of clinical protocols and appropriate training materials and for necessary workshops. They will also assist provincesin the preparationand implementationof other key MCH-relatedintervention, including the improvementof MCH managementand health education.
4. The Project CoordinationGroup will review and approve each segment of the program which has been prepared by the contracted technical unit, including the relevant budgets. It will also be responsiblefor quality assurance review of the training materials produced for the project. The Group will request the Bank's comments on all training modules developedfor the project.
5. Administrative,financial, and logisticalrequirements of the project will be the responsibility of FLO, which will also provide facilities for planning international technical assistance and overseas studies (training) for the center and for assisting the provinces in this respect.
Inplementation of Key National Level Activities
6. The national-level activities, which will be carried out by the Project CoordinationGroup assisted by the Technical Unit and the FLO are as follows:
(a) Project Managementand Supervision. The FLO will be responsiblefor the monitoringand supervisionof the project implementationand to ensure the complianceof procurement, progress reporting and other requirements. Specific activities to be carried out under the central component would include the following:
(i) ManagementInformation. Operationalizationof the MIS including the collectionand processingof the agreed indicators for the project. Information from the provinces will be forwarded annually in standard format to the Center for Health Statistics and Information and FLO for analysis of project inputs, expenditures, and process indicators. Reports of the review will be fed back to the provinces and forwardedto relevant departmentsof MOPH to monitorprogress and for planning of future activities. The project activities will then be evaluated and adjustments made in accordance with the project guidelines and resources. - 50 - ANNEX 5
(ii) SupervisionVisits. Supervisoryvisits from the center to the project areas will be used to assist the provinces to improve their project implementation.
(iii) Mid-termReview. The project mid-termand completionreports to be prepared and submittedto the World Bank.
(b) Coordination.
(i) Intraministry Coordination. Coordination of planning and implementation of activities of various MOPH departments. Although the MCH Department will have the main role, several other line departments will also be involved in project implementation.
(ii) InterprovincialCoordination. Sharingand disseminationof issues and experiencesamong project provinces and carrying out common tasks efficiently and economically.
(iii) Interagency Coordination. Coordination of activities with 300- County Project and among other externalinternal agencies like UNICEF, UNFPA, WHO, World Bank, SPC, and Ministry of Finance.
(c) Health Workers'Training Program. The National-levelComponent will carry out the followingkey activities related to the training program, mainly through assistance from the technical unit:
(i) Formulate Clinical Protocols. Standard MCH clinical protocols will be developedat the national level, with provincialparticipation. These protocolswill form the basis of project training initiativesand be used for supervision and performance assessment (Table A3.1, Annex 3). These clinicalprotocols, coveringpreventive and curative care, will be prepared by local experts with previous experience in preparation of similar protocols for the 300-County Project, with some initial external technical assistance. Drafts of the protocols will be field tested before finalization. The process will commence immediatelyafter the project is appraised.
(ii) Develop Training Materials. Based on the clinical protocols, packages of suitable training materials will be developed, incorporatingmaterials (revised if necessary) from the 300-County Project, other programs implementedin China, the village doctor's upgradingtraining from MOPH and relevant directionsand guidance issued by the Medical Administrationand Education Departments. An expert group will review all existing materials from other - 51- ANNEX 5
relevant sources with someinitial internationalassistance. They will produce training packages consisting of texts and teaching aids, teacher guides, etc. The provinces will be responsible for bulk reproduction and distribution of these materials to all provincial county and township trainers.
(iii) Develop Training Skills. A series of training of trainer (TOT) classes will be sponsored by the Center in the project provinces, primarily to train provincial master trainers and to ensure the desired standard is maintainedin the transfer of new knowledge and skills to the lower levels (Annex 3).
(d) Technical Support for the Provinces.
(i) Support Management Improvement. A key input at the national level is the developmentof new initiatives and technical assistance for managementimprovement to strengthenMCH managementskills at provincial and prefectural levels and supervisory skills at county and township levels. Main interventionsare expected to include: managementtraining; strengtheningof supervision capability; and improvementin managementinformation system. To advance these goals the Project CoordinationGroup will establish a team of experts from appropriate institutions in China, including those of project provinces. This team will identify training needs, develop training materials, and assist the provinces in establishingMCH management training in a designatedinstitution in the province.
(ii) Health Education Initiatives. A team will be established comprisingexperts from various healtheducation institutes, including those of project provinces, and experts from university departments. This team will assist provinces to develop and implement health education programs. The team will also provide support on research, evaluation, and training to provinces.
(iii) OperationResearch. Assist and adviseprovinces in designing and implementingindividual operationalresearch studies that would be carried out by the provinces. The central unit will endeavor to arrange domestic and external technical assistance to the provinces.
(e) National Level Research and Studies. In addition to the operational research studies at the individualprovinces' levels, certain studies can only be carried out efficientlyat the central level and are described below.
(i) Coordination of MCH Functions. The project has included a study to review, analyze and recommend efficient method of functionalcoordination of the responsibilitiesamong various county- - 52 - ANNEX5
level agencies dealing with MCH, includingthose performed by the countyMCH stations and the county hospitals. The research will be designed and carried out by a Chinese research institute with assistance from internationalexperts.
(ii) Other Studies. A number of other studies, to benefit multiple provinces, could be consideredeither financed under the project or through other resources. One study that has been identified is the operationalresearch in the use of the risk-approach managementin a comprehensive program of maternal and child health. Others could be developedduring the project implementation.
(f) Project Phase Preparationand Appraisal. The FLO will be responsible for coordinating the preparation and appraisal of the programs in the remaining four project provinces in the project. A major part of this work is the preparation of the Project Management Manual (PMM), based on documentsand materials developed during project preparation workshops, including the existing county and provincial guidelines, and the internal managementregulations and procedures agreed upon with the Bank. This manual will be used for project implementationin the first four provinces and to guide project preparationas well as implementationin the remaining four provinces.
(g) Disseminationof ProjectExperience. Disseminationand replicationof the successfulproject activities in other parts of the country is an essential task of the central component. The Center will issue technical reports, newsletters, arrange demonstration visits, and employ other means of communicationsto publicize project progress. -53- ANNEX
BASIC HEALTH SERVICES FOR THE POOREST
Introduction
1. The purpose of the MCH poverty relief fund (PRF) is to improve access to essential clinical health services for the poorest families in the project provinces, and thereby help in reducing maternal and under five mortality. Although the fund is not expected to completely solve the problem of financing essential health services for disadvantagedfamilies, it can makea substantialimpact and will provide experiencein this approach to improvinghealth in poor counties. Improvingfinancial access for the poorest will work synergistically with the other major project strategies of improved service quality, and directly funded public health services and health education programs.
2. Target Population Size and Identification. Althoughthe proportion of the population that cannot use essential MCH services due to inability to pay varies among counties, the MCH poverty relief fund under the project is only required to cover at minimum the poorest five percent of pregnant women and children under five in each county. A higher proportion may be coveredif circumstancesallow. The poorest families can be identified through existing proceduresestablished for the use of local civil affairs and poverty alleviation offices in carrying out their programs.
3. Health services covered by the fund include those judged to be the most cost-effective in reducing maternal and under five mortality and morbidity. The five service categories are routine maternal care, hospital delivery for high risk pregnancy, managementof serious obstetric complications,outpatient treatment of serious childhood infections(special emphasis on pneumoniaand diarrhea), and inpatienttreatment of severe childhood illnesses. Within each service category standard treatment guidelines as introduced under the project training component will be used to ensure that essential services are covered in a cost-effective manner. The list of services covered may be modified based on experience.
4. Estimated costs of the fund would be based on the populationcovered, the rate of subsidy for services in the coveredpopulation (100 percent versus a sliding scale), the number of target pregnant women and children in the population, the rate at which the target women and children are expectedto require the services covered, and the estimated cost per case. It is estimated that funds equal to about 0.1 yuan per capita of the entire county populationper year is enough to cover the poorest five percent of pregnant women and children. This is the minimumamount that each county PRF will provide each year of the project. Eligibility and coverage of subsidized services will be modified as experience on actual costs is gained. -54 - ANNEX6
5. All funds for the MCH poverty relief fund will come from government sources,with sharingof costs betweencounty, prefecturaland province levels. The money allocated for the PRF would not be part of the project cost. Full fundingis required over the life of project and unused funds in one year should be used to expand coverage rather than to reduce governmentobligations.
6. Management of the MCH Poverty Relief Fund. The fund shall exist as a special account managedby the county project office. Criteria for identificationof poor families will be established by the province and county levels, with actual identification taking place at the village and township levels. Pregnant women and children under five of the poorest families will be informed of the services they can avail free (or partially subsidized),and educatedon what these includeand when to seek them. Health providers will be educatedin PRF procedures, standard treatmentguidelines and records to be kept, and will be reimbursed by the county project office for essential services provided to eligible women and children.
7. Supervision,Reporting, and Evaluation. The county project office will regularly visit a sample of poor families to check on registration of eligible individuals, service coverage, and reporting accuracy. At minimum,annual visits will be made by the province/prefecturelevel. Annual reports from the counties to the provinces will allow calculation of rate of eligible persons being registered, rate of usage and average cost of each service type by subsidylevel, mortalityrates, and changesor suggestionsfor changes in fund operations. Summaryreports will be forwarded to the national level. Evaluation of the fund will focus on coverage, correct usage, content of services, costs, effects on mortality, and administrativefeasibility.
