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Completed World-Bank Assisted Operations

The First Population Project (1972-80) was financed by an IDA credit of US$21.2 million and a grant from the Swedish International Development Authority. The project supported the Family Welfare Program in five districts in the state of Karnataka and six districts in the state of Uttar Pradesh. The project was essentially an experimental demonstration project intended to test the efficacy of various program activities, and to develop ways for attaining better performance of the national program.

The project experience indicated ways subsequent World Bank support of the Family Welfare Program could be improved, and was the foundation for the government's subsequent accelerated program of family planning and maternal and child health. Also, the two population centers established under this project have carried out a variety of research.

The Second Population Project (1980-88) was supported by an IDA credit of US$46 million. The project assisted the Family Welfare Program in six districts of eastern Uttar Pradesh and three districts in the state of Andhra Pradesh. The project was part of a government effort to obtain external assistance to strengthen the Family Welfare Program in underprivileged districts of selected states.

The project gave further support for the integration of family planning and mother and child health care services, emphasized the importance of generating demand for services and, as in all subsequent projects, stressed the increased use of temporary contraceptive methods and gave substantial support for the construction of basic health facilities. An estimated 22.7 million women and children benefited from strengthened family welfare services provided under the project.

The Third Population Project (1984-91) was financed by an IDA credit of US$70 million. It too was implemented in underprivileged districts-six districts of northern Karnataka and four districts of the state of Kerala.

Project impact was particularly notable in Kerala, where project support helped bring program implementation in the underprivileged project districts up to the much higher standard already achieved in the rest of the state. In Kerala project districts, contraceptive use has increased and, on average, immunization of children has risen from about 28 percent to about 78 percent. Overall, approximately 18 million women and children in the 10 project districts were reached by the project-assisted family welfare program.

The Fourth Population Project (1986-94) was supported by an IDA credit of US$51 million and was implemented in West Bengal . In the four districts where facility construction was supported by the project, program implementation benefited more than 12 million women and children. The project emphasized maternal and child health. A comparison of fertility, mortality, and infant mortality rates between the pre-project year of 1984 and 1992 indicates substantial progress in these three vital indicators.

During the course of the project, the birth rate in West Bengal declined from 30.4 to 24.6 per 1,000, the death rate from 10.7 to 8.3 per 1,000, and the infant mortality rate from 82 to 64 per 1,000 live births. There was also very good progress in the share of couples using modern contraception, which improved from 33 to 52 percent. State-wide support for program management information, communications, and training components had a positive effect on the implementation and impact of West Bengal 's family welfare program in general.

The Fifth Population Project (1988-96), financed by an IDA credit of US$57 million, supported the National Family Welfare Program in the municipalities of Bombay and Madras , and was extended to other urban areas in the states of Maharashtra and Tamil Nadu. The main goal was to improve the service delivery and outreach systems of family welfare services in urban slums. Innovative features included support for involvement of non-governmental organizations (NGOs) and private medical practitioners in carrying out the Family Welfare Program. The project met its service delivery objectives and benefited some 2.5 million poor women and children in slum areas.

The Child Survival and Safe Motherhood Project (1991-96), financed by an IDA credit of US$214.5 million, supported the enhancement and expansion of the Maternal and Child Health (MCH) component of the National Family Welfare Program. It was national in scope, with emphasis on districts where maternal and infant mortality rates were higher than the national average.

The project's specific objectives were to enhance child survival, reduce maternal mortality and morbidity rates, and increase the effectiveness of service delivery by supporting:

    • child survival programs including the Universal Immunization Program, diarrhea control programs, and the control of acute respiratory infections;
    • a Safe Motherhood Initiative to improve ante-natal and delivery care for all pregnant women and to identify high-risk pregnancies; and
    • institutional systems development, including improving and expanding training programs for family welfare workers, education and communication, and management information.

More than 42 million women and children benefited annually from the services provided.

The Fifth ( Bombay and Madras ) Population Project will support the Government's goal of improving the availability and quality of family welfare services to poor urban families. In order to achieve this goal the project comprises several components; a service delivery expansion component comprising the construction, furnishing, equipping and staffing of new health posts (HP), and the rehabilitation/extension of existing facilities to create new HPs; and a training component to improve the quality of service provided by family welfare workers in both cities. To improve management of the family welfare program; a central coordinating office in the Bombay Public Health Department and three family health bureaux are to be created; and, in Tamil Nadu by strengthening the State and Madras city family welfare bureaux. A final component is to increase the involvement of private voluntary organizations and private medical practitioners in the family welfare program.
Ongoing World Bank-Assisted Operations

The Sixth Population Project, approved in 1989, provides assistance through an IDA credit of US$124.6 million. The project supports improvements in the efficiency and effectiveness of the delivery of family welfare services in the rural areas of the states of Andhra Pradesh, Madhya Pradesh, and Uttar Pradesh. The project has established a well-regarded and systematic program of in-service training and a training culture focused on improving performance of workers and an increased awareness of how to monitor and improve the quality and effectiveness of training.

