Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No 10812-NEP

STAFF APPRAISAL REPORT

NEPAL

POPULATION AND FAMILY HEALTH PROJECT

MARCH 18, 1994

Population and Human Resources DivisionCountry Department ISouth Asia Region

This document has a restricted distribution and may be used by recipients only in the performance oftheir official duties. Its contents may not otherwise be disclosed without i' orld Bank authorization.

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CURRENCY EOUIVALENTS(October 1993)

US$1.00 = NRs. 49.00

PRINCIPAL ABBREVIATIONS AND ACRONYMS USED

ANM - Auxiliary Nurse-Midwife

A&E - Architectural and EngineeringBPEP - Basic and Primary Education ProjectCEM - Country Economic Memoranda

CIF - Cost, Insurance, and FreightCIR - Contraceptive Prevalence Rate

EPI - Expanded Program for ImmunizationEP - Eighth Five-Year PlanFINNIDA - Finnish International Development AgencyFP - Family Planning

FP/MCH - Family Planning and Maternal and Child HealthFY - Fiscal Year

GDP - Gross Domestic Product

GTZ - Deutsche Gesellschaft fur Technische Zusammenarbeit (German)HMG - His Majesty's GovernmentHP - Health Post

ICB - International Competitive BiddingIDA - International Development AssociationIEC - Information, Education and Communication

IMR - Infant Mortality RateIUD - Intra-Uterine Device

KfW - Kreditanstalt fur Wiederaufbau (German)LCB - Locai Competitive Bidding

MCH - Maternal and Child Health

MCHW - Maternal and Child Health WorkerMIS - Management Information System

MOF - Ministry of FinanceMOH - Ministry of Health

NCP - National Committee for PopulationNGO - Non-Governmental Organization

NPC - National Planning CommissionO&M - Operations and Maintenance

ODA - Overseas Development Administration (British)PBHW - Panchayat Based Health WorkerPFHP - Population and Family Health ProjectPHC - Primary Health CenterPHRD - Policy and Human Resource Development

PIU - Project Implementation UnitSBD - Standard Bidding Document

SHP - Sub-Health PostTFR - Total Fertility Rate

UNDP - United Nations Development ProgrammeUNFPA - United Nations Population Fund

UNICEF - United Nations Children's Fund

USAID - United States Agency for International DevelopmentVDC - Village Development CommitteeVHW - Village Health WorkerWHO - World Health Organization

FISCAL YEAR: July 16-July 15

FOR OFFICIAL USE ONLY

NEPAL

PROPOSED POPULATION AND FAMILY HEALTH PROJECT

Cot tents

Page No.

Credit and Project Summary ................................ iii

I. SECTOR CONTEXT ................ 1...... ..... 1

A. The Challenge of Population and Developme; ... 1

B. HMG'S Family Planning and Maternal and Child HealthProgram. 3

C. Pending Sector Issues. 6D. IDA's Country and Sector Assistance Strategy and Rationale

for IDA's Involvement in the Project. 9

E. Lessons Learned. 9

II. THE PROJECT .11

A. Genesis and Objectives .11

B. Project Design and Components .12

C. Project Costs and Financing .18

D. Procurement Arrangements .21

E. Disbursement .23

F. Status of Preparation ..... . ........................... 24

III. IMPLEMENTATION AND SUPERVISION .25

A. Project Organization and Management .25B. Implementation Plan .25

C. Monitoring and Supervision .26

D. Accounts and Auditing .26

IV. PROGRAMS OF SPECIAL EMPHASIS ................................. 27

The report has been endorsed by Mrs. A. Hamilton, Director (SAlDR) and Mr. M.Karcher, Chief (SAlPH). Peer Reviewers were Messrs. 0. Pannenborg, Chief(AF1PH); S. Sudhakar, Senior Population Specialist (SA1PH); and C. Walker,

Senior Population, Health and Nutrition Specie-st (SA3PH). This report isbased on the findings of an IDA mission to Nepal in September-October 1993.Mission members included: Messrs./Mmes. B. Duza, Task Manager (SAlPH); M. Mac

Donald, Senior Population Specialist (ASTHR); I. Appasamy, OperationsAssistant (SA1PH); A. Bhulya (Demographer-Operations Researcher), J. Brandt(Logistics Specialist), T. Coyle (Architect), W. Robinson (Demographer-Health

Economist), and J. St. Germain (Architect), Consultants.

This document has a restricted distribution and may be used by recipients only in the performance of theirofficial duties. Its contents may not otherwise be disclosed without Woa Id Bank authorization. l

- ii -

V. BENEFITS AND RISKS ...... ................ .................... 27

A Benefits .............................................. 27

B. Risks ......................... ............... 28

C. Sustainability .29

VI. AGREEMENTS REACHED AND RECOMMENDATION .29

TABLES IN TEXT

Table 2.1 Project Cost Summary .19

Table 2.2 Financing Plan by Component ................ .... 20

Table 2.3 Procurement Methods .21

ANNEXES

ANNEX 1. H_ALTH DATA; MINISTRY STRUCTURE; PROGRAM COSTS

1.1 Population and Health Facilities in Nepal ............ 31

1.2 Pcpulation Projection and Related P-'rameters

for Nepal ........................................ .... 32

1.3 Contraceptive Method Mix for Nepal .................... 331.4 Structure of Population and Health Service Delivery

in Nepal ......... 34

1.5 HMG's FP/MCH Program Components by Financiers ......... 40

1.6 HMG's FP/MCH Program Components by Year ............... 41

ANNEX 2. PROJECT COSTS AND DISBURSEMENTS

2.1 Population and Family Health Project - Expenditures

by Components .. 42

2.2 Population and Family Health Project - Components

by Year ............................................... 44

2.3 IDA Disbursement Schedule .. 45

ANNEX 3. PROJECT MANAGEMENT. IMPLEMENTATION AND SUPERVISION3.1 Management Structure for Population and Family

Health Project ......................... 46

3.2 Project implementation Schedule by Components ......... 473.3 Implementation Schedule - Civil Works ................. 48

3.4 Yearly Critical Dates for Civil Works Implementation.. 49

3.5 List of Sites for First and Second Year

Construction Program of Health Facilities ............. 50

3.6 List of Proposed Sites for Primary Health Centers ..... 51

3.7 Implementation Sc:hedule - Logistics ................... 53

3.8 Implementation Schedule - MIS ......................... 543.9 Institutional Development Technical Assistance ........ 61

3.10 Construction Monitoring Plan .623.11 Implementation Plan - Field Operations Support .64

3.12 Bank Supervision Input into Key Activities .65

ANNEX 4. LIST OF DOCUMENTS IN PROJECT FILE .68

MAP: IBRD 25400 - Nepal Population and Family Health Project 70

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NEPAL

POPULATION AND FAMILY HEALTH PROJECT

Credit and Prolect Summary

Borrower: The Kingdom of Nepal

Amount: SDR 19.4 million (US$26.7 million)

Terms: Standard with 40 years maturity

ProiectDescriDtion: The six-year (FY1995 t- FY2000) Project has been designed within

the framework of the Government's comprehensive Family Planningand Maternal and Child Health (FP/MCH) Program. and wouldsupplement funds from domestic and foreign sources, ensuringresource availability and operation of the total Program. Itwould support the improvement of the quantity and quality of carein FP/MCH service delivery and finance activities designed to:(a) strengthen the effectiveness, access, and utilization of theoutreach and clinical programs; (b) refurbish the healthfacilities and logistics infrastructure; (cl provide operationaland management support; (d) develop a functioning ManagementInformation System; (e) provide maintenance support; and (f)enhance institutional development and the absorptive capacity ofthe sector.

Benefits andRisks: Benefits would include lower rates of births, and infant and

maternal mortality and morbidity through cost-effective ieliveryof the FP/MCH Program. The slower population growth and betterfamily health that would result from these efforts would be avital pre-condition for the poverty reducing and otherdevelopment and environment goals of Nepal. The principal riskwould be the inability of the Government to accomplish theeffective integration of FP/MCH activities with Primary HealthCare delivery and the ongoing decentralization of programexecution. Other risks would include the inability to ensureappropriate domestic resources and to maintain a critical mass ofstaff of service providers and managers, and HMG-donor-NGOcoordination in the sector, along with their long-rangecommitment to the sector. These risks are being addressed aspart of on-going institutional reforms in the sector and throughenhanced management, monitoring and supervision of the Project.

v

Poverty Categorv: Not Applicable

Eroject Costs:Local Foreign Total----------- (US$ Million)----------

Outreach Service Delivery 26.8 5.3 32.1FP/MCH Clinical Units 0.9 0.9 1.8Logistics & Supplies 0.9 0.4 1.3Institutional Development 2.5 1.3 3.8

Total Project Cost 31.1 7.9 39.0

Financinq Plan'

(Estimated)

Financier: Local Foreian Total

---------- US$ million--------------

Government 12.3 - 12.3

IDA 18.8 7.9 26.7Total 31.1 7.9 39.0

Estimated IDA risbursements:

FY 942 95 96 97 98 99 2000----------------------- US$ million ----------------------------

Annu.al 0.2 3.1 4.9 6.3 5.6 4.3 2.3Cumulative 0.2 3.3 8.2 14.5 20.1 24.4 26.7

Economic Rate of Return: Not Applicable

Map: IBRD 25400

lIncludes duties and taxes, estimated at US$1.5 million equivalent.

2Retroactive financing.

NEPAL

POPULATION AND FAMILY HEALTH PROJECTBASIC DATA

Variables Year Data

Total Area (Thousand kM2) 1991 141

Total Population (Millions) Mid-1991 19.4Density (Per kM2) Mid-1991 138

Population Growth Rate (Percent) Mid-1991 2.5

Crude Birth Rate (Per thourand) 1991 38

Crude Death Rate (Per thousand) 1991 13Life Expectancy at Birth (Years)

Male 1991 54Female 1991 53

Total Fertility Rate (TFR/Per Woman) 1991 5.5

Infant Mortality Rate (Per thousand

live births) 1991 101Under 5 Mortality Rate (Per thousand

live births) 1991 197

Maternal Mortality Rate (Per thousandlive births) 1988 8.3

Urban Population (Percent of total

population) 1991 10

Adult Literacy Rate (Percent)

Total 1990 26Females 1990 13

Age Structure (Percent)

0-14 1991 43.4

15-64 1991 53.7

65 and over 1991 2.9

Population Per Physician 1993 17,000GNP per capita (US$) 1991 180

Sources: World Development Report, The World Bank; 1993; Eduard Bos et al.,World Population Projections, 1992-93 Edition, The World Bank; andMOH/HMG, National Health Policy, 1991 (for under 5 mortality rate).

I. SECTOR CONTEXT

A. The Challenge of Population and Development

1.1 Understanding the implications of rapid population growth ispivotal for a realistic perspective of Nepal's development prospects. TheBank's 1991 Poverty and incomes Study for Nepal identifies this as the mostfundamental factor contributing to poverty, eroding the limited gains made inGDP and food production. Had the annual population growth rate been containedto 1.5 percent, rather than the 2.7 percent registered during the past twentyyears, the real per capita GDP would have risen 45 percent instead of 14percent during the oeriod. As the study documents: (a) there is no prospectof significantly increasing average incomes if the population continues todouble every 25 years, as in the recent past; (b) curbing population growth isthe central, single most important element of any poverty alleviation strategyfor Nepal; and (c) in the absence of an effective program to slow populationgrowth, all other poverty alleviation measures would prove ineffective. Inthat case, per capita annual incomes might stagnate at around US$180,resulting in the addition of 15 million absolute poor over the next twodecades.3 This would not be a desirable scenario for a country whuse 1991per capita G.4P ranked 121st among 127 countries cited in the 1993 WorldDevelopment Report. Such daunting conclusions are strongly endorsed in theBank's Country Economic Memoranda (CEM) and reiterated by various experts inthe field. Senior Nepali officials have often characterizec' the magnitude ofthe count2y's population problem as a "Himalayan challenge."

1.2 Illiteracy in the population 15 vears ai:d over is 74 percent, thefigure for females being a staggering 87 percent. Also germane to the contextof severe poverty, malnutrition, overcrowding and inadequate health servicesis that Nepal's health status is amongst the poorest in the world, even withinthe relatively impoverished South Asian region. Access to health care remainsextremely limited, with a doctor-population ratio of nearly 1:17,000 and onehospital bed per more than 4,000 persons. The situation is far worse inoutlying rural areas and mountains (Annex 1.1). Nepalfs infant mortality rateof 101, child mortality rate of 197, and maternal mortality rate of 8.3 perthousand live births are among the highest in the world; life expectancy of 53years at birth is among the lowest; and nutrition indicators remain at acritical range -- the percentage of households consuming less than therecommended levels of food being 47% in tle rural hills, followed by 40% inurban areas, 31% in the mountains, and 23% in the rural terai, which is a foodsurplus producing region.4

3 See: Nepal: Poverty and Incomes, The World Bank, 1991, pp. xi, xiii, 23.

4 Social Indicators of Development, 1993, The World Bank, p. 237; World Development Report, The World Bank,1993, pp. 238, 292; National Health Policy, MOH/HMG, Nepal, 1991, p.3; Nepal: Poverty and Incomes, TheWorlt Bank, 1991, p.74.

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1.3 The number of the absolute poor represented nearly 40 percent ofNepal's estimated population of 19.4 million as of mid-1991, with an annualrate of population growth of 2.5 percent.5 At this rate, the populationwould double again in the next 27 years. Although a subs.'antial part of this

increase is already determined by the great momentum for growth represented bythe large number of women in reproductive ages -- 4.5 m_llion in 1991,compared to 2.7 million in 1970 -- as a result of past high fertility, afaster reduction in fertility in the near future would make a significantdifference in the total population size twenty years from now. By the year2015, this could imply a total size of 33 million (low growth scenario),rather than 37 million (high growth scenario), as estimated in the SocialSectoi Strategy Review.6 Under more optimistic assumptions of somewhatfaster fertility decline, the Bank's 1992-93 Projections estimate possibledoubling of the current size at a later date, about 20307 (Annex 1.2 forprojected population growth and related parameters for Nepal). Achieving a

slower pace of population growth would call for undertaking the requiredinvestment and effort now.

1.4 In the process of continued high fertility and gradually declining-- albeit still high -- mortality, per capita agricultural land has dwindled

from 0.6 to 0.24 hectare between 1954 and 1990. The current average farm sizein the hills is below one hectare, deemed insufficient to support the average

farm household of 6 persons. The consequent pressure has pushed cultivationup the hills and fragile slopelands, associated with declining marginalproductivity, deforestation, and other forms of ecological disruptions. Thetemporary safety margin offered by agricultural expansion in he terai whichaccommodated an estimated 1.2 million migrants frc.n the hills in the l9(,s and19-0s is also approaching exhaustion. At the same time, in view of the youngage structure of the population, np- entrants would be joining the country'slabor force at an annual rate of about 0.4 million by the beginning of thecentury, twice the rate experienced during the 1980s. Given the limitedarable land base, the largest proportion of these new workers would have ' beabsorbed in off-farm employment. In contrast, the manufacturing sector iscurrently adding only some 9,000 jobs per year.8

1.5 This is the overall sector context against which one has to assessthe past and prospective FP/MCH (Family Planning and Maternal and ChildHealth) program of the country. Despite over two decades of official familyplanning programs, the contraceptive prevalence rate (CPR) remains around 20-23% of the currently married women, and the total fertility rate (TFR: numberof children per woman expected during the entire reproductive period) isestimated to be nearly 6. The current CPR is much lower than the raterequired for a significant impact on population growth -- a CPR of 40 percent

5 World Development Report, The World Bank, 1993, p.238; Eduard Bos et al., World Population 2roiections,

1992-93 Edition, The World Bank, 1992.

6 Nepal; Social Sector Stratepy Review, Vol. II, The World Bank, 1989 (Report No. '498-NEP).

7 Eduard Bos et al., World Population Projections, 1992-93 Edition, The World Bank, 1992, pp. 354-355.

8 See: Nepal: Poverty and Incomes, The World Bank, 1991, pp. xi, 24-25, 65.

3-

by the end of the century to bring down the population growth rate to two

percent per year, and a CPR of 60 percent needed for the population to begin

to acabilize.9 These latcer figures are considerably higher than the

Government's CPR goal of 33 percert set for the year 2000,10 which itself

would be ambitious in terms of current programmatic efforts but should be

achievable if the goal is backed by appropriate levels of institutional,

financial, and personnel efforts. The same would be true for the MCH goals,

discussed later.

B. HMG's Family Planning and Maternal and Child Health (FP/MCH) Program

1.6 Population Policy in the 1980s. Recognizing the critical

importance of populatioli issues, in the early 1980s His Majesty's Government

(HMG) developed a National Population Policy, which was adopted in !983.11

It was in principle a sound population strategy that included: (a) meeting

unmet demand for tamily planning; (b) integrating "population" into relevant

development programs; (c) adopting programs to intrease female education; and

(d) mobilizing community participation. A National Commission on Population

was established, under the Prime Minister, to take charge of executing the

population policy. Implementation of the policy, however, was piecemeal and

ineffective; inter-sectoral coordination weak; and acces- to family planning

service delivery limited and irregular. During the late 1980s, population

efforts lost momentum and the National Commission on Population was merged

with the National Planning Commission (NPC) in 1990.

