World Bank Document€¦ · Report No. 9262 PROJECT COMPLETION REPORT PAKISTAN POPULATION PROJECT...

Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No. 9262

PROJECT COMPLETION REPORT

PAKISTAN

POPULATION PROJECT(CREDIT 1350-PAK)

DECEMBER 28, 1990

Population and Human Resources DivisionCountry Department IEurope, Middle East and North Africa Regional Office

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 World Bank authorization.

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ABBREVIATIONS

AMC Advisory Management CommitteeAV Audio-VisualDHS Demographic and Health SurveyFP Family PlanningFWA Family Welfare AssistantFWC Family Welfare CentreFWW Family Welfare WorkerGOP Government of PakistanIDA International Development AssociationIEC Information, Education and CommunicationsILO International Labour OrganisationMCH Maternal and Child HealthNCO Non-governmental OrganizationODA Overseas Development Administration (United Kingdom)

PAC Project Administration CellPC-l Planning Commission (form) 1PCR Project Completion ReportPWD Population Welfare DivisionPWTI Population Welfare Training InstituteSAR Staff Appraisal ReportSDR Special Drawing RightsTGI Target Group InstitutionsUNFPA United Nations Population FundUSAID United States Agency for International Development

FISCAL YEAR OF BORROWER

Government of Pakistan : July 1 to June 30

FOR OFFICLL USE ONLYTHE WORLD BANK

Washington, D.C. 20433U.S.A.

OffKe of DOrectw-GfeneralOperations Evaluation

December 28, 1990

MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT

SUBJECT: Project Completion Report on PakistanPopulation Proiect (Credit 1350-PAK)

Attached, for information, is a copy of a report entitlec

"Project Completion Report on Pakistan: Population Project (Credit

1350-PAK)" prepared by the Europe, Middle East and North Africa

Regional Office with Part II contributed by the Borrower. No audit

of this project has been made by the Operations Evaluation

Department at this time.

Attachment

This document has a restricted distribution and may be used by recipients only in the performanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

FOR OFFICIAL USE ONLY


PAKISTAN


Table of Contents

Page No.

Preface ............... ............................... iEvaluation Summary ................................. iii

PART I PROJECT REVIEW FROM IDA'S PERSPECTIVE

Project Identity .1

Background .1

Project Objectives and Description. 2

Project Design and Organization .2

Project ImplementationCredit Effectiveness and Project Start-up 4Critical Variances. 4Factors Affecting Project Implementation 5Project Risks. 5Disbursements. 6Procurement. 6Consultants. 6

Project Results. 6

Project Sustainability. 7

IDA and Borrower Performance. 7

Lessons Learned. 8

Project Documentation and Data. 9

PART II PROJECT REVIEW FROM BORROWER'S PERSPECTIVE

General Comments. 9

Performance .11

Bank-Borrower Relationship .14

Adequacy of Detailed Informationin Report .14

Conclusions .15

This document has a restricted distribution and may be used by recipients only in the performanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

Page No.

PART III STATISTICAL INFORMATION

Related IBRD Loans and IDA Credits .... ...... 16

Project Timetable ........ ................... 16

Credit Disbursements ....... ................. 17

Project Implementation ...... ................ 18

Project Financing ........ ................... 22

Project Cost ........... ..................... 23

Proiect ResultsDirect Benefits ........ ................... 24Studies .............. ..................... 26

Covenants .............. ..................... 27

Use of IDA ResourcesStaff Inputs ......... ..................... 30Missions . .................................. 31

ANNEXES

Annex 1. Detailed Project Features .... .......... 32Annex 2. National Family Planning Performance 38Annex 3. National Teacher Enrollment for

Population Education Courses ...... 41

Attachment 1. ODA Comments on the PCR .................... 42

Attachment 2. USAID Comments on the PCR ..... ............. 43

DROJECT COMPLETION REPORT

PAKISTAN


Preface

This is the Project Completion Report (PCR) for the Population Project inPakistan, for which Credit 1350-PAK in the amount of US$18.0 million was approvedin April, 1983. The credit was closed on December 31, 1989, two years and ninemonths behind schedule. Sixty percent of the credit was disbursed and the lastdisbursement was made on January 12, 1990.

The PCR was prepared jointly by the Population and Human Resources Divisionof the Europe, Middle East and North Africa Regional Office (Preface, EvaluationSummary, Parts I and III), and the Borrower (Part II). Both cofinanciersprovided comments on the PCR (Attachments I and II).

Preparation of this PCR was started during IDA's final supervision missionor the Project in June, 1989, and is based inter alia, on the Staff AppraisalReport; the Credit Agreement; supervision reports; correspondence between IDAand the Borrower; and internal IDA rmiemoranda.

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PAKISTAN


EVALUATION SUMMARY

Project Objectives

1. .n November 1980, the Government of Pakistan (GOP) approved a newPopulation Welfare Plan which focused on bringing about behavioral changesfavoring a small family norm. The Plan gave priority to reducing populationgrowth through increasing con:raceptive use and decreasing the c:rude birth rateand it was unusual in that it institutionalized the separation of 'health' and'population' service delivery. The project was designed to assist key elementsof the Plan through, at the national level, its support for establishing andimplementing non-clinical training programs, establishing an information,education and communication (IEC) organization, and expanding populationeducation in schools' and at the regional level, implementing a comprehensivepopulation package comprising family planning (FP), maternal and child healthand community development in Family Welfare Centers (FWCs) in 13 districts, andestablishing FP services in health outlets of several provincial departments andpublic sector institutions. Provision was also made to improve programimplementation. The project was financed by IDA, USAID, ODA and the Government.ODA and USAID provided comments on Parts I and III (Attachments I and II). TheBorrower prepared Part II; where relevant, IDA's comments, identified as such,have been incorporated mainly in Part I.

Implementation

2. The project as summarized in the Staff Appraisal Report was not fullyimplemented. Several factors were responsible for this, among the most criticalbeing the gradual erosion of political support (which was never high) for theprogram stemming from a change to a more conservative and fundamentalist milieu;a very limited number of technical and managerial staff stretched very thinly,resulting in weak implementation; and a project design that was implementedthrough 36 separate government project documents which created vertical barr-ierswithin and between components. Further, by not establishing a ProjectAdministration Cell within the Population Welfare Division (PWD), the criticaltasks of progress chasing and coordination were only weakly undertaken, whichcontributed substantially to the project never being fully institutionalized.In terms of the larger project components, implementation was most disappointingfor the IEC and the FP through other departments/institutions components; thebest were probably the non-clinical training activities and parts of the FWC

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component. The project was originally planned to be implemented over four yearsbut was actually implemented over seven years. Sixty percent of the original

credit was disbursed.

Results

3. The project achieved only limited success in both its institutionaldevelopment and FP objectives. Achievements in efforts to improve the programimplementation process were mixed. Institutional constraints were substantialand their cumulative effect partly undermined the project design. Many projectactivities were implemented late. However, achievements of the project includethe introduction and establishing of in-service non-clinical training; andiincreased IEC capability and awareness; and onhanced FP service delivery quality.The project also helped demonstrate that women can staff and run small communitylevel clinics and provide quality care, often in very adverse circumstunces.

Sustainability

4. The project formed part of the regular government funding of thepopulation program. Most of the project activities are expected to continue inthe future. However, a recent development is that the current fiscal squeezehas affected the population program badly and across-the-board cuts are likelyboth in project supported components and elsewhere. Donor financed support forthe program continues to be considerable, and it is probable that various donorswill take over financing selected project activities.

Findings and Lessons

5. In retrospect, and apart from operational points, two lessons can belearned from the project that have broader applicability for IDA operations inthis sector in Pakistan. First, sustained political support is crucial for a

population operation to be successful in a difficult socio-cultural environmentsuch as existed in Pakistan. Second, projects should be firmly grounded in

recent sector work completed before project preparation work. Such analysesnot only help identify the issues and problems the sector faces and which the

project will address, but also 3nhances the quality of dialogue between theborrower and lender. In this instance, sector work including a thoroughinstitutional assessment may have helped to identify a different project designand a different operational approach, perhaps reflecting more accurately theadministrative and technical constraints of PWD.


PAKISTAN


PART I PROJECT REVIEW FROM IDA'S PERSPECTIVE

A. Project Identity

- Project Name Population Project- Credit Number 1350-PAK- RVr Unit Europe, Middle East and North Africa,

Country Department I- Country Pakistan- Sector Population- Financing IDA, USAID, ODA, Government of Pakistan

B. Background

1. Pakistan was one of the first developing countries to recognize theproblem of rapid population growth anc in 1960 introduced an official programintended to lower fertility. All population programs in Pakistan have operatedin a society where factors associated with high fertility rates, such as highilliteracy, poverty, few opportunities for women's development, and prestigeassociated with a large number of sons, have coexisted and reinforced oneanother. In addition to this difficult environment, the implementation of theprogram between 1960 and 1977 was fraught with problems. These included frequentinterruptions and changes in program direction, a low level of politicalcommitment, and indifference or frequently overt resistance to family planning,compounded by administrative weaknesses such as a lack of operational plans,inadequate training and supervision. As was common in many countries at thetime, family planning services were typically offered in isolation from otherhealth services. Evaluations of program activities concluded that their impacton birth rates had been minimal.

2. Project Setting. In 1980, after three years when the programvirtually stopped, the Government of Pakistan (GOP) decided to transfer theMinistry of Health's Population Division to the Ministry of Planning andDevelopment and rename it the Population Welfare Division (PWD). PWD'sresponsibilities were widened to include population policy making, planning andcoordination. Drawing on past experience, a new Population Welfare Plan wasformulated and approved by the Cabinet in November 1980. The Plan focused onbehavioral changes favoring a "small family" norm, working within an acceptablesocio-cultural framework. The approach was multisectoral, and called for theaci:ive participation of both public and private sectors and emphasized communityinvolvement. The Plan also recognized the importance of, and promoted supportfor, improvements in such areas as (female) education, women's functionalliteracy and the conditions of women and their participation in productive labor.

3. Within this framework, priority was to be accorded during 1981-84ro: (a) increasing the percentage of current contraceptive users from 6% to14%; P"d (b) decreasing the crude birth rate from approximately 42 per 1,000 to37.,. With a concurrent anticipated decrease in the crude death rate from 13

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per 1,000 to 10.5, the natural increase rate was expected to decline by 0.2points.

