Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No. 6303

PROJECT PERFORMANCE AUDIT REPORT

BANGLADESH

(FIRST) POPULATION PROJECT

(CREDIT 533-BD)

June 30, 1986

Operations Evaluation Department

This document has a rstricted distribution and may be used by reelpients only in the performance oftheir oillela duties. Its contents may nt otherwise be disclosed without World Bank authorization.

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

DEFINITIONS

Contraceptive The percentage of married women of reproductive agePrevalence Rate using a method of contraception (modern or traditional)

at a given point in time.

Crude Birth Rate Number of live births per year per 1,000 population.

Crude Death Rate Number of deaths per year per 1,000 population.

Rate of Natural Differences between crude birth and crude death rates;Increase usually expressed as a percentage.

Rate of Population Rate of natural increases adjusted for (net) migration,Growth expressed as a percentage of the total population in a

given year.

Age Specific Number of live births to women in a given age group perFertility Rate 1,000 women in the same age group, in a given year. It

is usually calculated for five-year age groups.

Total Fertility The average number of live children that would be bornRate per woman if she were to live to the end of her

child-bearing years, and bear children according to agiven set of age-specific fertility rates, The TotalFertility Rate often serves as an estimate of theaverage number of children per family.

Net Reproduction The number of live-born daughters a cohort of femalesRate would bear under a given fertility schedule and a given

set of survival probabilities, from birth to the end ofthe child-bearing years.

Infant Mortality Annual number of deaths of infants under one year perRate 1,000 live births during the same year.

Maternal Mortality Number of maternal deaths per 1,000 births attributableRate to pregnancy, childbirth, or puerperal complications

(i.e. within six weeks following childbirth).

Life Expectancy Average number of years expected to be lived bychildren born in a given year if mortality rates foreach age/sex group remain the same in the future.

Age Dependency Ratio of population 14 years and under plus populationRatio 65 years and over to population aged 15 to 64 yearsi

THE WORLD BANK Iu um UMWashington. D.C. 20433

U.SA.

ime of DirectmGWrrOpm"esM Evauo

June 30, 1986

MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT

SUBJECT: Project Performance Audit Report: Bangladesh - (First)Population Project (Credit 533-3D)

Attached, for information, is a copy of a report entitled"Bangladesh (First) Population Project (Credit 533-BD)" prepared bythe Operations Evaluation Department.

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 authoriation.

FOR OMTICIAL USE ONLY

BANGLADESH

POPULATION/HEALTH/NJTRITION STATUS AND TRENDS

KEY INDICATORS /a

Demographic At Appraisal Latest

Total population (January) (millions) 74 (1973) 93.6 (1981)

Crude birth rate (per thousand) 47 (1973) 45 (1983)/b

Crude death rate (per thousand) 17 (1973) 17 (1978)/b

Rate of natural increase (%) 3.0 2.6/c

Health

Population per physician (thousand) 9.6 (1976) 8.8 (1980)

Population per hospital bed (thousand) 6.0 (1976) 4.4 (1980)

Doctor-Nurse ratio 8:1 (1973)

Nutrition

Calorie intake as % of requirements 91 (1979)

Per capita protein intake (grams) 58.5 (1979)

Income

Per capita income (US$) 72 (1970) 120 (1980)

/a From Project Completion Report.7T For more recent estimates, see PPAM para. 7.

7- Government comments that the Planning Commission on the basis ofnational census, intercensal report, and other relevant surveys and

studies, have determined in mid-1985, the population growth to be 2.4%

annually (see Supplement 1).

FISCAL YEAR

July 1 - June 30

COUNTRY EXCRANGE RATES

Name of Currency (Abbrevation) : Taka (TK)

Appraisal Year (February 1975) : US$1.00 - TK 7.83After Devaluation (in 197') : US$1.00 - TK 15.00

After 1978:Fixed according to a specified basket of currencies. The USDollar rate, therefore, varied from day to day. On January 11,1983, for example, the official exchange rate was set at TK24.48 buying and TK 25.52 selling per US dollar. During theaudit mission it averaged TK 31.10. For the appraisal of theThird Population and Family Realth Project an exchange rate ofUS$1.00 - TK 26.50 was used.

ABBREVIATIONS

ADAB - Australian Development Assistance BureauBIDS - Bangladesh Institute of Development StudiesBPDU - Building Planning and Design UnitCBR - Crude Bank RateCIDA - Canadian International Development AgencyCPR - Contraceptive Prevalence RateEEU - External Evaluation Unit (Planning Commission)FP - Family PlanningFPA - Family Planning AssistantFTTHC - Field Training Thana Health ComplexFWA - Family Welfare AssistantFNC - Family Welfare CenterFWV - Family Welfare VisitorFWVTI - Family Welfare Visitor Training InstituteGOB - Government of BangladeshIEC - Information, Education and CommunicationIEK - Information, Education and MotivationIRDP - Integrated Rural Development ProgramIUD - Intra-Uterine DeviceKfW - Kreditanstalt fur Wiederaufbau (West German Financial

Aid Agency)MA - Medical AssistantMCH - Maternal and Child HealthMCH/PF - Maternal and Child Health and Family PlanningMCWC - Maternal and Child Welfare CenterMFPC - Model Family Planning ClinicMHPC - Ministry of Health and Population ControlMRPP - Ministry of Health and Population PlanningMIB - Ministry of Information and BroadcastingMOHPC - Ministry of Health and Population ControlNCPC - National Council for Population ControlNGO - Non-Governmental OrganizationNIPORT - National Institute of Population Research and TrainingNORAD - Norwegian Agency for International DevelopmenLODA - Overseas Development Administration (U.K.) (Also, OUW)OED - Operations Evaluation DepartmentPCFPD - Population Control & Family Planning DivisionPCR - Project Completion ReportPFC - Project Finance CellPHN - Population, Health and Nutrition DepartmentPPAM - Project Performance Audit MemorandumPPAR - Project Performance Audit ReportPPD - Population Planning DivisionPPO - Population Program OfficerPPS - Health and Population Planning Section of the Planning

CommissionPWD - Public Works DepartmentSFWV - Senior Family Welfare VisitorSIDA - Swedish International Development AuthorityTFR - Total Fertility RateTHC - Thana Health ComplexUFWC - Union Family Welfare CenterURC - Upazila Health Complex

ABBREVIATIONS (cont'd)

URFWC - Union Health and Family Welfare CenterUNDP - United Nations Development ProgrammeUNFPA - United Nations Fund for Population ActivitiesUNICEF - United Nations Childrens FundUSAID - United States Agency for International DevelopmentWHO - World Health Organization

PROJECT PERFORMANCE AUDIT REPORT

BANGLADESH

(FIRST) POPULATION PROJECT(CREDIT 533-BD)

TABLE OF CONTENTS

Page No.

Preface ............................... iBasic Data Sheet ........................... iEvaluation Summary ................ ........... vProject Implementation Illustrations ............................... xii

PROJECT PERFORMANCE AUDIT MEMORANDUM

I. INTRODUCTION o......................... ........ 1

A. Background ................ ...... 1B. Bank's Role in Population ............................ 1

II. PROJECT ENVIRONMENT ................... 3

A. Sector Context ............ ........ 3B. Population Policy, Program Development and

Organization .............. ...... 6C. Program Performance .................................. 10

III. PROJECT PERFORMANCE ............... 11

A. Project Preparation and Formation .................... 11B. Project Implementation .............................. 14C. Project Administration ............................... 15D. Project Impact ............ ........ 15

Iv. ISSUES ........................... 16

A. Cofinancing and Donor Coordination ................... 16B. Project Design and Supervision ....................... 18C. Utilization .............. .......... 22D. Management and Organization .......................... 24

E. Client Orientation ..... . ..................... 25

V. SUSTAINABILITY AND FOLLOW-UP .............................. 25

PPAM Tables

1. Staff Inputs ....................... ...... . ... 27

TABLE OF CONTENTS (cont'd)

Page No.

PPAM Annexes

1. Project Description First Project ......................... 292. Project Description Second Project ........................ 353. Project Description Third Project ........................ 394. Supervision of Bank Projects, Case Study .................. 45

PPAM Supplements

1. Comments from Borrower .... 0.............................. 592. Comments from Cofinanciers o..........o.................... 67

PROJECT COMPLETION REPORT

l. Project Formulation ...................................... 73II. Project Content ... o...... ...... *....................* 77

III. Project Implementation *.............................00 * 84IV. Project Contribution ............................ 99V. Covenants and Their Fulfilment ........................... 103VI. Role of Bank .................................... 104VII. Major Issues .........................................* . 106VIII. Lessons Learnt and Recommendations ....................... 109

IX. Conclusion ............................................... 110

PCR Annexes

1. Project Components Financed by Different Donors .............. 1112. Use of Savings ............................................... 1133. Field Workers of PCFPD .................................. *... 1154. Construction Schedule for Facilities ......................... 1165. Disbursements of Other Donors ................................ 1186. IDA Disbursements .................... 0........................ 1247. Training Output ........ 00.0000000...............0000. 1258. Achievement of Multi-Sectoral Components ..........o*.0..00 . 1269. Organization Structure ....................................... 12710. Facilities and Staff in Population Program ................... 12811. Financial Resources of Population Program ................... 12912. Acceptance of Selected FP Methods ............................ 13013. A Comparison of Contents of First and Second Project .oe.o.e. 131

IBRD 10939R Population Project LocationsIBRD 14233R Population II Physical FacilitiesIBRD 14234R Population II Locations for IEM SchemesIBRD 18783R Third Population and Family Health Project

PROJE'T PERFORMANCE AUDIT REPORT

BANGLADESH

(FIRST) POPULATION PROJECT(CREDIT 533-BD)

PREFACE

This a performance audit of the (First) Population Project inBangladesh, for which Credit 533-BD in the amount of US$15.0 million wasapproved on February 25, 1975. The Credit Closing Date was extended fromDecember 1979 to September 1982, and with a final disbursement on June 30,1983, the Credit was fully disbursed. In the meantime, a Second PopulationProject (Credit 921-BD in the amount of US$32.0 million) was approved onMay 29, 1979. Of this Credit about US$7.0 million remained undisbursed (asof 01/31/85). A Third Population and Family Health Project (with a Credit inthe amount of US$78.0 million) was approved on January 14, 1986. In additionto the funding from the Bank and the Government of Bangladesh (GOB), theFirst Population Project was cofinanced by the Governments of Australia(ADAB), Canada (CIDA), Federal Republic of Germany (KfW), Norway (NORAD),Sweden (SIDA) and the United Kingdom (ODA).

The audit report consists of an audit memorandum (PPM!) prepared bythe Operations Evaluation Department (OED), and a project completion report(PCR) dated September 1984, prepared by the Population, Health and NutritionDepartment (PHN). The audit memorandum is based on a review of the AppraisalReport No. 543a-BD dated February 3, 1975, the President's Report No.P-1568-BD of February 13, 1975, the Credit Agreement dated March 10, 1975 andthe PCR. In addition, correspondence with the Borrower and internal Bankmemoranda on project issues as contained in relevant Bank files have beenconsulted and Bank staff associated with the project have been intervioved.In 1978, a case study was undertaken to review the Bank's supervision experi-ence with this project (Operational Policy Review, the Supervision of BankProjects, OED Report No. 2858 dated Februray 22, 1980). The case study isreproduced as Annex 4 for ease of reference.

An OED mission visited Bangladesh in July 1985. Discussions wereheld with officials of the Ministry of Health and related ministries incharge of the pilot schemes and other components. Field trips to projectsites were also undertaken including the areas surrounding Chittagong,Raozan, Rangunia, Comilla, Muradnagor and Dhaka; Sy1het; Mymensingh;Jessore, Jhenaldaha, Kushtia, Rangpur, Gaibandha and Bogra. Representativesof the cofinanciers were consulted both at their headquarters as well as inBangladesh. The information obtained during the mission was used to verifythe conclusions of the PCR.

- ii -

The audit finds that the PCR covers the project's salient fea-tures. In addition to summarizing the objectves and results oi the project,the PPAM expands upon some issues important for this and other Bank-supportedpopulation projects.

The draft audit report was sent to the Borrower and cofinanciersfor comment on Marcy 14, 1986. Comments received have been appended to theaudit memorandum as a Supplement.

The valuable assistance provided during the preparation of thisreport by officials of GOB and executing and cofinancing agencies is grate-fully acknowledged.