1.7 Population Policy for the 1990s. The present Government has

demonstrated encouraging signs of awareness of the population and development

nexus, and in 1991, announced a new population policy, in conjunction with a

new health policy. These have been incorporated in the country's Eighth Five-

Year Plan (EP: 1992-97) .12 While HMG's awareness of population issues is

evidenced in these efforts, as well as in documents and speeches, strong

political priority accorded to population in Asian countries with the

successful population programs -- such as Indonesia, Thailand, and lately

Bangladesh -- is still to emerge in Nepal. Nonetheless, it is important to

note that in late 1991, HMG established a National Committee for Population

(NCP), chaired by the Prime Minister and comprised of Ministers from the

concerned line and core Ministries. The structure of the National Population

Program is shown in Annex 1.4. Improvement in the socio-economic environment

9 Nepal - Fertility and Family Planning Survey Report, 1991. MOH/HMG, 1991, p. 108; Nepal -

Fiscal Restructuring and Public Resource Management in the Nineties (Draft), The World Bank,

February 1994, Para. 5.125.

10 Population Poi.cw and Program, Briefing Paper for the International Donor Meeting on Population,

Kathmandu, March 1992, NPC/HMG.

11 National Pooulatic, ,trateqy, National Commission on Population, HMG, 1983.

12 See: National Pealth Policy, MOH/HMG, 1991; Population Policy and Program, Briefing Paper for

the Internatioaal Donor Meeting on Population, Kathmandu, March 1992, NPC/HMG; Eighth Five-

Year Plan, NPC/HMG, 1992.

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that would be conducive to fercility reduction is being supported in NepaLthrough the ongoing IDA-financEd Basic and Primary 3ducation Project (BPEP),with thrust on increasing fetaale enrollment and female participation in theteaching force; and the Higher E;lucation Project, recently approvec, by theBoard.

1.8 FP/MCH Programs in Nepal whicn started in the early 1970s havesince continued with support from extsrnal donors -- especially USAID, UNFPA,UNICEF and some international NGOs. Over time, these were developed into avertical program to deliver family planning, and limited MCH services.Despite meager resources and other constraints, some progress has beenachieved during the past twenty years. The CPR is estimaced to have risenfro.n 2 percent in 1976 to 7 percent in 1981, and above 20 percent in 199S, asnoted before. While the overall achievement in MCH has been rather trivial,steady progress has been recorded for the Expanded Program f)r Irmmnunization(EPI), with 21 to 80 percent coverage for different antigens.13

1.9 HMG's Cuirent Sectoral Strategy, 14 which is largely supported bythe donor community, includes plans to: (a) upgrade the health standard ofthe population through an integrated approach to Prim,'ry Health Care; (b)pro-ide FP/MCH services in a more effective manner; (c, promote equity ofaccess of the population, especially the rural population, to the services;and (d) decentralize program execution. These are to be achieved byestablishing 3,200 Sub-Health Posts (SHP), one in each Village DevelopmentCommittee (VDC) and deploying a new cadre of 3,200 MCH Workers at the SHPlevel; strer;gthening of the existing 816 Health Posts (HPs); and creating 205Primary Health Centers (PHCs), each under a doctor and with a three-bedfacility. The structure of FP/MCH service delivery, announced in September1993, is shown in Annex 1.4.

1.10 Specific goals for the FP/MCH Program, envisaged by HMGl5 for theyear 2000, comprise the following:

(a) Increasing the CPR from the present level of 23% to 33% andreducing the TFR from 5.8 to 4;

(b) Reducing infant, child, and maternal mortality rates respectivelyfrom 107 to 50, 197 to 70, and 8.5 to 4 per thousand; and

(c) Raising life expectancy at birth from 53 to 65 years.

13 See: references ted in Footnote 11.

14 See: references cited in Footnote 11.

15 See: references cited in Footnote 11.

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As a result of the inadequate statistical data base for the country, estimatesof uemographic and health parameters from different sources vary widely, butthe above figures of current fertility and mortality levels are consideredplausible. However, the demographic and health objectives for year 2000 mustbe assessed in a realistic manner. On the fertility side, seriousprogrammatic c'forts and resource commitments, as envisaged in theGovernment's Population and Family Health program, can make the CPR goalachievable and bring the more demanding TFR goal within reach. On the otherhand, there is a need for caution with regard to the mortality and lifeexpectancy goals set by the Government for the year 2000. These are unlikelyto be achieved by the end of the dec.ade, ev-n under the most optimiesticscenarios. There is no precedent in similar developing country settings forsuch dramati.c improvements over such a short period. The general WHOguidelines indicate that an annual gain in life expectancy in a developingcountry of about half-a-year is a realistic objecti',e. The proposed Projectsupports an outreach and clinical program that would widen the access to MCHcare throughout the country and set in motion an improvement in mortalityconditions over a longer time-frame.

1.11 Major components in HMG's current and prospective FP/MCH Procramconsist of outreach service delivery, clinical services, logistics andsupplies, and institutional development. Under the recently reorganizedorganogram (Annex 1.4), these activities would be planned and coordinatedthrough the Planning Division of the MOH and axecuted through the FamilyHealth Division of the new Department of Health Services of the MOH. FP/MCHwould be delivered within an integrated package of Primary Health Care.Implementation would be decentralized -- through the Health Directorates inthe five development regions and the 75 District Health Orfices. The workwill be carried out at the field level mostly through a network of 816existing Health Posts (HPs) and 3,200 new Sub-Health Posts (SHPs); and throughoutreach services delivered at the community and household levels. Supportivemechanisms for outreach and clinical services would include a ManagementInformation System (MIS); Information, Education and Communication (IEC)component; National and Regional Training Centers; and infrastructure forvarious health facilities. These activities would be supported partially fromdomestic sourcea and largely from donor funding.

1.12 FP/MCH Program Support. The incremental resource requirement forMOH has been stipulated as Rs.5.5 billion (US$127 million) in the Eighth Five-Year Plan (1992-97). This represents 4.8 percent of the total EP budgetoutlay. Including direct funding of certain components by some donors, thefigure is estimated to be Rs.7.5 billion (US$174 million) in HMG's FinancingPlan. This level of resource allocation should be adequate to cover theGovernment's total FP/MCH Program noted in Para 1.11 above at an estimatedcost of Rs.6.2 billion (US$127 million)16 for six years (FY95-2000),corresponding to the proposed Project period. As indicated in Annex 1.5, theexisting donors -- primarily UNFPA and USAID -- will continue to provide

16 Based on rate of exchange of US$1 - Nrs. 49.00; EFYP estimate based on rate of exchange of US$1

- NRs. 42.75.

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funding for contraceptives, with supplementary support from FINNIDA, a new

donor in the sector. KfW, another new donor, will be supplying essential

drugs, along with UNICEV, which will also support EPI vaccines. Most of the

resources for training, IEC, and MIS will be coming from UNFPA and USAID,

while HMG will cover part of the recurrent expenditures. In addition to the

above-mentioned external donors who have firmed up their commitment to the

'rogram, ODA is in the final stage of its decision to participate in it.

However, lack of adequate funding in some critical areas -- including MCH

Workers' salary, logistics, infrastructure, and operational and institutional

support -- makes the overall FP/MCH service delivery currently ineffective and

investments in other program areas wasteful.

C. Pending Sector Issues

1.13 A number of key issues have long plagued the implementation of

FP/MCH e3rvice delivery in the country, but their resolution has proved to be

extremely slow as a res;.X of various systemic problems as well as ad hoc and

segmented approaches taken to address them. Some of the outstanding problems

are:

(a) Priority and Accountability. Lack of perceived priority and

accountability for FP/MCH services has been endemic at the field

level, both on the part of the workers and their supervisors. This

is partially related tc the next problem, but perhaps also to the

lack of adequate Government attention to the program.

(b) Inadeouate Integration. Inadequate and hasty integration of the

previously vertical and "crash" programs in various fields

including FP/MCH. failed to produce the desired results in terms of

more cost-effective service delivery. Instead, the existing

services were largely disrupted. Many workers, including the only

female outreach workers (Panchayat-Based Health Workers/PBHWs) were

laid off; many others from previously vertical programs were poorly

re-trained and re-oriented for integrated service delivery. Only

the Expanded Program for Immunization (EPI) did reasonably well in

the process, partly at the expense of other components. The

Village Health Workers (VHWs) gave priority to immunizations for

which supplies were mostly available from external donor support,

in preference to family planning and other health measures which

were less well understood, had limited resources, and were most

difficult to deliver. Continuation of verticality in donor support

for particular components slowed down the process of integration.

The creation of a new Department of Health Services (DHS),

announced in July 1993 -- see Organogram in Annex 1.4 -- would

address the problems of incomplete integration and decentralization

of primary health care delivery, and HMG and donors seem to be more

aware now of the need to provide specialized services through a

coherent integrated package.

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(c) Resource Allocation and Utilization. The lack of priority to the

sector was reflected in inadequate resource allocation to FP/MCH,

and even reduction in the budget in FY93. Limited implementationof the program objectives was an inevitable consequence of resource

constraints. In addition, the inadequate allocations themselves

were often not fully spent, especially for the development budget.

An average of 36 percent of the health sector development budget

was not spent during FY90-FY92, compared to 30 percent for the

entire development budget. FP/MCH services that are largely tied

up with external grant funding have also suffered more in the

process. This underutilization of resources has raised skepticism

about the absorptive capacity of MOH and its FP/MCH operations.

Appropriate measures, thus, need to be taken toward institutionaldevelopment and reforms in financial management. Mechanisms for

fund release would require streamlining. The Bank s macro-economicanalysis attributes a large part of the problem to the lack of HMG

counterpart funding in support of the development budget. It has

been pointed out that most of the sector development budget is

recurrent in nature and requires sustained financing under the

regular budget. However, more than half of these expenditures are

parcelled into projects under the development budget for financing

by donors, which also results in unreliable service delivery as

financing is linked to the project cycle.17

(d) Poor HMG-Donor Coordination. As noted earlier, considerable

segmentation and loss of focus resulted from the earlier "project

approach" to FP/MCH. This has been exacerbated by a lack of

effective mechanisms for inter-ministerial, as well as HMG-Donor,

coordination in support of a comprehensive FP/MCH program.

(e) Staff Support. The program has suffered as a result of inadequate

outreach and clinical service providers, as well as managerial

staff. The inability of the program to retain female Auxiliary

Nurse-Midwives (ANMs) in the remote Health Posts (HPs), often dueto lack of secure accommodation, and failure to deploy local female

MCH Workers largely due to fund constraints have resulted in

limited service delivery. High levels of doctor and male paramedic

vacancies have also been a chronic problem in the outlying areas.

The Government has begun to pay attention to these problems, but

staff reductions across the board as a result of ongoingadministrative reforms may leave the recently reorganized FP/MCH

section under the Family Health Division without a critical mass of

staff for outreach and clinical services, and program management.

(f) Inadeauate Travel and Daily Allowances. Service delivery has

proven difficult owing to the inadequacy of travel (T/A) and daily

(D/A) allowances for field staff and their supervisors.

17 Nepal - Fiscal Restructuring and Public Resource Management in the Nineties (Draft), The World

Bank, February 1994, para. S.117.

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(g) Contraceptive Method Mix and Unmet Needs. Partly because of thedifficulty of terrain and limited institutional facilities, it wasinitially found convenient to arrange seasonal sterilization campsacross the country. In the process, temporary and spacing methodswere neglected, and the national family planning program becamesynor'mous with a sterilization program. Hasty measures d limitsterilization camps since the mid-1980s and to provide the servicesin static facilities in a selected number of "institutionalized"districts resulted in heavy decline in sterilization performarce --from a peak of 68,000 in FY84 to about 20,000 in recent years.Other methods, which could compensate for the loss of sterilizationclients, have yet to be effectively disseminated as householdvisitation by field workers is infrequent, and measures forpromoting these alternative methods are still weak. In 1986, about86 percent of all contraceptive use was by way of sterilization; by1991, 78.4 percent of CPR was still accounted for by sterilization(see Annex 1.3 for Contraceptive Method Mix). Overall, the qualityof care in sterilization and other clinical methods, especiallywhen administered in temporary camps, has also been questioned. Atthe same time, the "unmet need" for family planning in the 1991survey was identified as 28 percent among married women and 55percent of these women wanted family planning in order to "limitfamily size. "1'8 Besides creating new demand through targeted IEC,intensive program efforts can tap these potential clients andincreasingly reach younger women with fewer children through arationalized method mix of both permanent and temporary methods.It is worth noting that the sensitive topic of abortion has notbeen an issue in Nepal. It is not legal in the country and wasnever a part of the FP/MCH program. Nonetheless, although not welldocumented, the incidence of abortions is believed to besignificant in the country. Many of these abortions are supposedlydone under unhygienic and life-threatening circumstances,aggravating maternal mortality and morbidity among the women.Better access to family planning services should reduce abortionsand the accompanying misery of the women and their families.

(h) MIS and Locqistics Support. In the absence of a functioning MIS forFP/MCH, bot-a service delivery and its monitoring at the field levelbave proved intractable. Similarly, the logistics system needsmajor improvements, without which contraceptives and othercommodities, even when available, would continue to be erraticallysupplied.

(i) Infrastructure Development and Maintenance. Inadequateinfrastructure facilities, their suboptitmal utilization, and poormaintenance of the buildings and equipment have impacted adverselyupon the FP/MCH Program. Resolution of these problems would

18 NeDal - Fertility, Family Planning, and Health Survey. 1991, MOH/HMG, 1993, pp. 82-85; 107-117.

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require appropriate financial resources as well as skilledpersonnel to ensure year-round provision of quality services atboth outreach and static facilities.

D. IDA's Country and Sector Assistance Strategy andRationale for IDA Involvement in the Proiect

1.14 A major objective of IDA's country assistance strategy for Nepalcalls for addressing the interlinked challenges of low economic growth,endemic poverty, high population growth, and environmental degradation. Theirsolution is viewed in teims of more rapid and broad-based economic growth andhuman resources development, reinforced by a strong population program. Theurgency of tackling the problem of rapid population growth is a theme thatcuts across the four main areas of focus of this strategy: (a) povertyalleviation through productivity gains in agriculture, expansion in small-scale industries and services; (b) improvement of absorption capacity throughstrengthening the finances and management of sectoral institutions; (c) humanresource development; and (d) the development of hydropower resources ilNepal's macro-economic management and institutional capacity improve.Therefore, IDA's country assistance strategy identifies population and healthas a top priority sector, and the Government has acknowledged the importanceof protecting investment funds in this core area.

1.15 This priority emphasis is reflected in several ways. First,through its macroeconomic dialogue with HMG, IDA is in a position to help HMGwith the prioritization of public expenditures and with the allocation ofscarce domestic and external resources to high return investment programs. Inthe context of the on-going public expenditure review, HMG's population andfamily health program was identified as a core program for budget allocationpurposes, thus ensuring that adequate funds will be available for the programin a timely manner. Secondly, by taking an overall view of the needs of thesector rather than a more narrow project approach, IDA was able to assist theGovernment in formulating a comprehensive and sustainable population andfamily health program, which promotes a more rational contraceptive method mix-- along with a realistic financing plan -- which now serves as a frameworkfor external donor support. Thirdly, by helping the Government to organize adonors' conference on population in March 1992, IDA was instrumental inmobilizing additional Oonor resources for the sector, especially as somedonors were waiting for IDA to signal its entry into the sector beforecommitting themselves. Finally, by acting as a lender of last resort, IDA isable to fund critical inputs, such as O&M and TA/DA, without which services donot reach the intended beneficiaries. This will assist in expanding theabsorptive capacity of the sector and increasing its effectiveness.

E. Lessons Learned

1.16 IDA experience in the social sector in Nepal so far has been inseveral projects in education. Lessons learned underscore the need toapproach the issues at the systemic level; the value of cost-effective andaffordable interventions; and institutional reforms and building up

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institutional capacities for sustainability of the programs. While IDA has no

prior experience in Nepal in the population and health sector, these lessons

from the education projects proved most relevant in developing the proposed

Project with HMG and in dealing with the sectoral issues identified during the

process of Project preparation. IDA experience in the sector in parallelsituations elsewhere in the reQion also provided positive lessons in desi7ning

the proposed Project.