C. Project Obiectives and Description

4, The main objective of ttie project was to support the implementationot major aspects of the 1980 Population Plan. It wa.s to assist in: (a)accomplishing the transition from a single purpose family planning program toa multisectoral and community oriented population welfare program; (b)strengthening the organizational structure of the population program byestablishing and reorganizing units for (i) program training, (ii) information,education and communication (IEC), and (iii) population education; and (c)improving the program implementation process by developing detailed operationalplans with clear objectives, using these plans for supervision and monitoring,and improving staff quality through training. An additional objective, withinproject districts, was a reduction of three points in the crude birth rate by1987.

5. The project comprised the following components (see details in AnnexI): at the national level - (a) establishing and implementing training programs,(b) establishing an IEC organization, and (c) expanding the population educationprogram; at the regional level - (a) implementing a comprehensive populationpackage comprising Famaily Planning (FP)/Maternal and Child Health(MCH)/community development in Family Welfare Centres (FWCs) in 13 districts(covering 20 million people), and (b) establishing FP services in health outletsof several provincial government departments and public institutions. Provisionwas also made to improve program .Dlementation by developing better planning,monitoring and supervision procedures and carrying out evaluation studies as wellas small-scale experimental programs.

D. Project Design and Organization

6. The project was particularly timely given GOP's renewed emphasis onfertility reduction and FP demand creation through an integrated approach. Theaim of the project to provide fundamental inputs, with the objective ofinstitutionalizing and operationalizing the new program, was appropriate andcame at a key time as the program struggled to re-establish and reorient itself.The concepts of the Plan and project were coincident. The main considerationsin deciding on project composition, as reported in the Staff Appraisal Report(SAR), were: (a) the acceptance of the new program strategy as a sound approachand of the Population Plan as a viable means for reviving population efforts inPakistan; (b) the need to select inputs that would complement other donors'inputs (mainly UNFPA and USAID); (c) the avoidance of overambitious designs thatwould overtax a recently restructured system with traditionally low implementingcapacity; and (d) the need to improve the implementing process.

7. At the national level, the project supported two of the five "core"sub-programs of the Plan -- IEC and non-clinical training, while UNFPA assistedtwo others -- reproductive health services and clinical training. At theregional level, the project assisted the fifth "core" sub-program, in 13districts, to test the concept that community involvement and good quality MCHservices, combined with educational programs and FP services, can changeattitudes towards family size and family health. The regional component alsosupported two key multi-sectoral activities: introduction of FP services in

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health facilities of other government departments and in target groupinstitutions. The various components supported by the financing agencies aresummarized in Part III, Table 5.

8. Se-eral aspects of the project were innovative: (a) the concept ofFWCs as multipurpose, directed towards overall social development rather thanexclusively t family planning, and including active participation from thecommunity and other departmenits; (b) the separation of non-clinical training,with its emphasis on motivation and education, from traditional medical/healthtraining; (c) introducing such training through special institutions (PopulationWelfare Training Institutes (PWTIs)) to institutionalize non-clinical in-servicetraining; and (d) seeking to introduce FP services into all existing publichealth service facilities including those of large public institutions.

9. To assist with project execution, a detailed implementation volumewas prepared for use by federal and provincial staff. Those responsible forcoordination and implementation of each sub-component were clearly identified.However, at the federal and provincial level in PWD, the project per se wasnever assimilated; in the districts and outside PWD, there was littleunderstanding or appreciation of the project.

10. The institutional framework that the project was designed to supportnever became fully .perational, and this precluded the project from achievingits objectives. While the project design supported some of the most critical -- and weakest - - Plan components, particularly the IEC and non-clinical trainingactivities, it failed to address some of the issues that had plagued earlierprograms and which continued through into this Plan. The design and preparatorywork did not, in retrospect, take sufficient account of the governmentinstitutional constraints -- such as the rigidities of the project document (PC-1) system', the long-term implications for the projeet of government attempts toreduce staff numbers, the difficulties of recruiting technical staff andconsultants, the uniqueness of PWD's federal/provincial responsibility split andits financial and administrative implications-- all of which combined toundermine the project design. The result was a weak organizational response toproject start-up which continued throughout implementation. The failure toappoint a Project Administration Cell (PAC) compounded these problems. Giventhe history of the program, IDA was also over-optimistic in assuming that thenecessary institutional framework to support the new Plan would be in place andoperational within two years. In short, although the project scope, scale andobjectives were consistent, and despite attempts during preparation to simplifyinputs, experience showed that the design was too ambitious.

11. A key design and policy question is whether the project was correctin supporting the new Plan, given that it included the rather unusual aspect ofinstitutionalizing the separation of 'health' and 'population' service delivery.Justification for this separation was based on the wide social developmentapproach adopted, which built on community initiative and was based around MCH/FPservices offered by FWCs. In the cultural and political circumstances, such an

All government development projects require to be approved in the formof a PC-l. This is a detailed document and includes objectives, inputs,budgets, etc. Both the initial approval process and that for changes arelengthy.

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approach was seen as an important route to effective FP demand creation. Thedifficulties of this point were well recognized during project development andthe pragmatic conclusion appeared to be that, whatever the pros and cons, therewas no possibility of changing government policy. Thus, if IbA wished to supportthe population sector, there was no alternative. By including the provincialline departments in its regional component, the project design supported thewidening of the availability of FP services. The separation has continued whilethe widened scope of FP services has not yet materialized. There is someevidence that the IDA project has contributed to legitimizing this separation.

E. Project Implementation

12. Credit effectiveness and project start-up. The credit was approvedin April 1983, but both project effectiveness and start-up were delayed. Theproject was not declared effective until December 1983 because of (a) delays inthe approval of PC-ls; (b) delays in obtaining provincial agreements on programand project organization stemming from GOP's decision in April l183 toprovincialize field activities; and (c) IDA's difficulties in deciding how tohandle this problem and the ultimate decision to await official provincialagreements on the proposed organizational structures. Delays in project start-up resulted particularly from legal proceeuings initiated by PWD workers (mostlymotivators) dismissed during the 1981 re-organization. The Supreme Courtprohibited any staff hiring by PWD until mid-1984. Much of the project thusstarted two years later than originally envisaged and project implementationrequired two extensions of the closing date to allow sufficient time for ftillimplementation and adequate utilization of funds: the first from June 30, 1986to March 31, 1988 and the second from March 31, 1988 to June 30, 1989.

13. Critical variances. The project as conceived ir. the SAR was notfully implemented. Several factors were responsible for this: (a) gradualerosion of political support (which was never high) for the program stemmingfrom a change to a more conservative and fundamentalist socio-cultural milieu;(b) staff responsible for project execution and implementation were not the sameas those instrumental in designing the project and some staff never fullycomprehended its objectives and purpose - - this was compounded by frequent seniorstaff changes; (c) a limited number of trained and capable technical andmanagerial staff stretched very thinly, resulting in weak implementation -- aparticular problem was the appointment of non-specialists to technical positions;(d) the defederalizing of field activities; and (e) a project design that wasimplemented through 36 separate PC-ls, thereby creating vertical barriers betweenand within components.

14. IDA could not have affected the first two factors. In the thirdinstance, although systematic efforts were made by the Bank to encourage PWD toaddress the staffing problem, the issue was never resolved -- civil servicerules constrained PWD's flexibility considerably. Attempts by missions toencourage PWD to appoint qualified technicians were regarded as interferenceand precipitated a deterioration in IDA/PWD relations. Professional staffdevelopment was weak and poorly organized. The appointment of consultants wasa continuing problem and in one instance -- the non-appointment of a consultantfor IEC materials design and production -- PWD was in default of a legalcovenant. IDA was reluctant to push to the limit on this covenant (or elsewhere)because it viewed its presence in the population sector as critical to Pakistan'swider development efforts. Turning to defederalization, which was introduced

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just before project effectiveness, IDA expressed some concern about the retentionof financial control, planning and training as federal responsibilities whilemaking implementation a provincial responsibility. (Such an arrangement isprobably unique in Pakistan.) IDA never appreciated the full consequences ofthese arrangements, one aspect of which was that the provinces did not developany sense of ownership of the program. The effects of the lack of clearplanning, management and budgeting procedures within the federal/provincialorganizational structure only became evident during project implementation. Asto PC-is, IDA should have been cognizant of the implementation problems thatwould result from the large number of PC-ls, particularly given similarexperiences in other sectors.

15. Factors affecting project implementation. The implementation ofthe regional component and its outcome were affected adversely by the limitedcollaboration and consultation between PWD and other governmentministries/departments, particularly Health, and NGOs.2 As a result, thetremendous potential for utilizing existing facilities and activities to extendthe reach of FP was not capitalized upon. The multisectoral approach wasoperational only in FWCs and even this was not widely accepted; major reasonsincluded insufficient IEC support, emphasis on FP service delivery activities,limited political and administrative back-up, training curricula gaps and delays,and over-estimated ease of community mobilization.

16. Three key actions required by IDA, but never taken by PWD, had anadverse effect on implementation. Fizst, not hiring a consultant to advise onoperationalizing the IEC component, especially since PWD had almost no qualifiedtechnical staff in this area. Second, not familiarizing the provincial anddistrict staff sufficiently , particularly the newly appointed staff, about theproject through workshops and distribution of documents such as the SAR and theimplementation volume.3 Finally, not setting up a PAC as specified in the SAR.This absence of a PAC meant that the PAC's tasks were performed weakly by theregular directorates and that there was little chance of a firm horizontal linkbetween the project components being established. Another result wascoordination difficulties between the PWD federal directorates and the provincialpopulation departments. Consideration was given by IDA in late 1984 tocancelling the project due to the continuing implementation delays; however,IDA's management decided that it should be continued.

17. Project Risks. Administrative weaknesses and opposition to theprogram, the main risks identified in the SAR, persisted during the life of theproject. To minimize these risks, the project included administrativestrengthening through training, a new management approach and close monitoringof the management process. The management related inputs were mainly embeddedin the various project components and their implementation was often given lowpriority. Moreover, the two management audits, one baseline and one mid-project,

2 IDA Comment: The text has been amended to reflect the Borrower's commentin para. 36. However, the health initiatives discussed in para. 37 hadno impact on the implementation of IDA's project.