-iti -

PROJECT PERFORMANCE AUDIT REPORT

SANCIAiESHI C(FIRST) ?jP1AT10 PRJECT

BASIC DATA SMEET

Appraisal ALU<l Ør Actual as A *1Exlectation Current Estim_te paisal stimate

Total Project Costa (US$ million) 45.7 45.7 1004Loan Amuat (05$ million) 15.o 15.0 100tCtortnancing-Tutal (USs million) 24. 21.9 /a 892

AbAb . 2.3 10øø%CA 2.0 1.1 PÅ IbKtW 6.0 6.6 j110 11004) /cNOR"4 8.3 6.4 77% IbODA 3.1 2.5 81 5tiz) /c1D4 3.u .3.o 1001

Øate Physicdi kvmponents Completed 12/79 09/82 157t /dProportion completed by that date(Z) 35% 130% e

Economic Rate of Return n.a. n.a.Insticutional Performance good mixed

CUIUNLTfVR ÉESYIMA1I AND ACTUAL DISBURSEMENTS ~Fyl6 PY77 FY78 t_79 y80. FY8I FY82 FY83

Appralsal Estimate (US$ million) 1.3 4.1 8.0 1.2 14.9 15.0 -Actnal (lis$ million) 0.3 1.3 2.0 ..0 7.7 10.7 1.i l).tAct,4l as Z o£ Appraja.1l (1) 21 3. 23 29 32 71 14 lutDate ot Final DisburAement: lun 3, 1983

PROJECT DATPSOriginal AcLuat .b % ut

Plan Revis_ions Actual gaFicat Menti,n in Files - -10TY2Negotiations - 12/12-27/74Board Approvat - 02/25/75Signing (Credit Agreement Date) - 03/10/75Effectivenese - - 09/25/75Closing Date 12/31/79 12/31/80 09/30/82 15/2 /d

STupF INP'uTS /(Staft Weeks)

FY73 FY74 FY75 FY76 FY77 FY78 FY79 FY0_ FY81 FY82 FY83 FY84 Py85 Total

Idencilication/Preparation 1.7 3.0 0.6 5.3Appraisal 7.4 68.9 87.7 l64.dNegoziations 1.8 18.5 20.3Supervision 49.5 109.1 118.4 M09.3 09.7 9.4 )1.9 ]z.8 24.2 10.t (1.l 671.4

Subtotal 9.1 73.7 156.3 109.1 11.4 109.3 69.7 96.4 51.9 32.8 24.2 10.0 0.1 861.0

MISION IJA

Nø. of Speciali4atIons Pettormance Types otMission Date Persons Rpresented /g tating /h Trend li ProØJem /1

(mo~~/yr.)Identiflction/Preparation 01-05/73 /k

Appraisal 05-06/73Post-Appraisal 04/174

Supervision 1 04/75 n.A.Supervision 11 08/75 6 /1 A, C. E. P 2Supervisih-n 111 02/76 4 A, C, E, P li 2Supevision IV 08/7b 4 A, c. F. 2

Supervisivn V 04/77 5 In A, E, 0 2 l MSupervi4un Vi 11/*7 7 7i A, E. 0 2 l mSupervision Vil 05/78 9 1 A. E, 0 2 14Supervision ViII 11/78 9 /g A, E, 0, 2 2Supervision IX 03/79 3 /q A, 1: 2 2Supervision X 08/79 4.f. A, C, b 2

Supervision XI 12/79 b Lq A, C, u, t, M, K 2 2Supervision XII 04/80 6 /r -Supervision XIII 08/80 4 ./ A, c, c. 4 M, - --Superviston XIV 12/80 2 /r A, 0Supervision XV 06/81 2 Tr A, E 2Supervision XVI 12/81 2 7/ A, E -- -Supervision XVII 04/52 2 /r A, M 2 mSupervision XVIII 09/t2 3 A, N 2Completion 04/83 6 09-10/33 -

P Footnotes next page.

- iv -

OTER8 PROJECT DATA

Borrower: Government of Bangladesh (GOB)Executing Agencies: Ministry of Health and Population Planning

as well as:Ministry of Local Government, Rural Development and CooperativesMinistry of Labor and Social WelfareMinistry of AgricultureMinistry of EducationMinistry of Information and Broadcasting

Also involved were the External Resources Division of the Ministry ofFinance and the Health and Population Planning Section of the Planning Commission.

Follow-On Projects:Name Second Population and Family Health Project /s Third Population and Family Health Project ACredit Number 921-80 Not Yet SignedAmount (US$ million) 32.0 18,0Approval Date May 25, 1979 January 14, 1986

/a Actuals, as reported by Project Finance Cell as of June 30, 198J.b Further disbursements have been made, and these contributions were almost fully disbursed.

Tc Ditterence in US terms, but actually 1001./d Time overrun calculated from date of approval.I; Project savings largely due to devaluation gains used for additional construction aid equipment, but some of these not

completed by extended Closing Date./f Source: Planning and Budgeting Department.7- A - Architect; C a Information, Education, Commuanication Specialist; 0 a Disbursement Assistant; ;E s* Economist; M * Medical

Officer; N - Nutrition Specialist; 0 - Other, or unavailable; P * Population Specialist; R Researcher./h I - Problem-free or Minor Problems; 2 - Moderate Problems; and 3 * Major Problems.

1 * Improving; 2 - Stationary; and 3 * Deteriorating.N a managerial.Several mission involving different donor agencies.Plus 6 persons from cofinancing agencies.

N Plus a nursing specialist from NORAD.7n One-third of staff time spent on identification/preparation of Second project./o Half of staff time speent on identification/preparation of Second project.7 Three-quarters of staff time spend on appraisal of Second project.7j Time also spent on appraisal of Second project.

Also supervised Second project.To SAR, Second Population and Family Health Project, Report No. 2323-BD dated May 16, 1979.t SAR, Third Population and Family Health Project, Report, No. 5485-BD dated December 24, 1985.

- v -

PROJECT PERFOMANCE AUDIT REPORT

BANGLADESH

FIRST POPULATION PROJECT(CREDIT 533-BD)

EVALUATION SUMMARY

Introduction

Rapid population growth and rising and high population density bothconstrain and dominate long-term development in Bangladesh. The presentPopulation of 100 million, growing at a rate of about 2.6% annually, can beexpected to double in the next 25 years. Population density (1,800 personsPer square mile), already one of the highest in the world, will rise to 3,000by the beginning of the next century. However, current World Bank projec-tions further indicate that Bangladesh's population would only stop growingin the 21st century when it would reach a level of 450 million. What thatimplies for a country where the land-man ratio has already been reduced to0.2 acres and where about 50% of the population is landless, is beyond imagi-nation.

Against this background the need for population control was recog-nized by the Government and the donor community in 1973. A population pro-gram had begun earlier with the start of voluntary efforts in the early1950s, followed by the adoption of a national family planning program in thenEast Pakistan in 1965. A network of family planning clinics was set up andrun by an autonomous Family Planning Board, but interrupted by the war ofliberation the program had come to a virtual halt in the early 1970s. Thesubsequent formulation of a population policy for Bangladesh took place at atime when the international community overall supported certain acceptedstrategies, although there continued to be wide divergencies of opinion onthese issues among experts both within and outside Bangladesh (PPAM paras.15-16).

Since that time, the Government and donor communities have beenactively funding the population programs of Bangladesh. To date, the Bank,in conjunction with other donor agencies, has funded three population proj-ects in Bangladesh. All three are basically similar, but progressivelyexpanded substantially in size: appraisal estimates of project cost amountedto US$45.7 million for the First Population Project, US$110.0 million for theSecond Project and US$213.8 million for the Third Project. Credit 533-BD(Population I), in the amount of US$15.0 million, was approved in February1975. In addition to funding from the Bank and the Government of Bangladesh,the First Population Project was cofinanced by the Governments of Australia,Canada, the Federal Republic of Germany, Norway, Sweden and the UnitedKingdom. While the need for coordination was clearly recognized, lending

- vi -

agencies such as USAID, UNFPA, WHO, and later UNICEF, funded their ownprojects, as differences of opinion arose between the Bank and these agenciesabout organization and technical aspects of the program as well as about whowas to provide leadership. The Credit Closing Date was extended by threeyears to December 1982 and the Credit was fully disbursed in June 1983. Inthe meantime, Credit 921-BD (Population II), in the amount of US$32.0 mil-lion, was approved in May 1979. Of this Credit, about US$7.0 million remainsundisbursed (as of 01/31/85). A Credit in the amount of US$78.0 million wasapproved in January 1986 for a Third Population Project.

Project Objectives

At a time when services had been severely disrupted by the war ofindependence and the contraceptive prevalence rate from modern methods waslow, the First Population Project intended to develop and strengthen thenational population program. More specifically, the project was designed toimprove the organization and management capacity of the program, extendfamily planning services to the rural areas, make the delivery and planningservices more effective by training and introducing monitoring and evaluationsystems, mobilize demand for family planning services, and through demograp-hic research assist in the shaping of future population policy.

The project included the following components: (i) providing tech-nical assistance; (ii) establishing and supporting a total of 45 training andservice facilities; (iii) training and subsequent employment of about 3,700female family planning workers; (iv) supporting nine education/motivationpilot schemes in 61 different locations to be executed by six differentministries; (v) providing for research and evaluation studies; and (vi) sup-porting private sector and innovative activities. Total project costs wereestimated at US$45.7 million. Following currency devaluations, project sav-ings were allocated for additional activities, including construction of 80health and family planning clinics, while at the same time support for exist-ing activities was extended for another two years.

Project Implementation

The project was approved in February 1975. The IDA Credit wassigned in March 1975 and became effective in September of that year. Dis-bursements lagged substantially behind schedule, and by December 1979, theoriginal Closing Date, only 35% of the total amount had been disbursed. TheCredit was fully disbursed three and one-half years later.

Start-up project activities were delayed by over a year due todelays in declaring the Credit effective and in formalizing donor commit-ments. The construction component was further delayed due to technical*organizational, procedural and contractual problems. Once completed, majordifficulties were encountered in making the facilities operational, largelydue to design and quality control deficiencies. Nearly all the sites visited

- vii -

by the audit mission required major repairs and maintenance, while much ofthe equipment provided under the project was either not installed or notfunctional at the time.

Once the project started, the software components proceeded onschedule. However, there were substantial problems with administering thepilot schemes and training programs. Quality control was somewhat of aproblem in relation to training, which in many cases was completed wellbefore project training facilities had been finished. The managementinformation system and external evaluation unit were established late and amajor research study (determinants of reproductive behavior) was notcompleted. Recruiting technical assistance posed serious problems. Neitherthe national seminar nor the building utilization study were carried out.

The population wing of the Ministry of Health and Population Con-trol (MOHPC) was responsible for overall implementation and coordination. Aspecial construction unit and a finance cell were established within theministry for project purposes. An External Evaluation Unit was established(albeit late) in the Population Planning Section of the Planning Commissionand a National Population Council was established (the latter a condition ofeffectiveness). Implementation of the pilot schemes was the responsibilityof the respective ministries, who appointed population program officers tosupervise and coordinate these schemes. The main problem with the admin-istrative system of project implementation was the number of parties in-volved, some with supervisory, advisory or executive powers. Banksupervision missions and resident staff therefore had to spend a lot of timeon administrative and coordination matters.

Project and Program Results

With regard to specific components, the hardware component of theproject cannot really be regarded as being successful given the low utiliza-tion and maintenance problemo which the third project attempts to address.The results of the software components are mixed. Some components were notimplemented, not completed or were deleted, but other research and evaluationactivities can be termed successful in terms of their output. The pilotschemes have been effective in that they have been sustained, mainly throughincorporation into follow-up phases. They have also shown some success inincreasing the acceptance rates among their immediate but small targetgroups, although the comparative worth of this marginal increase needs to beweighed against the larger costs of the complex multi-sectoral approach in aninstitutionally constrained environment.

The audit is of the opinion that, in retrospect, the project wastoo ambitious and attempted to do too much. In a country with limitedresources, just beginning to focus again on the population issue, a morefocused project with a phased approach would have been, in the audit'sopinion, more cost-effective. However, the audit agrees that the project

- viii -

made a major contribution to developing the population program in Bangla-desh. Therefore, although it is impossible to establish causal links betweenproject inputs and program results, it is important to assess the results ofthe overall population program in Bangladesh as well (PPAM paras. 23-24).

The Bangladesh population program design has been stronglyinfluenced by donor agencies, who provide about 95% of the programresources. The program has adopted a multi-sectoral approach for motivationand recruitment of acceptors and relies heavily on the sterilization methodwith payments (although lower than in some other South Asian countries) beingprovided to both client and staff. Especially the use of such payments hasgenerated considerable controversy about this program, but mostly amongdonors. However, in the absence of a universally valid ethical system, valuejudgements are only relevant in the context of Bangladesh's goal to controlits rapidly growing population (PPAM paras. 21-22).

The institutional framework of the program has undergone at leastfour major changes over the last two decades. External influences of donorsand the Bank have contributed to such changes, and these institutionalupheavals invariably affected the efficiency of program execution over time.At present, the program operates under what is called functionalintegration. A single Secretary heads the Ministry, but the operationalstructure of MOHPC is separated into population and health wings underdifferent leadership with population and health functions integrated at thelower field levels. A substantial infrastructure, both in terms of manpoweras well as physical components, is in place to support program implementation(PPAM paras. 17-20).

The program as presently revised under the Third Five-YearDevelopment Plan aims at achieving replacement fertility by the year 2000 orbeyond. To achieve this goal, fertility would need to decline by 3.8 in thenext 15 years or so. This is a formidable challenge, if not impossible,given the fact that it took Thailand and Indonesia, two countries generallyrecognized as having good population programs, 20 years to reduce fertilityby 2.0 and 2.7, respectively.

The percentage declines in crude birth rate and total fertilityrate in Bangladesh between 1965 and 1985 were the lowest in South Asia.Despite intensive efforts, the fertility rate remains high, at 5.8. However,since 1981, when most of the program's success has taken place, the contra-ceptive prevalence rate has nearly doubled. This is expected to have someimpact on fertility. More recently, however, program performance hasdeclined. Sterilizations decreased substantially and rates of increase inother methods were much lower than in earlier comparable periods. Whateverthe specific numbers and their interpretation, the aggregate picture is oneof deteriorating program performance. To a large extent, knowledgeableobservers see the major cause for this decline in the dissatisfaction of

- ix -

family planning staff with their role and status within the broader frameworkof functional integration of health and family planning.