1.17 Of particular relevance is the leading role that IDA has played in

its long-standing commitment to the sector in Bangladesh, a country that is

equally constrained by poverty and its associated limitations. The Bangladesh

Population and Health Project is now widely acclaimed as a major success

story, and IDA is credited with its sustained support for a comprehensive and

well-coordinated national program. The country's total fertility rate has

fallen from 7 births per woman in 1975 to 4.5 births per woman in 1990. The

corresponding change in the contraceptive prevalence rate auring the period is

reflected in the dramatic rise from 8 to about 40 percent. Relevant

evaluation and research findings' include the following:

(a) incontrovertible evidence that there is demand for family planning

in rural Bangladesh;

(b) the value of programmatic interventions to mitigate the costs of

family planning; and

(c) confirmation that implementation of appropriate service elements

can bring about substantial demographic effects.

Based on the research, three key policies were implemented. First, Family

Welfare Centers have been established in over 80 percent of the local

jurisdictions that have an average population of around 20,000. Second,

surgical sterilization services are available in every district and

subdistrict hospital at no cost to the patient. And third, over 23,000 female

outreach workers deliver family planning services to couples in their homes.

1.18 These observations are directly relevant for the design of the

proposed Project. Given the similarities in the contexts of the two

countries, it should be possible for Nepal to achieve a breakthrough in its

population programs, provided the right policiee are adequately implemented.

1.19 As noted earlier, implementing an effective population program is

an essential element of IDA's Country Assistance Strategy as it will

contribute to the Government's poverty alleviation and human resource

development efforts.

19 Winthrop P. Carty, et al., Success in a ChallenQing Environment: Fertility Decline in

Bangladesh, Population Reference Bureau, Inc., 1993; John Cleland et al., Bangladesh: The

Determinants of Reproductive Change, The World Bank, 1994.

II. THE PROJECT

A. Genesis and Obiectives

Project Genesis

2.1 The Project originated from a Government request for IDA assistance

for the FP/MCH Program following the discussions of IDA's 1989 Social Sector

Strategy Review for Nepal (Report No. 7498-NEP), which highlighted the

population-resource strains noted above. The Bank's macro-economic analyses

have since echoed the concern that unless a major program intervention were

launched, aiming at reducing population growth, the gains of other investments

in Nepal would ultimately be frittered away. IDA was initially involved in

assisting with the drafting of a population strategy for Nepal in 1983, which

was discussed at the Aid Group meeting that year, and subsequently adopted as

Government policy (see para. 1.6). However, an IDA-supported project did notmaterialize at that time.

2.2 Against this backdrop, detailed preparations for the present

Project were undertaker, by HMG for over three years. A number of analytical

studies and other preparatory work were carried out with support from UNDP,

UNFPA, GTZ (Germany), Save the Children Fund (UK), and the Japanese Policy and

Human Resources Development (PHRD) Fund. While working closely with the

Government, IDA also had extensive consultations with the existing and

potential donors both at the headquarters and field levels.

Proiect Obiectives

2.3 The Project's main objective is to support the Government's efforts

to increase contraceptive prevalence and decrease the total fertility rate.

In addition, the Project would help to reduce maternal and child morbidity and

mortality, and to raise life expectancy. The Project would contribute to the

achievement of these goals through the financing of key components of HMG's

FP/MCH program that have inadequate funding and institutional support in order

to:

(a) increase the coverage, quality, and utilization of FP/MCH services

through outreach and clinical services, and ensured supplies of

contraceptive and drugs;

(b) improve the functions of the grassroots health facilities throughrecruitment and deployment of female MCH Workers and providingfield operations support; and

(c) enhance the Government's institutional capability, in particular

the managerial capability, to implement a comprehensivePopulation/MCH Program effectively.

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2.4 The focus of the Project would be on: (a) enhancing theutilization of existing personnel resources and health facilities; (b)supporting a new cadre of female MCH Workers, a long-felt need for thenational program in a traditional setting; (c) refurbishing and expanding thehealth infrastructure and logistics systems; and (d) strengthening MOH'smaintEnance and management capacities. With respect to family planning, thegoal would be to increase the CPR from 23% to 31% by expanding the coveragefrom the current figure of about 1.01 million couples to an estimated 1.74million couples annually by the end of the Project period. With respect tofamily health goals, the Project envisages a substantial expansion of clientaccess to the improved and expanded network of clinical facilities at thelevel of District Hospitals, Health Posts, and Sub-Health Posts (SHPs). Inparticular, by the end of the Project period, the goal would be to hold about50,000 outreach clinics each month, served by the 3,200 MCH workers and otherstaff operating out of the Sub-Health Posts. The expanded services andcounselling would also help safe motherhood goals for a growing number ofwomen through better child spacing, minimizing vulnerable pregnancies tooearly and too late in the reproductive life of a woman, as well as throughpre-natal care and more effective referral to the 25 new Primary HealthCenters (PHCs) and 35 MCH Units in the District Hospitals.

B. Proiect Design and Components

Evolution of the Project Design

2.5 Since this would be the first IDA-supported Project in the sectorfor Nepal and since MOH/HMG does not have prior experience with IDArequirements and procedures, considerable preparatory activities wereundertaken. Milestones in the evolution of the Project design included thefollowing:

(a) Background Technical Papers. Ten major reports were commissionedin 1990 from national experts on various aspects of the FP/MCHoutreach and clinical service delivery in the public, NGO, andprivate sectors.

(b) Reports of Seven Working Groups. These Working Groups were set upin 1991 under a National Steering Committee, with inter-ministerialand NGO representation. They embarked upon in-depth analyticalwork, done in three phases -- Situation Analysis; Analysis ofOptions for Interventions; and Resource and Management Implicationsfor Project Components. The reports examined management andoperational issues at various levels, and considered options andresource requirements for different program interventions.

(c) Comprehensive FP/MCH Program. The foregoing reports and analysesprovided a basis for defining the parameters and broad resourcerequirements for a comprehensive national FP/MCH Program. The

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technical inputs and outcomes were reflected in HMG's Eighth Five-Year Plan (1992-1997), and provided a framework for dialoguebetween HMG, IDA, and the donor community-at-large.

(d) International Donor Meeting. These efforts were followed by theconvening of an international donor meeting on population held inKathmandu in March 1992. IDA collaborated with HMG and othprdonors in the process leading up to the meeting and in thesubsequent follow-up. The documentation represented a furtherbasis for HMG-donor consultations on program objectives andpotential support.

(e) Detailed Financing Plan. The stage was now set for a detailedfinancing plan for the sector. Its preparation was facilitated byinput from the ongoing Health Resource Allocation Study for Nepal,a UNDP project executed by the Bank, as well as IDA's PublicExpenditure Review. The Financing Plan, submitted to IDA by HMG inAugust 1993 and shared with other donors, provides a comprehensiveprofile of requirements for the sector within the expected resourceenvelope of domestic and foreign funds for various components, andidentifies the f,inancing gaps for specified areas. A valuableoutcome emerging from the analysis of the Financing Plan was thefruitful dialogue with the Government and formulation ofalternative scenarios and sequencing of expansion andprioritization for various components of a feasible, affordable andsustainable FP/MCH program, keeping in view the competing demandson financial, personnel, and organizational resources available toHMG.

(f) Infrastructure Development Survey. A country-wide infrastructuresurvey of more than 800 health facilities was undertaken in 1993.Completed in October 1993, the Report provides a detailed pictureof the physical status of each of these facilities, along withtheir accessibility and utilization; it also formulates objectivecriteria for essential repairs and renovation, as well asreplacement on appropriate sites.

(g) Locristics Inventory. A similar inventory of the logisticsinfrastructure system was undertaken. Issues relating to thedistribution and storage of FP/MCH supplies in the country wereexamined, and recommendations for rehabilitation of the systemformulated.

(h) Operations Research. Operations research in selected areas ofthree districts was set up with a view to examining implementationissues at the field level.

2.6 Against the background of the studies and reviews noted above, theproposed six-year (FY95-2000) Population and Family Health Project has beenbased on the Government's FP/MCH Program, and addressee the pending sectorissues outlined in para. 1.13. The IDA Credit would supplement funds from

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domestic and foreign sources, ensuring resource availability for the total

Program. Duplication of efforts and funding for various components would be

avoided through coordination and continuing dialogue 'ich the Government and

the concerned donors, and where appropriate, through joint supervision

missions. The proposed three-tier management structure (Chapter III, para.

3.1) should also be a valuable mechanism for inter-ministerial, NGO, and donor

coordination. The Project would cost US$39 million, and cover about 31

percent of the estimated total of US$127 million for HMG's FP/MCH Program for

the Project period (Annex 1.5). The formulation assumes that the National

Program would continue to be supported by the domestic and concerned foreign

sources at least at the present level of support beyond the end of the EP.

2.7 The scope of the Project is fully consistent with the resource

envelope of Rs.5.5 billion for HMG's core FP/MCH and other MOH programs for

the Eighth Five-Year Plan, as endorsed in the Bank's CEM, and representing 4.8

percent of the total EP budget noted before, and compared to 4.3 percent of

the total Government expenditures in the 1980s, 3.3 percent in FY91-92, and

4.4 percent in FY93. It is also in line with the following sector priorities

and expenditure efficiency issues underscored by the CEM:20

(a) consolidating and utilizing the existing facilities and personnel,

and developing the new system of proposed health facilities only

gradually, in line with financial, staffing and managerial

potential;

(b) ensuring the budget for recurrent excpenditures for basic O&M

activities, including maintenance, and funding of the female MCHWs;

(c) focussing infrastructure investments first on constructing the HPs

and clinical services at the outreach level, limiting PHC expansion

to the most densely populated sources of demand; and

(d) protecting the critical mass of staff for outreach and clinical

services as well as program management and supervision, along with

non-wage operational costs.

2.8 While meeting the existing financing gap, the Project would upgrade

the infrastructure and provide operational support and MCH Workers' salaries,

which are now grossly under-funded; and supplement various components where

funding is only partially available -- including MIS, distribution of

supplies, and operations and maintenance -- in conjunction with other donors.

Details of the specific components are outlined below.

w Nepal - Fiscal Restructuring and Public Resource Management in the Nineties (Draft), The World Bank,

February 1994, para. 5.130; Financing Plan for Population and Family Health Program, MOH/HMG, August

1993, Table 1.

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2.9 Outreach Service Delivery (US$27.8 million). A major barrier topast program effectiveness has been inadequate outreach from health facilitiesto clients at the household and community levels. The Project will strengthenthis vital area, with support to several key sub-components as detailed below:

(a) Female MCH Workers at the Sub-Health Post Level (US$7.3 million).Introduction of this new female cadre to the FP/MCH Program has forlong been deemed by IDA and other donors as most critical in orderto reach women and children at the outreach level. The MCH Workerswould be recruited and posted locally, with three months' trainingin clinical and outreach service delivery. Appropriate domesticresources will be made available for the MCH Workers salariescomponent, considered crucial to implement the Project fully andeffectively. This would require the continued HMG support forabout 1,300 MCH Workers already reciuited by the Government;deployment of the remaining 1,900 MCH Workers--about 650 per year--during the next three years of the Eighth Five-Year Plan (by July1997); and their continued funding throughout the Project period(July 1994 to July 2000). Thus, from July 1997, there will be oneof these wor':ers in each of the 3,200 Sub-Health Posts being set upin the country. The primary goal is to take services nearer to thepeople. They will also provide services at outreach clinics in thelocal community.

(b) Health Posts (US$9.8 million). As a key element in the existinghealth service delivery network at the field level, the Credit willfund the construction/replacement of 125 new Health Posts in areaswhere they are currently located in rented facilities orinappropriate locations; in addition, 100 Health Posts will berenovated and repaired, thus covering about a quarter of thecountry's 816 Health Posts. Construction of the new HPs will startin the first year of the Project. The proposed sites for the unitsto be built during the first two years of the Project are listed inAnnex 3.5. Staff quarters for the female Auxiliary Nurse-Midwives(ANMs) will be provided in all these facilities, mitigating a majorconstraint in retaining technical female staff in outlying ruralareas, which seriously limits access of female clients to theexisting facilities. These ANMs are parademics with three years'training under the Institute of Medicine, and are nationallyrecruited and posted across the country. Construction of HPs willstart in the first year of the Project.

(c) Primary Health Centers (PHCs) (US$3.5 million). This is a newcomponent in HMG's recently announced Health Policy, with anultimate goal of establishing 205 such Centers in the country, eachunder a doctor and with a three-bed facility. The EP calls forsetting up 100 PHCs during the Plan period. Establishment of theseunits may pr--e tc be a worthwhile long-range goal for the future.However, in view of the scarcity of doctors in the country and highrecurring costs involved, the Project supports a slow and realisticphasing of their expansion. Thus, the Project will provide funding

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for the establishment of five new Centers and upgrading of 20existing Health Posts -- in grod catchment areas, with betterpotential for utilization of services. Construction will commencein the first year of the Project (for listing of sites, see Annexes3.5 and 3.6).

(d) Field Operations Support (US$7.2 million). One of the keyimpediments for the mobility of clinical and outreach serviceproviders, as well as their supervisors, has been the lack ofadequate and timely release of funds for the purpose. TheGovernment has recently revised the Travel Allowance/DailyAllowance (TA/DA) rates upward, roughly doubling the DA for allranks and increasing TA as well, which were frozen for nearlytwenty years. IDA funding of TA/DA is based on the premise thatwithout this field operations support for the outreach and clinicalworkers and their managers, investments in personnel,contraceptives and drugs, infrastructure and logistics, and allother activities of the Program would continue to prove wastefuland unproductive.

2.10 Clinical FP/MCH Units (US$1.5 million). Since access to qualityFP/MCH clinical services is still very limited, IDA will supplement thefunding that is mostly expected from other donors (see Annex 1.5). Under thiscomponent IDA will support the establishment of five out of a total of 35FP/MCH Clinical Units in selected District Hospitals in outlying rural areas.Construction of these units will take place, commencing in the third year ofthe Project.

2.11 Logistics and Supplies (US$1.1 million). As shown in Annex 1.5,contraceptives and essential drugs would be available from non-IDA sources.Their storage, distribution, and follow-up, however, would remain majorproblem areas, especially with the addition of 3,200 SHPs across the country.There is a need to develop an effective logistics system, with need-baseddelivery of supplies; and provide support to storage and distribution. Thus,the Project will support the development of an effective logistics system andfund the following sub-components of Logistics and Supplies:

(a) Construction and Renovation of Warehouses (US$0.4 million). TheProject will refurbish the dilapidated warehouses, and constructand expand a limited number of them, all on existing sites. Newconstruction will commence in the third year of the Project.

(b) Transportation of SuvDlies (US$0.4 million). The Project willcover the distribution of contraceptives, essential drugs, andmedical equipment procured from IDA and non-IDA sources, usingmeans appropriate for different terrains of the country. In thepast, the unreliable and irregular distributior. of thesecommodities ilas seriously jeopardized service delivery. Theproposed component would constitute a modest but critical programsupport to ensure the reliability and utilization of the healthinfrastructures and outreach workers across the country coveredunder the Project. The grant donors supplying most of the

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commodities cover the cost of freight up to the central, andsometimes regional, warehouses. IDA support is envisaged to coverthe distribution from these points to the district.s and outlyinghealth facilities, utilizing the private sector which has beenfound in the Project's logistics analysis to be much more cost-effective and practical, compared to the public sector, in view ofthe low utilization of the public sector transport fleet,seasonality of distribution, and prohibitive maintenance costs andarrangements.

(c) Field Operations SuDport (US$0.3 million). To keep track of thelogistics, TA/DA support will be provided to the field supervisorsbased at the regional level.

2.12 Institutional Development (US$3.4 million). For long-rangesustainability and capability building, several activities will be supportedunder this component:

(a) Management Information System - MIS - (US$1.1 million). Afunctioning record-keeping system at the field level is currentlylacking in the country. The problem has become acute in view ofthe recent integration of previously vertical projects, funded byvarious donors, each maintaining separate recordkeeping forspecific areas. An effective and integrated MIS for the FP/MCHProgram in general and the IDA-supported Project in particular isan essential tool for maintaining household and client recordsneeded by service providers and their managers. It is also animportant monitoring mechanism to assess the achievement of thestipulated FP/MCH goals, and an indispensable data base forplanning purposes. IDA will provide support to the development ofan effective field-based and integrated MIS and materials,equipment, and training. The focus will be on ensuring reliablerecords of worker visitation at the outreach level; specific FP/MCHservices delivered; supervisors' visits; and data compilation,reporting, and feedback for monitoring and evaluation -- initiallyin pilot districts and by the end of the Project period, throughoutthe country. During negotiations, an understanding was reachedwith the Government that in the event that grant funding becomesavailable for this component by November 1994, the correspondingamount under this component may either be cancelled, with priornotice to IDA, or subject to IDA agreement, reallocated for otherProject-related purposes.

(b) Clinical Training Centers (US$0.1 million). The Credit would fundthe creation of seven small units in existing hospitals in thenational capital and regional headquarters in order to providefacilities for on-the-job clinical training to various cadres ofservice providers. The establishment of these units will start inthe third year of the Project.

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(c) Maintenance Capacity Development (US$0.1 million). In the past,major investments in infrastructure and equipment have provedwasteful and underutilized as a result of their poor maintenanice.This happened because of funding scarcity as well as lack oftechnical expertise in the field. The Project will start buildingup capacity in this area through technical assistance, training andskill development, and preparation of training manuals.