IDA Comment: Although the Borrower states in para. 39 that the SAR andImplementation volumes were distributed, almost all staff interviewed, atall levels, by later IDA missions were unaware of the documents.

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which would have provided critical information on management development andenable diagnosis and corrections, were not undertaken on schedule (see Part III,Table 8). The strategy of increasing the program's acceptability by changingits image to one perceived as serving wider social needs never fullymaterialized. The IEC component, which was required to provide communicationsupport, was virtually absent during the critical early phase of programtransition. Momentum was not gained later largely because of the severeconstraints put on program publicity due to the perceived sensitive nature ofthe subject. This notwithstanding, there was no significant public criticismof the program or project during implementation. Paradoxically, the limitedpolitical support for the program at the start slowly ebbed away.

18. Disbursements were slower than anticipated in the SAR. Delays inthe initial approval of PC-ls and of re-submissions; subsequent further andcontinuing delays in the release of funds from the federal level to PWDdirectorates and the provinces; inclusion of items in the SAR that were not inthe approved PC-is; PC-ls not running for the entire project period; cuts inthe annual development plan; the delayed start of the project; and thesubstantial depreciation of the Pakistan rupee, compounded by the implementationproblems discussed above, resulted in low levels of disbursement. Despite twoextensions of the closing date and some increase in the proportion ofexpenditures reimbursed, only 60% of the credit was actually disbursed; theremaining 6.7 million SDR was cancelled. Most of the credit was used to financeoperating costs. Details are provided in Part III, Tables 5 and 6. The complexfinancing arrangements resulted in a large number of annual audit reports beingproduced, often one for each component. Thus, one year's audit report typicallycomprised twelve or more individual reports; delays were therefore common.

19. Procurement. No significant problems arose during local procurement.The co-financing agencies met much of the requirement for imported equipment andsupplies (e.g. USAID supplied contraceptives and ODA the audio-visual andtransport vans). Only one international contract under the credit, forcommunication and printing equipment, was let. This was delayed by disagreementsbetween PWD and IDA on specifications, quantities and procedures and became along-standing source of friction.

20. Consultants. The project received critical inputs from consultantsboth during project preparation (financed from a Project Preparation Facility)and during ear'y project implementation. However, GOP was increasingly reluctantto use consultants, especially credit-financed, during implementation (the twointernational consultants recruited during implementation, for trai.ning and IEC,were paid from ODA project grant funds). Only a small fraction of the 240 monthsof local consultant services and about half (all during project preparation) ofthe 52 months of foreign consultant services financed by the credit were used.

F. Project Results

21. The project achieved only limited success in both its institutionaldevelopment and family planning performance objectives. The transition from asingle purpose family planning program to a multi-sectoral and community orientedpopulation welfare program was never completed for the reasons discussed above.The project contributed to strengthening some parts of the organizationalstructure of the population program but failed elsewhere. The poRulationeducation component was successful in the early stages of project implementation.

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Thereafter the momentum decreased substantially in part because Lhe PC-1 for theperiod 1986-88 was not approved until August 1987 and funds were not releaseduntil November 1987, 17 months later. The IEC comDonent, intended as a majorsupport for the new Population Plan, was never institutionalized partly due toextended delays in establishing an appropriate staffed and organized structure.Hence, activities essential for implementing a national IEC program were neverinitiated, or initiated too late to provide support to other components. Theresults from the non-clinical training component were more positive. Thetraining system at thq provincial and district levels provided adequate technicalresources, but suffered inter alia from the lack of IEC support. Although thePWTIs are potentially capable and effective institutions, further technicalassistance and financial support will be necessary to transform them into a majorresource for the program. Finally, efforts to improve the implementation Drocesswere only partially successful. They were hampered by the slow release of fundsand delays in the training program, which prevented activities from proceedingon schedule. Planning and monitoring capabilities have increased but stillremain limited.

22. Project Benefits. Deciding whether the project achieved its ultimatebenefits of improved family planning and MCH practices will have to await theexecution of the much delayed Demographic and Health Survey (Part III, Table 8).However, while service statistics (Annex II, Tables Al-A3) show increases oftypically over 100% in contraceptives distributed during the period 1983-84 to1987-88, the government's (ambitious) targets were not achieved. Contraceptiveprevalence remained low and was estimated by PWD to have only risen from 9% in1984 to about 13% in June 1988. The 1988 figure is too low to have any realdemographic impact. Information on project districts is incomplete but suggeststhat their performance improved at about the national rate. The project had anunexpected benefit, with significant implications for the health sector, in thatit demonstrated that women can staff and run small community level clinics andprovide quality care, often in very adverse circumstances.

G. Proiect Sustainability

23. The population program continues to be entirely budgeted from thefederal Annual Development Programme. The project funding was part of thisprocess. Provision to continue many of the project activities is included incurrent forward budgets; additional recurrent costs arising directly from theproject were modest, although the project financed substantial amounts ofrecurrent costs. However, a recent development is that the current fiscalsqueeze has affected the overall population budget badly and across-the-boardcuts are likely -- both in project supported components and elsewhere. Thisuncertain fiscal foundation is exacerbated by the lack of substantial costrecovery prospects for the program, and the lack of visible expanding demandwhich would have stimulated funding for a much needed service. Donor supportfor the program has been substantial, typically over half of total costs. Itis probable that other donors, including ODA, USAID and UNFPA, will take overfinancing selected project activities, especially for training, IEC, monitoringand evaluatir,n and some FWC costs. The net result of the financial constraintshas been the virtual elimination of all program development efforts.

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H. Bank and Borrower Performance

24. IDA's performance from project identification to completion isconsidered generally satisfactory. The technical aspects of project developmentwork was thorough and detailed, and many of the relevant issues were identifiedat appraisal; the project was fully within GOP's new population strategy. Theappropriate covenants to execute the project were included in the DevelopmentCredit Agreement, of which one (Covenant 3.02 concerning the IEC consultant) wasunfulfilled at credit closing.

25. Between project effectiveness and completion eight supervisionmissions were fielded including the PCR mission. Missions were undertakenregularly during early implementation. There was a decline in frequency duringthe latter part of project implementation (see Part III, Table 11), which wasoffset by informal supervision carried out by IDA staff while undertaking otheroperational work in Pakistan. From 1986 onwards there were repeated changes ofresponsible headquarters staff and often no commonality of membership onsuccessive supervision missions. The utility of supervision missions was thusmuch reduced and informal complaints were made by PWD. Consistency ofinvolvement by Resident Mission (RMP) staff was maintained, although they werenot population experts.

26. Part III, Table 9 summarizes the Borrower's performance, which hasbeen partly discussed above. Since this was the first project in the populationsector in Pakistan, the expected administrative difficulties were experiencedduring the early phase of project implementation. To a lesser extent, thesecontinued throughout project implementation and cumulatively were a major causeof project implementation delays. Implementation also suffered from a lack ofcoordination, inadequate technical guidance, and weak linkages with provincialgovernment departments and local bodies. A rapidly changing social climate andfaltering political support for population activities further constrained theBorrower's ability to deal effectively with the project.

27. The net effect of these limitations, on both IDA's and the Borrower'sparts, was a gradual but steady erosion in their relationship. Increasingfrustration in IDA at slow project implementation led to attempts to expediteprogress through detailed work programs prepared jointly with PWD. This was seenas interference by the executing agencies and resulted in reluctance to implementsuch recommendations. This downward spiral, which affected PWD/RMP relationsalso, continued slowly through most of the implementation period; in the lastyear relations slowly improved.

I. Lessons Learned

28. The lessons for implementation of future projects are discussedabove and include actions such as the establishment of the PAC; ensuringcontinuity of IDA staff knowledgeable about the project on supervision missions;and more intense supervision. These may have made a difference in final projectoutcome and could also have relevance for cther sectors. Apart from theseoperational points, two other lessons that are applicable to future operationsin this sector in Pakistan are: firstly, sustained political support is crucialfor a population operation to be successful in a difficult socio-cultural milieusuch as currently exists. As the limited political support for populationactivities eroded, project implementers became more cautious and ministerial

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clearances were required even for some routine activities. In such situations,population project designs need to be more focused, less ambitious, and activelyand sympathetically supported by IDA staff familiar with the project.

29. Secondly, such projects should be firmly grounded in recent sectoranalysis completed before project preparation work. Population sector work wasconducted between 1975 and 1978, but the three year stoppage of activities andthe major new focus and organization of the Plan reduced its utilitysubstantially. Sector analyses not only help identify the issues and problemsthat the sector faces and which the project will address but also enhances thequality of dialogue between the borrower and lender. It would also have assistedwith obtaining a better identification of PWD's strengths and weaknesses. Itwas necessary for IDA to respond promptly to GOP's urgent request to assist inthe development and execution of the new Population Welfare Plan. But, becausethis was IDA's first operation in an obviously very difficult sector and witha recently formed executing agency, there was a great need to proceed with themaximum of preparation including a thorough institutional assessment. Sectorwork may have helped identify a different project design and a differentoperational approach, perhaps reflecting more accurately the administrative andtechnical constraints of PWD.

J. Project Documentation and Data

30. Original documentation for the project was good. Both the SAR andthe implementation volume provided useful and detailed guidance forimplementation and evaluation by the executing agencies. Had the documents beenwidely used, they would have greatly strengthened the institutional memory andmitigated the effects of the PWD and IDA staff changes.

31. Availability of Relevant Data to PCR Mission. Meetings were heldbetween IDA and PWD several months prior to the PCR mission to discusscontributions to the PCR. Most basic information required to complete Parts Iand III were readily made available to the mission. Data availability andquality are expected to be considerably enhanced following the completion of adiagnostic study of PWD's information system.

PART II PROJECT REVIEW FROM THE BORROWER'S PERSPECTIVE4

GENERAL COMMENTS:

32. The project was implemented at the national and regional levelsthrough four main components. It envisaged firstly, the establishment orstrengthening of 293 "amily Welfare Centres in 13 districts. This component also

4 This is the Borrower's unedited contribution. The Borrower agreed toprepare Part II by December 1989, and received Parts I and III on December15, 1989. Part II represents the views and conclusions of the Borrower,and should not be attributed to IDA or its affiliated organizations. Anumber of the Borrower's comments marked in the margin with a verticleline, are referred to in footnotes in Parts I and III and Annex I, and areidentified as "IDA Comments."