Sustainability

Operationally, the project set the stage for a wide expansion ofthe service delivery system. New institutional and staffing patterns weredeveloped, but overall, the sector expanded too rapidly, in the audit'sopinion, for effective absorption and sustenance by Government. This isdemonstrated by the fact that donors still have to provide almost all,including recurrent, resources for the program, and without outside supportthe program would simply collapse. Secondly, despite two projects and sub-stantial resource transfers, improvements in program performance have beenonly marginal, at least up until 1981, while very recently program perfor-mance has been deteriorating. Thirdly, institutionally the program has stillnot been stabilized; in fact, recent reorganizations towards integration havebeen blamed for much of the deteriorating program performance.

In the narrow sense, short-term sustainability is guaranteed asdonors under the Third Population Project continue to support the program,including substantial funding of non-incremental recurrent expenditures andeven maintenance of facilities built under earlier projects. However, long-term sustainability is both a serious issue as well as a challenge. It isalready abundantly clear that it will be impossible for the Government toabsorb all program costs by the end of the Third Population Project. Long-term involvement of the donors and the Bank, which the audit supports, istherefore not only necessary from the resource point of view, but also essen-tial as the population issue is not a short-term issue.

There are other serious issues as well. These relate to the mix ofcontraceptive services provided under the program, and there is a valid ques-tion as to whether the emphasis on sterilization is not at the expense ofother methods such as spacing. Furthermore, at present there is emphasis onmaternity and child health (MCH) services, but the audit is concerned thatsuch emphasis could possibly cause some neglect in delivering contraceptiveservices, especially in a functionally integrated system. They also relateto the multi-sectoral nature of the program with its heavy administrativedemands and possibly marginal benefits as well as the institutional arrange-ments. All these might detract from the major objective of these efforts,namely effective family planning. More focus on that objective is needed.

Lessons and Findings

A number of interesting issues arise from this project and programexperience which require further attention and thought:

- These population projects are to a certain extent unique becausethey are cofinanced by so many donors. There were good reasons forthat, but over time ideological differences about project content

- x -

developed as well as problems with the Bank's style of projectmanagement and supervision. At times, donor coordination (orbetter cofinancing within the framework of one project) became theoverriding concern probably at the expense of dialogue with theGovernment, and of project design (PPAM paras. 39-45).

- While the Bank in other sectors, such as rural development, hasmoved away from the multi-sectoral approach, this approach con-tinues to be maintained under these projects. However, there is aserious question as to how integrated these components are.Although by no means a unanimous view, a number of separateprojects may have been as effective, and possibly more effective,than the one complex multi-sectoral project (PPAM paras. 44-45).

- Project design appears to have been too complex and too large inscope and size. In retrospect, it appears that a more gradual andmore focussed approach might have been more effective (PPAM paras.47-49).

- The Bank has made an enormous effort to supervise these projects,and an interesting feature of that effort was the establishment ofa resident population office in the Bank's mission in Dhaka. Thecosts of this office were shared among the cofinanciers, and itsperformance has generally been regarded as outstanding. In retro-spect, however, more delegation of authority to the field couldhave substantially facilitated project administration and supervi-sion (PPAM para. 53).

- Logistics and management of the supervision effort was enormousgiven the number of components and cofinanciers involved. Itseems, however, that more efficient use of these resources couldhave been made by using smaller and more focussed supervision mis-sions as well as by delegating to some of the cofinanciers part ofthe supervision responsibility for their respective components(PPAM paras. 50-54). Most facilities constructed under the projectare under-utilized; most were inappropriately designed and toolarge. Also, maintenance was an almost universal problem. Itwould have been much more cost effective to start small and addlater. A review of facility design is urgently needed (PPAMparas. 55-59).

- While there is no doubt about the need for training, most projectsin Bangladesh include training components, in many cases includingthe construction of physical infrastructure. It might well be that

a country wide over-capacity in training facilities is being creat-ed this way. Increased attention to this is needed within theBank; a training construction moratorium might be considered untilmore detailed insights into this have been obtained (PPAM para.58).

- xi -

- The program has undergone multiple reorganizations, sometimes withdetrimental effects (PPAM paras. 17-18, 23, and 60).

- Information, education and communication (IEC) activities continueto concentrate on motivation, while in fact more "consumer" orient-ation might be required (PPAM paras. 61-62).

Xii •

BANGLADESH POPULATION

Project-built Family Welfre Health Centers

World Bank-30552:1

x11

MJW

Vey old heath dispenswy being replaced by a communiy-supported new health center.However, within less than 100 yards a project Family Welfare Health Center has been constructed.

44, 5.

tot

SOMO malntenance Is taking ploce, smm Is not (next page)

xiv -

World Ban-30M:3

- ,s h aenu .mm - m -u - .- -.. .- - . --. . . anu

Project-supported womn's oc~v es

i

roldBak-052:

xvi -

TraIning

Future Family Plonning Accepors aready assembed In t waling roomof a project Family Wlfare Health Center

Wmrl r~k,j~L

PROJECT PERFORMANCE AUDIT MR4ORANDUM

BANGLADESH

(FIRST) POPULATION PROJECT(CREDIT 533-BD)

I. INTRODUCTION

A. Background

1. Rapid population growth, and rising and high population density,both constrain and dominate long-term development in Bangladesh. The presentpopulation of 100 million, growing at a rate of about 2.6% annually, can beexpected to double in about the next 25 years. Population density (1,800persons per square mile), already one of the highest in the world, will riseto 3,000 by the year 2015.

2. The economy, dominated by agriculture (the sector accounts for 50%of GDP and employs over 75% of the labor force), is highly vulnerable tonatural and external factors. The essential ingredients for long-termsustained economic growth, such as an adequately trained and skilled laborforce, arable land for agriculture, capital infrastructure for production andmarketing, access to appropriate technology for raising productivity of laborand access to raw materials from domestic and external sources, are presentlyin short supply and in need of development and improvement.1!

B. Bank's Role in Population

3. Cumulative Bank Group commitments to Bangladesh total about US$3.4billion. 2 Support for population control constitutes 2% of that total. Asfor other sectors, imports program support accounted for the largest share,30%; followed by agriculture (including irrigation and rural development)24%; energy 13%; industry 11%; communications (transportation and telecom-munications) 9%; education and technical assistance 9%; and urban infrastruc-ture 2%.37

4. To date, the World Bank, in conjunction with other donor agencies,has financed two population projects in Bangladesh, while a third has justbeen approved (January 14, 1986). The first project intended to develop and

1/ See Bangladesh: Economic and Social Development Prospects, World BankReport 5409-BD dated April 2, 1985.

2/ This figure includes reactivation of 11 credits made to Pakistan before1971 and a consolidation credit and a loan approved in 1975 to coverliabilities arising from projects completed before independence, for atotal amount of abaut US$250 million.

3/ From President's Report (No. P-4206-BD dated December 24, 1985), ThirdPopulation and Family Health Project.

- 2 -

strengthen the national population program. More specifically, the projectwas designed to improve the organization and management capacity of the pro-gram, extend family planning services to the rural areas, make the deliveryand planning of services more effective by training and introducing monitor-ing and evaluation systems, mobilize demand for family planning services, andthrough demographic research assist *.n the shaping of future populationpolicy (for more details see Chapter III and Annex 1).

5. The main objective of the second projectd/ was to continue andexpand (with the exception of some pilot schemes and model clinics) activi-ties started under the first project and to further assist the Government inits efforts to integrate health and family planning services (Annex 2). Theprimary objective of the third project,li which again would coatinue tosupport activities begun under the first and second projects, is to reducefertility and infant and maternal mortality by providing support to theGovernment's family planning and maternal child health (MCH) program duringthe Third Five-Year Plan period (1985-90). In addition, the project wouldassist efforts to stimulate additional demand for family planning and to helpstrengthen the infrastructure for basic rural health services (Annex 3).

6. These three projects have and will provide substantial resourcesfor Bangladesh's population program, as the table below shows:

Population I Population II Population III(Cr. 533) (Cr. 921) (Cr. 1469-BD)

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

IDA 15.0 32.0 78.0ADAB 2.3 4.0 7.1UK 3.1 4.0 10.3CIDA 2.0 5.0 23.5KfW 6.0 18.2 28.7NORAD 8.3 20.0 23.6SIDA 3.0 8.0 -Netherlands - 7.9 6.1GOB 6.0 10.9 36.5

Total 45.7 110.0 213.8

4/ See also SAR, Second Population and Family Health Project, Report No.2323-BD dated May 16, 1979.

5/ See also SAR, Third Population and Family Health Project, Report No.5485-BD dated December 24, 1985.

- 3 -

II. PROJECT ENVIRONMENT

A. Sector Context

7. Demographic Status and Trends. The percentage declines between1965 and 1985 in Bangladesh in Crude Birth Rate (CBR) and Total FertilityRate (TFR) are the lowest for the South Asia Region as the table below shows

Decline in Decline inCountry CBR TFR

Bangladesh 9.6 14.9India 19.6 18.7Pakistan 15.8 22.7Sri Lanka 20.2 30.6

Source: World Development Report, 1984.

With the CBR at 41.5 per thousand and the death rate at 15.7 per thousand,according to the most recent estimates, the population is increasing at therate of about 2.6% annually. At the current rate of increase, the populationwill double in about 25 years. Current projections6/ indicate thatBangladesh could achieve replacement fertility by the year 2035. ButBangladesh's population would only stop growing in the 21st century, when itwould reach a level of 450 million. What that implies for a country wherethe land-man ratio has already been reduced to 0.2 acre and where about 50%of the population is landless is beyond imagination.

8. The high TFR of roughly six7 / is more or less homogeneous acrossthe country and between different groups in Bangladeshi society. However,although fertility remains high for all groups, there is evidence that thehighest and lowest income groups have lower fertility rates, 8 / implying thatthe middle income group tends to have relatively high fertility. In thatcase the effects of socio-economic development on the lowest income group mayraise their fertility.!/ The role of the population program in Bangladesh,therefore, becomes significant given the large proportion of the populationin the lowest income strata. The decline in mortality (which is related tohigh fertility in Bangladesh) has been very gradual, falling from 22 per

6/ World Population Projection 1984, My T. Vu, World Bank.

7/ A TFR of 2.1 to 2.5, depending on mortality conditions, indicates"replacement level" fertility.

8/ M. Alauddin, Rashid Faruqee, "Population and Family Planning in Bangla-desh; A Survey of the Research", World Bank Staff Working Paper No. 557,pp. 42-44.

9/ Project staff doubt that the incomes of the poorest will rise enoughover the next few years to increase their fertility.

thousand in 1960 to 17 per thousand in 1980. The decline in child mortalityhas not been very significant between 1960 and 1982, falling from 159 to 133per thousand for 0-1 year of age, and from 25 to 19 per thousand for 1-4years of age. Life expectancy increased for males by 3 years (45 to 48years) from 1960 to 1982, and for women by 7 years. Most of these increasesare attributed to a decline in adult mortality.

9. Demographically, age structure is a potential factor inaccelerating population growth. The composition of the age structureinfluences population growth even after fertility begins to decline, and onaverage it takes 50-70 years, depending on the initial lead time, before apopulation distribution completely adjusts to the changed fertilityrates. 10/ Bangladesh has a young age structure with 47% of the populationunder 15, indicating that in the future large numbers of persons willcontinue to move into their reproductive years. Forty percent of thepopulation is between 15 and 47 years of age (the reproductive years), andpresently are potential clients for family planning and MCH services,

10. Migration, although significant demographically and socially, isnot well researched in Bangladesh. It is estimated that net emigration fromBangladesh is about 1.5 million persons a decade which reduces the rate ofpopulation growth 0.2 percentage point a year.it/ Internally, the flow isfrom east to west, and it appears that women migrate more than men. 1 2 / Themost significant impact of internal migration is on the level of urbaniza-tion, notably in Dhaka, Chittagong, and Khulna. The male:female ratio(126:100) for the urban population indicates that single male members lookingfor employment constitute much of this urban migration.

11. Local Setting. The demographic future of Bangladesh will mostlikely he substantially influenced by fertility decisions made in ruralareas. Unlike most villages in Asia, the Bangladeshi village, although itexists within territorial boundaries, has no corporate features, little cohe-sive identity and only a residual degree of solidarity, and settlement pat-terns are dispersed rather than nucleated, 1 3 / This in itself has substan-tial implications for organizing services. Analysis of kinship and patronageties, the two most powerful organizing forces in Bangladeshi rural society,indicates that within this segmented social structure, separate interest

10/ World Development Report, 1984, World Bank.

11/ Khan, M.R., "Patterns of External Migration to and from Bangladesh", TheBangladesh Economic Review, Vol. 2, No. 2, April 1985.

12/ Krishnan, P. and Rowe, G., "Internal Migration in Bangladesh", RuralDemography (192) 1-11.

13/ Bertocci, Peter J., "Rural Development in Bangladesh", Rural Developmentin Bangladesh and Pakistan, ed. Stevens, Robert D., Alovi, H. andBertocci, Peter J., Honolulu, Hawaii, University Press, 1976. Also,Islam, A., A Bangladesh Village, Conflict and Cohesion: An Anthropolo-gical Study of Politics, Cambridge, Mass., 1974.