(d) Proiect Management (US$2.1 million). The Project will support thestaffing and operation of a full-time PIU within a three-tiermanagement system referred to in Chapter III. The Unit will beresponsible for monitoring Projec- implementation, liaising with,and preparing documentation for IDA, as well as coordinating withHMG's FP/MCH Program and other related agencies.

C. Project Costs and Financinq

Proje-t Costs

2.13 Cost Summary. The total cost of the Project is estimated atUS$39.0 million equivalent, including contingencies estimated at US$5.2million equivalent and applicable duties and taxes estimated at US$1.5million. Details by category of expenditure and proportion of foreignexchange are reflected in Annex 2 and summarized in Table 2.1 below.

2.14 Basis of Cost Estimates. As the land for the new health centersand warehouses is already owned by HMG, no p.:ovision has been made for landacquisition. Civil works costs are based on current market rates and quantitytake-off estimates from the prototype drawings. Costs of vehicles, equipmentand furniture are based on lists of items prepared by MOH and IDA, and costedat prevailing C.I.F. prices or local rates as applicable. Cost estimates ofconsultant services for technical assistance reflect a mix of the UnitedNations rates for foreign (including regional) and local consultants.Architectural and Engineering (A&E) services are costed at rates prevailing inNepal for local consulting services. Goods specifically imported for theProject may be admitted free of duties and taxes. Locally procured goods andservices, including materials for construction, carry duties and taxes atvarying rates.

2.15 Contingencies and Allowances. Project cost estimates includephysical contingencies (US$0.8) averaging 2 percent of base costs (5 percentof civil works, vehicles, equipment and furniture). Price contingencies(US$4.4 million, 13 percent of base costs) are escimated on the basis of localcost escalation at the following annual rates -- FY95: 6.5%, FY96: 6%, and 5%thereafter; and foreign costs as follows -- FY95: 2.4%, FY96: 3.2%, FY97:3.4%, FY98: 3.2%, FY99: 3.3%, and FY2000: 3.4%.

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Table 2.1: Project Cost Summary

% %Total(NRs Million) (US$ Million) Foreign Base

Local Foreign Total Local Foreign Total Exchange Costs

.. O01TREACH SERVICE DELIVERY

Wil Workers/Sub-Health Posts 355.3 - 355.3 7.3 - 7.3 - 21Hlcalth Posts 316.5 165.3 481.8 6.5 3.4 9.8 34 29Primarv Healt Centers 109.0 62.6 171.6 2.2 1.3 3.5 36 10Field Operautns Support 351.5 - 351.5 7.2 - 7.2 - 21

Subtotal 1,132.3 227.8 1,360.1 23.1 4.6 27.8 17 82

B. FP/MCH CLINICAL UNITS 34.2 40.2 74.5 0.7 0.8 1.5 54 4

(C. LOGISTICS AND SUPPLIES

Stores Construction/Renovation 14.0 7.4 21.4 0.3 0.2 0.4 35 1Supplies Transport 14.6 3.2 !7.7 0.3 0.1 0.4 18 1Field Operations Support 10.4 5.2 15.7 0.2 0.1 0.3 33 1

Subtotal 39.0 15.8 54.9 0.8 0.3 1.1 29 3

D. INSTITUTIONAL DEVELOPMENT

Management Information System 27.4 24.8 52.2 0.6 0.5 1.1 48 3Clinical Training Centers 4.2 1.8 5.9 0.1 0.0 0.1 30 -Maintenance Capacity Development 2.1 2.2 4.2 0.0 0.0 0.1 52 -Project Management 74.2 30.9 105.1 1.5 0.6 2.1 29 6

Subtotal 107.8 59.7 167.5 2.2 1.2 3.4 36 10

Total BASELINE COSTS 1,313.3 343.6 1,656.9 26.8 7.0 33.8 21 100

Phisical Contingencies 21.9 15.5 37.4 0.4 0.3 0.8 41 2P'rice C(onlingencies 190.0 27.3 217.3 3.9 0.6 4.4 13 13

Total PROJECT COSTS 1,525.2 386.5 1,911.7 31.1 7.9 39.0 20 115

2.16 Foreign Exchange ComDonent. As shown in Table 2.1 above, theestimated foreign exchange component (US$7.9 million, including contingencies)represents 20 percent of total Project costs. It has been calculaced asfollows: (a) civil works: 30 percent; (b) equipment: 85 percent; (c)vehicles: 25 percent; (d) foreign consultants: 85 percent; (e) studies: 40percent; (f) operations and maintenance: 17 percent; and (g) consumables: 40percent.

Financinq

2.17 of the total Project costs of US$39.0 million equivalent, the IDACredit of US$26.7 million (equivalent to SDR19.4 million) will provide 71percent of Project costs net of taxes and duties estimated at US$37.5 million.IDA will finance 100 percent of foreign exchange costs and 61 percent or localcosts. HMG counterpart funding will represent US$10.8 million equivalent netof taxes and duties (29 percent of the Project ccsts net of taxes and duties).Detailed investment and recurrent costs for the Project are shown in Annex 2.The summary Financing Plan is described in Table 2.2 below.

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Table 2.2: Financing Plan by Component(USS Million)

LocalIDA HMG Total For. (Excl. Duties &

Amount % Amount % Amount % Exch. Taxes) Taxes

A. OUTREACH SERVICE DEWIVERY

MCH Workers/Sub-Health Posts - - 8.9 100.0 8.9 22.7 - 8.9Health Posts 10.8 90.0 1.2 10.0 12.0 30.6 3.8 7.1 1.0Primary Health Centers 3.7 90.2 0.4 9.8 4.1 10.5 1.4 2.3 0.3FieldOperations Support 6.1 85.7 1.0 14.3 7.2 18.4 - 7.2

Subtotal 20.6 64.2 11.5 35.8 32.1 82.3 5.3 25.5 1.4

B. FP/MCH CLINICAL UNITS 1.6 89.0 0.2 11.0 1.8 4.7 0.9 0.8 0.1

C. LOGISTICS AND SUPPLIES

Stores Construction/Renovation 0.4 88.8 0.1 11.2 0.5 1.3 0.2 0.3 0.0SuppliesTransport 0.3 70.5 0.1 29.5 0.4 1.1 0.1 0.3 0.0Field Operations Support 0.3 92.2 0.0 7.8 0.3 0.9 0.1 0.2

Subtotal 1.1 83.6 0.2 16.4 1.3 3.2 0.3 0.9 0.0

D. INSTITUTIONAL DEVELOPMENT

Management Information System 1.1 94.7 0.1 5.3 1.2 3.0 0.6 0.6 0.0Clinical Training Centers 0.1 90.1 0.0 9.9 0.1 0.4 0.0 0.1 0.0Maintenance Capacity Development 0.1 92.8 0.0 7.2 0.1 0.2 0.' 0.0 0.0Project Management 2.1 86.8 0.3 13.2 2.4 6.2 0.7 1.7 0.0

Subtotal 3.4 89.5 0.4 10.5 3.8 9.8 1.3 2.5 0.0

TOTAL DISBURSEMENT 26.7 68.5 12.3 31.5 39.0 100.0 7.9 29.6 1.5

2.18 Retroactive Financing. To facilitate early start-up, the Creditwill provide retroactive financing of SDR 150,000 (US$200,000 equivalent) forexpenditures for various Project components incurred prior to Project signing,but after January 1, 1994.

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D. Procurement Arrangements

2.19 The procurement methods are summarized as follows:

Table 2.3 Procurement Methods

(US$ million)

Project Element Procurement Method

ICB LCB Othera Total

1. Civil Works and Related Furniture 14.9 0.3 15.2

(13.4) (0.3) (13.7)

2. Goods and Related Services

2.1 Equipment 2.3 0.2 0.2 2.7(2.3) (0.2) (0.1) (2.6)

2.2 Vehicles/Transport 0.7 0.2 0.9

(0.7) (0.1) (0.8)

3. Consultancy3.1 Project 0.7 0.7

Implementation (0.7) (0.7)

Support3.2 Capacity Building 0.7 0.7

and Institutional (0.7) (0.7)

Development

4. Training4.1 Foreign 0.1 0.1

(0.1) (0.1)

4.2 Local 0.3 0.3

(0.3) (0.3)

S. Miscellaneous

5.1 Salaries 9.1 9.1(0.2) (0.2)

5.2 Allowances 7.8 7.8

(6.7) (6.7)

5.3 Operations and Maintenance 1.5 1.5

(0.9) (0.9)

Total 3.0 15.1 20.9 39.0(3.0) (13.6) (10.1) (26.7)

Note: Figures in parenthesis are the respective amounts financed by IDA.

a/ Other procurement methods include force account, shopping, hiring of

consultant services following IDA guidelines and administrativeexpenditures following Government procedures.

-22-

2.20 Civil Works and Furniture (US$15.2 million). These will consistof: site improvements (including boundary walls and water service); repairand renovation of Health Posts (HPs); construction of new Health Posts toreplace those in rented or temporary buildings and those in total disrepair,Primary Health Centers (PHCs), FP/MCH Clinical Units, and Clinical TrainingCenters; and construction and refurbishing of Warehouses. Procurement offurniture and cabinetry will be packaged with bid packages for constructionworks for PHCs, Health Posts, and FP/MCH Units that will include five to eightbuildings in outlying rural areas in each package and amount to about US$0.5million. Since most of the civil works will be small and scattered ruralfacilities, contracts will be awarded on the basis of Local CompetitiveBidding (LCB) procedures acceptable to IDA. This would not exclude interestedfirms from outside Nepal from bidding. Warehouses and Clinical TrainingCenters, located around the capital and regional headquarters, will bepackaged separately. Small civil works amounting up to US$60,000 will beimplemented by force account.

2.21 Goods and Related Services (US$3.6 million). Equipment andvehicles will be grouped into packages of US$150,000 or more wherever possibleand will be procured through International Competitive Bidding (ICB) inaccordance with IDA guidelines. For bid comparison, goods manufactureddomestically will be allowed a preferential margin of 15% of the C.I.F. costsof the competing imports or the actual customs duties, whichever is lower.For contract packages of less than US$150,000 up to an aggregate amount ofUS$600,000, LCB procedures acceptable to IDA will be followed except thatcontracts below US$50,000 (up to an aggregate of US$200,000) for urgentlyneeded items may be procured under prudent local or international shoppingwith price quotations from at least three suppliers. Local distribution ofcontraceptives, essential drugs, and equipment provided for FP/MCH servicesfinanced by IDA and other sources would be hired according to shoppingprocedures acceptable to IDA, in packages not to exceed US$20,000, up to anaggregate amount of US$500,000 during the Project period.

2.22 Consultancies and Training (US$1.8 million). Local andinternational consultants will be contracted to assist the MOH in thedevelopment of a functioning logistics system, a trained maintenance force forthe physical plant, and a complete MIS system. A&E consultants will becontracted by the PIU from time to time during Project implementation toprepare site adaptation drawings, drawings for renovations and to supervisethe construction of all health facility buildings. All consultants will behired in accordance with IDA guidelines.

2.23 Procurement Plan. To ensure speedy initial implementation of theProject, detailed procurement plans have been prepared for the first two yearsof the Project. These will be updated annually by HMG to provide a rollingtwo-year procurement program as part of the procurement planning and review.Civil works contracts estimated at US$250,000 or more will be subject to priorreview by IDA, and this is expected to cover about 90 percent of thecontracts. All goods tendered through ICB will also be subject to priorreview by IDA.

-23-

E. Disbursement

2.24 The proposed Credit will finance about 71 percent of total Projectcosts, net of duties and taxes, and will be disbursed at the followingpercentages: 90 percent of 3xpenditures on civil works and related furniture;100* of expenditures on professional fees for Architectural/Engineeringservices and other IDA-financed consultants and international training; 100percent of foreign and local ex-factory expenditures on equipment andvehicles; 75 percent of other local purchases of equipment, vehicles andconsumables (stationeries and office supplies); 95 percent of agreed localtraining costs; and 100 percent of the salaries and operating costs of theProject Implementation Unit (PIU). Field operations support (TA/DA) will bedisbursed at the following rates: 100% until July 15, 1996, 90% until July15, 1998, and 70% thereafter; while support to the cost of distribution ofcontraceptives, essential drugs, and equipment will be shared 75%-25% betweenIDA and HMG throughout the Project period. Disbursements will be made over asix-year period, and the closing date will be December 31, 2000.

2.25 The Credit will cover certain recurrent expenditures for activitiesthat are currently in place and being expanded, including -- TA/DA support tothe service providers and managers throughout the country. The costs underthis component would be US$1.1 million for FY95. Full functioning of theProject Implementation Unit in FY95 would require operational and salarysupport of US$0.4 million. Thus, a total of US$1.5 million (38.5 percent)would be disbursed for "softwares" with minimal new effort during the firstyear. The remaining disbursement of US$2.4 million for other activitiesduring the year would mostly cover infrastructure development, preparation forwhich is at an advanced stage.

2.26 Disbursements against contracts for: (a) goods below US$50,000equivalent, (b) individual consultants below US$5,000 equivalent, and (c)civil works less than US$100,000 equivalent and works carried out by forceaccount, as well as salaries and operational support, will be made againstitemized statements of expenditure. Documentation supporting these statementswill be retained by the PIU for review by IDA missions. All otherexpenditures will be fully documented. During negotiations it was agreed thatHMG will open a Special Account at the Nepal Rastra Bank to facilitate paymentof eligible minor expenditures. This account will be maintained in US Dollarswith an authorized allocation of US$500,000. The account will be used forboth local and foreign payments for items costing less than US$50,000equivalent each, under all categories. All other expenditures will besubmitted to IDA for payment. It was also agreed during negotiations that, inorder to avoid any delay in fund release and Project implementation, theProject Implementation Unit will be authorized to operate the Special Accountdirectly for disbursement in accordance with IDA requirements.

-24-

F. Status of Preparation

2.27 Significant progress has been made with pre-implementationplanning:

(a) The Government's budget for FY94 already provides for an allocationof Rs.10 million (about US$200,000) against the Project, reflectingHMG's commitment for an early start-up.

(b) Details of various software components, including support to MCHWorkers, Field Operations, Transportation of Supplies, MIS,Maintenance Capacity, and Project Management have been defined andagreed to in principle.

(c) The Proiect Implementation Unit (PIU) has been established and thecore staff have been appointed. They are receiving in-country andexternal training on IDA procedures and requirements. With supportfrom the Japanese PHRD Grant Fund, the PIU is handling furtherpreparation activities for the Project start-up, including: (i)preparation of tender document packages for five prototype designsfor health facilities; (ii) detailed working drawings andspecifications; (iii) preparation of construction documents andimplementation of works identified for retroactive financing; (iv)finalization of site adaptation of the prototype designs; and (v)preparation of detailed equipment and furniture specifications.

(d) Infrastructure DeveloQment. The health and logisticsinfrastructure development, which will involve construction work in270 sites distributed throughout the country, will be phased overthe six years of the Project. Each year, contracts will beorganized into regional packages. Projects in each package will besupervised by a full-time engineer who will be supported by on-siteoverseers for each site. The number of sites to be included ineach category of health facilities improvement has been agreed towith HMG. Specific sites for inclusion in the Project have beenidentified based on overall need, as determined by a range ofobjective criteria -- the data for which were obtained from thenation-wide Infrastructure Survey referred to earlier. Duringnegotiations HMG confirmed (a) that all the sites for newconstruction in the first two years are located on HMG-owned land,and that there is no need for site acquisition, and (b) that thereare no liens or encumbrances on these sites. Sites for thesubsequent years will be finalized and acquired following theYearly Critical Dates for Civil Works Implementation (Annex 3.4),and List of Sites for Health Facilities (Annex 3.6). Prototypedesigns for each of the outreach health facility types have alsobeen prepared by HMG and reviewed by IDA. Final drawings,specifications, cost estimates and technical conditions for tenderfor the five prototype buildings (HPs and PHCs) were reviewed andapproved during negotiations.

I,, ,

-25-

(e) Bidding Documents. IDA's standard bidding documents - SBDs - (forsmall works) for civil works will be used, amended as appropriate.This document, with suggested amendments by HMG, has been clearedby IDA.

(f) Lists of Ecquipment and Furniture. Lists of equipment andfurniture have been reviewed by IDA (Project File) and have beenfinalized in conjunction with the PIU.