8. Preparations,Start-up, and InitialOperation. The provincesand counties will promulgatethe specificservices covered, review the standardtreatment guidelines and their expectedcosts, and recommendfor record keepingand reporting to the national level. Each of the four first-phase provinces would provide its detailed plan to the Association by October 31, 1994 and implementits plan by January 1, 1995.
9. Sustainability. It is expected that if, after five years operation, the MCH poverty relief funds can show a substantialcost-efficient impact on service utilization and mortality for those covered, many or most county governmentswill be willing to continue to provide funds after the project, or even expand the fund eligibilityand service coverage. - 55 - ANNEX 7
STANDARDIZED PROJECT EQUIPMENT
Introduction
1. The list of maternal and child health (MCH) care equipment was developed with two objectives in mind. The first objective was to prepare a guide which the counties and provinces could use in preparing proposals for various levels under this project. The second objective was to start a process to help the Government to eventually standardize basic equipment lists for maternal and child health services throughout the country. A fundamental principle applied was that an absence of basic minimum equipment can weaken the effectiveness of health services and, at the same time, procurement of ineffective equipment can be wasteful and even hazardous. It is, however, understood that any standard list should have enough flexibility and should be adjusted whenever fully justified. This project equipment list was prepared based on discussions among the Bank's mission, ministerial staff, and external technical consultants. The mission recognized that this list differs slightly from the standard ministry equipment guidelines. To achieve the second objective, it is the intent that during project implementation, a revised ministerial guideline will be finalized for nationwide use.
2. There are two lists of equipment: (a) essential equipment list and (b) optional equipment list. The standard lists for various service levels are given in Table A7. 1. Each facility is expected to have a complete set of essential equipment recommended for that level. If for some reason, a given facility will not carry out its normally designated functions, it will not need all of the essential equipment in the standard list and its equipment plan will be modified. The optional equipment items are those which a health facility requires to do additional MCH services or procedures over and above those specified in the project activities. These items can be considered under the project based on their appropriateness and cost-effectiveness. The appropriateness of a piece of equipment must take precedence over its cost-effectiveness.
(a) Appropriateness Criteria
(i) The clinical activity is appropriate for the level or institution.
(ii) The technology of the equipment can produce information to realize the desired outcome.
(iii) The technology is appropriate for the level of service. - 56 - ANNEX 7
(b) Informationneeded for Cost-Effectiveness
(i) Number of cases per year;
(ii) Cost of the equipment and its required associated supporting facilities;
(iii) Cost of training the users; and
(iv) Cost of operation, maintenanceand related consumable.
StandardEquipment
3. As a reference to first phase project provinces, and to facilitate the preparation by the second phase provinces, essential equipmentlists were developed for each service level for the clinical MCH services, training and managementcomponents of the project. These lists were based on the recommendationsof the Ministry of Public Health (MOPH) and officials from provincial health bureaus, the lists prepared by UNICEF for use in the 300-County Project, recommendationsof WHO for essential obstetric functions at first referral level, and the suggestions from a number of external specialists.
4. In quantifying their requirements under the project, the provinces and counties took into account currently available equipment. The project will ensure that all service units either already have or will procure all "essential" items listed for that particular service level. A mechanism for review and modification of the standard equipment list, and for approving procurement of equipment not in the list is provided. The proposals will be submitted to MOPH and the Bank for concurrence. Only upon agreement by MOPH and the Bank will the changes be made and funds from physical contingenciesallotted for the additionalprocurement.
EquipmentUnder the Project
5. The project equipment proposals were submitted by the project provinces and counties and discussed in detail with the national level and the Bank mission. In certain cases, proposed optional equipmentwere included only after the proponents made their justifications (para. 2) in furtherance of the project's objectives. "Optional equipment"may (a) represent items that were requested for one type of facility found only on the essential or optional list of another facility and (b) items not on any recommended list but were added upon justificationby the provinces. In cases where these have been accepted, the provinces assured the Bank mission that the functions of the institutions involved would warrant use of such equipment.
6. The total cost for equipmentfor the differentlevels are summarizedin Table A7.2 for each province. Table A7.1: STANDARDIZED EQUIPMENr LST
Villge Township Rkeerral Township MCH Station Coonty ospital PerePeeral Pro-iLcil EPS B h L d E55RL114111211 BxntHI EauttmenE5 aeSntalsemItK Essealnalt-weoE se,all EQutnoIm EssentialI Eutleme Sicihoscope Stotlhoscope Basi qaipnset set B,stc eqsopmne ta Basic qqtptntet a ilofat Incubator Ifani Incubator Lw Temp. Freezer BP Mhner BP Metr Infant l.cubaalr Telephone Infant Incubator Rdiant Heater for Neonates Rtadian Healer for Neonates Refrigerator Wooden F,etscope Wooden Stethosope RadamntHeater foe Nennares Electuonc Chinen/Engirsh Prnmer Radiant eater for Neonates Shadowless Lanp Shadowless Lamp Cold Bag Tape Measure Tape Measure Shadowless Lamp Phot-ocptee Shadowkss Lamp Operational Kit (A Leve) Anaest,esia Apparaiss Ice Ba. Nail Brash Nail Brush Operational Kit IA Level) Computr Operational Kit (A Level) Anaestheia Appararus Operating Table Visiting Cas Visiting Cas Delvery Kit (A Lovel) Camera Anaesthesia Appaatas Delivery Ktt (A Lcvel) Infam Blaehtgh Therapeutic Uni Optional,,E-Mg Delivery Kit (B Leve) Delivery Kit (A Le)e) Operating Table Color TV Operattng Table Operating Table Universal Delivery Bed Compuizr Infam Scale (Market) Thermometer Steam Sterirze (Medium) Overhead Proector High PressureSteam Sterilie- High PressureSteam Steriiern Electroc Chines/English PriMter Cold Chain Ca. Simple Boiing Stetilinet Infant Scale (Muket) Stam Sterleer (Small) Steam Sterlior (large) Iryngoscope Latyngoscope Slide Projector high PressureStam Sterilter Hetght/Weight Scale Steam Suerdirer (Small) HeightfWeighl Scale Height/Weight Scale Computer OuLt-1EQlrmen HeighL/Weight Scale Child Scal fn Three UYs HeightlWetght Scale Chtld Scale for Three UYS Child Scale fo Three Uses Camer Child Scale Ch-Id Scale for Three U.S Low Pressur Sortien Child Scale fw Three Ises low Presure Societe Low Pressur Sucton Color TV Ifigh Pressre Steam Sterilizer Low Pressue Suction Infant Blueight Therapetic Unit Table foe Gynecology Check Infant Blorilght Therpeutic Unit Infant Bbrlighi Therapeuti Unit Overhead projector Smple Delivery Bed Infam Resuscitaor Infant Resascor Doppler Feul Hert Mainr nf Infanit Resus,,tator Binocul Microscope Doppler Fetal Hea, Momttlw Doppler Fetal HearnMonito Infasn Scale (P.n) Doppler Fetal Heart Monitr Doppler Fea lleant Monior Vhicle (minibs) Infant Scale (Pan) Infant Scale (Pan) Shde Pnoycctoe Infant Scale (Pan) Infamt Sale (Pan) Vehicle (cross counry) Osygen Tank Onygen Tank Radio Cassena Recoder Onygen Tank Osygen Tank Photocop,rt De,hveryBed Delivery Bed VdOeoCasseite Recorder Table fo Gyntcology Chck Table for Gynecology Check High-Speed Primer Universal Delvery Bed Universal Delivery Bed Supervision Cu Untversal Deivery Bed Universal Delivery Bed Video Cassette Recorder Delivery Room Heater Delivery Room Heater Vaginal Speculom Delivery Rom leater Delivery Room leater VehIle Adjusable Delivery Room Ltght Adjustable Deltvery Room Light Copper T-1natin- Kit Adjustable Delvery Rwm Light Adjustble Delivery Room Light Vagina Specu)um Vaginal Speculum Refrigerator Vaginal Speculat Slide ProjectWo Optlonarl FittmntI Coper T-Insnron Kit Copper T-Ietnion Kit Bmnoclar MiroscWe Copper T-Inmrion Kit Copper T-Insenton Kit C02 Ljase Treatmet Machine '1 Refrigerator Refrigerator 721 SpecreopoLnteter Refrigerator Compuzr Semi-auto Chemistry Analyeor Onygen Took with Acessories Osygen Tank with Accessories Low Speed Centrifuge Ovygcr Tusk with Accessoies Camera Autotatic Urine Analyzer Ulumnc Nebulier Water Bath Gyncological Check Bag Color TV ELISA Photometr Ogga lgjigLDn Binocula Micrnscope Ultrasnic Nhubheer Overhead Projector Blond Bank Free.or Ultrasonic Nebulzer 721 Spectrophotameter Oional Fquipmenl BinocuL Microscope Ultrsomc Nebuhzer 2fJOmAX-ray Machme Btneucu Mahroscepe Low SpeedCertetfoge ECG Mabhte 721 Spectrophnomeser Binocula Microscope Blood Cell Coontr 721 Spectrophoutmetr Water Bath Laryngoscope Low Speed Centerfuge 721 Specuophosometer Na K-Cl Analyser Low SpeedCenutfage Washtog Machine Water Bath Low Speed Centrfuge Neonatal Monitor Water Bath ODWIlEgtiE gnl Tools fo Classrom ECUi Machme Water Bath FAX Machie Patirm Bed (Spring Bed) ECG Machine Urmversal Delivery Bed 200mA X-ray Mchine Elecronic Chines/Enghsh Printer Telephone LaryngnsoCpe Delivery Rwm Heater Telephone Photocopier Bicycle Washing Machne Adjusrble Deltery Room Light ECG Machine Motorcycle Twos for Classrom Delivery Kit (A Level) qptionalfggmen High-Speed Printer Delivery Kit (B Level) Table for Gyxcnlogy Check C02 Laer Tneatmeot Machie Semi-auw Chemsuty Analyzer V ideo Casete Recorder Infant BluWIght Therapeutic Unit Electic Heatng/Drying Oven UltrwsomtcNbtule Autrosatic Urit Analyser Vehile Radiam Heatr fee Neonaes 200fnA X-ay Machie Low Pressure Suctwo ELISA Photmetr Shadowless Lamp Telephon Onygen Took Hematology Analyzer sLgnaQDLt 9oEgrtng Table fee Gynecology Check Bicycle O,ygen Tank with Accessores Blood Cell Conmer C02 Laser Treatment Machio ECG Machin Motorcycle tfam Resuscitator Na-K Cl Analyser Semintoai Chesisry Analyter Atebulotwe Iofant Bborlight Th,,rape.aiw Unit Elecri Iteatteg/Drytg Oven Automatic Urin At.iaypoe Stthsco-pe hifam Incu-btor Etcttssttc Balanc El-ISA Photuowier BP Meter ladiot tr-ter fo Neonates Washlitt Ma-him Bloral Battk Raftigerasr, Wsoden Stetloscope Itigh-Speed Printer Blod Bank Free-r Hlematology Analy-rr Tape Measur Operating Table C02 Lsr Treatment Maxht, Refrigerator Visiting Cas Shadowless Lamp Phoocoptee Tools for Classroom Notes: Operational Kit (A Level) Overhead Profector I Copper T inwen kit should conain uterine sound naculu. Anaeslheso Apparawus Slide Projecltor spong.eforps. long handle cissws. sculu tray ad caner, et Neonatal Monmi Ambulauie 2 Bsic eqsipmen se - stethoscope.BP metr. tape mesoore, woden feoscope ndil bush, 2fXlmA X-ray MAchtn uniting bg. theromer, and tnstritmentcontainer Electic Hleating/Drymg Oven 3 Tols fo classrom: Blackboard erase desks, e. Elecuomc Balatre Hematology Analyzr Table A7.2: EQuiPMENrCosT SUmmARY
By Province and Service Level
Guangxi Shaanxi Sachunn Yunnan National Ld ITIOAL Service Level (RMBI (US $S (RMB) (US $S (RMB) (US Si (RMBI (US Sj (RMB) (US $( (RMB( (US $) A. Village Equipment 2446726 281233 3150464 362122 5071633 582946 4643979 533791 15312802 1760092 B. Township Equipment 3429457 394190 6370700 732264 19624766 2255720 5178089 595183 34603012 3977358 C. Referral/Central Township Equipment 1611157 185190 921800 105954 7396623 850187 1763580 202710 11693160 1344041 Vehicles: Ambulanc 1950000 224138 3300000 379310 6300000 724138 4950000 568966 16500000 1896552 D. MCH Station Equipment 3337565 383628 3610560 415007 10108270 1161870 5025120 577600 22081515 2538105 Vehicles: Supervisio 4500000 517241 5250000 603448 9900000 1137931 6000000 689655 25650000 2948276 E. Hospital Equipment 1193780 137216 2154900 247690 15365355 1766133 1314685 151113 20028720 2302152 Vehicles: Ambulanc 1050000 120690 450000 51724 1500000 172414 300000 34483 3300000 379310 L F. Prefecture Equipment 644000 74023 914800 105149 1762225 202555 1812475 208330 5133500 590057 Vehicles 450000 51724 1350000 155172 3000000 344828 1350000 155172 6150000 706897 G. EPS Equipment 340400 39126 635650 73063 754200 86690 279600 32138 2009850 231017 Vehicles: Cold Chai 0 0 0 0 900000 103448 0 0 900000 103448 H. Province 0 0 Equipment 106000 12184 176000 20230 744500 85575 202000 23218 1228500 141207 Vehicles 300000 34483 850000 97701 900000 103448 650000 74713 2700000 310345 1. County Project Office Equipment 0 0 0 0 1968000 226207 0 0 1968000 226207 J. Central Management Equjipment 332300 38195 332300 38195 TOTAL > Equipment 13109085 1506791.4 17934874 2061479.8 62795572 7217881.8 2Q219528 2324083.7 332300 38195 114391359 13148432 Vehicles 8250000 948276 112QQQQQ 1287356 225000 2586207 1325000Q 1522398 Q Q -21QQA A- XZ
GRAND TOTAL 21359085 2455067 29134874 3348836 85295572 9804089 33469528 3847072 332300 38195 169591359 19493260 -59- ANNEX 8
CIVIL WORKS
Introduction
1. Althoughadequate capacityexists in most current facilities to carry out the clinical work of the project, many buildings are in poor condition and unattractive to patients. In order to improve the quality of MCH services and increase the utilizationof the existing health facilities,limited rehabilitationand constructionof labor, delivery and obstetrical wards or other related clinical services will be supportedby the project. These civil works constructions are essential requirements in the conduct of MCH activities includingtraining. Civil works constructionat the provincial and prefectural levels will be to support the training and managementimprovement requirements.
2. Generalguidelines agreed upon by the Bank and the participatingprovinces in civil works constructionsare as follows:
(a) New constructionand rehabilitation will only be funded by the project if these will improve the quality of MCH services and support the administrativeand teachingareas;
(b) New constructionand/or rehabilitation will be limited to a maximum of 300 m2 per county except that Sichuan (which has very large county population) could include up to 500 m2;
(c) Project funds will only be used to finance constructionfrom the township level and above. Village level construction or rehabilitation will be the responsibilityof the local community.
3. Specific Guidelines. Level-specificguidelines are as follows:
(a) Township Level
(i) New constructionor rehabilitationof existing rooms will be funded if they will lead to improvementsin obstetric services.
(ii) Delivery rooms and obstetric wards should be clean and well-heated and well-lighted so they are suitable places for work and attractive to patients. - 60- ANNEX 8
(b) Central or Referral TownshipHospitals
(i) This level construction expenditure will be for renovation to rehabilitate existing facilities to provide suitable lighting, water supply, heating, and hygienicwalls and surfaces for operatingareas.
(ii) Funds will also be provided to meet routine maintenanceof newly constructed or rehabilitatedbuildings.
(c) MCH Station
(i) Conditionality of funding: Project funds can only be used to improve preventive and support services.
(d) County Hospital
(i) New construction will be funded if existing facilities cannot be rearranged to meet project objectives.