- 5 -

groups (extended family, nuclear family and factional patronage groupings),for their own socio-economic and individual group interests, press fertilityto levels detrimental to the community at large14 / and to macro level demo-graphic goals established by the Government. In addition to organizationalsocio-economic incentives that may motivate high fertility, religious factorsalso play an important role in rural decision-making. 1 5/ Furthermore,factors such as universal marriage at a young age, the enhancement of awomen's position in Bangladeshi rural society by giving birth to malechildren, 6 / the economic value of children, 7/ and high infant and childmortality, all act as barriers to a small family norm.

12. Socio-Economic Development. Although there are exceptions, ingeneral, the higher a country's average income the lower its fertility. Theexceptional cases, where fertility has begun to decline in spite of lowincome levels, demonstrate the importance of intervening factors such asavailability and accessibility of contraceptives, health and MCH services,and improvement in women's educational and economic status. 8 / The presentsocio-economic environment of Bangladesh, with its low per-capita income ofUS$130 equivalent per annum, an illiteracy rate of 77%, poor health andnutrition, and women's low social and economic status,, provides additionalchallenges to the population planning program.

13. Institutional Capacity. The country's planning and administrativesystem, within which population sector planning and administration operates,had been found institutionally inadequate to face the challenges of economicand social development as inherited at independence. Unforeseen externalfactors and deficient management and organization affected the implementationof the First Five-Year Plan. Beyond the need to establish appropriateagencies and institutions, factors such as attitude, reward systems andincentives, work habits, technical know-how and skills, procedures and

14/ W. Brian Arthur and . McNoll, An Analytical Survey of Population andDevelopment, Bangladesh Population and Development Review, PoNulationCouncil, Vol. 4, March 1978.

15/ Religion, according to field staff, is still a major factor in familyplanning acceptance, especially of sterilization, at the village level.

16/ Tahrunnessa, A. Abdullah and Sondra A. Zeidenstein Village Women ofBangladesh: Prospects for Change, Pergamon Press, 1982.

17/ Mead T. Cairn, "The Economic Activities of Children in a Village," Bang-ladesh Population and Development Review, Vol. 3, No. 1, pp. 201-228.

18/ "Population Change and Economic Development", World Bank, Chapter 4.

-6-

administratile process, were also major impediments. 1 / The system hasundergone various reforms, the latest presently in process, whereadministrative layers existing at different geographical -levels have beenreorganized into a decentralized system under which local authorities willhave more decision making power. 2 0 / This change has also been implementedin the Ministry of Health and Population Control (MOHPC). However,institutional problems continue to affect the implementation of developmentprograms in Bangladesh.2 1

14. The overall responsibilities for planning, monitoring and budgetingremain with the central ministries. Administratively, the country is dividedinto 64 districts, 464 Upazilas and 4,365 unions. Each union containsapproximately three wards (with a population of at about 5-7,000 each).

B. Population Policy, Program Development and Organization 22/

15. The need for population control was recognized by the Governmentand the donor community in 1973.23/ However, there were diverse opinionsconcerning the approach and the type of policy Government should adopt. Theexisting family planning program initiated by the Government of Pakistan hadcome to a virtual halt and had produced negligible results in actualcontraceptive acceptance, although it had increased awareness ofcontraceptive methods and created a positive attitude towards family

19/ Nurul Islam, Development Planning in Bangladesh, C. Hurst and Company,London, 1976.

20/ See also, "Bangladesh: Economic and Social Development Prospects",World Bank Report No. 5409, dated April 2, 1985 (Chapter VI).

21/ The Spring 1985 Project Implementation Review indicates thatinstitutional problems remain a main concern for implementing projectsin Bangladesh.

22/ For much more extensive details, see SAR, Third Population and FamilyHealth Project, Report No. 5485-BD dated December 24, 1985, Chapter II.

23/ Bangladesh's population program got underway two decades ago when EastPakistan adopted a national family planning program in 1965 aftervoluntary efforts had started in the early 1950s. A network of familyplanning clinics was set up, run by an autonomous Family Planning Board,independent of the health system. But interrupted by the war ofliberation, the program had come to a virtual halt in 1972-73.

- 7 -

planning.2 4/ The population field itself was at a crossroads. The fewsuccessful cases in the population sector, such as Japan, Taiwan, Singaporeand Korea, had experimented with incentives and disincentives and changingabortion and marriage laws to offset fertility. Policy issues such as non-family planning measures and beyond family planning policy approaches werebeing discussed amongst the international community. 2 / Also, in the early1970s there were strong recommendations from donors and JN agencies forcountries to take into consideration the relationship between populationgrowth and economic and social development and to formulate appropriatepolicies at the national level to deal with population within the develop-mental context.26/ As this pertained to Bangladesh, there was a divergenceof opinion on these issues amongst experts both within and outside Bangla-desh.27/ Within this environment, in 1976 Government officially adopted acomprehensive population policy giving high priority to population controlwithin the development process, and including approaches to influence ferti-lity by socio-economic determinants.

16. Meanwhile, in 1973 the Government had begun to prepare a rough planfor population activities to be included in the First Five-Year Plan. Theseplans were closely reviewed by the Bank, which provided assistance in final-izing and sharpening the focus as well as outlining the components to beincluded. The demographic objectives of the plan were to achieve a netreproduction rate of 1 by the year 2000. The strategy designed to influencedemographic behavior included information, education and motivation activi-ties, family planning services and incentives directed at developmentaldeterminants of fertility, such as employment, education, improved healthservices and women's participation in the labor force, or through legal mea-sures.28 / The Second Five-Year Plan retained the basic approach but ad-vanced the year for achieving replacement level fertility to 1990; however,as this was clearly unrealistic, it was later revised in the Third Plan to

24/ Report of the Commission for Evaluation of the Family PlanningProgramme in Bangladesh, 1970.

25/ For details see Philip M. Houser, "Non-Family Planning Methods ofPopulation Control" and Bernard Berelson, "Beyond Family Planning,"Population Control: Implication Trends and Prospects, Proceedings ofthe Pakistan International Family Planning Conference at Dacca, 1968.

26/ UN, "The Population Debate: Dimensions and Perspectives", BucharestWorld Population Conference, 1974.

27/ National Population Conference 1974 Dacca. Also see: Duza, B., "Popu-lation Policy in Bangladesh" (and following discussion) in E.A.G.Robinson and The Economic Development of Bangladesh within a SocialisticFramework, Holsted Press, New York, 1974, pp. 260-288.

28/ First Five-Year Plan (1975-78), Planning Commibsion, Government ofBangladesh, pp. 126-135.

- 8 -

the original year, 2000, or beyond. To achieve this goal, fertility inBangladesh would need to decline by 3.8 in the next 15 years or so.29 /

17. The institutional framework for the population program has been anissue right from the start of the program. Between 1963 and 1983, theorganization of the program in terms of its institutional base for leader-ship, staff responsibilities and tasks, has undergone four major changes.The program moved from integrated (under Ministry of Health) to vertical(managed and coordinated by an autonomous body in 1965) to integrated againwith health (1973) to semi-integrated (1975) with two fairly independentdivisions, with separate directorates and advisors for health and populationestablished under the MORPC. Population became the responsibility of thePopulation Control and Family Planning Division (PCFPD) headed by an addi-tional secretary, Finally, decentralization, and a functionally integratedsystem at the field level, was initiated in 1979 and formalized in 1983.Some of these changes were due to political and leadership changes within thecountry and the influence of special groups dominating policy decisions.However, external influence by the Bank and other donors also contributed tothe multiple restructuring of the program's organizational base.

18. At present, under what is called functional integration, the struc-ture of the MOHPC is separated into a Health Wing and a Population Wing,under the leadership of the Secretary. 3 0/ This separation also exists atthe district level, where each wing is represented by its respective staffmembers. However, at the Upazila level the structure is integrated, with theUpazila Health and Family Planning Officer (medical doctor) providing theleadership and coordination for both wings and their respective staffs.

19. The rural health/family planning infrastructure consists of UpazilaHealth Complexes (UHC) with 31 beds to cover a population of approximately200,000. The professional staff includes 7 to 9 medical officers, a HealthInspector and an immunization technician, financed by the Health Wing, andfrom the Population Wing, a Family Planning Officer (FPO), two Family WelfareVisitors (FWV) and all administrative staff. These staffing goals have beenachieved for about 80% of the complexes.

20. At the union level, the Union Health and Family Welfare Centers(UHFHC) are staffed by a Medical Assistant (MA) from the Health Wing, an FWV

29/ It took Thailand and Indonesia, two of the more successful cases, anaverage of 20 years to reduce fertility by 2.0 and 2.7, respectively.

30/ The Secretary of MOHPC is assisted by an Additional Secretary forPopulation Control in the Population Control Wing. The PopulationControl Wing is responsible for MCH and population programs; the HealthWing is responsible for all other health services. Each wing has itsown Director General, a Secretariat responsible for planning, budgetingand monitoring and functional directorates responsible for operationalaspects of the program.

from the Population Wing and occasionally a pharmacist plus one sweeper andwatchman. These centers provide FP and primary health care services to about15-25,000 people. Rural dispensaries, operated by the Health Wing, alsoprovide service at the union level. 3 1 / Representing the two wings, theoutreach work at the ward level is carried out by a male Health Assistant(HA) and a female Family Welfare Assistant (FWA) supervised respectively byan Assistant Health Inspector and a Family Planning Assistant (FPA). Inaddition, services are provided also through hospitals, and Maternity andChild Welfare Centers (MCWC) at the district and sub-district levels. Atpresent, the infrastructure consists of 64 district hospitals, about 350UHCs, approximately 1,123 UHFWCs and 1,300 rural dispensaries and 91 MCWCs;in terms of staffing, 12,179 FWAs, 7,110 HAs, 4,259 FWVs, 3,380 MAs and 4,222FPAs had been recruited by 1985. It must be noted that population staff atall levels have lower grade levels in the government salary scales thanhealth staff.

21. Program development in Bangladesh took place simultaneously withdonor agencies' developing their respective projects. Since 95% of theprogram resources were provided by donor projects, the design- of such proj-ects substantially influenced the design of the population program. Thewhole population dialogue in Bangladesh has taken place within the frameworkof the broader donor aid consortium and its conditionality. 3 2 / The programhas adopted a multisectoral approach for motivation and recruitment of accep-tors and relies heavily on the sterilizations and IUDs. Payments are pro-vided both to clients as compensation and to staff as a reward for motivatingand servicing clients.3 3/

22. The program has generated considerable controversy over time, espe-cially amongst donors. 3 4 / The use of payments in the promotion of clinicalmethods (sterilization and IUD) has been the major source of disagreement.Poor conditions under which sterilizations were conducted have resulted in

31/ There is a plan to upgrade these dispensaries to UHFWC.

32/ I. Faaland (ed.), Aid and Influence, The Case of Bangladesh, theMacMillian Press, Ltd., Hong Kong, 1981.

33/ Their compensation rates are TK 175 for male or female sterilizationsand TK 15 for an IUD. These rates are lower than in India and SriLanka. Referral fees range from TK 15 to TK 45 for both sterilizationsand IUDs, and doctors and attending clinical staff receive TK 20 and TK12, respectively, for each sterilization.

34/ As a result, during negotiations of the Third project one of the donorsdecided to discontinue its participation.

- 10 -

the establishment of sterilization surveillance teams,L/ and some of thenegative effects of the payment system, such as competition among staff, lackof proper counselling and follow-up, and the pressure to meet targets, /have been reviewed by Government as part of the Third Project package. How-ever, the more ethical issues, in the absence of an overridingly correctethical system or a universally approved ranking of human rights, 3 7 / areonly relevant in the context of Bangladesh's goal to control its rapidlyincreasing population. A continuous review and monitoring system, andincreased participation by the local communities, whose rights and values arethe issue here, is the only way of ensuring that some ethical standards aremaintained. 8,

C. Program Performance

23. Despite intensive efforts, the Crude Birth Rate (CBR) in Bangladeshhas until recently remained almost constant for the last two decades, andthere has been relatively little decline in the fertility rate, which remainshigh at approximately 5.8. However, much of the program's success has takenaplace since 1981. The Contraceptive Prevalence Rate (CPR) has nearly doubledsince 1978, from approximately 12% to 24-26% in 1985, with much of theincrease taking place after 1981. This increase in CPR is expected to havesome impact on fertility; however, reliable data on fertility since 1981 arenot available. 3 9 / More recently, however, family planning performance hasdeclined. Sterilizations suffered a decline of bout 40% in 1985 compared to1984. The rates of increased acceptance for spaLing methods, driven by lowerthan expected rises in IUD insertions, are well below previously recorded

35/ These teams have reported that at present Bangladesh's mortality recordin connection with sterilizations is generally satisfactory.

36/ "Preliminary Report on a Study of Motivation and Referral Fee System",Bangladesh, October 1985; also, WHO and SIDA studies to observe qualityof services and clinic condition under which sterilizations areprovided. See also, Betsy Hartman and Hillary Standing, "Food, Sarisand Sterilization", draft paper, Bangladesh International Action Group.

37/ Berlson, B., Eiberman J., "Government Efforts to Influence Fertility,The Ethical Issues", Population and Development Review 1974-5, Vol 5.

38/ For a review of incentive schemes and experiences, see Henry P. David"Country Experience with Incentives", Incentives Fertility Behavior andIntegrated Community Development: An Overview, Trananational ResearchFertility Institute, 1980.