III. IMPLEMENTATION AND SUPERVISION

A. Project Organization and Management

3.1 The management structure for the Project (Annex 3.1) agreed to withHMG will consist of: (a) a FP/MCH Development Board, chaired by the Ministerof Health and comprised of senior representatives of key HMG Ministries, withresponsibility for overall policy formulation and inter-Ministerialcoordination of HMG's FP/MCH Program and the IDA-supported PFH Project; (b) anExecutive Steering Committee, chaired by the Secretary of Health and comprisedof the Director General, Department of Health Services, and MOH DivisionalChiefs and representatives of other Ministries, responsible for monitoring anddirecting the operations of PFH Project and coordinating Project activitieswith the other components in the FP/MCH Program; and (c) a ProjectImplementation Unit (PIU), consisting of full-time senior personnel,responsible for the day-to-day management and implementation of the PFHP, aswell as documentation necessary for IDA management. Core responsibilities atvarious levels are outlined in Annex 3.1 as well. The PIU will also serve asthe secretariat of the Executive Steering Committee and give operationalsupport to the Development Board, and will serve primarily as a seniormanagement team in order to furnish detailed technical services relyinglargely on private consulting firms, various HMG agencies, and individualcontract staff, as needed. Essential equipment, furniture, vehicles, staffsalaries, consultant fees and operating costs for the Unit will be providedunder the Project. The Unit will be headed by a Project Director and will beassisted by a Deputy Director and four Chiefs responsible for four functionalSections: Program Monitoring and Supervision; Logistics and Procurement;Infrastructure Development; and Finance and Administration.

B. Implementation Plan

3.2 Implementation plans for various components of the Project aredetailed in Annex 3. These include specification of the key activities andthe critical dates envisaged for their completion during the Project period.

-26-

C. Monitori .nd Supervision

3.3 Project Monitorinq and Mid-term Review. Project monitoring will beassisted by the management structure proposed for overseeing the PIU (para.3.1), and through the detailed implementation schedules and performanceindicators for different activities outlined in Annexes 3.2-3.4, 3.7-3.8, and3.10-3.12. The expansion of contraceptive use and family health services willbe monitored through the MIS records and periodic Demographic and HealthSurveys (DHS). During negotiations agreement was reached with HMG that itwill conduct with IDA, a comprehensive mid-term review of the Project no laterthan May 31, 1997. Also during negotiations, agreement was reached with HMGto have semi-annual progress reports from the PIU to IDA as well as an HMG-IDAProject Completion Review, the scope and timing of which would be determinedduring IDA reviews toward the end of the Project period.

3.4 Supervision Plans. Supervision of the Project will requireadditional staff weeks beyond the normal co-efficient for Nepal Projects.This is due to: (a) the national scope of the Project which requires extensiveinternal travel over difficult terrain; (b) the complex interdependencybetween various software operations and the challenges of contraceptive anddrug distribution; (c) requirements for ensuring full operational status ofthe health facilities; and (d) the need for extensive interaction with MOH/HMGon IDA procedures and requiLements, this being the first IDA-supported Projectin the sector; and (e) the need for close donor coordination in thesupervision of the Government's overall FP/MCH program. At a minimum, theProject will require bi-annual visits of FP/MCH and logistics specialists, andan architect to review technical progress in addition to a management expertexperienced in the supervision of complex national FP/MCH programs. Duringnegotiations agreement was reached with HMG that it will review the status ofProject implementation jointly with IDA by March 31, 1995 and by March 31 eachyear thereafter and finalize the plans for the following fiscal year. For theProject start-up, this review will commence during the Project launchworkshop.

D. Accounts and Auditing

3.5 The PIU will establish and maintain separate accounts for allProject expenditures and separate categories for each procurement account.The accounts will be maintained in accordance with sound accounting practices.Accoumts and financial statements for each fiscal year will be prepared andaudited by the Office of the Auditor General of Nepal, who would be acceptableto IDA as an independent auditor. Certified copies of the audited accountsand financial statements, together with the auditor's report and auditor'sopinion on the operations of the Special Account and on Statements ofExpenditures will be furnished to IDA as soon as possible, but not later thantwelve months after the end of the fiscal year.

-27-

IV. PROGRAMS OF SPECIAL EMPHASIS

4.1 Environmental Protection. The program supported by this Projectwill have no adverse envircnn,ental effect ana is rated as a 'Category C'operation. Indeed, the IDA assistance to family planning and MCH representsan integral part of the environmental strategy for Nepal. Rapid populationgrowth, which has led to deforestation, breakdown in the fodder-livestock-soilnutrient chain, and the expansion of cultivation into fragile slopelands, is amajor cause of degradation of the physical environment. Curbing populationgrowth is thus a prerequisite to solving the environmental problems, which aremore acute in the hills of Nepal, and are increasingly exerting pressure inthe terai. In addition, the Project will have direct positive effects on thelocal environment by promoting health and sanitation education.

4.2 Poverty Alleviation. Reduction of population growth shouldrepresent a pivotal strategy for poverty alleviation in the country. Thecontribution of the Project toward achieving this goal should be sianificantboth in terms of lowering the size of the population through the FP Programand enhancing its quality through the MCH Program.

4.3 Women and Children in Development. Women and children suffer theworst as a result of implications of population pressure and poor healthconditions felt at the micro level of the household. The family planning aswell as MCH components would alleviate these conditions through reducedpressure on the household economy; better health of mothers and childrenresulting from child spacing and avoidance of vulnerable pregnancies; andbenefits of immunization and related programs. The Project would also supportthe new cadre of female MCH Workers at the Sub-Health Post level to provideclinic based and outreach services to women and children. Besides, supportfor the female Auxiliary Nurse-Midwives at the Health Post and PHC levelswould increase utilization and access of the health facilities by the femaleclients. Additionally, support for these two female cadres in HMG's programswould create viable role models for the rural women for non-familial rolesthat are promoted in women-in-development programs.

V. BENEFITS AND RISKS

A. Benefits

5.1 The Project would be a catalyst in helping the development of acomprehensive program of population and family health, as a departure from theerstwhile segmentation of efforts in the field. By meeting crucial financinggaps in the national program, the Project would help ensure, for the firsttime, the funding for HMG's total FP/MCH Program. Significant steps would betaken to build a foundation for a strong program for ac:iieving the nationalpopulation objectives.

-28 -

5.2 By enhancing the utilization of services and promoting access to

the FP/MCH facilities, the Project would contribute to the welfare of the

family and better health of women and children at the micro level of the

household; and reducing poverty and environmental stress, and achieving other

national development goals at the macro level. Besides improving the quantity

and quality of care, the special focus on expanding the workforce of female

service providers would have an additional benefit of creating new role models

for rural women, which would facilitate women-in-development programs.

B. Risks

5.3 The principal risk would be the inability of the Government to

fully carry out the ongoing organizational reforms in MOH. This would

particularly concern the process of effective integration of FP/MCH and

related activities under the Primary Health Care system, along with

administrative and financial decentralization of the program at regional and

district levels. Given the problem of difficult terrain across the country,

failure to take appropriate measures in these areas would seriously handicap

the Project's execution. The joint annual HMG/IDA reviews will pay particular

attention to these issues while formulating the implementation plan for the

subsequent years.

5.4 Another major risk would entail the inability of the Government to

ensure the availability of appropriate domestic resources for the female MCH

Workers' salaries, considered crucial to implement the Project fully and

effectively. HMG has provided assurance to protect the budget for this, along

with other components of the IDA-supported Project, including non-wage

recurrent costs for O&M (see para. 5.9 below).

5.5 A third risk is the possibility of inadequate staffing due to

drastic staff reductions in MOH as a result of the administrative reforms

currently taking place in Nepal. In its public expenditure review dialogue,

IDA has emphasized the need to maintain a critical mass of staff for outreach

and clinical services as well as for program management and supervision in the

population and health sector. However, if staff are not available, the IDA-

supported program should be restructured to adjust to available staff levels.

5.6 HMG-Donor-NGO coordination has not proved easy in the past, and may

continue to be a challenge in view of the complexity of the national FP/MCH

program and the multiplicity of domestic and foreign actors involved in the

field. To minimize this risk, annual local Donor meetings would be held to

discuss implementation progress and constraints. As part of the coordination

process, the management plan for the Project envisages a number of mechanisms

for improved coordination.

5.7 A potential implementation risk is the MOH's unfamiliarity with

IDA's policies and procedures, especially procurement. Thus, the timely

achievement of the Project objectives may be difficult without close

monitoring. To address this concern, provision has been made for a project

launch workshop and for more frequent initial supervision by both Resident

Mission and Headquarters staff.

-29-

C. Sustainability

5.8 At a total cost of US$39.0 million, the six-year IDA-supportedProject would place a nominal burden (less than one percent) on theGovernment's total public expenditures during that period. However, since theIDA-supported Project is an integral component of the Government'scomprehensive FP/MCH program and would not stand on its own, it is necessaryto ensure that the overall FP/MCH program is sustainable. The estimated totalcost of the comprehensive FP/MCH program amounts to some U$127.0 million overthe six-year period (Annex 1.5), out of which capital and recurrentexpenditures account for $35.4 million and $91.6 million respectively. Thetotal annual expenditures of the FP/MCH program are projected to increasegradually from about $15.0 million in FY95 to about $23.8 million in FY98,before declining to $22.5 million in FY2000, the last year of the Projectperiod (Annex 1.6). As a percentage of the total public expenditures, 2 1 theshare of the FP/MCH program would increase from 1.8% in FY95 to 2.1% in FY97,before declining to 1.6% in FY2000 .22

5.9 Given these low percentages and given also the critical importanceof the Government's FP/MCH program for the country's development outlook, itis highly unlikely that the FP/MCH program would crowd out other moreimportant claims on public resources. The sustainability of the program,therefore, depends entirely on the Government's willingness to allocatesufficient resources to the program. In the context of the on-going publicexpenditure review and of the investment prioritization exercise, theGovernment has included the entire FP/MCH program, along with other priorityhealth programs (immunization, malaria control and diarrhoea control), in theso-called "core program," which is to be protected in case of unforeseenbudgetary shortfalls during any given fiscal year. While this does notconstitute an iron-clad guaranty against possible budgetary cutbacks, it doessignal the Government's seriousness about the FP/MCH program and it willensure more timely and streamlined fund releases to the FP/MCH program.

VI. AGREEMENTS REACHED AND RECOMMENDATION

6.1 During negotiations, the following agreements were reached with theGovernment:

(a) in the event that grant funding becomes available for the MIScomponent by November 1994, the corresponding amount under thiscomponent may either be cancelled, with prior notice to IDA, orsubject to IDA agreement, reallocated for other Project-relatedpurposes (para. 2.12(a));

21 Nepal - Fiscal Restructuring and Public Resource Management in the Nineties (Draft), The World

Bank, February 1994, Table 3.3.

22 Since the breakdown between development and regular expenditures in the Government's budget is

highly arbitrary and varies among sectors, more detailed comparisons between sectoral investmentcosts and the development budget and between sectoral recurrent expenditures and the regularbudget are not particularly meaningful.

-30-

(b) HMG will open a Special Account at the Nepal Rastra Bank to

facilitate payment of eligible minor expenditures, and the Project

Implementation Unit will be authorized to operate the Account

directly for disbursement in accordance with IDA requirements

(para. 2.26);

(c) HMG will conduct with IDA, a comprehensive mid-term review of theProject no later than May 31, 1997 (para. 3.3);

(d) the PIU will submit semi-annual progress reports to IDA, and an

HMG-IDA Project Completion Review will be carried out at the end of

the Project period (para. 3.3); and

(e) by March 31, 1995 and by March 31 each year thereafter HMG will

review the status of Project implementation jointly with IDA, and

finalize the plans for the following fiscal year; for the Project

start-up, this review will commence during the Project launch

workshop (para. 3.4).

6.2 Recommendation. Subject to the above conditions, the Project would

be suitable for an IDA Credit of SDR 19.4 million (US$26.7 million equivalent)

to the Kingdom of Nepal on standard IDA terms with 40 years maturity.

-31-AiinexS 1.1I

NEPAL

POPULATION AND FAMILY HEALTH PROJECT

Annex l.lA: Population and Hospital Distribution

Ecological Health Health

Belt Hospitals Beds Centers Posts Population(million)

Mountain 12 183 8 157 1.4

Hill 40 1,556 9 435 8.4

Terai 25 1,095 1 225 8.6

Nepal (Total) 77 2,834 18 816 18.5

Sources: MOH Health Information Bulletin, 1992.PBpulation Census of Nepal, 1991.

Annex l.lB: Distribution of Nepal's Population byEcological Region, 1981 and 1991

Ecoloc*ical Region 1981

Mountain 8.7 7.8

Hill 47.7 45.6

Terai 43.7 46.6

Source: Population Census of Nepal, 1981, 1991.

Nepal - Population Projection and Related Parameters. 1985-2030

YearsVariaWle 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030

Population (Millions) 16.7 18.9 21.5 24.1 26.8 29.4 32.0 34.4 36.6 38.7

Birth Rate (Per Thousand) 40.2 39.6 35.5 32.2 29.0 26.1 23.3 20.3 19.2

Death Rate (Per Thousand) 15.1 14.0 12.5 11.2 10.2 9.4 8.7 8.2 7.9

Growth Rate (Percent) 2.5 2.6 2.3 2.1 1.9 1.7 1.5 1.2 1.1

Total Fertility Rate (Per Woman) 5.9 5.6 5.0 4.4 3.8 3.2 2.8 2.4 2.2 J

Life Expectancy at Birth (Years) 51.0 52.6 54 56.8 58.5 60.4 62.3 64.3 66.3

Infant Mortality Rate (Per 127 117 106 93 83 73 63 53 43Thousand Live Births)

Source: Eduard Bos et al., World Population Projections, 1992-93 Edition, The World Bank, 1992, pp. 354-355.

-33-

Arnnex 1.3

NEPALContraceptive Prevalence Rate (CPR) among

Currently Married Women by Tvye of Method (Percent)

Currently Married, All CurrentlyContraceptive Method Non-Pregnant Women Married Women

Any Method 25.1 22.7

Any Modern Method 24.1 21.8Female Sterilization 12.1 11.0

Male Sterilization 7.5 6.8

Pill 1.1 1.0Injection 2.3 2.1

Condom 0.6 0.r

Norplant 0.3 0.2

IUD 0.2 0.2

Diaphragm, Foam, Jelly 0.0 0.0

Any Traditional Method 1.0 0.9Periodic Abstinence 0.5 0.5

Withdrawal 0.5 0.4Others 0.1 0.1

Currently Not Using 74.9 77.3

Total 100.0 100.0

Source: Nepal Fertility. Family Planning and Health Survey (1991), MOH/HMG,

1993.

National Population Program

NCD |National Development Council

INPC aoa Comte On Populatio

Charman; Prime Minister i Chairman. Prime Ministef

Vice Chairman

nvironment Economic onitoring £ Regional Program PopulationDlision lnayivision Dnanning Division Division L iiiDvison vision n Division Division

Line |Agencies

|NGOs

Private

Sector ;

-35-

Annex 1. 4

Hierarchical Organization Structure of Ministry of Health Page 2 of 6

| Mnln5sry of Health NJepal Nurslng Council O C epal Health Reeeartch CouncilT

Nepal Ayurvrld CouncilG Lr* rN:eZ tl CouP^nefl I

iDept. of Health D* )pc of Drug | Dept. of ;| ServicRlea Adminiistratton

|RCentral Hospiegtls |HE Iotms X ~~~~~~~~~~~~HomeopathlC

Hospetar

Nat TubrercllosCs nCentret

OENTRAL o Ayurved HospitulngLEVEL _ou PbspitLb

+ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~oa Natlrnel Trisnnensetrr

. . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..................... ..

e.H ServceDiectorateI

Retional Hospital

REGIONAL |Regonal Training ConLreLEVEL

|ORog TubCruloses C ntrC

|Regional Medical Store

................ .......................... ..... ....... . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ZONAL ZnlAyurvd Dispen arLEVEL Zonal Hospitl |ost

.~~~~~~~~~~~~~ ~ ~ ~ ~ ~ ~ . Zon.al Ayurved Dlsp-anm-,-y-........................... ....... . .. .. .. ... ..