4. The civil works constructions'physical requirements and their corresponding cost are detailed in Table A8. 1. - 61- ANNEX 8
Table A8.1: SUMMARYOF CIVL WORKS CONSTRUCTION
By Province and Service Level
GRAND TOTAL Level/Province Area (Sq. Meter) Cost (RMB) New Rehab Ioal NM Rehab iTta GUANGXI Township 769 8571 9340 461400 2571300 3032700 CentralTownship 893 2246 3139 535800 673800 1209600 MCH Station 9128 2958 12086 5476800 887400 6364200 Hospital 70 1555 1625 42000 466500 508500 EPS 294 270 564 176400 81000 257400 Other 0 40 40 0 12000 12000 Prefecture 0 0 0 0 0 0 Total 11154 15640 26794 6692400 4692000 11384400
SHAANXI Township 1673 12884 14557 836500 3865200 4701700 CentralTownship 333 3667 4000 166500 1100100 1266600 MCH Station 12130 8300 20430 7278000 2490000 9768000 Hospital 600 1505 2105 360000 451500 811500 Prefecture 500 0 500 350000 0 350000 Province 1500 0 1500 1200000 0 1200000 Total 16736 26356 43092 10191000 7906800 1809780
,ICHUAN Township 0 28313 28313 0 2718048 2718048 CentralTownship 0 6683 6683 0 1530407 1530407 MCHStation 23480 15100 38580 11740000 4530000 16270000 Province 500 0 500 650000 0 650000 Total 23980 50096 74076 12390000 8778455 21168455
YUNNAN Township 0 740 740 0 444000 444000 CentralTownship 0 570 570 0 342000 342000 MCHStation 12000 5340 17340 12000000 4272000 16272000 Prefecture 2000 0 2000 2000000 0 2000000 Province 500 0 500 500000 0 500000 Total 14500 6650 21150 14500000 505800 19558000
GRAND TOTAL 66370 98742 165112 43773400 2435255 70208655 Table A9.1: ExPENDnJRE AccouNTs BY COMPONENrs-FnSr BATCH PROvINCES ($ million)
GUANGXI SHAANXI StCHUAN YUNNAN NATIONAL LEVEL Basic Basic Basic Basic Bask H.aUh HeatH HlthHealth H Heallh HalhH Health Health Health Health Physical Cate Woetars Managamni Cams Worters' Managsint Care Workes Manage'etnt Cas Wor ers' Managerntma Cas Wokers' Management Contlngancis D ivwy Trainlng mp t Dl Traiing Imp nt Ddhy Tran9 Imprnnwn D lyy TrinIng Impnvt Dy Training Impwmnto Total % Amount 1Istment Coats A. ChV Works 1.31 - 190 o 2 38 - 0 07 198 - 0o29 - - 8.07 so 0.40 8. Equiprent 1.19 003 029 1,87 0,08 033 828 012 084 184 0.07 0.42 - - 004 1315 50 0.88 C. Vohicls Amianct 0 34 0 43 - - 0 90 - - 080 - - - 2 28 50 0 11 Swwson rCW - 08e0 - 08o - - 18o9 - 02e - - 4.07 50 0.20 Sutota Vohke 0.34 0.80 0e43 - o.8 090 1.89 080 0 92 - 8.34 5.0 032 0. Training Lorg Term TnWng - 031 - - 059 - - 1.78 - 0.85 - - , 331 50 0.17 Short TermTNgT 1.73 2.22 - 4.92 - 188 10.54 5.0 0.53 OvenseasShmes 0.11 - - 009 , 0.07 - - o00 0o9 0.42 5.0 0.02 Subtotal Traing - 214 - 2.90 - - 78 - - 2.37 0-09 - 14 27 50 0.71 E Technic Asaistance LocalSpeoedkso 0.01 001 0.01 0.03 0.03 004 008 008 0.11 0.02 0.02 003 0.19 018 028 113 50 0.08 ForeqlSpeaaists 0.01 0.01 0.01 0.01 001 001 001 001 0.01 0.01 0.01 001 o08 o00 008 034. 50 0.02 Subtotal TochrkalAssistance 002 002 0.03 0.04 004 005 009 009 013 0.03 0.03 0,04 0.28 025 034 1.47 so 0.07 F. Operaon Rearch 0 04 - 0 04 0 03 - 003 0 03 - 0 03 0.12 - 0.12 - 0 08 049 50 0.02 Total Inveslm. tCosts 2890 2 20 0 88 4 07 301 144 964 697 2 76 4 55 2.47 1 78 0 28 0 34 0o44 43 79 50 219 11-Recurrenot Cos A. Program Supporlta 194 - 224 229 - 284 385 - 443 2.40 - 2.78 021 024 2298 50 1.15 S. Malntnance 023 0 00 0.07 0.32 001 0.11 078 001 021 0.35 0.01 013 - - 0oD 221 50 011 Total RecrrentCosts 217 000 2.31 281 0.01 2.75 481 001 464 275 0.01 2.89 - 021 024 2519 50 1.28 Totai BASELINECOSTS 5 07 2.20 3.2Z7 88 3.01 419 1424 698 7.40 730 248 4.87 028 055 08 e88.98 50 3.45 PtlaiConbsrvncies 025 O.11 01 033 0.15 021 071 0.35 0.37 0.32 012 0.23 0.01 003 003 345 Pnc Conbsiwmas 1 01 0 8 0 82 1.31 0 8 1 08 2 31 1.85 1.80 1.39 0 .4 1 15 0.08 013 018 15 .0 48 0.72 Total PROJECT COSTS 8.34 2 90 4 25 8 33 3.88 5.45 17 28 918 9.57 9 06 3 24 8. 5 0 33 0 70 0o88 87 50 4.8 4.17
Tasa ------Foe.gnE-dap 134 0.15 025 183 017 028 8.03 0.19 0.70 2.15 013 035 0.07 0.17 012 1392 48 O.88
bi Incdes Supptos. Traportaton, A_wnod,9on Mas. *nd AIowwx=c fr preventve servies aid manaremenL Not The 1nia estenatas of mals nc liefiat lowrprwlcas. namely Guange Shaarm, Shumwn, Yunnan ad Nabonal level Table A9.2: EXPENDruREAccoumrs BY CoMPONENs-TENiAIVE ESTIMATESFOR THE SECONDBATCH PROViNCES ($ million)
GANSU CINGHAI JIANGXI NEI MONGOL Basic Basic Basic Basic Health Health Heahth Health Health Health Health Health Physical Care Workers' Management Care Workers' Management Care Workers' Management Care Workers' Management Contingencies Delivery Training Improvement Delivery Training Improvement Delivery Training Improvement Delivery Training Improvement Total % Amount 1.Investment Costs A Civil Works 1.06 - 0.12 0,77 - 0.09 1.65 - 0.18 1.41 - 0,16 5.45 5.0 0.27 B. Equipment 1.88 0.04 0.29 0.93 002 014 201 0.05 031 2.15 0.05 0.33 8.20 50 0.41 C. Vehicles Ambulances 0.72 - 0.10 - - 0.69 - - 0 69 - - 2.21 5.0 011 SupervisionCar - - 0.21 - - 0.43 - - 0.66 - - 082 2.11 5.0 0.11 Subtotal Vehicles 0.72 - 0.21 010 - 0 43 0.69 - 0.66 0 69 - 0.82 4.32 5.0 0.22 D. Training LongTern Training - 0.31 - - 0.28 - - 0 40 - - 0.59 - 1 58 5.0 0 08 ShortTern Trainn9g 1.24 - - 0.63 - - 1 80 - - 1.60 - 5.28 5.0 0.26 Oversea Studies - 0.03 - 0.02 - - 013 - - 0.09 - 0.28 5.0 0.01 Subtotal Tralning - 1.58 - 093 - - 2 34 - 2.29 - 7.13 5.0 0.36 E. Technicl Assistance LocalSpecialists 0.03 0.03 0 04 0.03 0 03 0 04 0.01 0.01 0.01 0.02 0 02 0 02 0 31 5 0 0 02 ForeignSpecialists 0.01 0.01 0.01 0 00 0.00 0 01 0 01 0 01 0.01 0.01 0.01 0 01 010 5 0 0 00 Subtotal Technical Assistance 0.04 0 04 0 06 0 03 0.03 0.05 0 02 0 02 0.03 0 02 0.02 0.03 0.41 5 0 0 02 F. OperationResearch 0.03 - 0.03 0 05 - 0 05 0 05 - 0 05 0.05 - 0.05 0.34 5 0 0.02 Total InvestmentCosts 3 74 1.67 0.71 1.89 0.98 0 75 4 42 2 40 1 22 4 33 2.36 1.38 25.85 5 0 1 29 II. Recurrent Costs A. ProgramSupportla 1.59 - 1.83 0.50 - 057 204 - 235 198 - 228 13.13 50 0.66 B. Maintenance 0.26 0.00 0.08 0.15 0 00 0.20 0.33 0 00 0.11 0.34 0 00 0 11 1.59 50 0 08 Total RecurrentCosts 1.85 0.00 1.92 0.65 0.00 077 237 000 2.45 2.31 0.00 2.38 1472 50 074 Total BASEUNECOSTS 5.59 1.67 2.63 2.53 0.98 1.52 6.79 2.41 3.67 664 2.37 3.76 40.57 5.0 2.03 Phy kalContingencies 0.28 0.08 0.13 0.13 0.05 0.08 034 0.12 0.18 0.33 0.12 0.19 2.03 - - Price Contingencies 0.93 045 0.65 044 0.25 0.37 1.21 0.64 0.92 1 15 061 0.93 855 48 0.41 Total PROJECTCOSTS 6.80 2.21 3.41 3.10 1.29 1.97 8.34 3.16 4.77 812 310 4.88 51.16 4.8 2.44
Taxes ------ForeignExchange 2.31 0.08 0.25 0.87 0.04 0.12 2.38 0.20 0.26 2.49 0.15 0.27 9.42 48 0.45
la incJuds:Supplies, Transpoulation, Accommodation. Meals and Allowancesfor preventiveservices and management. Note Prelinlrwy est*nde of costsIn the secondbatch provices, namely,Gansu, Jiangxl, Nei Mongol,and Qinghai. Thesecosts are subjet to be reviewedand approvedby the Associatlon. Table A9.3: ExPENDITuRE AccouNTs BY YEARS-GuAaNGx, SHAAN3a,SIcHuAN, YUNNANAND NATIONALLEVEL