39/ The demographic data base in Bangladesh remains weak; differentestimates are available for most key indicators. The Second BangladeshFertility Survey will take place in 1986 (the first was conducted in1975).

- 11 -

levels. The rate of increase in CYP (couple years of protection) was con-siderably less than the substantial increases in earlier years. Whatever thespecific numbers, the aggregate picture is one of deteriorating program per-formance. At such levels it is unlikely that program targets for 1990 can bemet. Knowledgeable observers see dissatisfaction of family planning staff asprobably the main cause of the downturn (but Government disagrees that inte-gration is the cause of decline and fall in performance -- see Supplement1). This relates to unresolved issues about their role and status within thebroader framework of getting functional integration of health and familyplanning to work satisfactorily.

24. Sterilization accounts for about 34% of all contraceptive use, ofwhich approximately 75% was female sterilization. There are some reserva-tions regarding the impact of sterilization on population growth. It isargued that women accepting sterilization are older and have high parity,that it substitutes for other methods and that the potential fertility inacceptors may be low to begin with due to factors such as secondary steri-lity. Although sterilization in the case of Bangladesh does seem to havesome demographic impact,40 / there is a valid question of whether the programemphasis on sterilization is at the expense of spacing methods, by whichyounger couples with low parity could be reached more effectively. Further,the slowing down of sterilizations indicates a possible saturation of thetarget group in some areas, or a shift in demand to other methods. In theThird Five-Year Plan, there is both emphasis on other methods and expansionof Maternal and Child Health services; the latter is an important componentof the Third Project. However, the audit has some concerns that high empha-sis on MCH may cause some neglect in delivering contraceptive services.4 1/

III. PROJECT PERFORMANCE AND SUMMARY

A. Project Formulation

25. Project formulation took nearly three years from time of firstdiscussion until all funding arrangements with the donors were completed.Discussions with Government regarding the Bank's involvement in plan formula-tion for population activities, to be included in the First Five-Year Plan,were initiated in 1972. However, it was quite clear from the outset thatdonor agencies would dominate the dialogue and development of the project.By 1973, the Bank's position was that it would like to have direct influenceon the development of the program as well P on the operation of the projectthrough its project package and agreement.

40/ Meashan, A.R. "The Demographic Impact of Tubectomy in Bangladesh",International Family Planning Perspectives, Vol. 8 No. 1, March 1982,pp. 18-21.

41/ Project staff continue to believe that a phased, focused and carefullydesigned MCH program should be an essential feature of the nationalfertility reduction effort.

- 12 -

26. Nevertheless, the need for effective donor coordination to meet therequirements of the program was recognized as early as 1973, and leadingagencies such as USAID, UNFPA, WHO and the Bank attempted to collaboratethrough mission work and close communication. However, between 1972 and1974, both UNFPA and USAID had negotiated their own projects with the GOB.Between these two agencies and the Bank, differences of opinion arose aboutleadership, organization and technical aspects of the project. As a fairamount of project work had been done by 1973-74, the options available wereeither to reduce the size of the project or to find alternative financingsources. Reducing the physical size of the project was unacceptable as itwas felt that size was needed to impact on the population problem (PCR para.1.14), a judgement not necessarily shared by the audit (PPAM para. 46).Thus, under the alternative option, the Bank contacted five donor agencies inthe United Kingdom, Norway, Canada, Sweden, and Germany to participate inthe project. Each agency, to a certain extent, had then to identify thecontent of their components. Meanwhile, due to price escalation, the projectcost had increased from US$20 million to US$45 million.

27. In spite of the fact that among donors there were major reserva-tions about Government commitment, organizational structure to implement theprogram and the cost of the project (PCR para. 1.17), in addition to concernswithin the Bank over the time period for project implementation (which wasfelt to be too short given local capacity and resources), cost and size ofbuildings and inclusion of too many pilot schemes; PCR, para. 1.15), prepara-tion continued and the project was presented to the Board in February 1975.The project's goals were te avert births4 2 / through expansion of servicesand IEC activities, and also to build a social infrastructure conducive tofertility control. These ambitious goals required inputs and institutionalinfrastructure which contributed to complexity and risks. The fact that itwas a complex and a high risk project in terms of impact and implementationwas, however, recognized and acknowledged in project files and to a somewhatlesser extent in the appraisal report.

28. The project (total cost of US$45.7 million) was approved onFebruary 25, 1975. IDA Credit 533-BD was signed March 10, 1975 and becameeffective on September 25, 1975. Project disbursements lagged substantiallybehind schedule, and by December 1979, the original Closing Date, only 35% ofthe credit was disbursed. By September 1982, the final Closing Date, the

42/ At the time of appraisal it was estimated that about 65 million birthsneeded to be averted to achieve the goal of a two-child family by theend of the century, requiring about 60% of women within thereproductive ages to accept family planning. However, realistically itwas estimated that the program, if it maintained the activitiesgenerated by the project with full use of its resoures, could avertabout 23 million births (one-third the required total). The project wasestimated to directly avert only 1.3 million births (SAR para. 5.02).

- 13 -

credit was fully disbursed. 4 3 / The contributions of other donors had alsobeen fully disbursed by that time, except for CIDA and NORAD, whose disburse-ments had reached 64% and 80%, respectively.

29. The project was designed to assist the development of a nationalfertility control program. The project components consisted of (for fulldetails see Annex 1):

(a) technical assistance and general support for strengthening thepopulation program organization;

(b) constructing, furnishing, equipping and supporting training andservice-cum-training facilities (45 In total) for the Ministry ofHealth and Population Planning;

(c) training and subsequent employment for four years of 3,700 femalefamily welfare workers as members of male/female home visitingteams in rural areas;

(d) provision of audio visual equipment, vehicles and operating costsfor three years for the establishment and support of nine educa-tion/motivation pilot schemes in 61 thanas and a general programsupport to the six executing ministries; 44/

(e) salary support, operating cnsts, and other support for institutionscapable of conducting research and evaluation studies; and

(f) support to the Population Planning Division to assist the privatesector in family planning activities and for the development ofinnovative activities in the public sector during the life of theproject.

30. Project components were expanded when, mainly due to the Taka deva-luation of June 1974 and changes in values of other donor currencies comparedto the US dollar, project savings were allocated for additional activitiessuch as re-training, extending salary support, more transport, constructionof 80 UHFWCs, and support for further research and communication activities.At the same time, support for existing schemes was extended by two years (PCR

43/ Project staff indicate that the project was fully disbursed in less thaneight years against an overall population disbursement profile of tenyears and a Bangladesh IDA disbursement profile of 8.5 years.

44/ Ministries of Local Government, Rural Development and Cooperatives;Labor and Social Welfare; Agriculture; Education; Information andBroadcasting; and Health and Population Planning.

- 14 -

para. 2.06). As in an earlier audit,45/ it should be mentioned that in thisproject, as well as in moany other PHN projects, it is common to reallocatesavings to other project components or related population activities not ori-

ginally envisaged at appraisal. While the audit does not have any negativeassessment to make regarding these re-allocations, it nevertheless would like

to crossrefer these to other experiences in the Bank. It is normal practicethat substantial changes in project content (reallocating about one-third of

the loan must be considered to be substantial) be reported to the ExecutiveDirectors, either in a separate memo (as recently happened for the KenyaSecond Population Project and the Korea Population Project) or at least inthe Report on Bank and IDA Operations. Also, it is normal practice undermany other Bank projects that savings, due to devaluations, be cancelled.

B. Project Implementation

31. Start-up project activities were delayed by over a year due todelays in declaring the project effective and in formalizing donor commit-ments. The construction component was delayed by three years and experienced

problems throughout implementation. Technical, organizational and staffingissues, in addition to site acquisition and contractor-related problems, werethe main causes for delay. Differences between Bank and Government proce-dures, and contract design which was contrary to usual Bangladesh practice,also caused delays (PCR paras. 3.44-3.48).

32. Once completed, major difficulties were experienced in making thefacilities operational due to design and quality control deficiencies (PCRpara. 3.49). Nearly all the sites visited by the audit mission requiredmajor repairs and maintenance. Some problems, such as with electrical wiringand water leakage, were due to initial faulty design, and others were the

result of normal wear and tear. Much of the modern equipment such as X-raymachines, operating overhead lights and equipment sterilizers, had either

never been installed in the UHCs visited by the mission (5 of the 8), or, ifinstalled, were not functional at the time.

33. Once the project started, the software components proceeded on

schedule. However, in the case of the pilot schemes, there were administra-

tive complexities in terms of monitoring, supervision and coordination due to

the involvement of six different ministries responsible for implementation.Delays in hiring population officers were also experienced. In the case of

training, quality control and administering training out of rented and inade-

quate facilities while training buildings were being constructed, was a prob-

lem (PCR paras. 3.09-3.10). In the case of UHCs and model clinics, notraining could be provided until these sites were completed (PCR paras.

3.10-3.11).

45/ See PPAR, Indonesia Second Population Project (Loan 1472-IND), OEDReport under preparation.

-- 15 -

34. As for research and evaluation support, a management informationsystem was established in the Population wing only in 1979, due to initialtechnical problems in the design and organization changes, a result of whichresearch and evaluation functions were transferred to another agency, NIPORT(PCR para. 3.33). The External Evaluation Unit in the Planning Commissionbecame functional only in 1978, primarily due to lack of leadership fornearly half of the project period and constant staff changes (PCR para.3.34). The other research study, determinants of reproductive behavior, wasnever completed, although a considerable amount of field work and massiveamounts of data were collected. Reasons included complex research design andlack of effective assistance from the collaborating university, and lack ofdirection and structure in data collection. Once collected, data could notbe processed and analyzed because of a shortage of trained staff at the localinstitution and lack of facilities to process it (PCR paras. 3.35-3.36). Fortechnical assistance, major problems were encountered in recruiting advisors,in part due to Government's inexperience with such recruitment. Signing thecontract with the consortium of consulting firms (one British and two local)that would serve as executive architects and management consultants wasconsiderably delayed because of a controversy between the Government and theforeign firm (see PCR para. 3.39). Neither the national seminar, nor thebuilding utilization study, were carried out.

C. Project Administration

35. The PCFPD (now the population wing) in MORPC was responsible foroverall implementation and coordination. For the construction component, aBuilding Planning and Design UniL (BPDU) was established. A Project FinanceCell was also set up in PCFPD. The implementation of pilot schemes was theresponsibility of the ministries concerned who appointed, as per the CreditAgreement, Population Program Officers (PPO) in their ministries, to super-vise and coordinate the schemes. An External Evaluation Unit was establishedin the Population Planning Section of the Planning Commission, and a NationalPopulation Council to strengthen the population program was also established(the latter a condition of effectiveness). The main problem with the admin-istrative system for project implementation was the number of parties in-volved--some with executive, some with supervisory, and others with advisorypower. For example, BPDU provided overall direction, a private firm ofarchitects did the planning and design (including preparation of tenders),the Public Works Department (PWD) had formal. management responsibilities forconstruction, while the consulting firm provided progress reports. The Bankitself, of course, undertook supervision. In addition, the Directorate ofSupply and Inspection was responsible for procurement. As a result, both theBank's resident mission and the head office supervision missions had to spendconsiderable time sorting out coordination problems.

46!

D. Project Impact

36. The audit agrees with the PCR that the major contribution of theProject was in developing a population program in Bangladesh. However, the

46/ M. Alimullah Miyan, "The Management of Population Assistance Programs",OECD Development Center, 1984.

- 16 -

audit is also of the opinion that the program was too ambitious and attemptedto do too much (PPAM para. 46). In a country with limited capacity justbeginning its population program, a more focused project, possibly with fewerpilot schemes and a smaller civil works component, and with a phased approachto institutional building could, in the audit's opinion, have been more costeffective and possibly would have had a greater sustainable impact on programdevelopment and performance. The present contraceptive/performance rate,although dramatically improved since 1981, is among the lowest in the region,and performance has slowed down dramatically during the last year (PPAMpara. 23). MOHPC's institutional base, especially in its Population Wing,continued to remain in flux, primarily because of the added requirements ofeach additional project, as well as those financed by other donors, andbecause of the continuous reorganizations, especially the mst recentattempts at functional integration (see also PPAM paras. 17-18).

37. In reference to specific project components, the hardware componentcannot be assessed by the audit as being successful, given low utilizationand maintenance problems (PPAM para. 53). In the case of the software com-ponent, the results are of mixed effectiveness. Two of the technical assis-tance activities were not carried out. 4 7 / The management study, however,set the stage for further organizational changes needed for the Second Proj-ect but failed to provide adequate solutions for problematic relationshipsbetween the health and population divisions; nor did it assist in strengthen-ing coordination linkages between the different agencies involved, two areaswhich remain of major concern in MDHPC. The evaluation and research activi-ties supported by the project can be qualified as successful in terms oftheir output. A number of internal and external evaluations have been doneand a statistical monitoring system is in place. However, to what extentthese are used for management and policy decisions is not clear. Donors con-tinue to rely on their own evaluation and monitoring systems through thetechnical assistance they provide.

38. Although the study of Bangladesh's laws (to asess their pronatalimpact) was done and submitted, its impact on changes and amendments toexisting law is not evident. The pilot schemes have been effective in thatthey have been sustained and incorporated within the program, and individual-ly have shown some success in increasing the acceptance rate amongst itsimmediate but small target groups (PCR paras. 3.14-3.27). The comparativeworth of this marginal increase needs to be weighed against the larger costto the population sector of operating a multisectoral approach, givenresource constraints.