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included Provincial Line Departments (PLDs) and Target Group Institutions (TGIs).Secondly it sought to create an Information. Education and Communication (IEC)organization which involved production and dissemination of publicity materialand greater use of Radio, Television and Press for education of the generalpublic. The project was also designed to introduce r3pulation Education. ineducational institutions through strengthening the curricula at the secondaryand intermediate levels with the objective of reaching over two million students.It was also planned to train teachers and familiarize students with the problemsarising from rapid population growth. Finally Non-Clinical Training was plannedto be improved and the Population Welfare Training Institutes strengthened bydeveloping curricula, better training facilities and through providing means totrain the master trainers.

33. In reviewing the programme as a whole the IDA in its Project Review(Part I of the Report) has made a number of general comments regarding theproject design, its implemientation and why the results achieved were not entirelysatisfactory.

34. It has been stated that the institutional framework that the projectwas designed to support never became fully operational. Both at the federal andprovincial levels the project was never fully assimilated and especially in thefield there was little understanding or appreciation of the work to be done.One of the main reasons for unsatisfactory performance was said to be the failureto set up a Project Administration Cell. Another reason was that design andpreparatory work did not, in retrospect, take sufficient account of governmentinstitutional constraints such as the rigidities of the PC-I system that delayedproject approval. The non-availability of technical staff, failure to appointconsultants and the division of responsibility between the Federal and ProvincialGovernments were some of the other reasons put forward. More importantly, itwas felt that the lack of adequate political support for the programme duringthe period in question became a very serious constraint.

35. The Population Welfare Division feels that although some of theshort-comings pointed out about the structuring and implementation of the projectare well-founded, the project review does not make due allowance for thepolitical, administrative and financial constraints under which the project wasimplemented. It also does not fully recognize all the implications that followfrom these constraints. For example the inability to prevent frequent staffingchanges among project personnel, the lack of political support and division ofresponsibility between the centre and Provinces are problems which cannot easilybe solved because of the socio-economic conditions and administrative compulsionsprevalent in the country. Also the production and implementing of the IECmeasures with the necessary freedom keeping in view the present cultural milieuis not something which would be just solved by engaging a foreign consultant.On the other hand it is not correct to say that there was lack of necessarycollaboration and consultation between the Population Welfare Division and otherGovernment Ministries/Departments particularly the Health and Education Division.

36. For example the subject of Population Education was incorporated inthe formal school system and training of teachers was organized with the activeinvolvement of the Ministry of Education, without this collaboration it wouldnot have been possible to achieve the desired results.

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37. Similarly special efforts were made in 1987 for a more effectiveinvolvement of the Provincial Health Departments for family planning servicedelivery. Decisions taken by government in September, 1985 in relation to theRural Health Services formed the basis of this endeavor. Separate projectproposals were drawn up in collaboration with the health departments, one foreach Province and on for the Federal District. The proposals aimed atinvolvement of over 5000 different types of health service outlets throughtraining of medical and para-medical personnel and provision of equipment (IUDkits) and other commodities needed for family planning motivation and healthservice.

38. It is also not entirely correct to say that the IEC component wasnever institutionalized because of delay in establishing properly staffed andorganized structure. The IEC activities through the media had remained dormantduring 1977-85. As soon as government thought that conditions permitted thelaunching of IEC campaigns, suitable programmes were developed and put acrossthrough Radio, T.V. and the Press. The IEC structure is also organized with aFederal Directorate of Communication IEC Cells in Provincial Headquarters andone Deputy District Population Officer (C&T) in each district to organize thecommunity IEC activities. The IEC PC-I for the Sixth Plan (1983-88) wasdeveloped in close collaboration with the ODA/IDA Consultants and the staffingpattern for the Federal and Provincial Organizations was determined with theadvice of these consultants.

39. As regards proper orientation of field staff for implementing theproject, it may be mentioned that special briefings, workshops were organizedby the PWTI Karachi, to familiarise all concerned about the project concept,components and activities. The Staff Appraisal Report and the ImplementationVolume were also distributed to the provinces, PWTIs and to selected districtsto serve as a regular reference input.

PERFORMANCE

40. In the Project Review (Part I) it is stated that the project achievedonly limited success in both its institutional development and the achievementof its family planning objectives. Although the project contributed to thestrengthening of some part of the organizational structure, the transition froma single purpose programme to a multi-sectoral and community oriented populationwelfare programme could not be fully achieved. It is said that the IEC componentwas never properly institutionalized and could not provide adequate technicalsupport to the training component. On the other hand, the results in the Non-Clinical Training component were more positive but further technical assistanceand financial support would be necessary zo make them into a major resource forthe programme. Although preliminary evaluation indicates that the ambitioustargets planned in the project were not actually achieved, an accurate ideaabout the real achievements of the project would have to await the initiationof the much delayed Demographic and Health Survey in the country.

41. The implementation of the project, some of its shortcomings and theprogress achieved in each of the four main components is discussed below.

42. Family Welfare Centres (FWCs): The performance of the FWCs duringthe period under review, by and large, reached the expected level of "good"

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performance if judged in accordance with the criteria laid down by the IDA. Forexample most FWCs had satisfactory premises (three rooms). The monthlyattendance for family planning increased by 240 per cent between 1982-83 and1984-85. During 1989 the average daily attendance per FWC included 4 to 5 familyplanning clients out of which 2 to 3 were new cases. There were also 1 to 3ante-natal and post-natal cases and 13 to 15 cases of a general nature Thecentres maintained most of the necessary documentation such as the ClinicalRecord cards and Client identification cards. It was, however, felt that tomaintain the several registers and reports initially prescribed took up too muchof staffs time and energy. To reduce the amount of the paper work, it wasdecided, in 1989, to discontinue the Antenatal, Postnatal and Child Care cards.

43. It was expected that each FWC would cover a population of about20,000. Actually the coverage was less than half that figure. A survey in mid-1985 showed that about 75 per cent of the clientele came from within a radiusof 5 kms of the centre.

44. For the Provincial Line Departments, which formed part of thiscomponent, the project provided funds for provision of services through 700outlcts and training of 6 trainers alongwith necessary equipment, material andcontraceptives. The PLD component had a delayed start in all provinces andgenerally did not come up to expectations. There were several administrativeand other problems. The trainers of the Health Ministry could not be trainedand their work was down by the programme personnel. The number of PLD outletsinvolved in family planning work in the Bank districts were less than half thenumber provided for. In late 1987 a meeting was chaired by the Federal Ministerconcerned in which Provincial Ministers and Secretaries were invited in orderto generate greater interest in this component. This resulted in someimprovement but it was not very marked.

45. Project support was also provided to 50 outlets of Target GroupInstitutions (TGIs) including training of clinical and non-clinical staff. Thiscomponent remained a Federal activity throughout. In all, 14 large organizationswere involved in the project operating through 175 service outlets. Thiscomponent experienced the usual teething problems which were overcome and therewas steady improvement in the achievement of prescribed targets. The mainproblem in project execution however, was the monitoring cf activities of TGIsfrom the federal level because of the remote location of service points.Although an evaluation in early 1988 showed fairly satisfactory results butmonitoring and supervision still remained a weak area. Almost all the fundsbudgeted for TGIs were utilized.

46. Non Clinical Training: The training component was well conceivedand represented a definite need of the programme. The overall performance inthis component in terms of indicators laid down in the Staff Appraisal Reportreflects a satisfactory level of achievement. The utilization of credit,however, was on the low side as compared to the estimates given in the SAR andImplementation Volume. This was mainly due to over-estimation, heavy contingencyprovisions and incorporation of items/activities which were not approved as partof the PC-I. The rigid conditions linked to procurement of equipments alsoposed difficulties and delayed the utilization of funds. There were some delaysin the recruitment of staff for the PWTIs and this alongwith the ADP restrictionswere some of the main problems which effected the performance and level ofutilization of the credit. Lack of a proper system for, evaluation of training

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activities, for improving the skill of faculty members and refiiing coursecontent however remained a weak area of the component.

47. Population Education The Population Education component was alsoa well conceived project which envisaged revision of curricula, incorporationof relevant material in text books, development of teachers guides and trainingof middle and secondary school teachers. It was designed to provide a conceptualbase for awareness of the implications of population growth. One of the maindifficulties in implementing, the project was the inadequate level of ADPprovision from GOP resources which contributed to the low utilization of thecredit. Funds were also released late and consequently plan activities couldnot be undertaken in accordance with the time schedule. The financialrequirements for carrying out the population education activities were in generalassessed on the high side with the result that actual utilization of funds wasalways low. The expenditure on workshops and cost of non-expendable equipmentincluded in the project were in particular over-estimated. The Bank support forthe component remained satisfactory during the project period.

48. IEC Component: The Bank estimates during the project preparationstage were rather optimistic. The financial and commodity needs to thecommunication activities, assessed for the Sixth Plan, were on the high side withthe result that fund could not be fully utilized. In respect of procurement ofequipment the Population Welfare Division considered the quantity as unrealisticand wanted to reduce the amount involved but on the insistence of the Bank fullprocurement was made. After de-federalization of the programme some problemswere felt vis-a-vis management and coordination of activities to be carried outby the provinces. This adversely effected utilization c. funds to some extentbecause the provinces in many cases had to seek prior approval of the PopulationWelfare Division. However, the strategy was changed during the 7th plan and someof the activities such as local Radio programmes, Films and Publications etc.were entrusted to the Provinces and funds were placed at their disposal to ensurequick execution of the programmes. During the project period, level of ADPprovisions were at times not commensurate with the Bank reimbursement scale.This also contributed to low utilization of the credit.

49. During the period April 1985 to 1988, IEC programmes were carriedout through Radio, T.V., Press, A.V. Vans, cinema slides, cultural events,seminars and group meetings. As little field research had been done in IEC thePopulation Welfare Division assigned an audience research study to the NationalInstitute of Population Studies. NIPS carried out the survey and its report wassubmitted to the Division in 1989 which shows encouraging results of thisactivity. It appears that IEC support to other components particularly theservice delivery was available and the link between IEC campaigns and the familyplanning practices has also been largely established. The NIPS study made usefulrecommendations for strengthening the IEC programme which are being made use ofin the development of new programmes.