BasoCost (RMB Million) Base Cost (USSMillion) Foreign Exchange 1994 1995 1996 1"7 1998 Total 1994 1995 1996 1997 1998 Total % Amount 1.lnvestment Costs A. Clvil Works 28.08 35.10 7.02 - - 70.21 3.23 4.03 0.81 - - 8.07 - - B. Equlpment 22.88 68.63 22.88 - - 114.39 2.63 7.89 2.63 - - 13.15 75.0 9.86 C. Vehiclas Ambulances - 19.80 - - - 19.80 - 2.28 - - - 2.28 100.0 2.28 Supervision Car - 17.70 17.70 - - 35.40 - 2.03 2.03 - - 4.07 - - Subtotal Vehices - 37.50 17.70 - - 55.20 - 4.31 2.03 - - 6.34 35.9 2.28 D. Training Long Term Trainirg 8.64 11.52 8.64 - - 28.80 0.99 1.32 0.99 - - 3.31 - - Short Term Training 9.17 20.63 20.63 20.63 20.63 91.69 1.05 2.37 2.37 2.37 2.37 10.54 - - OverseasStudies 0.73 0.73 0.73 0.73 0.73 3.64 0.08 0.08 0.08 0.08 0.08 0.42 100.0 0.42 Subtotal Training 18.54 32.88 30.00 21.36 21.36 124.13 2.13 3.78 3.45 2.45 2.45 14.27 2.9 0.42 E. Technical Assistance Local Specialists 1.96 1.96 1.96 1.96 1.96 9.82 0.23 0.23 0.23 0.23 0.23 1.13 - - ForeignSpecialists 0.60 0.60 0.60 0.60 0.60 2.98 0.07 0.07 0.07 0.07 0.07 0.34 100.0 0.34 Subtotal Technical Assistance 2.56 2.56 2.56 2.56 2.56 12.80 0.29 0.29 0.29 0.29 0.29 1.47 23.3 0.34 F. Operation Research - 2.14 2.14 - - 4.28 - 0.25 0.25 - - 0.49 - - Totallnvestment Costs 72.06 178.82 82.30 23.92 23.92 381.00 8.28 20.55 9.46 2.75 2.75 43.79 29.5 12.90 II. Recurrent Costs
A. Program Supportla 39.81 40.04 40.04 40.04 40.04 199.96 4.58 4.60 4.60 4.60 4.60 22.98 - - B. Maintenance 2.40 2.40 4.80 4.80 4.80 19.18 0.28 0.28 0.55 0.55 0.55 2.21 Total Recurrent Costs 42.21 42.44 44.83 44.83 44.83 219.15 4.85 4.88 5.15 5.15 5.15 25.19 - - Total BASEUNE COSTS 114.27 221.25 127.13 68.75 68.75 600.15 13.13 25.43 14.61 7.90 7.90 68.98 18.7 12.90 PhysicalContingencies 5.71 11.06 6.36 3.44 3.44 30.01 0.66 1.27 0.73 0.40 0.40 3.45 18.7 0.64 Price Contingencies 7.33 32.18 32.83 26.03 32.69 131.06 0.84 3.70 3.77 2.99 3.76 15.06 2.5 0.38 Total PROJECTCOSTS 127.31 264.50 166.32 98.22 104.88 761.22 14.63 30.40 19.12 11.29 12.06 87.50 15.9 13.92 Taxes ForeignExchange 19.52 78.07 20.43 1.51 1.56 121.10 2.24 8.97 2.35 0.17 0.18 13.92 la Indudes: Supplies, Transportation.Accommodation, Meals, and Allowancesfor preventiveservices and management. Note: The final estimatesof costs in the first four-provinces,namely, Guangxi. Shaanxi, Sichuan. Yunnan, and Nationallevel. Table A9.4: EXPENDmRE Accous BY YEARS-TENrATIVEESTmAES FORTHE SECONDBATCH PROVINCES
Base Cost (RtMBMillion) Base Cost (US$ Mlillon) Foreign Exchange 1994 1956 1996 197 1998 Total 1994 1956 1996 1997 1998 Total % Amount 1.Investment Costs A. Civil Works 18.95 23.69 4.74 - - 47.38 2.18 2.72 0.54 - - 5.45 - - B. Equipnmnt 14.27 42.82 14.27 - - 71.36 1.64 4.92 1.64 - - 8.20 75.0 6.15 C. Vehicle Ambulances - 19.20 - - - 19.20 - 2.21 - - - 2.21 100.0 2.21 SupervisionCar - 9.20 9.20 - - 18.40 - 1.06 1.06 - - 2.11 - - Subtotal Vehicles - 28.40 9.20 - - 37.60 - 3.26 1.06 - - 4.32 51.1 2.21 D. Training Long Term Training 4.12 5.49 412 - - 13.73 0.47 0.63 0.47 - - 1.58 - - Short Term Training 4.59 10.34 10.34 10.34 10.34 45.93 0.53 1.19 1.19 1.19 1.19 5.28 - - OverseasStudies 0.48 0.48 0.48 0.48 0.48 2.41 0.06 0.06 0.06 0.06 0.06 0.28 100.0 0.28 Subtotal Training 9.19 16.31 14.94 10.82 10.82 62.07 1.06 1.87 1.72 1.24 1.24 7.13 3.9 0.28 E. Technical Assistance Local Specialists 0.54 0.54 0.54 0.54 0.54 2.70 0.06 0.06 0.06 0.06 0.06 0.31 - ForeignSpecialists 0.17 0.17 0.17 0.17 0.17 0.84 0.02 0.02 0.02 0.02 0.02 0.10 100.0 0.10 Subtotal Technical Assistance 0.71 0.71 0.71 0.71 0.71 3.53 0.08 0.08 0.08 0.08 0.08 0.41 23.7 0.10 F. Opraton Research - 1.49 1.49 - - 2.97 - 0.17 0.17 - - 0.34 - - LA TotallnvestnmntCosts 43.12 113.41 45.34 11.52 11.52 224.92 4.96 13.04 5.21 1.32 1.32 25.85 33.8 8.73 11.Recurrent Costs A. Progrm Support la 22.85 22.85 22.85 22.85 22.85 114.25 2.63 2.63 2.63 2.63 2.63 13.13 - - B. Maintenance 1.73 1.73 3.46 3.46 3.46 13.82 0.20 0.20 0.40 0.40 0.40 1.59 Total Recurrent Costs 24.58 24.58 26.31 26.31 26.31 128.07 2.82 2.82 3.02 3.02 3.02 14.72 - - Total BASEUNE COSTS 67.70 137.99 71.64 37.83 37.83 352.99 7.78 15.86 8.23 4.35 4.35 40.57 21.5 8.73 Physical Contingencies 3.39 6.90 3.58 1.89 1.89 17.65 0.39 0.79 0.41 0.22 0.22 2.03 21.5 0.44 PriceContingencies 4.42 19.24 18.40 14.34 18.02 74.42 0.51 2.21 2.12 1.65 2.07 8.55 2.9 0.25 Total PROJECTCOSTS 75.50 164.12 93.63 54.06 57.73 445.05 8.68 18.86 10.76 6.21 6.64 51.16 18.4 9.42
Taxes ------ForeignExchange 11.99 55.88 12.55 0.74 0.77 81.93 1.38 6.42 1.44 0.09 0.09 9.42
\a includes:Supplies, Transportation,Accommodation. Meals andAllowances for preventiveservices and management. Note: Preliminaryestimates of costs in the second batch provinces,namely. Gansu, Jlangxi, NeiMongol. and Oinghai. Thesecosts are subjectto be reviewedand approvedby the Associabon. Table A9.5: PROJECTCOMPONENTS BY YEAR-FIRST BATCHPROVINCES
Base Cost (RMB Million) BaseCost (USSMillion) 1994 1995 1996 1997 1998 Total 1994 1995 1996 1997 1998 Total A. GUANGXI 1. Basic Health Care Delivery 10.29 18.74 7.29 3.91 3.91 44.13 1.18 2.15 0.84 0.45 0.45 5.07 2. Health Workers' Training 2.59 4.84 4.47 3.61 3.61 19.13 0.30 0.56 0.51 0.42 0.42 2.20 3. Management Improvement 4.52 8.31 7.39 4.09 4.09 28.41 0.52 0.96 0.85 0.47 0.47 3.27 Subtotal GUANGXI 17.39 31.89 19.16 11.62 11.62 91.67 2.00 3.67 2.20 1.34 1.34 10.54 B. SHAANXI 1. Basic Health Care Delivery 13.93 25.29 9.44 4.75 4.75 58.17 1.60 2.91 1.09 0.55 0.55 6.69 2. Health Workers' Training 3.82 6.97 6.24 4.59 4.59 26.21 0.44 0.80 0.72 0.53 0.53 3.01 3. Management Improvement 5.99 11.13 9.49 4.92 4.92 36.44 0.69 1.28 1.09 0.57 0.57 4.19 Subtotal SHAANXI 23.74 43.38 25.17 14.26 14.26 120.82 2.73 4.99 2.89 1.64 1.64 13.89 C. SICHUAN 1. Basic Health Care Delivery 26.78 58.54 21.58 8.51 8.51 123.91 3.08 6.73 2.48 0.98 0.98 14.24 2. Health Workers' Training 9.39 16.69 14.76 9.95 9.95 60.74 1.08 1.92 1.70 1.14 1.14 6.98 3. Management Improvement 9.88 20.35 17.38 8.38 8.38 64.37 1.14 2.34 2.00 0.96 0.96 7.40 Subtotal SICHUAN 46.05 95.57 53.72 26.84 26.84 249.02 5.29 10.99 6.17 3.09 3.09 28.62 D. YUNNAN ON 1. Basic Health Care Delivery 14.63 28.49 10.40 4.99 4.99 63.50 1.68 3.27 1.20 0.57 0.57 7.30 2. Health Workers' Training 3.43 6.05 5.24 3.42 3.42 21.55 0.39 0.69 0.60 0.39 0.39 2.48 3. Management Improvement 6.74 12.94 10.64 5.16 5.16 40.63 0.77 1.49 1.22 0.59 0.59 4.67 Subtotal YUNNAN 24.79 47.48 26.28 13.56 13.56 125.68 2.85 5.46 3.02 1.56 1.56 14.45 E. NATIONAL LEVEL 1. Basic Health Care Delivery 0.45 0.45 0.45 0.45 0.45 2.23 0.05 0.05 0.05 0.05 0.05 0.26 2. Health Workers' Training 0.77 1.00 1.00 1.00 1.00 4.78 0.09 0.12 0.12 0.12 0.12 0.55 3. Management Improvement 1.08 1.49 1.36 1.02 1.02 5.95 0.12 0.17 0.16 0.12 0.12 0.68 Subtotal NATIONAL LEVEL 2.30 2.93 2.81 2.46 2.46 12.97 0.26 0.34 0.32 0.28 0.28 1.49 TotalBASELINE COSTS 114.27 221.25 127.13 68.75 68.75 600.15 13.13 25.43 14.61 7.90 7.90 68.98 Physical Contingencies 5.71 11.06 6.36 3.44 3.44 30.01 0.66 1.27 0.73 0.40 0.40 3.45 Prce Contingencies 7.33 32.18 32.83 26.03 32.69 131.06 0.84 3.70 3.77 2.99 3.76 15.06 TotalPROJECT COSTS 127.31 264.50 166.32 98.22 104.88 761.22 14.63 30.40 19.12 11.29 12.06 87.50
Taxes ForeignExchange 19.52 78.07 20.43 1.51 1.56 121.10 2.24 8.97 2.35 0.17 0.18 13.92