IV. ISSUES

A. Cofinancing and Donor Collaboration

39. The Bangladesh population projects are, to a certain extent, uniqueas they are cofinanced by such a large number of donors (see PPAM para. 6).This is somewhat contrary to conventional wisdom which dictates that having

47/ Conducting a national seminar on population problems for politicalleaders and conducting studies on building utilization.

- 17 -

too many cofinanciers makes projects unwieldy. However, given the importanceof the population issue, the need for resources and interest by such a largenumber of donor agencies in providing assistance, coordination among donoragencies was viewed as necessary both by the donor community and the Govern-ment. But early in the process of discussions and negotiations of the firstproject, differences among donors arose (PPAM para. 26 and PCR para. 1.12).Agencies with already defined mandates, ideologies and technical preferences

opted to establish and maintain their independent projects (UNFPA, USAID andUNICEF). Other donors, after much prodding by the Bank, finally participatedin the IDA project for the following reasons: (i) the population issue wasamong the most important development constraints in Bangladesh; (ii) mostdonors had limited and relatively small budgets for population activities in1973-74 and yet wanted to have some influence on policy-making, and the Bankproject provided an opportunity for such leverage which individually thesedonors were reluctant to or could not apply; and (iii) the Bank's experiencewas needed to manage and supervise the project.

40. However, problems began to emerge during the life of the projectand in negotiating follow-on projects. Ideological differences over approachand project content and problems with the Bank's management and supervisionof the project became contentious issues in the view of many donors. Also,with experience gained over time, donor agencies began to define theirmandates more clearly and develop ideological and technical preferences whichresulted in differences of opinion concerning the best approach to theBangladesh population problem.

41. These ideologies have become more diverse over time, making recon-

cilation within a single project framework increasingly difficult. The sub-

stantial debate among donors, including the Bank, about the shape and size of

the Third Population Project seems to reflect more the ideologies and percep-tions of the participating donors than the technically and institutionallyfeasible alternatives for assisting Bangladesh with its population program.The fact that the discussions on these issues take place, to a large extent

among donors and in Western capitals, further symbolizes that attitude. The

audit believes that the Bank, in its efforts to keep the consortium together,

at times tried to reach the best compromise rather than provide the bestadvice to Government. As a result of the need to reconcile a large number of

different opinions, the dialogue with Government also became somewhat

constrained, and the Bank was sometimes perceived as supporting what was good

for the donors rather than for Bangladesh. Political dimensions have also

increased as aid agencies have to justify program inputs to their political

constituencies, which have become more vocal on population issues) rather

than on what recipient clients may want or should have the choice to do.

42. Secondly, as donor involvement continued and increased in financial

magnitude, the need for accountability increased, requiring feedback on

performance concerning their respective components. The Bank's approach to

supervision and monitoring was viewed as inadequate for the information needs

of some donor agencies. As a result, several donors undertook their own

independent reviews and special evaluations, which further taxed local

institutional capacity and caused stress in the coordination mechanisms.

- 18 -

43. All donors agree that population is one of the most serious issuesfor Bangladesh's future development and, as such, the program's objectivesare not in doubt. Most also feel that they can be more effective ininfluencing strategy as part of the consortium, and this has been a majorreason why so many donors have cofinanced and continue cofinancing thisprogram. The role of the Government in the cofinancing scenerio has beenpassive. At the onset the Government felt that a project of this naturewould maximize the input of all donors and also make the program moremanageable as they would only have to deal with a few leading agencies(UNFPA, USAID and IDA). However, over time, there is a strong sense amongstGOB officials that they have, as a result, lost much leverage in the process,leverage that they possibly can regain by increasing their input. A majordistinction between the population program in Bangladesh and populationprograms in, say, Indonesia and Thailand, is that in those programs theGovernments concerned finance, to a large extent, their own programs, whileBangladesh is dependent on donor support for almost 90% of its populationprogram financing. As a result, the leverage that can be used by donors issubstantially higher.

44. The Bangladesh population projects could be labeled as "integrated"projects, both in terms of their components as well as their financing, andas such, they are not too different from the integrated rural developmentprojects financed by the Bank in many countries, although some may challengethis comparison. It is interesting to note that on the basis of experiencethe Bank has largely abandoned the integrated approach and is now fundingmuch simpler rural development projects; but it has maintained an integratedapproach in many of its population projects. But how well integrated are thepopulation efforts in Bangladesh? The PCR itself notes that the "populationactivities have not been knitted into an effective network for mutuallysynergistic interaction" (PCR para. 7.07). On the financing side, whilethere is no doubt that coordination in the population sector is essential,questions can be raised as to whether that implies formal cofinancing. Forexample, financing the women's component as a separate project, in theaudit's view, would not have damaged the overall population program. Dutchaid officials informed the audit mission that they did not regard theircontribution to the Second Population Project as cofinancing, despite suchindications in Bank documents. 4 8 / During preparation and appraisal of theThird project, substantial pressure was brought to bear on UNICEF to bringits contribution to population activities in Bangladesh under the cofinancingumbrella of the project. UNICEF resisted the pressure and its staff stronglyresented it. In the end, despite the absence of formal cofinancing, UNICEF'scontribution will remain available for Bangladesh's population program. Inthe audit's view, the importance of cofinancing per se might have beenoveremphasized at the expense of other approaches to coordination.

45. On the other hand, there are those who firmly hold the view that,because of the close links and interaction between various aspects of family

48/ Their contribution to the Third project, however, is regarded by them ascofinancing.

- 19 -

planning (for example, training, public information, contraceptive servicedelivery) and between family planning and maternal and child health care, themost effective way to reduce the fertility rate in Bangladesh is through theintegrated approach. Given the widespread interest among all the principaldonors in participating in the family planning program in Bangladesh, it isalso argued that it would be difficult to achieve a coordinated approach tothe program had all donors chosen to finance components of the program asseparate projects; the existence of a donor consortium financing an agreedfamily planning program with a cofinancing framework is considered morelikely to achieve the effective coordination among donor and with theGovernment which is viewed as critical in a program of this nature.

B. Project Design and Supervision

46. Problems related to donor coordination, intensive supervision (seeTable 1), intensive involvement by the programs division and Bank managementindicate that difficulties were experienced in executing the BangladeshPopulation Project. These difficulties, in the opinion of the audit, couldhave been lessened through:

(a) a more focused approach, on the basis of some priority order, tohave been expanded gradually as institutions and level of demandfor family planning developed; and

(b) changes in the Bank's supervision methods with some delegation ofsupervision responsibilities to other donors providing inputs.49/

Project Design

47. The Bangladesh program not only involves multiple agencies (as incase of the Kenya population projects), but the approach is also based on themulti-sectoral concept. Since the population project was instrumental indetermining the shape of Bangladesh's population program, it is Important toreview the number of options available in terms of project design and contentin 1973. These consisted of:

(a) a vertical approach by strengthening the delivery of family plan-ning services through an autonomous body with direct responsibilityfor service delivery and coordination with other agencies (as inthe case of Indonesia's BKKBN);

(b) a family planning/health integrated prv1.am (as, for example, inThailand);

(c) family planning integrated with Maternal Child Health (as in thecase of Jamaica); and

49/ Bank staff have indicated that this will happen under the Third project.

- 20 -

(d) family planning integrated with development. 50!

48. For its first phase and start-up activities, the Bank chose toadopt a project design which was in a sense a mix of all of the aboveapproaches. Organizationally, the project design supported a verticalapproach in terms of setting up a strong family planning division.Operationally, it developed infrastructure (civil works and staffing) for anintegrated approach with health. Conceptually, it put the project in thecontext of development by supporting multiple agencies outside MOHPC torecruit and motivate clients, and to improve the social status of the ruralpopulation, especially women. In the audit's opinion, in a countryreactivating its family planning program with little institutional base, theproject was too complex and wide-ranging. The PCR (paras. 7.02-7.06) alsoquestions the pro.ect design, but rationalizes it by stating that "the designwas an act of faith in view of the lack of prior experience in Bangladesh,and it was felt that doing something imperfect was better than not doing itat all" (PCR para 7.06). Nevertheless, by 1974 there was substantial experi-ence in the field of population in general, and other options than doingsomething large and imperfect were available.

49. Although at a conceptual level a multi-sectoral approach may havebeen justifiable, the audit is not convinced of its institutional or techni-cal rationale. Rather than having so many different types of activitiesscattered in small geographic units all over the country, a few carefullyselected pilot schemes, concentrated in selected regions, might have provid-ed, in the audit's opinion, more information and feedback and be more repli-cable. As it now stands, this multi-sectoral approach has embedded itself inthe program, thus making subsequent projects equally complex. Project com-ponents often have more than population control objectives, such as, forexample, the women's component, where the main objective is to improve theeconomic status of women. While worthwhile in itself, the linkage with thepopulation program is open to question.

Supervision

50. The Bank has made an enormous effort to supervise and guide thepopulation program in Bangladesh. Over the last decade more than 1,600 staffweeks (more than 40 staff years) have been provided, of which more than 1,000staff weeks were spent on supervision (see Table 1), substantially higherthan the average Bank project. This does not take into account staff inputsprovided by other donors and the time used by the resident population projectoffice.

51. In 1978, OED undertook an indepth review of the Bank's supervisionefforts. 51/ This includes a case study of the Bangladesh Population

50/ Massain T. Aumed, (ed), Proceedings of the Seminar on Family PlanningNovember 21-25, 1973 Dhaka. The rationale for this approach existed intheory on the basis of experience in the Western countries. Also, seePPAM para. 15 for factors that influenced project design.

51/ Operational Policy Review, The Supervision of Bank Projects, OED ReportNo. 2858 dated February 22, 1980.

- 21 -

Project, attached to the PPAM as Annex 4 for ease of reference. Many of theconclusions of that case study are still valid today.

52. From the beginning, the Bank decided that the project would requirea large amount of supervision. Consequently, until a resident populationproject officer was appointed, supervision missions took place initially atthree-month intervals and at six-month intervals thereafter. There was ahigh degree of continuity, and supervision missi-ns were planned well inadvance and all parties involved notified. As a result, supervision missionswere exceptionally large, with around 5-7 Bank staff members and consultantsas well as a large number of cofinancier representatives. It was usualpractice for the Bank to obtain approval of all cofinanciers about designchanges and inform them about progress, and this produced an unusual amountof correspondence.52/ Additional administrative burdens were imposed on theBank as it acted as the executing agency for four of the donors. 5 3 / Therewas no dissatisfaction on their part with how this was done by the Bank.Nevertheless, donors felt that the Bank's supervision reports containedinadequate information regarding the specific components which they werefunding.

53. An interesting feature of the supervision effort was the establish-ment of a resident population project office in the Bank's resident missionin Dhaka. The cost of that office was part of the project and was sharedamong the donors. Nevertheless, in retrospect, it seems clear that at thetime insufficient delegation of authority was provided to the resident officeto handle day-to-day operational decisions and approval of consultantappointments, contracts and matters related to procurement, and had to bereferred to headquarters. This caused delays and a tremendous amount ofcorrespondence between the resident office and headquarters.54!

54. The size of the missions in which cofinanciers participated madelogistics and management of the supervision efforts complicated andcommunications with Government cumbersome. Also, the need for extersiveinternal communication reduced the time available for field visits. Manysupervisions were also covering the Second project, once that was approved,or got involved with issues relevant for the preparation of the Thirdproject. Given the substantial resources spent on supervision, it is worthconsidering how they might be used more effectively. The audit wishes tooffer the following suggestions for consideration:

(a) smaller supervision missions focused on specific components orprojects; 55

52/ At present project correspondence files cover 26 volumes.

53/ The other two donors handled there own disbursements.

54/ The population specialist and the Resident Mission (RMB) in Dhaka nowapprove appointments and procurement. They now make a number of day-to-day decisions, and the RMB disbursement unit processes withdrawal

applications.

55/ Three small supervision missions might be more effective than, forexample, two large missions.

- 22 -

(b) more delegation of day-to-day operations to the field;56/

(c) closer involvement of other donors, perhaps delegating to them somedegree of supervision responsibility for the components theyfinance; and

(d) limit the large mission to a maximum of once a year when allcofinanciers could jointly and formally review project progress inDhaka.

C. Utilization

55. Poor client motivation, location and design of infrastructure, typeof services provided and lack of staff credibility, the audit discovered,were major factors explaining the under-utilization of almost all the infra-structure constructed under the project. For example, URCs, with a staff of5 medical doctors, 3 health inspectors, an FP officer, a Family WelfareVisitor and other nursing, clinical and support staff, process on averageonly 80-100 out-patients a day, and just 50% of the beds are occupied at anygiven time. Of the services provided less than 8-10% are family planningrelated. In the case of UHFWC, utilization, on average, was low (rangingfrom 8-20 clients a day, most of them for health-related services) but varieddepending on the location of the center. Centers located near villages orhousehold clusters tended to be utilized more than those established at somedistance from a village. The general public found the centers of limiteduse, as what they needed was often unavailable (and what was available wasoften not worth the time and effort it took to get to the centers), or theywere dissatisfied with the level of services and/or found the centersphysically inaccessible. 57/ In the case of family planning services, theaudit believes that the social setting (PPAM para. 11), quality and limitedamount of services, and the heavy reliance on a single approach, i.e.,sterilization, are the main obstacles to much wider acceptance.