|Distrtict Hoo pal DISTRICT r Onig M"eirwirt OtMilee |LEVEL

~~~~~. .. .. .. .. . .. . .. .. . .. . .. . .. .. .. .. .. .. .. .. .. .......... ............... ..... ... . ...> ~~ELECTORAL^ ~~CONSTITUENCYPfmyHelhCnr

. . .. .. .. .. .. . .. . .. .. . .. . .. .. .. .. .. .. ............ ............. .. .. .. . .. .. .. . . .. .

i t~~EVEL Health PostvdOlpnsr

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . ......... VDC LEVEL | Sub Health POSt|

Ministry of Health

MinisterHealth Policy &

AdvisoryCommittee

Secretary

Health Councils i

Policy. Planning.Adminhftatlon Foioreign Ad

Divivion |ivin

Pirsonnel Internal Financial Plnning a Mon oring &Administrallon Adminislralion Administration Programming Esluation

Section a Managemenr Section Secthn SectionSection

Organization A Adm|nhslrStve Aid ComputerManagement Support for ProcessingSub.Sectlon Swetdary & Sub-Section

Senior Officers

1* N

0.

Department of Health Services

F irepetpr7

I_ ,. I .. . . . . . . . . . . .. . .

FinanceCentir PubNational Ntionl Nal Health

SoctPon SoHctlon e**th Tuberculosi Health Edue. nrorm. Laboralory Centto Training Com nunicslion

Crntfe C*ntr]

Section Soctilon Sectilon Section Sect Ion Conir ol 801nSotnScln |

l~~~~~WAt ldi ol

Sncion Planning .rIctio Control Sci ContMot | Disaen A Inoormation e

Section secSection | Section M a Unn gmecnt i S cthn io n

Section SPIio

Department of Health ServicesFamily Health Division

DirectorGeneral Summary _

Class Adm Tech Total

G4 1 1:.,>j. $ :~, . . G-ll (US) - 4 4

Director . G;II (AS) - 2 2_______________ ~~~~~~ ~~G-111 6 6

G-l Tech(- 1- 417 17

'IN-: ~rny.lnng Chil~ HbaRKh Aid's& STD

S,.NO (PHN) (US G-ll Tech) - I PHA (US G-11 Tech) I 1 PHA (US G-ll Tech) - Sr.PHO (US G-l1 Tech) -PHO (G-l1l Tech) - FPO (G-l1l Tech) - 2 Sr.MO (GHS) H.Ed (G4Il Tech) I(Healh Inspection) (Health Inspection) (AS G4i Tech) 2 (Health Education)PHN (NG4 Tech) I Supervision Offce,

(0i1l Tech) 2(Health Inpecdion)Supeivlsor(NG.1 Tech) - 3

I;oH

-39-

Annex 1. 4Page 6 of 6

Structure of Health Service Deliveryfrom District to Village

|District Heath and Curative Service Directorate's Office|

District Hospital (75) | District Public Health Section (75)

Electoral Constituency Level

Primary Hcalth Center (206)

1. Medical Officer 12. Health Assistant 13. A.H.W. 34. A.N.M. 35. V.H.W. 16. Sweepers 27. Maternity Bed I8. General Beds 2

(District Division Level)

Health Post (816)

1. Health Assistant 12. A.H.W. 23. A.N.M. 24. V.H.W. 1 j

(Village DevelopmentCommittee Level)

Sub Health Post (3199)

1. A.H.W. 12. V.H.W. I3. MCH Worker 1

Ward Level

Ward level Village Health Volunteers

NEPALHMG'S FPJMCH Program (FY95-2000)

Components by Financiers /a

(USS Million)

IDA UNFPA UNICEF USAID KfW FINNIDA HMG Total

A. OUTREACH SERVICE DELIVERY

MCH Workers/Sub-Health Posts - - 4.9 - 6.2 - 19.3 30.4Health Posts 10.8 - - - - - 6.6 17.4Primary Health Centers 3.7 - 0.2 - - - 1.2 5.1Monitoring&SupevisionSupport 6.1 1.5 - - - 1.0 8.7

Sub-total 20.7 1.5 5.1 - 6.2 - 28.1 61.7B. CLINICAL FPIMCH SERVICES

FP/MCH Clinical Units 1.6 0.2 - 4.5 - - 0.4 6.7Mobile Surgical Teams - 1.2 - - - - 0.0 1.2QualityAssurance Program . - 0.7 * - 0.3 - 0.5 - 1.5Other Clinical Activities - 0.2 - 3.5 - - 4.9 8.6

Sub-total 1.6 2.4 - 8.3 - 0.5 5.3 18.1C. LOGISTICS AND SUPPLIES

Contraceptives and Drugs - 4.2 - 8.0 - 1.3 0.0 13.5Stores Construction/Renovation 0.4 - - - - - 0.1 0.5Supplies Transport 0.3 0.2 - - - - 0.2 0.6Monitoring & Supervision Support 0.3 - - - - - 0.0 0.3Logistics Maintenance - 0.1 - - - - 3.2 3.3Otlher Logistics & Supplies - - - 1.5 - - - 1.5

Sub-total 1.0 4.5 - 9.5 - 1.3 3.5 19.8

D. IEC AND DEMAND GENERATION - 2.6 - 0.7 - - - 3.3

L POP. POL & IEC (NPC) - 6.4 - - - 6.4

F. HOSPITAL BOARDS - - - - - - 5.4 5.4

G. INSTMTTIONAL DEVELOPMENTTraining - 4.4 - - 1 - 5.5Management Information System 1.1 0.7 - 0.6 - - 0.1 2.5Clinical Training Centers 0.1 - - 0.7 - - 1.0 1.8Maintenance Capacity Development 0.1 - - - - - 0.0 0.1Project Management 2.1 - - - - - 0.4 2.5

Sub-total 3.4 5.1 - 1.3 - 1.1 1.4 12.3

TOTAL 26.7 22.5 5.1 19.8 6.2 2.9 43.7 127.0

al Source: MOH Financing Plan, August 1993 (Table 8), Donor inputs, and ccnsultations with HMG.Note: These are indicative figures only, based on available data and nission projections.

NEPALHMG'S FPIMCH Program (FY95-2000)

Components by Year

(USS Million)

94195 95/96 96/97 97/98 98/99 99/2000 rotal

A. OUTREACH SERVICE DELIVERY

MC1H Workers/Sub-Health Posts 2.7 3.6 5.1 6.1 6.4 6.6 30 4

Hlealth Posts 1.5 2.6 3.6 3.3 3.2 3.3 17.4

PrimaryHealthCenters 0.7 1.0 1.3 1.0 0.9 0.2 5. 1

Monitoring& Supervision Support 1.3 1.3 1.4 .5 1.5 1 5 8.7

Sub-total 6.2 8.4 11.4 11.9 12.1 11.7 61 7

B. CLINICAL FP/MCH SERVICESFPlMCH Clinical Units 0.9 1.1 1.3 1 4 1 6 0.4 6.7

Mobile Surgical Teams 0.2 0.2 0.2 0 2 0.2 0 2 1 2

QualityAssurance Program 0.2 02 02 0.3 03 0.3 1 5

OtherClinical Activities 0.4 1.1 1.6 2.1 1 7 1 7 8.6

Sub-total 1.7 2.6 3.3 4.0 3 8 2.6 18.1

C. LOGISTICS ^ ND SUPPLIESContraceptivesandDrugs 1.7 2.2 2.4 24 2.4 24 13.5

Stores ConstructiorJRcnovation 0.1 0.2 0.1 0.0 0.1 0 0 0.5

Supplies Transport 0.1 0.1 0.1 0.1 0.1 0.1 06

Monitoring & Supervision Support 0.1 0.1 0.1 0.0 0.0 0.0 0.3

Logistics Maintenance 0.4 0.5 0.6 0.6 0.6 0.6 3.3

Other Logistics & Supplies 0.2 0.2 0.3 0.3 0.3 0.3 1.5

Sub-total 2.5 3.3 3.5 3.5 3.5 3.5 19.8

D. IEC AND DEMAND GENERATION 0.5 0.5 0.6 0.6 0.5 0.6 3.3

E. POP. POL & IEC (NPC) 0.9 1.0 1.1 1.1 1.2 1.2 6.4

F. HOSPITAL BOARDS 0.9 0.9 0.9 0.9 0.9 0.9 5.4

G. INSTITUTIONAL DEVELOPMENTTraining 0.7 0.8 0.9 0.9 1.0 1.2 5.5

Management Information System 0.8 0.6 0.4 0.3 0.2 0.2 2.5

ClinicalTrainingCenters 0.1 0.3 0.5 0.3 0.2 04 1.8

Maintenance Capacity Development - - 0.1 0.0 - - 0 1

Project Management 0.8 0.6 0.4 0.3 0.2 0.2 2 5

Sub-total 2.4 2 3 2.2 1.9 1 6 2.0 12 3

TOTAL 15.1 19.0 23.0 23.8 23 6 22.5 127.0

NEPALPopulation and Family lieath Project

Expenditure Accounts by Components - Base Costs(NRa Million)

OUTREACII SlRVICI. DEIIVERY l.O)tISTI('S AND) SUPPLI.S INSnlnmONAI. DEVELO'PMENTMCII WorkensJ Primary Field 'IP/MICll Stores Feld Management Clinical Maint 1'roject Fhysical

Sub-llealth Iealth Ili:3th Operations Clinical Construction Supplics Operations Informatlion Training Capac Manage- ContingencissP'ost% Posts ('cntcrs Support llnits Rcnovation Transport Supprt Systcms Ccnters 1kV mcnt Total % Arnmunt

1. Invrnment CostsACivilWork - 404.1 141.6 - 29.7 173 - - - 56 - - 5983 50 299

B. ProfessionalFcs - - - - - - - - - - - 8 0 8 0

C.Furniturc - 12.9 1.8 - 03 01 - - - 02 - - 153 3

D. Equipmcnt - 48.8 22.2 - 23 7 2 6 - - 20 7 01 - 0 7 118 9 5 0 5 9

E. Vchicies - - - - 86 - II - 1 7 - - 20 3 31 8 5 0 1 6F. Techncal Assistance

Fomeign Consultants - 3.0 1.4 1.5 - - 6 2 49 - 2 6 - 19 5 -

Lecal Consultants - - - - - - - II - 0 5 28 2 29 8

Intcenationl Fellowships - - - - - * 4 4 4 4Rcgional Fellowships

Subtotal - 3.0 1 4 - I5 - - 6 2 6 0 - 1 32 6 57 7

G Local Training - -- - - - 3 5 7 7 I I - 12 4

H Studics - - 49 49Toial lnsetment Costs - 468 8 167 0 63 7 200 I 1 9 7 36 2 S 9 4 2 66 65 843 1 4 4 3-4 4 .

iI. Recurrent CostsA Incrmmental Salanec 355.3 - - - - - 8 1 435 1 - *

B. Operations and MaintenanceBuilding NAint. - 13.0 4.6 - 3 3 1 4 - - - - - 22 3Vehicles Maint. 3- - 3.1 - 71 -173 27 4

Fqupmncnt Maint - . . . 4 4 - . 4 4Subtotal - 13 0 4.6 - 10 8 1 4 71 - - - - 17 3 54 2

C Supplics Transporttion - - - - 9 6 - - - - 6

D. Consunnbles - - - - - - - - 7 6 - - 03 3 9E Travel and Daily Allowances - - .151 5 - 6 0 2 5 - - 11 0 82 9

TotalRecurrentCosts 3553 130 46 3515 108 14 166 60 160 387 8139

Total BASELINE tOSTS 355 3 4SI 8 1716 351 5 74 5 214 17 7 15 7 522 5 9 4 2 103 I 1656 9 2 A ; 4

PhysicalContingencres - 22 6 8 2 - 3 1 1 0 0 1 - I 0 - I 1 37 4

PriceContingencres 790 813 219 * 118 19 28 10 41 08 05 121 2173 24 '2

Total 'ROJE(`T COSTS 434 3 55 8 201 7 351 5 89 4 24 3 20 6 16 7 57 5 7 0 4 8 118 3 1,911 7 2 2 42

Fraxes 502 170 - 41 20 00 - 0 1 07 - 02 744 48 z

Foreign I.xchangc 188 5 70 1 - 45 7 8 I 3 5 5 5 27 1 2 0 2 4 13 4 3R6 5 4 1(7

It t

0*Os .

NEPALPopulation and Family Ilealth Project

Expenditure Accounts by Components - Base Costs(USS Minion)

OUTREACII SERVICE DELIVERY LOGISTICS AND SUPPLES INSTITLrnONAL DEVELOPMENT

MCH Workerst Primary Ficld FP/MCli Stores Field Management Clinrial Maint. Project Physical

Sub-llcalth lIcalth licalth Operations Clinical Construction Supplies Operation Information Training Capac. Managc- Continmics

Posts Posts Centers Support Units Renovabton Transport Support Systems Centers Dev. ment Total % Amount

L Investment Cos

A.CidWorks 8.2 2.9 0.6 0.4 - - - 0.1 - - 12.2 5.0 0.6

B. Profcurml Fees - - - - - - - - - - 0.2 0.2 -

C. Fumss 0.3 0.0 0.0 0.0 0.0 - 0.3

D. Equipmt - 1.0 0.5 - 0.5 0.1 - - 0.4 0.0 - 0.0 2.4 5.0 0.1

E.Vtdc - -- - 0.2 - 0.0 - 0.0 - 0.4 0.6 5.0 0.0

P. Techaicl A9SSitaeFCignC llmnb - 0.1 0.0 - 0.0 - - 0.1 0.1 - 0.1 - 0.4 - -

LOcl ComtslatatA - - - - - - - - 0.0 - .0 0.6 0.6 - -

tu tial Fdw5 - - - - - - - - - - - 0.1 0.1 - -

Regial FeiDowbip - - - -- - - - - -

Subtota 0.1 0.0 - 0.0 - 0.1 0.1 - 0.1 0.7 1.1

G. IAaTrainng - - - - - - - 0.1 0.2 - 0.0 - 0.3

It Sldc. - - .- . - . 0.1 0.1S-dc

Tetan,eslsftCosb - 9.6 3.4 1.3 0.4 0.0 0.2 0.7 01 01 1.4 17.2 4.4 0.8

IL RPcuret Costa

A. Incemena Saais 7.3 - - - - - - - - 0.2 7.4 -

EL Opwetam asd M ln_teceBtidiigMaiL- 0.3 0.1 0.1 0.0 - - - - 0.5 - -

V cs Maint - - - - 0.1 - 0.1 - - - - 0.4 0.6 - -

Equ*ntd Mabd - - - - 0.1 -- - - - 0.1 - -

Subtotl - 0.3 0.1 - 0.2 0.0 0.1 - - - - 0.4 1.1

C. SuppSTrapthion - -- - - - 0.2 - - - - - 0.2

D. Cwntnabes 0.1 0.0 0.1

ETraW and D*yAlwms - - - 7.2 - - - 0.1 0.3 - - 0.3 7.8 -

Total Recurent Cost 7.3 0.3 0.1 7.2 0.2 0.0 0.3 0.1 0.3 _ - 0.8 16.6 - -

Todl BASELINE COSTS 7.3 9.8 3.5 7.2 1.5 0.4 0.4 0.3 1.1 0.1 0.1 2.1 33.8 2.3 0.8

PlyucilCoatisngecui - 0.5 0.2 - 0.1 0.0 0.0 - 0.0 0.0 0.0 0.8 - -

Prces Cosrngectus 1.6 1.7 0.4 - 0.2 0.0 0.1 0.0 0.1 0.0 0.0 0.2 4.4 2.4 0.1

Total PRJECT COSTS 8.9 12.0 4.1 7.2 1.8 0.5 0.4 0.3 1.2 0.1 0.1 2.4 39.0 2.2 0.9

Taxes 1.0 0.3 - 0.1 0.0 0.0 - 0.0 00 - 0.0 1.5 4.8 0.1

Foreign Exchange - 3.8 1.4 - 0.9 0.2 0.1 0.1 0.6 0.0 0.0 n.7 7.9 4.3 0.3 PC

Ototo_9"

NQ

-44-

Annex 2.2

NEPALPopulation "' Family Health Project

Project Coml..oeats by Year - Base CostsJSS Million)

Base Cost93/94 94/95 95/96 96/97 97/98 98/99 99/00 Total

A. OUTREACH SERVICE DELIVERY

MCH Workers/Sub-Health Posts - 0.6 0.9 1.2 1.5 1.5 1.5 7.3Health Posts - 0.7 1.5 2.7 2.3 1.9 0.8 9.8Primary Health Centers - 06 0.8 1.0 0.8 0.2 0.1 3.5Field Operations Support - 1.0 1.1 1.2 1.3 1.3 1.3 7.2

Subtotal - 2.9 4.4 6.1 5.8 4.9 3.6 27.8

B. FPJMCH CLINICAL UNITS - 0.1 0.2 0.4 0.4 0.4 0.1 1.5

C. LOGISTICS AND SUPPLIES

Stores Construction/Renovation 0.0 0.1 0.1 0.0 0.0 0.0 0.0 0.4Sn.pplies Transport 0.0 0.1 0.1 0.1 0.1 0.1 0.0 0.4.:ieldOperations Support - 0.1 0.1 0.1 0.0 0.0 0.0 0.3

Subtotal 0.0 0.3 0.3 0.2 0.1 0.1 0.1 1.1

D. INSTITUTIONAL DEVELOPMENTManagement Information System - 0.1 0.3 0.2 0.2 0.1 0.1 1.1Clinical Training Centers - - 0.0 0.1 0.0 - - 0.1Maintenance Capacity Development - - - 0.1 0.0 - - 0.1Project Management 0.2 0.4 0.5 0.3 0.3 0.3 0.2 2.1

Subtotal 0.2 0.5 0.8 0.7 0.6 0.4 0.3 3.4

Total BASELINE COSTS 0.2 3.8 5.7 7.3 6.9 5.8 4.0 33.8

Physical Contingencies 0.0 0.1 0.2 0.2 0.2 0.1 0.0 0.8Price Contingencies - 0.1 0.3 0.8 1.1 1.2 0.9 4.4

Total PROJECT COSTS 0.2 3.9 6.2 8.3 8.2 7.1 5.0 39.0

Taxes 0.0 0.1 0.2 0.4 0.4 0.3 0.1 1.5Foreign Exchange 0.1 0.9 2.0 2.2 1.4 1.0 0.4 7.9

-45-

Annex 2.3

NEPAL

POPULATION AND FAMILY HEALTH PROJECT

EDA Disbursement Schedule

Amounts Cumulative CumulativeIDA Fiscal Year Disbursed Disbursements Disbursements Disbursement

& Semester (- USS Million ) Percentage Profile

19941st (January 94 -June 94) /a 0.20 0.20 1%

199S1st (July 94 - December 94) 1.54 1.74 7%

2nd (January 95 - June 95) 1.54 3.29 12% 3%

19961st (July 95 - December 95) 2.46 5.75 22%2nd (January 96 - June 96) 2.46 8.20 31% 8%

1997Ist (July 96 - December 96) 3.13 11.33 42%2nd (January 97 - June 97) 3.13 14.46 54% 22%

19981st (July 97 -December 97) 2.81 17.27 65%2nd (January 98 - June 98) 2.81 20.07 75% 42%

19991st (July 98 -December 98) 2.14 22.21 83%2nd (January 99 - June 99) 2.14 24.35 91% 67%

20001st (July 99 - December 99) 1.18 25.53 96%2nd (January 2000 - June 2000) 1.18 26.72 100% 84%

2001Ist (July 2000 - December 2000)2nd (January 2001 - June 2001) - - 98%

20021st (July 2001 - December 2001)2nd (January 2002 - June 2002) - - 100%

Closing Date: December 31, 2000

a/ Retoactive Financing of S200,000.

-46-

Annex 3.1

NEPAL

POPULATION AND FAMILY HEALTH PROJECT

Management Structure

HM

Policy + Inter-Ministerial FP/MCH Program MOH, Minister (ChairTnan)

Coordination Devel MOH. Secretary} MOH, DO, DFIS/MOH

MOH, Chief Planning Division(Member Secretary)

* MOF, Chief for Foreign, Aid Division* MHPP, Secretary* NPC, Chief Pop. & Health Division

||X <si ~~~~~~~~~* MOH, Secretary (Chairman)

| .*(PFHP) MOH, Chief Planning Div. (Coordinator)

Intra-Ministerial Coordination Executive * MOH, DO, DHSSteering ttee MOH/DHS, Director, Planning Division

* MOH/DHS, Director, Family Health DivisionMOH/DHS, Director Logistics Division

* MOF, UnderSecretary, Foreign Aid Division* MHPP, Director-General, Depatment of

BuildingsP* PU Director

Managemaent Monitoringand Implementation Project Implementation Unit

Prepare status reports (PFHP)for S. C., Board & IDA PW_ PIUDirecto

Project bIplementation Unit(PFHP)

PIU Deputy Drco

rPrograrn MonitoringA & Logistics & Prc - Infifastructure Fiac & d;;1

Supwnision Setion n < men Section IDevlomn Swnionxl Section _ _

* Monitor general program performance * Coordinte logistics infrastnucture * Prepare all design * Project accounting

* Compile data from MOW donors & with logistics system development bid documents * Funding disbursements

others on service delivery. * Monitor regional logistics * Manage all bid & award * Financial auditing

* Field visits to verify performance supervisorM cells procedures * Office adrministration support

indicators * Prepare bid documents * Supenvse construction activities * Financial reporting

' Status reports for S.C., Board & IDA * Manage all bid procedures & implementation scheduleMonitor supervision & outreach Monitor installation in facilities * Monitor & revise

service delivety support inplemention schedule on

* Monitor & supavise implementation service delivery perfomanceof MIS Program activities

Project Implementation Schedule: Nepal - Population and Family Health Project

Pre-Proj. Year 1 Year 2 Year 3 Year 4 Year 5 Year 6Acdlvitlesl/Time ScheduLe -FY 93 194 94 /95 95 196 96 /97 97198 98199 99 2000

A. Instititutonal Dev. & Project ManagementFinfflize Management Plan/ Est. Core PIU PIU Staff Training. & EquipNVeNcices ProcurementPIU Operations & SupportMON Maintenance Capacity Dev.IT.A.&Training _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

