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World Bank Document 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
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