BANK-BORROWER RELATIONSHIP

50. The overall relationship between the Bank and the Borrower has beeneffective, supportive and mutually beneficial. There has however been over-emphasis on the conditions and operational details of the activities whichnormally are better left to the judgement of the borrower. A comparative studyof the aide-memoire would reveal series of conditions running through the

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implementation period of the project. This inevitably created problems for theBorrower, and considerable effort and energy are directed in fulfilling theserequirements at the cost of the programme as the whole. The need is to adopta balanced and flexible approach, which is supportive and reflects appreciationof the constraints under which work has to be done.

51. It is also desirable that the borrower be given freer choice in theassessment of its needs and in revising these in the light of experiences gainedduring implementation.

52. Another need is for donor agencies to try to understand the priorityareas identified by the Borrower and provide assistance accordingly. Agencymissions should also not be over-critical of programme implementation and shouldtry to understand the governments, political and administrative constraints underwhich the programme is being implemented.

53. The format for progress reports was complicated and unnecessarilydetailed. This could be avoided and in fact the format was later revised to makeit simpler and more easy to operate.

ADEQUACY OF DETAILED INFORMATION IN REPORT

54. The factual information and details given in the report appear tobe generally correct and adequate. There is however some variation in theinformation provided under item-6 of Annex-I.5 The number of teachers requiredto be trained during the period 1982-89 was 15140. Against this target 11,076teachers were trained. It has also been stated in Annex-I that PopulationEducation concepts are already included in the course curricula of teachers'courses and primary level courses in Science, Social Studies and in languages.The correct position is that Population Education concept has been incorporatedin the text books of classes VI-X as per decision of the Government of Pakistan.In addition, Population concepts have also been included in the courses ofPrimary Teaching Certificate (PTC) and Certificate of Teaching (CT). Noprovision has been made for inclusion of these concepts in Grades 11-12.

CONCLUSIONS

55. The Population We'lfare Division agrees in principle to some of theconclusions in the project review namely that sustained political support iscrucial for population operations to be successful and the project should befirmly grounded in recent sector analysis before project preparation isundertaken. This not only identifies the issues and problems the sector facesbut also enhances the quality of dialogue between the borrower and the lender.Some other points and need to be kept in view in undertaking future projects arefirstly, since a lot of implementation is being undertaken by provincialagencies, it would be very desirable if representatives of the provinces areinvolved from the stage of project preparation so that they are fully familiarwith the intricacies of the project. Provincial representation on the formalreview meetings with donor missions would also be helpful. There is need toadopt a more practical approach and for better appreciation and understandingof the established procedures and constraints under which the project has to

5 The reference is now to Part III, Table 7 (see footnote 3).

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operate in a developing country. A similar apporach should abe adopted in layingdown the procedure for procurement of equipment etc. as this has often delayeduse of related allocations.

56. On the other hand short-fall in the ADP provisions were often aserinus constraint and delays in the release of funds was also a reason for slowimplementation of the project.

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PART III STATISTICAL INFORMATION

1. Related IBRD loans and IDA Credits None

2. Project Timetable

Item Planned Revised Actual

-Identification Feb-March 1981 - Feb-March 1981

-Preparation Mission I June-July 1981 - June-July 1981

-Preparation Mission II November 1981

-Appraisal March 1982 May 1982

-Negotiations October 1982 Feb-March 1983

-Board Approval January 1983 April 1983

-Credit Signature May 1983

-CreditEffectiveness August 1983 December 1983

-ProjectCompletion June 30, 1986 March 31, 1988 June 30, 1989

-Credit Closing March 31, 1987 Sept 30, 1988 Dec 31, 1989

Comments: a) Appraisal was delayed because of the nced for a second preparation

mission. b) Credit effectiveness was delayed because of late approval of PC-ls

and by GOP's plans to provincialise some project activities. c) Tho project

extensions were approved to complete project implementation.

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3, Credit Disbursements

Cumulative Estimated and Actual Disbursements(millions of SDR)

GOP Fiscal Year 1983 1984 1985 1986 1987 1988 1989 1990

Appraisal'/Estimate 1.66 5.20 9.82 14.23 16.60 - - -

Actual 0.00 1.42 2.73 4.49 5.23 7.17 8.98 9.93

Actual asX of estimate 0.00 27.31 27.80 31.55 31.51 43.19 54.10 59.82

Date of FinalDisbursement January 12, 1990

Cancelled 6.67

Comments: The low levels of disbursement were primarily attributable to twofactors: (a) delayed project start-up resulting in, for early project years, nodisbursements for operating costs being made at 90%; few made at 75%; and themajority made at 55%; and (b) no new activities being undertaken in projectdistricts requiring additional services or equipment (covered at 100% of costs).

1 Estimated from Annex 7, SAR, using the US$-SDR conversion factor of0.92.

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4. Project Implementation

Indicators/ Appraisal Estimate Actual

IEC COMPONENT

1. Building Organizational Capability

-Director develop first IEC masterplan and First plan developeddistribute to all deputies by July 1,1983. in 1985.

-By end 1983, all district officers will no records maintainedhave received basic training at PWTIs but majority trained

and received re-training

-Quarterly review of plan progress, provin- Not done, but expectedcially and nationally. to start shortly.

-By July 1983, all TGIs to be provided TOI evaluation surveyeducational material covering main in May, 1988, foundcontraceptive services. lack of IEC material

hampering motivationactivities andservice delivery.

-By end July 1983 at least 35% of FWCs By 1985, 15 informationhave full complement of printed booklets featuring FP,material; by end Sept 1983, 25% will MCH, nutrition preparedhave pre-tested slide/tape equipment and and distributed; slide/programs. tape equipment recently

procured and yet to bedistributed.

-By July 1983, district deputies attend at No records availableleast 75% of monthly AMC meetings.

-By end March 1984 district deputies to No records availableprovide first follow-up team trainingcourses at FWC level

2. In FWC service areas:

-Numbers/types of community volunteers Community volunteersparticipating in field motivation and contraceptive

distributors recruited,with numbers in positionranging from 90%-11O%of target, by province.Extent and type ofactivity not known.

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-Increased attendance at FWCs By 1989, daily attend-ance per FWC increasedto 13-15 with 4-5 familyplanning clients, and2-3 new acceptors.

-Meetings by field staff with groups in Information on FWCs andcommunities its activities imparted

during film shows by AVvans.

-Participation in FWC sponsored development No involvement by IEC

activity staff. FWC develop-ment activities res-tricted to eg. sewingclasses, vegetablegardens.

-Increased adoption of recommended MCH behavior No information avail-able since the mid-censal demographicsurvey has not yet beenconducted.

-Increase in accep'ance and continued use of Some increase, seecontraception Annex II, Tables Al to

A3. No information oncontinued use.

3. Institution building -,rocess:

- .ctive public/private -:romotion No records availableof FP by increased num'er of local leaders

-involvement of increaEed numbers of front-line No records available

field workers in FWC and FP promotion

-Significant increases ia contraceptive use. 1984: 9.1% usage.Service statisticsestimated 13% by June1988.

FWC COMPONI,NT

1. Progress in implementation:

-by mid-1983, 70% of FWCs in project FWC evaluation survey

districts should be located in conducted in 1985adequate and renovated facilities. found most Centres had

Staff vacancies less than 20%. satisfactory premises;

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vacancies still remainin female staff (FWA)critical to increasingFP acceptance.

-by end 1983, all FWCs in project districts Additional resourcesshould be operating under new scheme for scheme excluded in

PC-1.

2. Indicators of Quality/Acceptability:

- by end of project period, each FWC By 1989, 13-15 clientsshould have on a daily basis: with 4-5 to pick up

contraceptives, 2-3- 14 FP/MCH care clients new acceptors, 1-2- 3-4 clients to pick up contraceptives ante-natal cases

-FWCs implement system of referrals of mothers/ Regular referralchildren to health facilities and receive system not been set upinstructions in follow-up for administrative

reasons. Ad hocarrangements oftenmade.

-3 pre-natal checks, post-natal check with No information tabulated,FWA or FWW, advice on birth spacing or and decided to discon-sterilization tinue information cards

in 1988.

-maternal card with OB/GYN history and advice Simplified cardon FP given introduced in 1989.

-home follow-up visits by FWAs for clients that Varied according tofailed to reattend for further supplies location of FWC, and

d_dication of female FWA.

-acceptors increase by 10% annually, FP users Service statisticsby 2-4% show increased acceptance

of FP methods (see AnnexII).

-weight/growth charts for infants, to be filled Financial constraintsby FWAs, and mid-arm circumference measurement affected supply ofrecorded in clinic card. growth charts; but

growth monitoringnevertheless encouragedat FWC.

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Comments: Because of the delayed start-up and problems with projectimplementation, the focus of supervision missions was on key isEues/actionsidentified by previous supervision mission rather than on process indicatorsoutlined in the appraisal report. This also affected the process evaluation ofthe Programme Training Component. Evaluation of the impact of the PopulationEducation Comnponent was not expected to occur within the project period.

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5. Project Financing

OriginalPlanned Expenditure

(Credit Agreement) Amended Final Categories(in US$ millions)

IDA 18.0 11.8 Equipment; consultantservices; training; PAC;subsequent projectpreparation; operatingcosts; PPF.

Co-financingInstitutions:

ODA - U.K. 2.7 2.9 2.1"/ Vehicles; evaluationstudies; seed funds;innovative activities.

USAID 3.4 3.4 Contraceptives

Domestic 4.1 3.42/ Operating costs; training;vehicles; equipment.

Total 28.2 28.4 20.7

Comments: (a) The undisbursed IDA balance was considered under the proposed(1988-89) "support of government social sec_.or objectives." A GOP proposal wasreviewed by IDA Management, but declared ineligible for further funding.(b) The ODA grant was increased to US$2.9 million in 1985.

1 Estimated from annex 3, table 1 of the "Report of the ODA Review andPre-appraisal Mission", Overseas Development Administration, London,September, 1989. ODA expenditure is continuing.