8. Program Dcv., Monitoring & SupervisionDefine Program & Services Supp. Performance Crit.Support to MOH Monitoring & SupervisionMonitoring of MOH Support -ma mmMIS Analysis & Design /Tech. Assistance MMIS - Equipment & Supplies ProcurementMIS - Training __ _ __ _ __ _ __ _ __ _ _ _ __ _ __ _ __ _ __ _ __SEEN =_ _ _ _ __ _ __ _

C. Logistics System Development Support-IDefine Logistics Monitoring Plan

Rt,pair of Ex. Warehouses TNew Warehouse ConstructionD TTTWarehouse Equip. & Furn., Vehicle ProcurementTransportation SupportLogistics MonitoringLogistics Tech. Assistance am______________ mm___ mm______ I=______ m m______

D. Health FacRiitis ImprovementFinalize Project Implementation PlanPrepare Sample Bid Documents & Site SelectionPrepare Design & Tender DocumentNew HP ConstructionTTTTTTAdd'I. Works Existing Health Posts TTTBESE PHC Construction/UpgradingTTTTNew FP/MCH UnitsD TTT

New Clinical Training CentersD TTTPrepare Equip. Specifications & Bid DocumentsTender & Procurement - Equipment_fAnnual_Pkgs) _______________________

Legend: D = Design T = Tender/Award PeriodmN4

IMPLEMENTATION SCHEDULECIVIL WORKS

PROJECT 1 2 1 4 5 6

YEAR TOTALFISCAL 94/95 95/96 96/97 97/98 98/99 99/2000YEAR

No. No. of No. No. of No. No. of No. No. of No. No. *f No. No. of

BUIIDING of Tender of Tender of Tender of Tender of Tender of TenderTYPES Bldgs. Pack Bldga. Bldgs. Bldgs. Pack Bldgs. Pack Bldgs. Pack Bldgs. Pack

NEW PHC 1 2 2 5

UPGRADEDPHC 5 1 4 1 4 1 4 1 2 1 1 1 20

NENW EALTH 2M SM 6M 6M 4M 2M 25POST 2H 2 5R 3 13H 5 13H 5 12H S SH 3 50

ST ST 13T 12T 10 ST so

RENOVATED

HP 7 2 15 3 25 4 27 S 20 4 6 2 100

PP/MCH I 2 2 5 >

UNITS

. INI=AL 2 3 1 2 2= 7TEG CTRS

NEWWARMIOUS 2 1 1 4

| RBPAIR 2 2 4

APPROX.NO. OFPACKAGES 5 7 1 017 10 12 11 6

LEGEND? N - Mountain Note - Warehouse Construction and repairs will not be done in thisH - Hill -ackage system.T - Terai

YEARLY CRITICAL DATES FOR CIVIL WORKS IMPLEMENTATION

YEAR 1 YEAR 2 (3,4,5)

PROJECT PANAGENENT JAN APR MAY MAY JUNE JUNE JULY AUG AUG OCT OCT 15- JAN APR MAY MAY JUNE JUNEACTIVITIES 15 1 1 30 21 23 15 1 25-30 15 JA 15 15 1 1 30 21 23

PIU Contracts Consultantsto Prepare Site Adaptationor Renovation Drawings X X

PIU Receives SiteAdeptation and Renovation X XDrawings

Start Advertising forTender. Remind Consultants Xto Contract for Site SPN X

Issue Tender Docunents X X

tenders Received mnd Xopened Pubticty X 4

Tenders Evatuation XComplete X

Tender Evaluation Sent toIDA K x

Approval And/Or Coumentsfrom IDA X

Approval From ProjectMNwagement K

Issue of Constr. Contractnd Advance Payment X

Start Construction =

Site Selections forFolloifng Year to IDA X

Evaluate Consultants andContractors of Past Year X =

w

-.50-

Annex 3.5

LIST OF SITES FOR FIRST AND

SECOND YEAR CONSTRUCTION PROGRAM

FOR HEALTH FACILITIES

Primary Health Centers (PHCs)

1st Year District

Upgraded from Health Posts 1. Katari Udayapur

2. Yadukuha Dhanusha

3. Baggauda Chitawan

4. Damauli Tanahu

5. Patan Baitadi

2nd Year

New 1. Mangalbare Morang

Upgraded from HealthPosts 1. Gausala Bazar Mahottari

2. Satwariya Parsa

3. Dumkauli Nawalparasi4. Kanchanpur Saptari

Health Posts (HPs) New

1st Year 1. Sabaila Dhanusha2. Mahendrakot Kapilbastu3. Garkhakot Jajarkot4. Jhurkiya Morang5. Sitalpati Sankhuwasabha6. Rampur Okhaldhunga7. Godar Dhanusha8. Sinurjoda Dhanusha9. Betani Makawanpur

2nd Year 1. Devisthan Sindhupalchok2. Aru Chanaute Gorkha3. Chitithala Lamjung4. Dhakadhahi Rupandehi5. Jharkot Mustang6. Ila Dolpa7. Deudakala Bardiya8. Phattepur Banke9. Hekapa Humla10. Raikawar-Bichawa Kanchanpur11. Sirkot Achham12. Khiratadi Bajhang13. Sinam Taplejung14. Kumar Khoda Jhapa15. Chisapani Khotang

-51-Annex 3.6Page 1 of 2

PROPOSED SITES - PRIMARY HEALTH CENTERS (PHCs)

District Present Health Post

Area

A. Eastern Region:

1 Ilam Bajhigaon

2 Jhapa Dhulabari

3 Bhojpur Kaltang

4 Morang Mangalbare (New site)

5 Morang Bayerban

6 Sunsari Itahari

7 Udayapur Katari

8 Saptari Kanchanpur

9 Siraha Malahniya

B. Central Region

1 Sindhuli Sirthuli

2 Dhanusha Yadukuha

3 Mahottari Gausala Bazar

4 Sarlahi a) Bhaktipur

b) Sisutia

5 Chitawan Baggauda

6 Makwanpur Palung

7 Parsa Satwariya

8 Bara a) Simrangara

b) Simra

9 Rautahat Dumariya Motiwan

C. Western Region1 Gorkha Makat Singh

2 Kaski Shisuwa

3 Tanahu Damauli

4 Syangja Garun Dhyanling

5 Nawalparasi Dumkauli

6 Palpa Tanahu

7 Rupandehi Lumbini

8 Kapilvastu a) Maharajganjb) New site (Possibility of

new site in between Ilaka no.

9 and 10)

9 Gulmi Aslewa

-52-Annex 3.6Page 2 of 2

District Present Health PostArea

D. Mid-Western ReQion1 Dang Tulsipur2 Banke Bankatwa3 Bardiya Rajapur4 Surkhet Saharkot

E. Far-West1 Kailali Tikapur2 Kanchanpur Sripur3 Baitadi Patan4 Darchula Rithachaupata

Summary Distribution of Potential Sites

Regional Category Far- Mid- Western Central Eastern TotalWestern Western

Terai 2 3 3 7 6 21Hills 1 1 6 2 3 13Mountains 1 - - - - 1

Total 4 4 9 9 9 35

-53-NEPAL

Annex 3.7PROJECT IMPLEMENTATION SCHEDULE: POPULATION AND FAMILY HEALTH PROJECT

COMPONENT: LOGISTICS

PRE-PROJECr POST PROJECT EFFECTIVENESSACTIVITY YEAR 1 2 3 4 5 6

93/94 94/95 95/96 96/97 97/98 98/99 99/00Element: Misc. civil works

Job: Bridge repair, Pathalaiya_ Perimeter wall, PathalaiyaWater system, Pathalaiya __ _

Nepalgunj compound wall ...... ...........-,_

lement: Renovations, RepairsJob: Bldg. #3 roof repair, Pathalaiya -e =

Bldg. #1 roof repair, Pathalaiya .s._-Bldg. #2 roof repair, Pathalaiya ......Bldg. #4 roof repair, PathalaiyaBldg. #1 roof repair, Butwal -___:Staff quarter construction, Biratnagar ___aa

Bldg. #2: roof repair, Nepalgunj ______..

Bldg. #1: construct second storey, Nepalgu iBldg. #4: construct second storey, Nepalgux _i _*sf_a

Construct generator house, Nepalgunj ... ___

_Old bldg. roof repair, NepalgunjRoof repair, Dangadhi a ' ,; '. *

Conversion of garages, Teku Central Whse --- .- __ ,___==

Element New ConstructionJob: Regional whse, Biratnagar

Malaria whse, PathalaiyaStaff quarters, Pathalaiya X; ,*

Central whses, TekuSubregional whse, Dipayal -. =.=.=.=.=

Element Logistics monitoringJob: Motorcycle procurement a

Monitoring trips .. .. ...

Procurement of Equipment/Furniturelement Warehouse equipment

Job: Warehouse furniture

Element TransportationJob: movement of supplies

Element Training/Technical AssistanceJob: organize training sessions X X X X X X

conduct technical support assignments XX XX XX

-54-Annex 3.8Page 1 of 7

NEPALPOPULATION AND FAMILY HEALTH PROJECT

IMPLEMENTATION SCHEDULE FOR FIELD-BASED INTEGRATED

MANAGEMENT INFORMATION SYSTEM

A. Pre-Project Activities (up to July 1994)

1. In consultation with IDA, identify local and international resource

person(s) for Technical Assistance in the following areas:

Review of existing management information system.Finalization of reporting forms and registers to be used in pilot

districts.

Detailed implementation schedule for MIS after July 1994.Identifying required equipment for the implementation of the pilot

MIS.

2. Liaise with other donors for MIS by MOH.

3. Full staffing of the MIS Section in the Planning Division of the

Department of Health Services.

4. Procurement of required vehicle and equipment.

Indicators

By July 1994:

MOH will provide the name(s) of the local and international resource

person(s).

MOH will provide a working schedule for these resource person(s).

All staff at the MIS Section of the Planning Division of the

Department of Health Services will be in place.

MOH will complete a review of the existing management information

system and will present the findings to the World Bank.

MOH will present the registers and forms to be used in the pilot

districts.

MOH will provide the names of the pilot districts.

MOH will provide a detailed implementation schedule for MIS during

the Project period.

MOH will provide a list of the equipment procured for the pilot MIS.

-55-Annex 3.8Page 2 of 7

B. Activities in Year One: 1994/95

Implementation of the pilot MIS over an estimated one-year period (July 94

- June 95):

1. Printing of forms and registers to be used in pilot districts.

2. Procurement of equipment for the Regions and Districts involved in

the pilot MIS.

3. Training of staff from MIS Section of the Planning Division in the

Department Health Services and the Planning, Monitoring and Data

Section of relevant Regional Health Services Directorates.

4. Training of staff of the Statistics Section of the District Health

Office, and staff of health facilities in the pilot districts.

5. Distribution of forms and registers to DHO and health facilities in

the pilot districts.

6. Distribution of equipment to the Regional Health Directorate and

District Health Office involved in the pilot MIS.

7. Ongoing supervision of health workers in the utilization of MIS:

reporting and feedback.

B. Mid-term evaluation of the utilization of MIS in the pilot districts

by local resource persons.

9. Preparation of a model annual report, based on the pilot MIS.

10. Two District level MIS review meetings (January and May 1995) to be

attended by representatives of the DHO and health facilities in the

pilot districts, chaired by the relevant Regional Health

Directorate.

11. Identification of local and international resource persons who will

evaluate the pilot MIS.

Indicators

By the time of the arrival of the First Supervision Mission (by December 1994):

MOH will provide a report of the training of staff from central,regional and district levels involved in the Pilot MIS.

MOH will provide a list of equipment, forms and registers, and the

places where these have been distributed.

MOH will produce a progress report, including a sample annual report

based on the information generated through MIS.

-56-Annex 3.8Page 3 of 7

By the time of the arrival of the Second Supervision Mission (by June 1995):

MOH will present the Mid-term evaluation report as prepared bylocal resource persons.

MOH will present the reports of the two district level MIS reviewmeetings which will take place in the pilot districts.

MOH will provide the names of the local and international resourcepersons who will evaluate the pilot MIS.

C. Activities in Year Two: 1995/96

1. Evaluation .f the pilot MIS by local and international resourcepersons (September 1995).

2. Continuation of MIS in the former pilot districts.

3. Expansion of MIS to other districts in a phased manner; number,location and timing to be decided by MOH, based on recommendationsmade by the evaluation team:

a. Printing of forms and registers to be used in all districtsinvolved in MIS.

b. Procurement of equipment for the regions and districtsinvolved in MIS.

c. Training of staff from MIS Section of the Planning Division inthe Department of Health Services and the Planning, Monitoringand Data Section of relevant Regional Health ServicesDirectorates.

d. Training of staff of the Statistics Section of the DistrictHealth Office, and staff of health facilities in the relevantdistricts.

e. Distribution of forms and registers to DHO and healthfacilities in the relevant districts.

f. Distribution of equipment to the relevant Regional HealthDirectorates and District Health Offices previously notinvolved in the pilot MIS.

g. Ongoing supervision of health workers in the utilization ofMIS: reporting and feedback.

h. One District level MIS review meeting (May 1996) to beattended by representatives of the DHO and health facilitiesin the district, chaired by the relevant Regional HealthDirectorate.

-57-Annex 3.8Page 4 of 7

4. A short-term review of MIS by local and international resourcepersons to assess progress and address possible problems (May 1996).

Indicators

By the time of the arrival of the Third Supervision Mission (by December 1995):

MOH will. present the Pilot MIS Evaluation Report, prepared by localand international resource persons.

MOH will provide a list of districts to which the MIS will beexpanded, including a timetable.

MOH will provide a report of the training of staff from central

level, as well as from regions and districts newly involved in MIS.

MOH will provide a list of equipment, forms and registers, and theplaces where these have been distributed.

By the time of the arrival of the Fourth Supervision Mission (by June 1996):

MOH will provide a report of the training of staff from regions and

districts newly involved in MIS.

MOH will present a summary report of the district level MIS review

meetings which will take place during 1995/96.

MOH will present the short-term review prepared in May 1996.

D. Activities in Year Three: 1996/97

1. Continuing expansion of MIS:

a. Printing of forms and registers to be used in all districtsinvolved in MIS.

b. Procurement of equipment for the regions and districts newlyinvolved in MIS.

c. Training of staff of the Planning, Monitoring and Data Sectionof relevant Regional Health Services Directorates and

Statistics Section of the District Health Office, and staff of

health facilities in the,relevant districts.

d. Distribution of forms and registers to DHO and healthfacilities in the relevant districts.

e. Distribution of equipment to Regional Health Directorates andDistrict Health Offices newly involved in MIS.

f. Ongoing supervision of health workers in the utilization ofMIS: reporting and feedback.

-58-Annex 3.8Page 5 of 7

g. One District level MIS review meeting (May 1997) to beattended by representatives of the DHO and health facilitiesin the district, chaired by the relevant Regional HealthDirectorate.

2. A short-term review of MIS by local and international resourcepersons to assess progress and address possible problems (May 1997)

Indicators

By the time of the arrival of the Fifth Supervision Mission (by December 1996):

MOH will provide a list of districts to which the MIS will befurther expanded, including a timetable.

MOH will provide a report of the training of staff from regions anddistricts newly involved in MIS.

MOH will provide a-list of equipment, forms and registers, and theplaces where these have been distributed.

MOH will present the first annual report (1995/96) based oninformation provided through MIS in relevant districts.

By the time of the arrival of the Sixth Supervision Mission (by June 1997):

MOH will provide a report of the training of staff from regions anddistricts newly involved in MIS.

MOH will present a summary report of the district level MIS reviewmeetings which will take place during 1996/97.

MOH will present the short-term review prepared in May 1997.

S. Activities in Year Four: 1997/98

1. Completion of expansion of MIS.

2. Printing of forms and registers to be used in all districts involvedin MIS.

3. Procurement of equipment for the remaining regions and districts.

4. Training of staff of the Planning, Monitoring and Data Section ofthe remaining Regional Health Services Directorates and StatisticsSection of the District Health Offices, and staff of healthfacilities in the remaining districts

5. Distribution of forms and registers to DHO and health facilities inall districts.