Note: Thefinal estimratesof costsin the firt four-provinces,namely, Guangxi, Shaanxi, Sichuan, Yunnan and National level . Table A9.6: PROJECT COMPONENTS BY YEAR-TENTATIVE ESTMAES FOR THE SECOND BATCH PROVINCES
BaseCost (RMB Million) Base Cost (USS Million) 1994 1995 1996 1997 1998 Total 1994 1995 1996 1997 1998 Total A. GANSU 1. BasicHealth Care Delivery 10.10 24.00 7.75 3.41 3.41 48.66 1.16 2.76 0.89 0.39 0.39 5.59 2. HealthWorkers' Training 2.10 3.87 3.45 2.58 2.58 14.57 0.24 0.44 0.40 0.30 0.30 1.67 3. ManagementImprovement 4.29 6.47 5.15 3.47 3.47 22.85 0.49 0.74 0.59 0.40 0.40 2.63 SubtotalGANSU 16.49 34.33 16.34 9.46 9.46 86.08 1.89 3.95 1.88 1.09 1.09 9.89 B.QINGHAI 1. Basic Health Care Delivery 5.39 10.40 3.74 1.25 1.25 22.03 0.62 1.20 0.43 0.14 0.14 2.53 2. HealthWorkers' Training 1.40 2.41 2.09 1.33 1.33 8.57 0.16 0.28 0.24 0.15 0.15 0.98 3. ManagementImprovement 1.84 4.48 3.91 1.51 1.51 13.25 0.21 0.52 0.45 0.17 0.17 1.52 Subtotal QINGHAI 8.63 17.29 9.74 4.09 4.09 43.85 0.99 1.99 1.12 0.47 0.47 5.04 C. JIANGXI 1. Basic Health Care Delivery 13.19 27.83 9.44 4.30 4.30 59.07 1.52 3.20 1.09 0.49 0.49 6.79 2. HealthWorkers' Training 2.97 5.45 4.93 3.80 3.80 20.95 0.34 0.63 0.57 0.44 0.44 2.41 3. ManagementImprovement 5.42 9.70 8.10 4.36 4.36 31.94 0.62 1.11 0.93 0.50 0.50 3.67 Subtotal JIANGXI 21.58 42.97 22.48 12.46 12.46 111.95 2.48 4.94 2.58 1.43 1.43 12.87 D. NEI MONGOL 1. Basic Health Care Delivery 12.51 27.43 9.39 4.21 4.21 57.76 1.44 3.15 1.08 0.48 0.48 6.64 2. HealthWorkers' Training 3.24 5.67 4.99 3.35 3.35 20.61 0.37 0.65 0.57 0.39 0.39 2.37 3. Management Improvement 5.25 10.28 8.71 4.25 4.25 32.74 0.60 1.18 1.00 0.49 0.49 3.76 Subtotal NEI MONGOL 21.00 43.39 23.08 11.82 11.82 111.11 2.41 4.99 2.65 1.36 1.36 12.77 Total BASEUNE COSTS 67.70 137.99 71.64 37.83 37.83 352.99 7.78 15.86 8.23 4.35 4.35 40.57 Physical Contingencies 3.39 6.90 3.58 1.89 1.89 17.65 0.39 0.79 0.41 0.22 0.22 2.03 PriceContingencies 4.42 19.24 18.40 14.34 18.02 74.42 0.51 2.21 2.12 1.65 2.07 8.55 Total PROJECTCOSTS 75.50 164.12 93.63 54.06 57.73 445.05 8.68 18.86 10.76 6.21 6.64 51.16
Taxes ForeignExchange 11.99 55.88 12.55 0.74 0.77 81.93 1.38 6.42 1.44 0.09 0.09 9.42
Note:Preliminary estimates of costsin the secondbatch provinces, namely, Gansu, Jiangxi, Nei Mongol, and Qinghai. These costs are subject to be reviewedand approved by the Association. PROJECT ORGANIZATIONAL CHART
PROJECT LEADING GROUP Chair: Minister of Public Health - Central Degartments and Offices: MCHH Maternal I and Child Health MAD MedicalM Administration MCHD MAD DCD MSED EDD ClIS | DCD a Disease Control MSED a Med. Science & Education EDD * Endemic Disease CHIS a Center of Health Info. & Statistics Coordination FLO - Foreign Loan Office
OVINCIAL LEADING GROUP
Provincial Bureaus: Planning Finance Heal t MCH - MernalteFa Child Health 00 Bureau MA - Medical Administration MSE - Medical Science and Education ED - Endemic Disease FLO - Foreign Loan Office PPO - Project Office MCH MA DC MSE ED FLO PPO TAG - Technical Advisory Group
CONT I-P IN | GROUP
[ " ' | ~~~~~~Bureau
P.0 PROJECT IMPLEMENTATION SCHEDULE
Calendar Year 1994 1995 1996 1997 1998 1999 2000 200 Bank Fiscal Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 Quarter 1st 2nd3 3rd 4th 1st 3rd Indst 2nd 3rd 14th4th 1st 2nd 33d 1st 2nd d4th4 tdd 3rd 14th ls 2nd 3rd 4th 1st 2nd 3rd 4th
Design, Contracting & Construction * * * * * *_ __ _ =-______Warranty PeriodI_ _. Etuipment 8 Vehicles= _ | r======_==== Preparation of Bidding Documents Invitation for Bids Contract Awards & Delivery Warranty Period lllll|1e a[hnmiAssistance I IL I__=_======SpecialistServices 7 _ i 7 7 7 - 1 - - - - __ Operation Research 1 Loan Process'a & Gen. Admin. Negotiations X Board Approval x Credit Signing X Effectiveness X Retroactive Financing Announcement of GPN X Mid-Term Review X Phase 11Commences Audit Reports due Dates X I rx x X Project Completion x x Credit Closing I X Project Completion Report - 70 - ANNEX 12
ESTIMATED CREDIT DISBURSEMENT SCHEDULE
Bank Semester Amount ($ million) Cumulative Disbursement FY Absolute Cumulative as % of Total Profile China La
1995 1 4.00 4.00 4 3 2 7.97 11.97 13 14
1996 1 12.63 24.60 27 38 2 15.63 40.23 45 50
1997 1 11.53 51.76 58 66 2 9.23 60.99 68 70
1998 1 7.30 68.29 76 78 2 6.22 74.51 83 86
1999 1 6.48 80.99 90 86 2 9.01 90.00 97 94
2000 1 - - 100 94 2 - - - 96
2001 1 - - 98 2 - - 100
La StandardDisbursement Profile for human resource sector project in China. & Initial deposit in Special Account and Retroactive Financing. - 71- ANNEX 13
PROJECT PERFORMANCE INDICATORS
1. The indicators selected for monitoringand evaluation are intended to help health managers to focus on actions that will be effective in meeting the MCH program's objectives, to assess progress in implementationand identify problem areas in a timely manner, so that corrections and adjustmentscan be planned. The indicatorsalso provide informationnecessary for the Associationto monitor progress in project implementation and evaluate the impact of the investment in relation to the project's development objectives.
2. Three sets of indicators will be used to monitor the implementationof this project: input indicators, process/outputindicators, and outcome indicators. The data will be collected through current reporting mechanisms,modified if necessary, and from some additional periodic surveys and studies. Detailed arrangementsfor collection, processing and reporting of the selected indicators will be decided at the Project Launch Workshop (see Annex 15).
3. Input indicators will track planned resource inputs such as fund disbursement, technical assistance (staff-months),enrollment and time (staff-months)in training programs and procurement of goods and civil works.
4. Process/outputindicators will enable the program managers and the Bank to assess annually the activity and utilizationpatterns under the three project components. Eight indicatorswill be tracked to assess the Basic Health Care Delivery and Management components:
(a) antenatal and postnatal contact rates;
(b) "new method" delivery rate;
(c) home delivery/hospitaldelivery ratio;
(d) incidence of low birth weight (collectedthrough surveillancepoints);
(e) coverage of tetanus toxoid immunization(for women of childbearingage or pregnant women);
(f) coverage of Immunizations(EPI), tetanus, polio;
(g) breast-feedingrate at four months; and - 72 - ANNEX 13
(h) number of supervision visits from county to township, township to village, compared with target.
5. Eight indicators will also be tracked under the Health Workers' Training Component, four for short courses and four for longer-term training:
Short Courses
(a) number of trained trainers available compared with target;
(b) number of training courses held compared with target;
(c) number trained compared with target; and
(d) number (percent) of trained staff with satisfactory case management observed during field assessment by supervisor six months after training.