2 Estimated from IDA and ODA actual expenditures on various categories;for example, equipment by IDA and vehicles by ODA specified wereprocured, hence GOP commitment for taxes and duties was included inthe total.

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6. Proiect Costs

Appraisal ActualEstimates Amended Cost

(in U.S. $ Millions)

1. Equipment and materials 2.1 2.9

2. Consultant services,preparation of mid-censal surveyand future projects 2.6 0.31

3. Local training and projectadministration cell 3.6 0.9

4. Operating costs 15.3 16.4

5. Refunding of ProjectPreparation Advance 0.3 0.2

6. Unallocated 4.3 0.0

TOTAL 28.2 28.4"/ 20.7

Comments: Actual costs are estimates as of March 8, 1990. See footnotes intable 5.

The ODA grant was amended from 2.7 to 2.9 in 1985.

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7. Proiect Results: Direct Benefits

Major Appraisal Estimated at PercentageComponents/Sub-Components Estimate Closing Date Achieved

National Components:

Program Training- establish PWTIs 2 3 150- training: 1/

PWD field staffPLD and TGI ) 158,869 ) 90,558 57Community-based groups 1

IEC 2/- establish an IEC establish federal establishedorganization and provincial

organizations- AV and transport 90 90 100

vans

Population Education- teacher training 36,000 3/ 11,076 31- AV kits 16,000 10,000 4/ 63- teacher training 20,000 8,550 5/ 43

through correspondencecourses

Regional Component:

Family Welfare Centres 2/- establish multi-purpose

FWCs 292 293 100

Provincial Line Departments- establish FP and education/

motivation activities inhealth outlets 700 982 6/ -

- non-clinical training 6 trainers none trained 0in MOH

Target Group Institutes- establish FP/IEC

services 50 health 174 6/ -outlets

- posting motivatorsat selected outlets 78 51 65

- non-clinical training 6 trainers none trained 0

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- - Not applicable1/ Targets for period 1982-83 to 1987-88.2/ See Table 4 for additional details on this component.3/ IDA Comment: Although PWD states in para 54 that 15,140 teachers were

to be trained during the period 1982-89, the SAR gives a totalof 36,000 teachers to be trained by the end of the project period.

4/ For period 1983-86.5/ See Annex III for details.6/ Because the Borrower was unable to establish sufficient outlets in the

project districts, IDA acquiesced to PWD's request to extend coveragenationwide.

8. Project Results: Studies

Studies Purpose (from ImDlementation Volume Status and ImDact

1. Annual task analyses of Process evaluation of regional One completed during project preparation.

sample FWCs and other components. Formed the basis of the FUC component.FP outlets in project andcontrol districts.

2. Annual cost effectiveness Process evaluation of regional Detailedmethodologyestablished. Furtherdesk studies of FWCs, using components. work awaiting government budget.data from existing servicestatistics system.

3. Two management audits of Process evaluation of regional Firstunder implementation with ODA funds.PWD, baseline and mid- component. Field work completed, first draft inproject. April, 1990.

4. Two marketing-type surveys Process evaluation of regional One planned. ODA approved funds, but no

on Public Acceptability component. government budget. a'of FWCs.

5. Mid-censal demographic Measure program impact on To be undertaken as part of Demographicsurvey. fertility. Health Survey. Projectproposalprepared

but no allocation in government budget.USAID funded.

6. Studies on program Process evaluation of regional Eight studies completed oracceptance and fertility component. ongoing. Ideterminants.

1 The Economic Value of Children Evaluation of Non-Clinical Training ProjectEvaluation of Outreach Component in FWCs Ongoing:Population Projections - Communication Evaluation (USAID)State of the Population of Pakistan - NGO evaluationFWC Evaluation Survey, 1985

Comments: The evaluation component is mostly ODA and USAID financed.

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9. Status of Covenants

Description of Covenant Date Status of Implementation

1. Section 3.01 (b). Establish- Not established; functionsment of Project Administra- were weakly performed bytion Cell within PWD. regular directorates.

2. Section 3.02. (i) Employment Feb. 1, 1984 Employed in accordance withof Consultants Bank procedures.(ii) Employment of 2 IEC Training consultantConsultants employed; long-term IEC

design and productionconsultant was to beemployed during projectextension FY87-88 and FY88-89, but no action was takenby PWD. Some short-termconsultants using grantmoney have been provided.

3. Section 3.04 (b). Monitor MIS functioningand record progress of the ineffectively; UNFPA/project. ICOMP diagnostic study in

progress.

4. Section 3.04 (d). Prepare Detailed arrangements forproject completion report preparation of PCR madenot later than six months during last two supervisionafter closing date. missions.

5. Section 3.05 (a). Employ- Mar. 1, 1984 Employed.ment of Instructor inDirectorate Training andPopulation Education.

6. Section 3.05 (b). Distribu- Dec. 1, 1983 Distributed in Feb. 1984.tion of FWC manual. A revised manual of guide-

lines for implementationprepared and recentlydistributed.

7. Section 3.05 (c). Employ- Not employed. Functionsment of qualified procure- very weakly performed byment and logistic staff. regular directorates.

8. Section 3.05 (d). Furnish July 1, 1984 Furnished every six monthsreport on FWC staffing.

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DescriRtion of Covenant Date Status of Implementation

9. Section 3.05 (e). Annual Annually reviewed andreview and approval of approved.training plans.

10. Section 3.05 (f). Annual Annually reviewed andreview and approval of approved.national and provincial plansfor IEC for following year.

11. Section 3.06. Memorandum of Jan. 1, 1984 Formalized, and beingunderstanding with Ministry implemented; content ofof Education (MOE) concerning population education inpopulation education. training/teaching remains

very weak.

12. Section 3.07. Establishment July 1, 1984 Established.of MOE population educationcell.

13. Section 3.08. Establishment Dec. 1, 1983 Established, but operatedof IEC directorate in PWD ineffectively, primarilywith appointment of qualified because no specializedstaff. staff incorporated in the

directorate.

14. Section 3.09 (a). Appoint- Mar. 1, 1984 Critical vacancies stillment of PWTI staff exist in PWTI in Multan.

15. Section 3.09 (b). Prepara- Prepared annually andtion of annual training utilized.plans.

16. Section 3.10. Provincial Jul, 1, 1984 Started with listingPWDs to prepare annual of new FWCs and FP outletsplan of action for FP in other departments. Noservices in health and other action plans prepared.line departments Provision of FP services

by provincial healthdepartment outletsformalized in Seventh FiveYear Plan. USAID financingmajor FP training projectfor health staff.

17. Section 4.01 (a, b). Mainte- System of maintaining andnance and retaining of appro- retaining accounts esta-priate project accounts. blished and operational.

18. Section 4.01 (c, d). Annual Audits seriously delayed.auditing and presentation of Audit for FY 1988-89, dueaudits to the Association. on March 31, 1990, not yet

received.

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10. Use of Bank Resources: Staff Inputs

State of Staff Weeks 1/Project Cycle Actual

Through Appraisal 195.6

Appraisal throughEffectiveness 14.3

Supervision 150.6 2/

TOTAL 360.5

1/ Time spent in Headquarters and in the field.2/ Upto and including FY89.

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11. Use of Bank Resources: Missions

Mission Month/ Number Specialization Types of Performance

Year of Represented a/ Problems b/ StatusPersons Rating c/

Reconnaissance 2-3/81 4 PS; MCH/FP;TRG; CT/NCT

Preparation 6-7/81 6 PS; PH; TRG,EV; IEC; OPP

Preparation 11/81 3 PS; OP; OPPAppraisal 5/82 7 PS; TRG/PE; IEC;

EV; E/F; MCH/FP; OPP

Post-Appraisal 9-10/82 4 PS; TRG/PE;IEC; OPP

Review 7-8/83 4 PS; IEC; TRG; PA M; T 2

Supervision I 12/83 4 PS; D;TRG; PA M; T 2

Supervision II 4/84 4 PS; D; IEC; PA M; T 2

Supervision III 11-12/84 5 PS; MCH/FP, IEC;PE; PA P; M; T 3

Supervision IV 9/85 4 PS; PA; H/FP; HC T; M 2

Supervision V 4-5/86 6 PS;2, OP; IEC;PA; H/FP T; M 2

Supervision VI 10/86 2 2 OP T; M 2

Supervision VII 6/87 1 PS T; M 3

Supervision VIII 2-3/88 3 PS; IEC/TRG/PE; D T; M 3

Supervision IX 6-7/89 2 PS; D M 3

a/ PS - Population Specialist; E = Economist; MCH = Material child health;

FP - Family planning; CT = Clinical training; NCT = Non-clinical training;

TRG = Training specialist; PE = Population education; EV - Evaluation

specialist; IEC = IEC specialist; F - Financial analyst; PH = Public health

specialist; OPP - Operations officer (RMP); OP - Operations Officer,

Headquarters; PA = Projects advisor (RMP); D = Demographer, MC Management

consultant; H/FP - Health/FP Administration

b/ M = Managerial; T = Technical; P Political

c/ 1 = Problem-free or minor problem; 2 = Moderate problems; 3 Major

problems.

- 31 - Annex IPage 1 of 6

DETAILED PROJECT FEATURES!'/

1. The project comprised the following national and regional components.

A. National Scope Components

2. Project Training: This component, under the Directorate of ProgramTraining and Education, would assist in establishing two Population WelfareTraining Institutes - one in Lahore to serve the province of Punjab, withstaff in Peshawar to cover NWFP and one in Karachi to serve the province ofSind, with staff in Quetta to train workers in Baluchistan. The Directoratewould be responsible for undertaking and/or assigning to the traininginstitutes development of course curricula, teaching aids, and trainingmanuals; it would also have a program of continued education for trainers,including a master trainers program.

3. Each Institute would perform the fol'lowing functions: (a) develop andupdate annual regional training plans and assist district officers inpreparing local training plans; (b) develop curricula, materials and malkualsfor various courses to be given either by PWTI staff, or district officers, ortrainers of other government departments and institutions; (c) train trainersand offer them support, technical assistance and monitoring; (d) define andmanage contracts with consultants, firms and private organizations to assistPWTIs in their various tasks; (e) design and conduct selective orientationsessions on the population welfare program (although their main function vis-a-vis training of non-population workers would be to monitor and support suchsessions conducted by other departments and institutions); (f) periodicallyevaluate all training programs and revised curricula as necessary; and (g)identify needs for training in management, jointly with the management of thePopulation Welfare Division and conduct and/or arrange for such training.