56. In general, UHCs are inappropriately designed and too large. Ser-vices are not systematically linked from one section of the building toanother for client convenience. The old UHC, although small and in poorcondition, appears more functional. The audit questions the Bank's proce-dures in approving such a design, given that one of the Bank's architectswent on record as having serious reservations. Similarly, the UFHWC is, inthe audit's opinion, over-designed by at least two rooms for the presentlevel of services being provided (or future services that can reasonably beexpected). They are also poorly maintained. Most UHFWCs are fully staffed

56/ Especially as the resident mission employs regular Banks staff members,as well as local procurement specialists who all could be consulted ifneeded.

57/ It is interesting to note that rural dispensaries, housed in many casesin small deteriorating buildings, cater to a much larger clientele.

- 23 -

except many are without a pharmacist, but the audit feels that this does notpose a problem at present given the low utilization of the UFHWCs. A reviewof UHFWC designs is needed at this time. The audit believes that it wouldhave been more cost-effective to start small and add additional space as thelevel of services and demand increased.

57. The audit found that, in general, the field staff were interestedin their work but they felt, as did their supervisors, that their usefulnessto people in rural areas was limited as they provided a limited range of ser-vices. Family planning and delivering contraceptives (pills and condoms)were not considered services that would help them to establish credibility inthe community. Further, since most of the Government reward and paymentsystem is built around sterilizations and IUDs, distributing pills andcondoms in itself is not a high priority for fieldworkers. The audit ob-served that field level staff had no systematic way of recording informationon areas and clients they covered. 5 8 / The audit also observed that thecenter staff and the field workers had some problems in keeping the center'sown records, and that there was no systematic work plan for them to organizetheir center and field activities.

58. In the case of training centers, the output is about 50% of thecapacity, primarily because nearly all the cadre for which training centerswere constructed had been trained even before the centers were completed. Atpresent, most of the training centers constructed under the project arelargely utilized for in-service training. According to the audit'sobservation, the quality of training and training methodologies requireserious review at this point to make training more skill-specific. Also,the staffing needs review. For example, the management staff in thesecenters are on deputation and therefore feel insecure, which inadvertentlyaffects their commitment. Under this project as well as many others inBangladesh, substantial training facilities are being constructed. Thisraises the question of coordination between training components includedunder various projects. There is an obvious need for increased attention tothis within the Bank. While the need for project-sponsored training is notin doubt, it might be that a country-wide over-capacity is being created interms of physical infrastructure. In any case, utilization of the projecttraining centere should be maximized, if necessary by making space availablefor other than project-specific training.59/

59. The performance of the model clinics was poor and their utilizationlow, and although model clinics have not been included in subsequent proj-ects, their efficiency needs to be enhanced. On average, model clinics haveconducted less than 300 sterilizations a year between in 1982-85, and their

58/ The practices applied in Thailand's population program may be useful:each health center keeps comprehensive information on villages andhouseholds within its reach, subd-vided by field worker.

59/ Additional draining envisaged under the Third project might also improveutilization of the centers.

- 24 -

performance with regard to training was also poor. This makes these centerspresently very expensive to operate given the level of staffing with interalia 15 full-time doctors. Converting these model clinics into maternitywards in the hospitals to which they are attached might be a solution.

D. Management and Organization

60. The population program has undergone multiple reorganizations (PPAMparas. 17-18). As each change brings its own set of staffing rules, struc-tures and relationships, which all require time to become established andeffective, the audit must caution against too frequent changes since theycreate a sense of insecurity and uncertainty among the staff whioh inadver-tently might affect their morale and commitment, as was observed in Bangla-desh. Further, the managerial and technical rationale underlying thesechanges is not clear since the relationship between organizational change andprogram performance is not evident. At present there is already a negativeassociation between organizational changes and program performance (PPAMpara. 23). The Bank, in the audit's opinion, over-emphasized the managementaspects of the program. It also promoted increased supervision and improve-ment in the client-worker ratios, as solutions to program problems. However,this might not remedy some of the underlying constraints such as the absenceof acceptable services (or service mix) to the client, lack of credibility ofthe staff in the eyes of the client, poor family planning/health staffmotivation and commitment, and limited client participation. Improvedmanagement by itself will not solve all problems.

E. Client Orientation

61. For family planning services to be effective, services not onlyhave to be available but also accessible and acceptable and used on a contin-uous basis by the clients. Research in Bangladesh has focused on deter-minants of fertility more than on factors associated with contraception. 6 0/Whether clients are satisfied or dissatisfied with the service system or whattype of services they like is not well understood. Although, in general,village involvement, especially of the leaders, has been an important factorfor program effectiveness,6 1/ there is actually little community involvementin the population projects. The First project did attempt to involve thecommunities in the construction of UHFWCs with the idea that these centersmight become focal points for broader community activities. However, thispractice was discontinued after reported unsuccessful experience during thefirst two years of the Second project (and the last two years of the Firstproject). Even project components such as the Mothers Clubs, where there ispotential for community involvement, are to a large extent managed byGovernment, and there is limited training for women leaders to becomeeffective motivators, community mobilizers and organizers.

60/ See World Bank staff Working Paper No. 557, A Survey of Research,op. cit.

61/ Sanders, Keith, et. al., "Impact of Family Planning through VillageLeadership," Community Development Foundation, Dhaka, 1976.

- 25 -

62. The audit discovered that most IEC activities continue to focus onmotivating communities to a positive attitude towards family planning. How-ever, there is more need for information on the type of services available,where to get them and how to use them more effectively. In other words,"consumer" education is required. Communities could and should be effective-ly used for this purpose. Other countries (for example, Sri Lanka) haveexperience with using satisfied users from the community to both motivate,educate and make door-to-door services available.

VI. SUSTAINABILITY AND FOLLOW-UP

63. The sustainability of the project is a major issue, given the rela-tionship between population growth in Bangladesh and its development. How-ever, the issue must be considered within the larger resource constraints ofthe country. The audit strongly supports long-term involvement of the Bankin the sector due to the built-in time factor involved in fertility reductionunder the best of conditions. However, such involvement need not necessarilybe based on an exponential expansion in the cost and size of projects. Afterall, money does not have a direct effect on CPR, neither do some of the otherproject components, although important by themselves.

64. Operationally, the project established and set the stage for awider expansion of service delivery systems. New institutional and staffingpatterns were developed which expanded the sector too rapidly, in the audit'sopinion, for effective absorption and sustenance by the Government. There-fore, recurrent costs for field staff salaries continue to be included in thesubsequent project costs. It has taken two projects to institutionalize thefield infrastructure, at marginal improvement in program performance until1981. The audit feels that, in retrospect, it might have been possible tophase-in the delivery system more slowly because the large project expansiondetracted from some critical areas, such as the quality of training, supervi-sion and statistical procedures, work program planning, inadequate clinicrecord keeping and maintenance. These, at present, are lacking, and as thePCR states, are now difficult to change (PCR paras. 7.05-7.06).

65. Since development of the Second project took place while the Firstwas being implemented, the basic project design was maintained and sustained,and was again incorporated, albeit on a larger scale, in the Third project.In the narrow sense, sustainability is guaranteed as donors under the Thirdproject will continue to support the program, including substantial fundingfor non-incremental recurrent expenditure and even maintenance of facilitiesbuilt under the earlier projects. However, short-term sustainability mightbe at the expense of long-term sustainability. What will happen by the endof the Third project? It will clearly be impossible for Government to sus-tain the program at that time on its own. 6 2 / However, limited attention is

62/ Government states that it "would be in a position to make a decision inthis matter after the study on the health sector and the projection ofresources during the Third Five Year Plan period and beyond. Governmentwill absorb the recurrent cost of essential items after 1990 to theextent possible" (see Supplement 1).

- 26 -

focused on that issue. What is needed is a long-term framework (20 years ormore) within which the Bank's projects and their direction can be betterunderstood.

66. The population- projects have become large and remain multisec-toral. Program performance has been deteriorating, endangering achievementof program objectives. However, the magnitude of the projects and problemsshould not distract from the major objectives of these efforts, namely effec-tive family planning. More focus on that is needed.

PROJECT PERFORMANCE AUDIT HEMRANDUM

BANGLADESH (FIRST) POPULATION PROJECT(CREDIT 533-BD)

FY73 FY74 FY75 FY76 FY77 FY78 FY79 FY80 FY81 FY82 FY83 FY84 FY85 Total

Population I

Identification/Preparation 1.7 3.0 0.6 5.3Appraisal 7.4 68.9 87.7 164.0Negotiations 1.8 18.5 * 20.3Supervision 49.5 109.1 118.4 109.3 69.7 96.4 51.9 32.8 24.2 10.0 0.1 671.4

Subtotal 9.1 73.7 156.3 109.1 118.4 109.3 69.7 96.4 51.9 32.8 24.2 10.0 0.1 861.0

Population II

Identification/Preparation 11.5 47.1 9.0 67.6Appraisal 55.5 127.8 183.3Negotiations 20.8 80.8Supervision 2.2 69.3 116.0 69.1 52.8 24.7 6.4 340.5

Subtotal 11.5 102.6 159,8 69.3 116.0 69.1 52.8 24.7 6.4 612.2 #

Population III

Identification/Preparation 5.1 19.0 30.8 47.1 102.0Appraisal 109.1 109.1NegotiationsSupervision

Subtotal 5.1 19.0 30.8 156.2 211.1

Total

Identification/Preparation 1.7 3.0 0.6 11.5 47.1 9.0 19.0 30.8 47.1 174.9Appraisal 7.4 68.9 87.7 55.5 127.8 5.1 109.1 456.4Negotiations 1.8 18.5 20.8 41.1Supervision 49.5 109.1 118.4 109.3 71.9 165.7 167.9 101.9 77.0 34.7 6.5 1,011.9

GRAND TOTAL 9.1 73.7 156.3 109.1 129.9 211.9 229.5 165.7 167.9 107.0 96.0 65.5 162.7 1,684.3

Source: Planning and Budgeting Department.

2i-

6

-29 - ANNEX 1Page 1 of 5

PROJECT PERFORMANCE AUDIT MEMORANDUM

BANGLADESH (FIRST) POPULATION PROJECT(CREDIT 533-BD)

Project Description: First Population Project 1/

A. Objectives and Design

The project is designed to assist the development of a comprehen-sive national fertility-control program. It will expand facilities and staffto serve the existing demand for family planning services and will launch awide set of activities designed to create additional demand for such ser-vices. The following considerations underlie project development:

(a) A major constraining on the expansion of health and family planningservices is the shortage of intermediate level health manpoweri.e., nurses and family welfare visitors (FWV--a category of para-medical manpower utilized for health and family planning).Bangladesh is unique in its adverse ratio of doctors to nurses,estimated at 8:1. The shortage of such manpower is mainly theresult of a limited physical capacity for training tutors, nursesand FWs. The Government has established 13 new schools for thetraining of nurses, but the increased number of nurses is likely tobe absorbed by the hospital in urban areas. Therefore the mainreliance in the rural areas will have to be on FWVs for a longtime. The project supplements this national effort by the con-struction of one college for nursing for the training of nursetutors (who will also teach FWVs and eight schools for the basictraining of FWVs, who will be the key staff in the rural healthscheme. In addition, eight thana health complexes with 24 subcen-ters will provide field training for FWVs and medical students andfour model family planning clinics in medical colleges will givepractical training to medical students in family planning methods.

(b) The home visiting program of the team of field workers is the mainsource at present for the distribution of pills, condoms and othermethods as well as for other simple health services. The projectprovides training and salary support for the female members of theteam who would be mainly responsible for maternal and child healthand family planning services.

1/ Verbatim from Appraisal Report of the Bangladesh Population Project,Report No. 243a-BD dated February 3, 1975, paras. 3.01 and 3.02.

-30 - ANNEX IPage 2 of 5

(c) The Government's policy of changing social attitudes towards familysize by integrating the population planning program with the deve-lopment programs of individual ministries is based on evidence thatfamily planning programs which are integrated with other develop-ment efforts have a better chance of success. The project willhelp the Government integrate family planning motivation and educa-tion with schemes designed to (i) raise the economic and socialstatus of women, and (ii) train village leaders in rural develop-ment programs. The total number of thanas covered during the proj-ect period by different schemes would be about 61, or 15% of thetotal 413 thanas. These thanas have been selected to cover themajor administrative,geographic and socio-economic conditions foundin the country. The schemes dealing with raising the socio-econo-mic status of women are new and would be initiated in only a limit-ed number of villages in selected thanas. The project supportsthese schemes because of their possible direct bearing on reproduc-tive behavior. Schemes dealing with training village leaders arealready in operation; the project will add a family planning train-ing element in ongoing training programs for all the villages ofthe selected thanas.

(d) Films and radios are found to be popular mass media in ruralareas. The project creates the capacity for the production offamily planning films and radio broadcasts--the contents of whichwill be guided by the results of action-oriented attitude research.

(e) Introduction of population education in the primary and secondaryschool systems is necessary to create awareness of population pro-blems among future parents. The project supports the developmentof curriculum and teacher-training for this purpose.

(f) At this stage of program development a strong system of evaluationof all program components is crucial. The project would supportand internal evaluation (by the implementing ministries and thePPD) as well as an external evaluation by the Health and PopulationPlanning Section of the Planning Commission.

(g) For the long-term development of the population program, a study onthe determinants of reproductive behavior to assess the factorsinfluencing the family-size decision is essential. The projectsupports these studies. In addition the project also supports astudy of existing laws for their pronatality impact.