Longer-termTraining
(e) number of designated clinical training bases meeting agreed criteria (compared with target for the year and cumulative);
(f) numberscompleting training to a satisfactorystandard compared with target;
(g) number (percent) of facilities with enough clinically trained staff compared with target; and
(h) number (percent) of trained staff with satisfactory case management observed during field assessmentby supervisor six months after training.
6. Outcome indicators will track change in health status of mothers and children, improvements in which constitute the overall development objectives of the project. The indicatorsselected are consideredto be sensitiveto the project interventions (although also affected by other influences) and will be available through routine informationsystems or special surveys:
(a) infant mortality rate (IMR),
(b) maternal mortality rate (MMR),
(c) under 5-mortalityrates (U5MR),
(d) neonatal tetanus mortality rate (NTMR), and
(e) neonatal mortality rate (NMR). - 73 - ANNEX 13
7. The following tables give the proposed format for the summary collection of indicator values. These, along with the formats for collecting data before this level of collation, will be finalizedat the Project Launch Workshop.
Table A13.1: PRocEss/OuTpuT INDICATORS By County and Province By Year To be collected annually County Antenatal Postnatal Tetanus New Home/hospital name visit rate visit rate toxoid delivery delivery rate l______(3x) coverage rate
Table A13.2: PROcESs/OUTcoMEINDICATORS By County and Province By Year To be collected annually County name Immunization Breast-feeding % Low birth weight coverage at 4 months
Table A13.3: PROCESSINDICATOR-NUMER OF SUPERVSON VISTS To be collected annually County Province to county County to township Township to village name Planned Actual Planned Actual Planned Actual -74- ANNEX 13
Table A13.4: PROCESS INDICATORS-SHORT-COURSETRAiNNG To be collected annually County name Trained trainers available Training courses held Planned Actual Planned Actual
Provincial
T otal ______Project Total
Table A13.5: PROCESS INDICATORS - SHORT CoURSE TRAINING To be collected annually Number of Staff with satisfactory case management County Number of health workers trained after training name Planned Actual (Sample Survey)
Province Total Project Toa - 75 - ANNEX-13
Table A13.6: PROCESS INDICATORS-LONGER-TERM TRAINING To be collected annually
Number of staff trained to County Number of clinical training bases satisf. standard name Planned Actual Planned Actual
Province Total
Project |Total
Table A13.7: PROCESSINDICATORS-LONGER-TERM TRAINING To be collected annually
Number of trained staff Number of facilities with with satisf. case County name enough trained staff management Planned Actual Planned Actual
Province Total Project Total - 76 - ANNEX 13
Table A13.8: OUTCOMEINDICATORS-HEALTH STATUS To be collected annually by routine reports or special studies Province IMR MR U5MR NTMR Neonatal MR
Guangxi counties
Shaanxi counties l Sichuan counties Yunnan counties Gansu counties
Jiangxi counties
Nei Mongol counties Qinghai counties - 77 - ANNEX 14
TECHNICAL ASSISTANCE AND OVERSEAS STUDIES
Introduction
1. International technical assistance and overseas studies will be provided to expose the MOPH departments and project provinces to good modem practice in (a) matemal and child care and (b) MCH service managementincluding the optimum training of appropriate personnel.
2. Consultantsand institutions will be sought experiencedin developmentof MCH program in developing countries which have similar maternal and child care problems to those of China. They may be able to maintain contact in the future for the benefit of sustainingthe improvementsexpected to be brought about by the project.
PrincipalTechnical Assistance Needs
3. The provinces have strongly identified four areas in which international assistancewill be required, namely, (a) safe motherhoodinitiatives; (b) modern programs for care of well and sick children; (c) MCH program management;and (d) the training and performanceevaluation of health staff responsiblefor care of pregnantwomen and children age 0-4 year. Other areas including MCH related health education, management informationsystems, perinatal medicines, and health financing for benefit of the poorer families have also been identified as important internationalTA needs.
InternationalTechnical Assistance Inputs 4. InternationalTechnical Assistance. The project will require 28 person- week of internationalconsultant service for the central component and 20 weeks for the provinces.
5. Study Tours. Study tours including at least one delegate from each province and one from the Center, with an interpreter if necessary. The subject areas will be those identified in para. 3. Each study tour should be of 3 or 4 weeks duration and the countries to be visited should include both developedand developingcountries of special interest or acknowledgedcapability.
6. Overseas Training/Fellowships. About 30 study fellowships of varying durationhave been requested, six for the Center and the remainder for the provinces. The subject of study cover a wide field and it will be important to spread the experience and knowledge gained as orderly as possible throughout the project provinces by means of presentation at technical meetings, in-servicetraining programs, conferences, publication of reports and direct technical assistance by the returned student to those who may need it. - 78 - ANNEX 14
Table A14.1: INTERNATIONALTECHNICAL ASsIsrANcE (Phase I)
Duration Timing Area Terms of reference (p-w) year
Central
Training 1. Assist design of Clinical Protocols 4 Mar. 1994 2. Assist development of training materials 7 1994 1995
Special 1. Assist design of KAP studies, analyses 12 2/year studies and interpretation of results
Operational 1. Integration of functions of county MCH 5 1 in 1994 research stations and hospital obstetric and paedia- tric function; assist with research design, 2 in 1995 outcome analyses and interpretation 2 in 1996
Province
Management 1. Review provincial MCH management and 2 1995 assist system reform to promote improved 2 1996 resource allocation 2. Assist managers to improve use of MCH 4 1995 MIS in planning 3. Design of special surveys 2 1994 4. Advise on resource mobilization for the 2 1995 poor essential services based on true costs
1. Review outcomes of project training on 4 1996 knowledge, skills, and practice
1. Review health education program and 40 1996 assist with formulation of evaluation methods and indicators
T2 48 - 79 - ANNEX 14
Table A14.2: OVERSEASFELOWSHPS
Duration Timing Area Terms of reference (p-w) year
Cental MCH ser- 1. Study MCH service planning and manage- 6 Per- 1 each vice manage- ment, MIS utilization and financial man- sons year of ment agement project 24 weeks each
Guangxi MCH man- 1. Safe motherhoodinitiatives and high-risk 4 1995 agement obstetric managementmethods 4 1997 2. Child growth and developmentcommun- 4 1995 ity-based programs 4 1997 Training 1. Modern MCH-trainingmethods and pro- 4 1996 grams Management 1. Overseas MCH managementmodels 4 1996 Shaanxi MCH man- 1. Overseas systems of MCH managementLa 36 1998 agement 2. Study internationalmethods of prevention 24 1997 and managementof anemia in pregnancy
Perinatal 1. Organizationof emergency rescue system 36 1995 care in obstetric care Lg Neonatal 1. Modern methods treatmentin neonatal 24 1996 care emergencies
Sichuan Management 1. Overseas MCH managementsystems 12 1995 2. Resource allocationand cost benefit anal- 12 1995 ysis in MCH programs 3. MIS in MCH programs, analysis, inter- 12 1996 pretation, utilization 4. Survey design and implementation,analy- 12 1996 sis and utilization of data .... continued - 80- ANNEX 14
Table A14.2: OVERSEASFELLOWSEIPS (cont'd)
Duration Timing Area Terms of reference (p-w) year
Perinatal 1. Managementof high risk pregnancy 12 1996 care
Child care 1. Overseas community-basedchild care 12 1996 program
Yunnan
Perinatal 1. Perinatal epidemiologyand commun- 24 1996 care ity-based problem management
Child care 1. Prevention and treatment of child 12 1995 nutritional problems age 0-4
Health edu- 1. Modem health education methods in 12 1997 cation MCH programs
MCH man- 1. Overseas methods of MCH manage- 12 1996 agement ment
IQIt 420
La This fellowship may be too long and could be used for two staff. Lb This could be done as part of a more comprehensive study of nutritional problems of MCH of shorter duration. Lb Probably too long as an observationvisit unless a formal course is available. The duration specified would allow two fellowships.
Overseas Study Tours
7. The needs of most topic areas mentionedby the provinces and the national- level component are satisfied by the following four study tours (one per year from 1995 to 1998):
(a) Safe motherhood initiatives in countries which can demonstrate programs relevant to China;
(b) MCH program managementin rural areas including care of the poor; - 81- ANNEX 14
(c) Community-basedchild care programs in rural areas; and
(d) Modem MCH training programs for health providers at rural and semi- urban levels includingevaluation methods.
8. While excellentapproaches may be found in the USA, Europe, and other developed countries, it will be important to include developing countries which have successfully addressedMCH needs similar to those in the project. Each study tour should be three to four weeks in duration and should comprise at least one delegate from each province and one from the center. - 82 - ANNE 15
PROPOSED PROJECT SUPERVISION PLAN
Proposed Staff date Input Activities Expected sill requirement (SW)
Nov/Dec. Project Launch Workshop I 6 1994
Review of project implementation plan, prep- Economist, Public Health Special- aration for health workers' training, retroac- ist, Procurement Specialist tive financing work, project organization, procurement, financial management and reporting requirements
April 1995 Suvervision Mission 6
Review progress procurement, financial man- Economist, Public Health Special- agement, program activities, training, poverty ist, Procurement Specialist, Finan- relief fund, operation research, and technical cial Analyst, Health Management assistance. Expert Review progress on procurement, financial management, training, poverty relief.