4. Information, Education and Communication: The wide gap betweenawareness and practice of family planning and the need to change the publicimage of the population program from a single purpose approach to a multi-sectoral effort requires a reorganized and revitalized IEC structure andprogram, utilizing a blend of channels from face-to-face communication togroup meetings and mass media. The main focus of this component is toene7ourage the adoption of the small family norm and to assist in removingresistance to contraceptive use. The IEC strategy consists of identifying andaddressing specific target audiences through a variety of channels, each onehaving a particular role in achieving program goals.

5. The preferred form for direct family planning motivation will beindividual or group discussion in which the provider of information and advicewill be a knowledgeable member of the local community (such as satisfied

1/ Summarised from the SAR.

- 32 - Annex I

Page 2 of 6

acceptors and service providers). The project design encourages communityparticipation using approaches tested in other social action programs.Program effectiveness will depend on correct identification and collaborationwith these indigenous systems, coupled with coordinated support from massmedia and other channels.

6. Interpersonal communication and group discussions would befacilitated by appropriate audio-visual (AV) equipment, production ofpublicity and educational materials (print, film strips with discussionformats put together as "motivational kits"), and cassette players with pre-recorded scripts. Each district will also operate an AV van, equipped with16mm motion picture projector for use with large groups. The vans will beused to show entertainment features - including dramas, puppets, localentertainers' films - and to make announcements abut FWC activities. Therewill also be structured workshops and seminars for special interest groupsdesigned to expose, inform, and elicit support for the program among leaders,indigenous entertainers, officials of other departments or any other group.

7. Television will be used only for legitimizing the new plan throughspot announcements, news items and documentaries, incorporation of the smallfamily norm in entertainment programming, and dissemination of the six broad"themes" identified in the plan. Radio will be used effectively forbroadcasting interviews about FWC activities with FWC staff and volunteers asa way of enhancing worker's prestige and generating interest in the program.Print Media (mainly press) will be used to reach literate, influential personsand promote the program.

8. An IEC organization will be established through this project, capableof designing, implementing and evaluating programs for a wide range of

audiences, through multiple channels, encompassing the program describedabove; it would also provide communication training, supervision, manuals, andeducational materials to workers and volunteers. At the national level, aDirectorate of Communication and Production (C&PD), in Lahore, with threedivisions and one section for production and publications, will be responsiblefor, inter ia, developing and obtaining policy clearances, designing,testing and -aproducing materials, overseeing IEC staff selection at alllevels; maintaining regular contacts with the training directorates;supporting the provincial and district IEC-training staff; and developing and

implementing IEC workplans using appropriate media and strategies based onevaluation/research findings. In each of the four provinces, a DeputyDirector for IEC reporting to the Population Director General will be themanager of the IEC field program. Each district will be staffed by acommunication officer with responsibilites for training, follow-up andsupervision of FWC staff and v3lunteers concerning their IEC work, as well as

for field-level coordination with other government departments.

9. Population Education in the Formal School System: This national sub-component seeks to reinforce the population education program currently inexistence in the formal school system of the Ministry of Education. Itintends to reach 2.2 million students from intermediate and secondary levelswith instruction that will encourage critical thinking in relating population

-33 - Annex IPage 3 of 6

dynamics to its effects upon communities and families. A second objective isto provide teachers with an understanding of the consequences of populationgrowth for the country, the community and the family and fully acquaint themwith the objectives and activities of the population welfare program. Teachertraining will be supplemented by correspondence courses to be conducted by theOpen University, with appropriate radio, television, and seminars.

10. Population education concepts are already included in the schoolcurricula of teachers' courses and primary level courses in sciences, socialstudies, and languages (Urdu and English). The project will enablepreparation of instructional and textbooks units for grades 1 to 3. Inaddition, it would assist integration of population concepts in the tensubjects taught in grades 11 and 12 of the intermediate level, the review ofexisting textbooks for content on pop!u ation education, and the development ofcurricula content for grades 4 to 10 _ This sequence follows the currentschedule of overall cirricula development and textbook review of the FederalMOE and provincial departments of education.

B. Regional Component

11. This component provides co-ordinated packages of new programactivities in thirteen districts with a total of about 20 million people. Ofthese districts, three in Karachi and Sheikhupura in Punjab include towns andcities where public response to FP may be more forthcoming; five otherdistricts in .NWFP and Baluchistan provinces were selected inspite of lowlevels of program acceptability to make a beginning with new programactivities in all provinces; and Jhang and Multan in Punjab and Tharparkar andSukkur in Sind, agricultural districts with past low program performance, wereselected to take advantage of other community development activities. Theproject would implement three sub-programs of the Plan in the selecteddistricts: (a) FWC's; (b) family planning service outlets of othergovernment departments; and (c) family planning outlets in target groupinstitutions. Other Plan sub-programs and "projects" would also take place inthose districts, either financed as part of the national project component(i.e. program training, IEC, and population education in schools includingteacher training) or by other donors-e.g. clinical training of health and FWCstaff, contraceptive surgery in RHS centers, etc. The main differencesbetween project and non-project districts would be that in t1he former:

(a) the various activities would be programmed on a monthly basisand operational plans and schedules would be prepared by eachwork unit and individual staff and used by DPWOs to monitorprogress, identify problems and offer support;

(b) several new approaches, especially the FWC concept, cooperationwith health departments and other institutions, and IEC

2V IDA Comment: With reference to the Borrower's comment in paragraph 54,the above information has been summarised from the SAR.

- 34 -Annex I

Page 4 of 6

activities, would be first tested in project districts, thusencouraging a phased implementation of activities whose designmany need adaptation and modification before nationwideextension;

(c) additional resources from the project would be available inprojected districts for changing staffing patterns of FWCs asthe work volume increases; making financial and technicalresources available to health departments and otherinstitutions to provide family planning services; providingadequate incentives to volunteers; supplementing rentallowances for appropriate housing and location of FWC's;providing for appropriate maintenance of equipment and cente.s;

(d) contractual medical services would be available for advisingand assisting in the implementation of improved service,supervision and referral in FWCs and other FlE service outlets;and

(e) a comprehensive evaluation scheme would be an on-going activityin project and control districts, to provide reliableinformation for future program planning.

12. Family Welfare Centers: The project would assist in conversion ofabout 250 clinics remaining from the old population program which were singlepurpose family planning service points with some ad hoc curative functions,into FP/MCH/community development centers, named FWCs. The project would alsoassist the establishment of 42 FWCs in locations selected for their easyaccess and complimentarity with other health outlets.

13. Advisory Management Committees (AMC) will be formed in each FWC areaand will facilitate and support the center's functions. The AMC is expectedto: (a) assist as necessary in obtaining physical facilities for FWCs, andmaintain them; (b) identify and recruit community volunteers; and (c) bethe channel for identifying genuine community needs, working out a communityactivity plan, seeking funding and mobilizing community resources, andestablishing links with relevant Government departments.

14. Each centre would be staffed by five workers: a Family WelfareWorker, one female Family Welfare Assistant (FFWA), a male Family WelfareAssistant (MFWA), and two support staff. A Family Welfare Counsellorreporting to the District Population Welfare Officer would supervise twocenters and spend two weeks of the month in each center. Services availableat the center would include antenatal delivery and postnatal care; FP adviceand services; nutrition surveillance of children under 5 years; pediatriccare; immunisations; and health education of mothers. For referral purposes,the center will keep a list of nearby hospitals, health centers and outpatientdepartments, either Government or private and the names of doctors in chargeof maternity and children sections.

- 35- Annex IPage 5 of 6

15. The project will also test the alternative of obtaining cooperationfrom private sector associations to run a few of these centers. ThePopulation Welfare Division will provide funds to the NGOs equivalent to thestar:dard cost of running a center, and perhaps trained staff, and the privateorganization would agree to contribute additional funds and voluntary manpowerfor administering the centers and for bringing them up to pre-agreed higherstandards of services.

16. The project will provide each FWC with seed money for communityactivities through the District Population Offices. The FWC staff isresponsible for establishing an appropriate program for women's meetings atthe centers and stimulating the AMC to take at least one project in skilldevelopment and income generation at a time. In selecting any activity, theAMC and the staff should ensure that the priority and focus of populationwelfare is maintained. Among the income generating activities two types maybe distinguished: (a) those which result in products that can be marketedand (b) those which benefit the families by extending the family budget.

17. Family Planning Service Outlets and Other Government Departments:This sub-component would introduce family planning services andeducation/motivation in 700 health facilities of several provincial governmentdepartments and local bodies. All four provincial population DGs arepreparing action plans with the respective secretaries of health and othersectors. Since RTIs have a heavy load with the training of the clinical staffof the Population Division (mainly FWWs, counselors and female FWAs), thissub-component would finance training in family planning of six trainers fromparticipating departments so that such training can be institutionalized inthe schools and auxiliary training center of the participating departments.The project would also provide equipment and materials (including IEC aids) toparticipating health outlets, for service delivery. Participating departmentswould be provided with an initial supply of contraceptives; the funds obtainedfrom initial sales to clients would be kept by each department as a revolvingfund for subsequent purchases.

18. Family Planning Service Outlets of "Target Group Institutions: Theobjective and design of this sub-component are similar to those described forservice outlets in other provincial government departments, however, it willbe administered in a slightly different way. Because public sectorinstitutions relate to the Federal Government, this component would be aresponsibility of the Federal Population Welfare Division, assisted by theprovincial population directorates as required. Public sector institutionswould provide family planning services and information/education to theiremployees and families through 50 health outlets that those organizations havein the project districts. The main institutions are: Armed Forces, WAPDA,Fauji Foundation, Pakistan International Airlines, Pakistan Railways andPakistan Steel Mills. The project will train staff in clinical aspects offamily planning, as well as in motivation/education as would be relevant tovarious types of staff. It would also finance training of six trainers, oneeach from the respective organization, to institutionalize FP training. Theinstitutions would buy contraceptives from the Population Welfare Division andthe project would provide IEC printed and audio-visual materials and would

- 36 -Annex I

Page 6 of 6

assist in preparing various IEC activities for the constituents of thoseorganizations.