-59-Annex 3.8Page 6 of 7

6. Distribution of equipment to the remaining Regional HealthDirectorates and District Health Offices.

7. Ongoing supervision of health workers in the utilization of MIS:reporting and feedback.

8. One District level MIS review meeting (May 1998) attended byrepresentatives of the DHO and health facilities in the district,chaired by the relevant Regional Health Directorate.

9. A short-term review of MIS by local and international resourcepersons to assess progress and address possible problems (May 1998)

Indicators

By the time of the arrival of the Seventh Supervision Mission (by December 1997)

MOH will provide a list of districts to which the MIS will befurther expanded, including a timetable.

MOH will provide a report of the training of staff from regions anddistricts newly involved in MIS.

MOH will provide a list of equipment, forms and registers, and theplaces where these will be distributed.

MOH will present the second annual report (1996/97) based oninformation provided through MIS in relevant districts.

By the time of the arrival of the Eighth Supervision Mission (by June 1998):

MOH will provide a report of the training of staff from regions anddistricts newly involved in MIS.

MOH will present a summary report of the district level MIS reviewmeetings which will take place during 1997/98.

MOH will present the report prepared by the short-term review in May1998.

F. Activities in Years Five and Six (1998/99 & 1999/2000):

a. Continuation of monitoring MIS.

b. Printing and distributing of forms and registers.

c. Ongoing supervision of health workers in the utilization of MIS:reporting and feedback.

d. One District level MIS review meeting (May 1999 and May 2000)attended by representatives of the DHO and health facilities in thedistrict, chaired by the relevant Regional Health Directorate.

-60-Annex 3.8Page 7 of 7

e. Refresher training for district health staff.

f. Final Evaluation of the integrated MIS by a team of local andinternational resource persons (May 1999 and May 2000).

Indicators

By the time of the arrival of the Ninth Supervision Mission (by December 1998):

MOH will present the third annual report (1997/98) based on

information provided tbrough MIS in all districts.

MOH will provide a report of the refresher training of staff fromdistricts involved in MIS.

MOH will present a summary report of the district level MIS reviewmeetings which have taken place during 1997/98.

By the time of the arrival of the Tenth Supervision Mission (by June 1999):

MOH will present the evaluation report of integrated MIS prepared by

the evaluation team in May 1999.

MOH will finalize plans for Year Six (1999/2000).

During Year Six (1999/2000):

MOH will continue the monitoring of the field-based integrated MIS,

evaluation of data compilation and processing, and feedback atvarious levels; and prepare final reports on the MIS experience for

joint review by MOH and IDA Supervision Missions with a view to

finalizing MIS instrumentation for implementation throughout the

country.

I

-61-Annex 3.9

NEPALPOPULATION AND FAMILY HEALTH PROJECT

INSTITUTIONAL DEVELOPMENT TECHNICAL ASSISTANCE

Logistics

6 months international TA Short-term consultant to12 months local TA assist MOH in four ways:

1. Help organize annual trainingprograms for all logisticsstaff.

2. Review activities of RegionalMonitoring and Supervision Teams

and develop solutions toproblems.

3. Review transportation system;evaluate; develop solutions.

4. Systematically assess need foradditional storage space.

Maintenance CaDacity Buildina

3 months international TA 1. To develop and conduct a18 months local TA training Workshop for local

staff who will becometrainers for fac4.litiesmanagement and maintenance.

2. . :pare maintenancei. .ruction manual for use bylocal trainers.

MIS

5 months international TA 1. Assess needs and gaps in MIS.36 months local TA

2. Develop instrumentation, datacollection, and analysisplans for field records and MISfeedback at various levels.

3. Develop training modules andconduct training of trainers atvarious levels.

4. Set up pilot MIS in selectedDistricts, and formulate plansfor expansion throughout thecountry.

5. Help MOH establish a function-ing field-based andintegrated MIS.

-62-

Annex 3.10Page 1 of 2

NEPALPOPULATION AND FAMiILY HEALTH PROJECT

CONSTRUCTION MONITORING PLAN

1. The Infrastructure Development Section of the PTU will beresponsible for all construction activities of the Project. This section willconsist of the following, and will be augmented by staff and/or consultants asneeded:

1 Chief (Engineer)1 Senior Architect1 Senior Engineer1 Engineer2 Draftsmen/overseers

2. The 270 new and/or renovated buildings inzluded in the Projectconsist of the following types:

a. 225 Health Posts (HPs: 125 new, 100 renovated)b. 25 PHCs (5 new, 20 upgraded from HPs)c. 5 FP/MCH Unitsd. 7 Clinical Training Centerse. 8 Warehouses (4 new, 4 renovated)

3. Prototype drawings approved by HMG and IDA have been developedalong with outline specification and cost estimates for three types of HealthPosts (Terai/High Client Load, Hill/Medium Client Load, and Mountain/LowClient Load) and two types of PHCs (upgraded and new).

4. Final drawings, specifications, cost estimates and technicalconditions for tenders are being developed tor the five prototype buildingsfor PHCs and HPs described above. This will enable to tender 150 (125 HPs and25 PHCs) of the 270 buildings over the next six years with only siteadaptation drawings (compound walls, drainage, and planting) to be preparedfor each yearly tender. Tender packages for PHCs and HPs will be advertisedfor commencement of construction from the first year of the Project; whilethose for warehouses, FP/MCH Units, and Clinical Training Centers will beadvertised for the third and subsequent years of the Project, along withpreparation of corresponding final drawings and related documentation.

5. All tendering will be LCB and will be advertised and issued by thePIU. The Unit will also be responsible for opening and evaluating alltenders. Tendering will be done each spring, and will be in the form ofpackages of a number of buildings (5-8) for each tender. T1--. number ofpackages per year will vary, starting at about 5 in the first year andincreasing to about 12 in the third, fourth and fifth years. Detailedschedules of infrastructure activities and implementation modalities are notedin the Project Management Plans (Project File) and referred to in Annex 3.3.As indicated there, major construction works are targetted to be completed byYear 5, with Year 6 primarily devoted to following-up any unfinishedconstruction and renovation.

-63-

Annex 3.10Page 2 of 2

6. For earch package, consultants will be contracted by the PIU toprovide one full-time overseer at each site and one full-time engineer tosupervise progress of the package as well as the work of the overseers. Thisprocedure applies to all packages and all sites during the length of theProject. During the year the PIU will make surprise inspections at all qites.

7. The full-time engineer for each package will be responsible forobtaining As-Built drawing from the contractor for each building in thepackage at the time of completion of the works.

8. Since construction of each of these buildings will take about ayear, it will be possible to evaluate both contractors and consultantsfollowing the completion of a package and decide whether they should beconsidered for the following year's work.

9. During subsequent visits, PIU staff and IDA Supervision Missions willascertain the level of utilization of the constructed and renovatedfacilities, including availability of appropriate staffing and supplies.

-64-

Annex 3.11

NEPALPOPULATION AND FAMILY HEALTH PROJECT

FIELD OPERATIONS SUPPORT

As shown on the Management Structure, the "Program Monitoring andSupervision Section" has the responsibility to monitor the supervision andoutreach service delivery support.

.'hile monitoring this service delivery, it will administer thedisbursement of funds and reimbursing MOH for TA/DA expenses as incurred. Allregular HMG accounting and auditing procedures will be followed so as topermit accountability in a purely financial sense. This Section will also setup its own procedures to insure that the TA/DA reimbursements are exclusivelyfor client outreach and for field supervisory travel, and this will be done asfollows: (a) the MOH will prepare a schedule of estimated TA/DA needs byquarter, in advance of the beginning of the quarter, and advances against suchtravel can be made by the PIU to eliminate the long delays in reimbursing thetraveller which have plagued the system in the past; (b) a summary reportlisting the persons and installations using such funds and also the date, timeand objective of the travel will be filed with the PIU by the MOH everyquarter; and (c) the staff of this Section will go to the field regularly tomake unannounced visits to installations using the funds, to inspect thevoucher files which they are supposed to maintain, and to observe the outcomeof such travel.

-65-

Annex 3.12

Page 1 of 3

NEPAL

POPULATION AND HEALTH PROJECT

BANK SUPERVISION INPUT INTO KEY ACTIVITIES

Tentative Main Staff Weeks

Dates Activity Specialty in field

FY 94

ril-May Finalize Implementation Task Manager 12 wks

1994 Plans and Operations Architect

Manual. Procurement Specialist

Review procurement Logistics Specialist

procedures for retroactive Management Specialist

financing.

July-August Project Launch Task Manager

1994 Review plans for coming Architect

years. Procurement Specialist 15 wks

Review monitoring Logistics Specialist

and supervision. Disbursement Specialist

Management Specialist

FP/MCH Physician

FY95

November 1994 Supervision Mission Task Manager

Review sites for years Architect

3-4. Procurement Specialist

Review starting of Logistics Specialist 15 wks

construction and FP/MCH Physician

procurement, and plans

for next year.

May 1995 Supervision Mission Task Manager

Review construction Architect

and procurement program. Procurement Specialist 12 wks

Review logistics and Logistics Specialist

MIS plans. MIS Specialist

-66-

Annex 3.12

Page 2 of 3

Tentative Main Staff Weeks

Dates Activity Specialty in field

FY96

November 1995 Supervision Mission Task Manager

Review construction Architect

completion. Procurement Specialist 15 wks

Review procurement Logistics Specialist

progress, and plans FP/MCH Physician

for remaining years.

Review plan for next year.

lay 1996 Supervision Mission Task manager

Review construction and Architect 12 wks

procurement progress. Procurement Specialist

Review monitoring MIS Specialist

and supervision.Financial report.

FY97

'ovember 1996 Supervision Mission Task Manager

Review construction Architect

completion and pro- Procurment Specialist 15 wks

curement progress. Logistics Specialist

Review plans for next FP/MCH Physician

year.Joint Midterm Task Manager

Review of Project Architect

with HMG. Procurement 12 wks

Logistics Specialist

MIS Specialist

lay 1997 Supervision Mission

Review sites for years 5-6

and plans for remaining

years.Review MIS.

FY 98

November 1997 Supervision Mission Task Manager

Review starting of Architect

construction and Procurement Specialist 15 wks

procurement and plans FP/MCH Physician

for the next year.

-67-Annex 3.12Page 3 of 3

Tentative Main Staff Weeks

Dates Activity Secialt in field

May 1998 Supervision Mission Task Manager

Review construction Architect 12 wks

and procurement Procurement Specialist

program and plans for MIS Specialist

next year.

November 1998 Supervision Mission Task Manager

Review construction Architect 15 wks

and procurement, and Procurement Specialist

plans for next year. Logistics Specialist

FP/MCH Physician

May 1999 Supervision Mission Task Manager

Review construction Architect 12 wks

and procurement Procurement Specialist

program, and plans for MIS Specialist

next year.

November 1999 Supervision Mission Task Manager

Review of remaining Architect 15 wks

construction and Procurement Specialist

procurement plans. FP/MCH Physician

May 2000 Supervision Mission Task Manager

Joint HMG-IDA Architect 20 wks

Project Completion Review. Procurement SpecialistLogistics SpecialistMIS Specialist

FP/MCH Physician

-68-

Annex 4

Page 1 of 2

NEPALPOPULATION 7n^'D FAMILY HEALTH PROJECT

SELECTED DOCUMENTS IN PROJECT FILE

A. Reports and Studies Related to the Sector/Subsector

1. MOH (HMG), National Health Policy of His Majesty's Government of

Nepal, 1991.

2. NPC (HMG), Population Policy and Program, presented to the

International Donors Conference, Kathmandu, March 1992.

3. NPC (HMG), Eighth Five-Year Plan, Summary, Unofficial Translation,

July 1992.

4. CBS (HMG), The Analysis of the 1991 Population Census, 1993.

5. MOH (HMG), Nepal Fertility, Family Planning and Health Survey

(1991), 1993.

6. MOP (HMG), Organization Structure of the Ministry of Health, July

1993.

7. MOH (HMG), Financing Plan for FP/MCH Program, 1993.

B. Reports and Studies Related to the Project

1. Special Reports prepared by consultants for the Preparation Mission

(July-August 1990).

2. Reports of Seven Working Groups prepared for Pre-Appraisal anid

Appraisal Missions.

Phase I. Situation Analysis (February 1991)

Phase II. Options for Interventions (April 1991)

Phase III. Resource and Management Implications for Project

Components (July 1991, November 1991)

3. Re orts of JGF Operations Research for Project Preparation, October

1993.

4. JGF Infrastructure Development Survey Report, October 1993.

5. Technical Reports on Project Design and Phasing by national and

international consultants, February-October 1993.

-69-

Annex 4

Page 2 of 2

C. Working Papers

1. IDA Technical Appraisal Mission: Nepal - Population and Family

Health Project, July 1991.

Aide MemoireWorking Papers

Project Costs

Back-to-Office Report

Post-Mission Letter to the Government

2. IDA Post-Appraisal Mission: Nepal - Population and Family Health

Project, April 1992.

Aide MemoireWorking Papers

Project Costs

Back-to-Office Report

Post-Mission Letter to the Government

3. IDA Pre-Negotiations Mission: N epal - Population and Family

Health Project, September-October 1993.

Aide Memoire

Working PapersProject Costs

Back-to-Office Report

Post-Mission Letter to the Government

4. Other Documents

a. Detailed Cost Tables for the Project

b. Working Papers for all Project Costs

c. Prototype Drawings for Health Facilities

d. Outline Specifications and Preliminary Cost Estimates for

Prototypes

e. Furniture and Equipment Lists

f. TORs for PIU Members

g. Project Management Plansh. List of Alterations required and estimated Costs for PIU

Officei. Proposed Project Items to be implemented through Retroactive

Financing

j. Copy of Approved Changes in the Sample Bidding Documents:

Procurement of Works (Smaller Contracts)

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