Sept. 1995 Supervision Mission 8
Review of project progress: procurement, Economist, Public Health Spec., fmancial management, training, program Health Management Expert activities, and operation research
Mar. 1996 Supervision Mission 8
Review of progress: procurement, financial Economist, Public Health Spec., management, training, program activities, and Health Management Expert implementation plans based on the results of operation research studies
Sept. 1996 Supervision Mission 18
Review of project progress: financial manage- Economist, Public Health Special- ment, program activities, poverty alleviation, ist, Health Management Expert and health management reformed based on operation research recommendations and plans for the mid-term evaluation review.
1997-2000 Supervision Mission: Minimum of two per Economist, Public Health Special- 8 year and last mission to discuss with Bor- ist rower the preparation of PCR - 83 - ANNEX 16
PROJECT PREPARATION AND APPRAISAL IN ADDITIONAL PROVINCES
Introduction
1. This project was designedto be prepared and appraisedin stages for greater flexibilityand manageabilityas well as to develop local capacity to prepare and appraise good quality projects. Therefore, it was decided that the project would be prepared and appraised in a total of eight provinces, divided into two phases of four provinces each. The first phase covered four provinces, namely, Guangxi,Shaanxi, Sichuan, and Yunnan; and the secondphase is expectedto cover another four provinces, namely, Gansu, Jiangxi, Nei Mongol, and Qinghai. The preparationand appraisal of the programs in the first four provinces were closely supervisedby the Bank staff. The programs in the remaining four provinces are being prepared and appraised by MOPH, closely following the experience of the first phase. The role of the Bank staff in the secondphase would be to review and approve the project proposals to ensure project quality and offer technical assistance to MOPH whenever necessary.
2. The size of the first phase program is roughly two thirds of the total project and is expectedto use roughly two thirds of the IDA credit, leaving about one third for the remainingfour provinces. MOPH expects to start the project implementationin the four second phase provinces approximatelysix months behind the first four provinces. The purpose of this annex is to outline the proceduresexpected to be followedin carrying out the project preparation and appraisal after the first phase.
Project PreparationProcess and Agreed Conditions
3. The project preparation steps and conditionsare as follows:
Step A: Selection of Provinces and Counties. The final four provinces-Gansu, Jiangxi, Nei Mongol,and Qinghai-were selected under the same principles and criteria as applied for the first four. They were selected from among those with the highest maternal mortality rates (MMRs), the highest infant mortality rates (IMRs), and the lowest per capita income. The list of counties is shown in Table A16.1 below.
Step B: Baseline Survey. A baseline survey in all project counties were conducted following the experience of the first phase provinces but with shorter and more relevant questionnairesagreed with the Bank. - 84 - ANNEX 16
Step C: First Workshops. In order to familiarize the second phase project provinces with the general design and procedures for project preparation, representativesof all four provinces attended both the pre-appraisal and appraisal meetingsbetween the Bank, MOPH and first phase provinces in November 1993 and March 1994 respectively,and discussed project procedures with the MOPH.
Step D: ProvincialFeasibility Plans. In February, 1994 the second phase provinces submitted indicative plans to the MOPH with plans and project costs per county, local government commitment and availabilityof counterpart funds.
Step E: CountyMagistrates' Workshops. Workshopswere held in each of the secondphase provinces with representativesof the MOPH (FLO and line departments) (April-May 1994). The workshops:
(a) reviewed the national policy and commitments;
(b) introduced the objectives, conceptual framework, and procedures for preparation and implementation of the proposed project;
(c) provided specific guidelines for county and prefecture/provincialproposal preparation based on phase one materials;
(d) providedguidelines for calculationand presentationof county and prefectural/provincialcost tables and;
(e) invitedprovinces and countiesto suggest modificationsin the project design based on their local situations.
Step F: County and Provincial Proposal Preparation. Each province will have collected a project proposal from each individual county, review the proposals for their consistency with the project guidelines,add prefecturaland provincial components(not to exceed 10 percent of total base costs), determine the first year's detailed annual plan for the project and submit the unified proposals to the FLO/MOPH.
Step G: Review and Field-Check of Provincial and County Proposals (September-November1994). MOPH will have thoroughlyreviewed each provincialproposal, visitingeach province (includinga number of countiesas required). MOPH will have also made random review and evaluation of the counties' proposals to make sure that the planned activitiesare within the parametersand guidelinesagreed in - 85 - ANNEX 16
the first phase preparation. Most important, that the planned activities will have been checkedto ensure their consistencywith the resources and the project objectives. MOPH will have provided the detailed feedbacks to the provinces to revise the proposals before appraisal. Any province with severe problems will have to delay appraisal and the start of its implementationuntil they are corrected.
Step H: World Bank's Review of the Staff Appraisal Report prepared by MOPH following the agreed guidelines and procedures (expected November/December1994). - 86- ANNEX 16
PROJECTCOUNTS IN THE FIRST BATCH OF PROVINCES
GUANGXI SHAANXI SICHUAN YUNNAN Xiang Zhou Yang Xian Jin Tang Shi Mian Ludian Sang Jiang Xi Xiang Tong Nan Tian Quan Yongshan Xin Cheng Mian Xian Rong Xian Lu Shan Suijiang Jin Xiu Zhen Ba Yan Bian Aba Yiliang Guan Yuan Lue Yang Mi Yi Gan Zi Xianwai Long Sheng An Kang Xu Yong Mian Ning Fuyuan Zi Yuan Xun Yang Gu Lin Xi De Luoping Luo Cheng Zi Yang Mian Zhu Yan Yuan Huize Da Hua Ping Li Cang Xi Ning Nan Nanhua Hua Jiang Lan Gao Jian Ge Gan Luo Dayao Ba Ma Shang Zhou Wang Cang Wuding Fong Shan Luo Nan Peng Xi Lufeng Tian E Zhen An Zi Yang Kaiyuan Dong Lan Shang Nan An Yue Mengzi Lu Chuang Wei Nan Long Chang Mile Pin Nan Fu Ping Wu Tong Qiao Yuanyang De Bao Pu Cheng Qian Wei Wenshan Na Po He Yang Mu Chuan Maguan Jing Xi Han Cheng Jing Yan Qiubei Long Lin Lan Tian Cheng Kou Puer Lin Yu Qian Xian Yun Yang Jingdong Le Ye Li Quan Feng Jie Zhenyuan Xi Lin Bin Xian Xi Chong Jinghong He Xian Chun Hua Wu Long Menghai Teng Xian Yong Shou Fu Ling Bingchuan Meng Shan Yao Xian Qian Jiang Nanjian Tian Deng Yan Chuan Xiu Shan Yunlong Long Zhou Yan Chang You Yang Heqing Shang Si Wu Qi Shi Zhu Baoshan Pu Bei Zhi Dan Yi Bin Tengchong Huang Ling Chang Ning Longling Sui De Jun Lian Luxi Shen Mu Jian Gan Lianghe Heng Shan Lin Shui Huaping Jing Bian Yue Chi Ninglang Wu Sheng Lushui Xuan Han Zongdian Da Xian Yunxian Wan Yuan Yongde Ba Zhong Zhenkang - 87- ANNEX 16
Table A16.1: LIST OF PROJECT PROVINCES AND COUNTIES
Second Phase Counties
Prefectures Counties Prefectures Counties
GANSU NEI MONGOL
Lanzhou Honggu, Gaolan Hulunbeier Elunchun, Eergunazuo, Ewenke, Jinchang Yongchang Zhalantun Bayin Jingyuan, Jingtai Xingan Tuquan Tianshui Qingchen, Taian, Wushan Zhelimu Huolinhe, Kezuozhong, Kailu, Zhangyie Mingle, Lingze, Gaotai Kulun Wuwei Wuwei, Gulang Chifeng Balinyou, Wengniute, Aohan, Gannan Zhuoni, Zhouqu Kalaqin Dingxi Zhang, Longxi Xilinquole Abaga, Sunitezuo, Suniteyou, Longnan Cheng, Wen, Li Zhengxiangbai, Zhenglan, Pingliang Pingliang, Jingchuan, Zhuanglang, Duolun, Taipusi Jingning Wulanchabu Chayouzhong, Xinghe, Qingyang Xifeng, Qingyang, Heshui, Chayouqian, Liangcheng, Zhengning Fengzhen, Helin, Qingshuihe Linxia Linxia, Yongjing, Hezheng Baotou Jiaoqu, Tumeteyou Yikezhao Hangjin, Dongsheng, Etuoke, JIANGXI Etuokeqian Bayannaoer Wulatehou, Wuyuan, Hangjinhuo, Nanchang Xinjian Linhe, Wulateqian, Dengkou Jindezhen Changjiang, Fuliang Wuhai Haibowanqu Xinyu Fenyi Alashan Ayou, Ejina Yingtan Guixi Ganzhou Gan, Nankang, Anyuan, Dingnan, QINGHAI Ningdu, Huichang, Xunwu Yichun Fengcheng, Fengxin, Tonggu Xining Datong Shangrao Guangfeng, Yanshan, Hengfeng, Haidong Minhe, Huangzhong, Huangyuan Wannian, Wuyuan Haibei Menyuan, Qilian, Haiyan, Gangca Jian Jian, Jishui, Yongfeng, Suichuan, Hainan Gonghe, Tongde, Guide, Xinghai, Yongxing Guinan Pingxiang Lianhua, Shangli Guoluo Maqin, Banma, Gande, Dari, Fuzhou Chongren, Lean, Yihuang, Jiuzhi, Maduo Dongxiang Yushu Zaduo, Zhiduo, Qumalai Haixi Delingha
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