C. Project Administration, Evaluation and Preparation of Future Projec...s

19. Project Administration: The project would establish a ProjectAdministration Cell in the Population Welfare Division by financing salaries,travel and per diem for supervision, vehicles for national and provincialpopulation offices, vehicle operation, and maintenance.

20. Monitoring and Evaluation: Under this component, it would financeconsultant services, travel and per diem, data processing and other operatingcosts for undertaking, in project and control districts the followingevaluation activities: (i) yearly samples of FWCs for task analyses throughobservers; (ii) two FWC cost-effectiveness studies based on information fromthe regular service statistics and financial/accounting systems; (iii) onebaseline and one mid-project management audit of streams of administrativeprocesses in each province; (iv) two marketing-type sample surveys onreceptivity of FWCs among communities; and (v) block allocation for studieson program acceptance and fertility determinants.

21. Preparation of Future Projects: This component would provideconsultant services of an engineering adviser and architectural firm(s) forpreliminary design and detailed drawings of 12-14 training buildings, andtravel and per diem for the following project preparation activities: (i)selecting and acquiring sites; (ii) planning accommodation requirements andpreparing detailed accommodation schedules; and (iii) producing engineeringdesigns, and detailed drawings.

D. Innovative Activities

22. Approximately 3% of the total base cost will be allocated to small-scale experimental programs to be identified during the project period. UK-ODA financed this component. Each proposal would be reviewed by ODA and IDAbefore implementation.

Annex IIPage 1 of 3

NATIONAL FAMILY PLANNING PERFORMANCE

Table A.l. Targets and Achievements of Contraceptive Delivery by Methodduring 1983-86 to 1987-88

Contraceptive 1983-84 1984-85 1985-86 1986-87 1987-88 TOTAL

Method Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved------------------------------------------------------------- __--------------__------------------------------------------------------------__-

Sales of Condoms(Units) 128700000 58563652 133099872 81567835 151554420 84389081 168654564 100729955 143754192 137403008 725763048 462653531

Sales of oral-pill (Cycles) 4225000 740707 3907836 927439 3953252 1274049 4521060 1445372 3874776 1879216 20481924 6266783

Insertions ofIUD 188000 152310 231972 196636 269692 241905 401520 315769 639180 507884 1730364 1414504

Number ofinjectables 95000 96035 549972 110427 677380 225179 819336 384190 947676 434603 3089364 1250434

ContraceptiveSurgery (Cases) 76000 41068 116928 58926 129676 69962 155616 69439 167880 77386 646100 316781

Sale of FoamBottles 59700 38460 120024 44930 193492 76717 277092 104977 274920 139405 925228 404489

Source:-----------------------------------------Monit----------__-----rin----__---------and-----------Evaluation.----------------------------_

Source: PWD, Monitoring and Evaluation.

Annex IIPage 2 of 3

Table A.?. Trend of Growth in National Performance of Contraceptive

Delivery Services, 1983-88

Performance during X Targets established 7

Contraceptive method 1983-84 1987-88 Increase 1983-84 1987-88 Increase

Sales of Condoms (Units) 58563652 137403008 134.62 128700000 143754192 11.70

Sales of oral pill (Cycles) 740707 1879216 153.71 4225000 3874776 -8.29 1

Insertions of IUD 152310 507884 223.45 188000 639180 239.99

Number of Injectables 96035 434603 352.55 95000 947676 897.55

Contraceptive Surgery (Cases) 41068 77386 88.43 76000 167880 120.89

Sale of Foam Bottles 38460 139405 262.47 59700 274920 360.50

Source: FWD, Monitoring and Evaluation.

Annex IIPage 3 of 3

Table A.3 Targets and Achievements of Births Avertedl/ by Contraceptive Methods

during 1983-84 to 1987-88

Contraceptive 1983-84 1984-85 1985-86 1986-87 1987-88 Total

Method Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved

Condom 154634 70364 159920 98004 182093 101394 202639 121027 172721 165090 872007 555880

Oral Pill 43387 7606 40130 9524 40596 13083 46427 14843 39790 19298 210330 64354

IUD 32639 26443 40273 34138 46822 41997 69708 54821 110969 88174 300410 245574

Injectable 2283 2308 13217 2654 16279 5412 19691 9233 22775 10445 74246 30051

Contraceptive

Surgery 20321 10981 31264 15756 34673 18706 41609 18567 44888 20691 172754 84701

Foam 1793 1155 3604 1349 5811 2304 8321 3152 8256 4186 27785 12147

Sub Total 255056 118857 288409 161425 326274 182896 388395 221643 399399 307885 1657532 992707

Carry Over 92704 50136 65033 79925 91945 379743

Grand Total 118002 211561 247929 301568 399830 1278891

Source: PWD, Monitoring and Evaluation.

1/ Estimates of births averted are the result of a mechanical exercise based on acceptance statistics.

Annex III

NATIONAL TEACHER ENROLLMENT FOR POPULATION EDUCATION COURSES

Autumn 84 Spring 85 Autumn 85 Spring 86 Autumn 86 Spring, 87 Autumn, 87 Spring, 88 Autumn, 88

Course T I F I T F T F T F F T F T F T IF

Population Education 863 286 1012 314 1042 356 1076 310 1112 377 1357 395 1135 250 1502 65 800 NA

for Primary/MiddleSchools

Population Education - - - - - - - - - - - - - - - - 531 NA

for secondary scbools__. __.

Note: T = Total; F - Females; NA not available; - = not applicable

Source: Alama Iqbal Open University 4:-

- 41 -

Atta c'w'ent J

OVERSEAS DEVELOPMENT ADMINISTRATIONEland House. Stag Place, London SWI E SOH

relex: 263907/U FAX:01.273 Telepholt 01273 0654at Switchboard: 01 273 3000

OtNI 273

four tel

Mr C. Walker MSG NO. 1854

Population and Human ASP 171/774/006AResources Division A 7 4The World Bank 6 February 1990

International Bank forReconstruction and Development1818 H Street, NWWashington DC 20433USA

PAKISTAN; POPULATION PROJECT COMPLETION R RPOaT

With reference to your fax of 15 December 1989 to Alan Burner we havenow received comments from our advisers.

2. In general the report has been prepared with care and a goodmeasure of Insight into the problems of programme design and projectimplementation. We therefore recommend overall endorsement.

3. There are a few minor points of amendment on details of the ODA

inpuxs. They are as follows:

(t) Para. 19 should read "ODA audio-visual and transport

vans".

(ii) Page 23: ODA final credit agreement should read 2.9.(it was increased in the 1985 aemeifdment).

(iii) Page 26: Project results table. The first draft of the

First Management Audit im now del*yed but we expect it by April1990.

Please contact Ian Thomas or myself if you need any more information.

With best wishes.

(9 Pat Scutt (Mrs)Southern Asia Department

RCV BY:92 21 512875 ;19- 3-90 : 16:15 11 0092 51 824807-'KARACHI SHERATON HTL;# 119--03/'90 16:18 WJORLD BANK ISLAMAnBAD PAKISTAN 001/00:3

- 43 - ATTACIIMENT II

UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENTqgl|| MISSION TO PAKISTAN

Coble uSAInPAK 18- Sixtt Avcnue, Ramna 6,Tleox 54270 PK Post Of fiue Box 1028

Telephones 824071.79 l,4mobbd, P8k.stan

March 15, 1990

Mr. Bashir Parvez, Projects AdvisorWorld Bank Resident Mission in PakistanP.O. Box 1025Islamabad

5ubject: Pakistan Population Project Completion Report

Dear Mr. Parvez:

Thank you for sharing with us the draft of the subject report. USAIDstaff were pleased to have a chance to review the draft and compare theWorld Bank's experience with our own.

The World Bank project encountered many of the same constraints as theAID projects are facing. In particular, lack of strong politicalsupport, weak management and lack of adequate technical expertise,including technical consultants, are critical Issues.

We have several other specific conmnents on the draft report.

1. Project Administration Cell (PAC):. We fully agree. A fullyoperational PACwou1d nave been most useful for timelyimplementation of the project.

2. Defederalization: The transfer of program implementationresponsibilIties to the provincial governments was a politicalaction. It not only complicated program management, monitoring andsupervision but also resulted in increased administrative andbureaucratic hurdles. It did not necessarily "wldenu PWD'sresponsibilities as the report indicated on page 1, but may havenarrowed PWD's role especially as it reduced PWD's effectiveness Inmonitoring program implementation In the field. In our opinion, PWDmight have produced the desired results by its retention offinancial control, had the program not faced other administrativeconstraints and budgetary cuts.

3. ProgrOm opposition: (Page 5. Para 17) There has certainly been al FcK or support to the program but we did not notice an "Opposition".

4. Hostility: (Page 8, Para 18) The sociocultural milieu is notfWiti1e to the program, though it may not be as conducive asdesired. The Government's apparent concerns that there will behostility have generally been unfounded. In our opinion, a

RCV JY:92 21 512875 .19- 3-9S : 16:16 OOi2 51 a24d 7ARACHI SmEA-,N mTL;g 13 '03',90 16:19 WORLD BA~NK I SLAMABAD PAK ISTAN 002/003

- 44 - ATTACHIENT II

lr, Bashir Parvez, Projects AdvisorPage Two

major constraint to the program has been the government's fear ofarousing hostility. This seems to have produced a reluctance todevelop an active program that is appropriate within thesociocultural milieu.

5. Multi-sectoral ApProach; A multi-sectoral approach may be tooconq,1vcatea, given tne program s weak management and administrativecapabilities, frequent changes at upper levels in the staff, andweak political support. It may be more effective in the future tofocus efforts in other sectors more narrowly, and to phase them inslowly.

Again, we appreciated the chance to reew the draft project completionreport, and believe the findings are useful in considering our own workalso.

Sincerely,

en Aarnes, ChiefHealth, Population and Nutrition

World Bank Document€¦ · Report No. 9262 PROJECT COMPLETION REPORT PAKISTAN POPULATION PROJECT...

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