Three state institutes of health and family welfare, 18 regional training centers, 91 district centers/teams, and 23 field practice demonstration areas have been established and are conducting regular in-service training; 23 basic auxiliary nurse midwife (ANM) training schools have also been strengthened. In addition, 1,620 sub-centers with ANM residence have been constructed, equipment and furniture have been provided to sub-centers, and primary health centers and delivery kits have been provided to traditional birth attendants.

Overall, it is estimated that up to 40 million rural households in the three project states are benefiting from program improvements achieved with project support.

The Seventh Population Project, which supports the National Family Welfare Program in the states of Bihar, Gujarat, Haryana, Jammu & Kashmir, and Punjab , through an IDA credit of US$81.6 million, was approved in 1990. This project, which also has a special training focus, is similar to the Sixth Population Project. At least 22 million families in the rural areas of the project states will ultimately benefit from project-assisted improvements in the quality and coverage of program services.

Since the project began in 1991, rates of sterilization and use of IUDs, oral pills, and conventional contraceptives have been steadily rising. Systematic and regular in-service training for family welfare workers has also been established.

The Eighth Population Project, financed through an IDA credit of US$79 million, became effective in March 1992. The project supports the improvement of family welfare services in the slum areas of Bangalore , Calcutta , Delhi , and Hyderabad . It focuses on the reduction of fertility as well as maternal and infant mortality rates among people living in urban slums by improving the outreach of family welfare services, upgrading the quality of family welfare services, expanding the demand for health services through expanded information, education and communication activities, and improving the administration and management of municipal health departments.

The Ninth Population Project, which became effective in September 1994, is being implemented in three states- Assam , Karnataka, and Rajasthan-and is financed through an IDA credit of US$88.6 million. The project supports improved access to, demand for, and quality of family welfare services, particularly among poor, remote, and tribal peoples.

The project aims to:

    • strengthen family welfare service delivery, including establishment of first-referral units;
    • improve the quality of family welfare service;
    • strengthen demand-generation activities through improved information, education, and communications planning and activities;
    • strengthen program management and implementation capacity; and
    • provide funds for innovative schemes to improve service delivery.

Future Operations

on a major analysis done collaboratively by the World Bank and Government of India , and recent India n program developments, the India n government is preparing a Reproductive and Child Health (RCH) Project, which would support the National Family Welfare Program in improving the health status of women and children, especially the poor and underserved. An essential package of reproductive and child health services is integral to the project approach.

The project would include two major components:

    • a nation-wide policy reform package, covering monitoring and evaluation, institutional strengthening, and service delivery; and
    • a local capacity enhancement component that would fund district and city sub-projects aimed at meeting specific needs of local priority groups.
The project is expected to be approved in mid-1997, and would be financed with an IDA credit of about US$248 million.

Research and Analysis
Two major studies, Improving Women's Health in India (1996) and India 's Family Welfare Program: Moving to a Reproductive and Child Health Approach (1995), provide background for the Bank Group's discussions with the India n government on further developing public, voluntary, and private sector capacity to address needs of the Family Welfare Program and health problems of India 's women. The former was published as part of the Bank's Directions in Development series and the latter was published as part of the Bank's Development in Practice series.

Both studies build on an earlier study entitled Family Welfare Strategy in India : Changing the Signals (1990). Taken together, these studies provide support for the important steps the government has taken in moving away from a target-driven, demographic approach emphasizing female sterilization, toward a client-centered approach that helps people meet their broader health and family planning goals.

Improving Women's Health in India provides a comprehensive overview both of women's health issues and the government's programs to improve them. Despite considerable progress, the report argues that India still has a large, unfinished agenda in the areas of reproductive and child health. The report emphasizes women's reproductive health and the factors underlying excess female mortality at early ages, especially in the northern "Hindi belt" states of Bihar , Rajasthan, Madhya Pradesh, and Uttar Pradesh. These states account for almost 40 percent of India 's population and exhibit well-documented unfavorable demographic trends compared with the rest of India .

The book also points out the needs of women in rural areas where mortality levels are substantially higher than in urban areas and access to care is limited. Its focus is on the measures necessary to address existing policy and implementation constraints and improve the quality, acceptability, and use of services essential to women's health. Further progress and more resources are needed.

In 1994, the Cairo Conference formalized a growing international consensus that improving reproductive health, including family planning, is essential to human welfare: reducing unwanted pregnancies safely and providing high-quality health services both satisfies the needs of individuals and stabilizes the population.

This perspective, strongly supported by the Government of India in its Program of Action in the India Country Report prepared for the Cairo Conference, led to a major piece of collaborative analytical work with the World Bank Group entitled India 's Family Welfare Program: Moving to a Reproductive and Child Health Approach. The report identifies the major constraints on India 's Family Welfare Program and recommends ways in which these constraints might be overcome. In addition, it discusses an "Essential Reproductive Health Package" designed to provide a cluster of recommended reproductive health services directed primarily at the needs of actual and potential patients. The Reproductive and Child Health Project was based partly on this work.


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