(h) The success of both the program and the project will depend onviable organizational structures for their implementation, coupledwith a strong political commitment. The project included a manage-ment study for the review of the present organization of theMOHPP. For implementation of the project in ministries other thanthe MOHPP, the project will establish the position of population

-31 - ANNEX IPage 3 of 5

program officer. The overall coordination, evaluation and monitor-ing of project activities will be the responsibility of the PPD inthe MOHPP in collaboration with the PPS in the Planning Commis-sion. A seminar on population problems for political leaders isincluded in the project for creating awareness of the gravity ofpopulation problems. The project also includes various studies andtechnical assistance to help reduce construction time and costs.

B. Summary Project Description

The project will consist of the following components:

(a) Technical assistance and general support for strengthening thepopulation program organization.

(i) Obtaining the services of a management firm to assist theMinistry of Health and Population Planning in improving itsinternal organization;

(ii) Conducting a national seminar on population problems for poli-tical leaders; and

(iii) Conducting studies on building utilization.

(b) Constructing, furnishing, equipping and supporting the followingtraining and service-cum-training facilities for the Ministry ofHealth and Population Planning.

(i) One college of nursing in Dacca to graduate 60 tutors annuallyto train nurses and public health nursing staff;

(ii) Eight family welfare visitor training schools to train 60students annually;

(iii) Eight new thana health complexes with (a) a 25 bed maternityward unit, (b) dormitories for 25 trainees, (c) an outpatientclinic, and (d) staff housing to serve as rural field trainingcenters for medical and paramedical personnel in health andfamily planning services;

(iv) Twenty-four union health subcenters with dormitory capacityfor two trainees for union-level field training (three perhealth complex described above); and

(v) Four model clinics in medical colleges for family planningtraining of medical students, and the retraining of 50 medicalstudents annually.

- 32 - ANNEX 1Page 4 of 5

(c) Training and subsequent employment for four years for 3,700 femalefamily welfare workers as members of male/female home-visitingteams in rural areas.

(d) Provision of audiovisual equipment, vehicles and operating costsfor three years for the establishment and support of nine educa-tion/motivation pilot schemes in 61 thanas and general program sup-port to the designated ministries.

Ministry of Local Government, Rural Development and Cooperatives:

(i) A pilot scheme for the use of model farmers and cooperativemanagers as change agents for family planning; and

(ii) A pilot scheme for the rural women's functional literacy pro-gram as a means of acceptance of family planning.

Ministry of Labor and Social Welfare:

(i) A pilot scheme for the formation of rural mothers' clubs forfamily planning motivation;

(ii) A pilot scheme for the women's vocational training programs asa means of acceptance of family planning; and

(iii) A pilot scheme for the family planning program for organizedlabor.

Ministry of Agriculture:

(i) A pilot scheme for the use of agricultural assistants forpopulation education.

Ministry of Education:

(i) A pilot scheme for the use of a mobile population educationteam to hold seminars on population problems for schoolteachers to obtain their support in influencing the community;

(ii) Curriculum development and teachers' training for the intro-duction of population education in the primary and secondaryschool curricula; and

(iii) A national seminar on population education.

Ministry of Information and Broadcasting:

(i) A pilot scheme for the use of audiovisual vans for familyplanning films;

(ii) Establishing a Population Program Cell for Radio Bangladesh;

- 33 ANNBX 1Page 5 of 5

(iii) Expansion of the film producing capacity of the Department ofFilms for producing family planning films;

(iv) Setting up a Population Feature Writing Bureau; and

(v) Training the public relations officer in population problems.

Ministry of Health and Population Planning:

(1) The pilot scheme for the use of family planning motivationkits by family welfare workers.

(e) Salary support, operating costs, support for institutions capableof conducting research studies and evaluation.

(i) The establishment of an Evaluation Unit at the Health andPopulation Planning Section of the Planning Commission forprogram evaluation;

(ii) Special evaluation studies of the pilot schemes to be conduct-ed by the PPD through the concerned ministries;

(III) A study on the determinants of reproductive behavior by theBangladesh Institute of Development Studies; and

(iv) A study of national laws to assess their pronatality impact tobe conducted by PPD through a special committee.

-- 3V-

-35 - ANNEX 2Page 1 of 3

PROJECT PERFORMANCE AUDIT MEMORANDUM

BANGLADESH (FIRST) POPULATION PROJECT(CREDIT 533-BD)

Project Description: Second Population Project I/

A. Object and Design

Object. The object of the project is to reduce fertility and mor-tality by: (a) primarily extending and strengthening the family planningservice and health care delivery system; (b) increasing and improving thequality of training of health and fami.ly planning manpower; (c) extending theIBM activities of the first project; (d) strengthening evaluation andresearch capacities; and (e) improving program and project implementation.

Design. The project is designed to continue and expand the activi-ties begun under the first project. It is based on the population and healthprogram strategies and takes into account GOB's investment priorities andimplementation capacity, and the experience gained under the first project.

B. Composition

The project includes:

(a) Health Care and Family Planning Service Delivery

(i) strengthening the delivery of health and family planningservices at the village level by, inter alia, providing con-tinuing salary support for the FWAs recruited under the firstproject,2 / (6,500 in the second year, 5,500 in the third, and4,500 in the fourth year, providing 253 ambulances for FWs,four vehicle maintenance vans, 19 vehicles for supervisionfrom the district, and providing FWAs with two-way radios and4,000 bicycles on a pilot basis;

1/ Verbatim from Bangladesh Staff Appraisal of A Second Population andFamily Health Project, Report No. 2323-BD dated May 16, 1979, paras.4.01-4.03.

2/ Savings from the first project were used to provide salary support for8,000 FWAs from January 1979 and this support will continue through theinitial year of the second project, terminating in June 1980.

- 36 -ANNEX 2Page 2 of 3

(ii) improving health, MCH and family planning services by con-structing, furnishing and equipping: (a) 700 new FWCs; and(b) 19 THCs; and

(iii) improving health, MCH and family planning services by provid-ing drugs.

(b) Training of Health and Family Planning Manpower

(i) continuing the MCH/FP training of medical students by continu-ing operating cost 3 / support for the four model family cli-nics provided under the first project;

(ii) improving the training of FWVs by providing, inter alia, tech-nical assistance, books, materials and operating expenses forrefresher courses, and expanding an existing Fh?1 trainingschool to accommodate about 80 students;

(iii) expanding the training capacity of MAs by constructing, equip-ping and furnishing and providing vehicles, fellowships andstudents' stipends for four new training schools for MAs;

(iv) strengthening the training of FWAs and FPAs by constructing,equipping and furnishing, and providing advisory assistanceand operating expenses for 19 training centers for FWAs andFPAs; and

(v) improving the training of PCFPD staff in management by con-structing, equipping and furnishing the training building forthe PCFPD.

(c) Information, Education and Motivation Activities

(i) improving the dissemination of information on family planningand health through: (a) mass media activities of the Ministryof Information and Broadcasting by providing, inter alia,vehicles, equipment, fellowships and continuing and incre-mental operating costs; (b) women's development programs inabout 84 thanas (42 of first project and 42 new) by providing,inter alia, equipment, vehicles, technical assistance, con-tinuing (except mothers' clubs) and incremental operating

3/ Operating cost includes salaries, vehicle maintenance, materials andtravel allowances. Continuing operating cost refers to continuation ofoperating cost support initiated in the first project and incrementalcost refers to operating cost of new activities under the secondproject.

- 37 - ANNEX 2Page 3 of 3

costs; construction, equipment and furniture for women's voca-tional training centers in 12 thanas and by establishing amarketing and design cell; (c) the training of communityleaders and use of folk media by the IEM Unit of PCFPD byproviding incremental operating costs; and (d) strengtheningthe Health Education Bureau of the Health Division by provid-ing, inter alia, equipment, vehicles, technical assistance,and incremental operating costs.

(d) Evaluation and Research

(i) increasing evaluation and monitoring capacity by providingvehicles, equipment, technical assistance and continuing andincremental operating costs of the Service Statistics Unit ofPCFPD and the External and Evaluation Unit of the PlanningCommission; and

(ii) assisting the Health Information Unit of the Health Divisionto collect health management information and establish medicalaudit teams by providing vehicles, equipment, technical assis-tance and incremental operating cost.

(e) Innovative and Private Sector Activities, making funds availablefor financing innovative population subprojects in the public andprviate sectors.

(f) Project Implementation, strengthening project implementation capa-city by: (a) providing the BPDU, the FWC Administrative Unit, theSupplied Directorate, the Public Works Department and the ProjectFinance Cell of PCFPD with vehicles, equipment, consultant servi-ces, and incremental operating cost; (b) providing additional stafffor the Population Program Officers at four implementing Ministriesother than MOHPC; and (c) providing additional staff to assist thePopulation Project Officer at the Bank's Dacca office.

ガ 盤グジ J タ次ィノ ：ど多メ

ー 8 ど一

- 39 - ANNEX 3Page I of 5

PROJECT PERFOMANCE AUDIT MR40RANDUM

BANGLADESH (FIRST) POPULATION PROJECT(CREDIT 533-BD)

Project Description: Third Population Project

A, Objectives and Design

The major objective of the proposed project is to assist theGovernment of Bangladesh in achieving its fertility and Infant and maternalmortality reduction goals, Corollary objectives are to maintain programmomentum thereafter by stimulating additional demand for family planning, andto help strengthen the infrastructure for basic rural health services. Theproject proposes to achieve these aims by:

(a) Strengthening management and supervision of the servicedelivery system;

(b) Strengthening and broadening maternal and child health(MCH) activities through programs for immunization, diar-rhea management and safer childbirth;

(c) increasing the effective coverage of rural family plan-ning and health services through provision of additionalfield workers and Union Health and Family Welfare Centers(UHFWCS);

(d) Improving technical skills of field workers, through pro-grams of training and retraining-,

(e) Supplying drugs, supplies and medicines for both MCH andfamily planning;

(f) Developing information, education and motivation (IBM)programs designed to increase the demand for family plan-ning and MCH service;

(g) Supporting women's vocational training and cooperativeprograms which promote family planning acceptance, andnon-government organizations (NGOs) which promote andprovide family planning services;

I/ Verbatim from Staff Appraisal Report Bangladesh Third Population andFamily Health Project, Report No 5485-BD dated December 24, 1985,paras. 3.01-3.03.

-40 - ANNEX 3Page 2 of 5

(h) Strengthening the MOHPC's management information system,and supporting research on the performance of the familyplanning and health program and ways to improve it; and

(i) Supporting experimentation with other programs outsidethe service delivery system to encourage couples to delayhaving or to have fewer children.

The project is designed to incorporate the assistance of most ofthe major foreign donors to the Government's family planning and health pro-gram for the Third Plan. This strategy will ensure that support is in linewith GOB priorities and will minimize the Government's aid management bur-den. The project will thus finance most of the major family planning and MCHactivities in Bangladesh for the Third Plan. It will also build on theaccomplishments of the Second Project. Recognizing the long time horizon forprogram and institutional development in the population and health sectors,and the GOB's continuing dependence on external financial assistance, theproject will continue selective support to major activities supported underthe Second Project. These are field staff salaries, transport, drugs, UHFWCconstruction, training, 1E4, women's programs, and evaluation and research.The project will respond to problems which arose during implementation of theSecond Plan through the following actions:

(a) A special emphasis on strengthening management and super-vision of the field service delivery system;

(b) A major institutional development program for NIPORT;

(c) Introduction of a limited package of priority MCH ser-vices on an outreach basis made possible by the Substan-tial network of outreach workers built up under the Firstand Second plans;

(d) A substantial increase in the number of female FamilyWelfare Assistance (FWAs); and

(e) A maintenance program for the facilities constructedunder the First and Second Projects.

B. Summary Project Description

The project will be implemented over five years and will have sevencomponents:

(a) Family Planning/MCH service Delivery Consolidation andExpansion;

(b) Maternal and Child Health Programs;

(c) Communications;

-41 - ANNEX 3Page 3 of 5

(d) Women's Program;

(e) Support to NGOs and Innovative Programs;

(f) Research and Evaluation; and

(g) Project Management Support.

The project will be implemented over five years and will have sevencomponents: (a) Family Planning/MCH Service Delivery Consolidation andExpansion; (b) Maternal and Child Health Programs; (c) Communications; (d)Women's Programs; (e) Support to NGOs and Innovative Programs (f) Researchand Evaluation, and (g) Project Management Support. The Component costsgiven below reflect base costs only. No contingencies are included.

(a) Family Planning/MCH service Delivery Consolidation and Expansion(US$147.4 million

(i) Strengthening of the management and supervisionsystem through creation of additional supervisorycadres, provision of transport and travel allowan-ces, development of improved supervision routinesand performance, monitoring arrangements, and sup-port to independent quality control and managementdevelopment programs (US$21.6 million);

(ii) In-service training for district and upazila staffthrough development of NIPORT, training of NIPORTstaff, in-service training for all existing fieldstaff at the union and ward levels, and training ofthe new cadres of Senior Family Welfare Visitors(SFWVs) and FWAs (US$11.5 million);

(iii) Financing of salaries of 10,000 additional and 4,500continuing FWAs (US$25.2 million);

(iv) Supply of FWA materials and MCH-related drugs, forall UHCs, MCWCs and UHFWCs (US$28.5 million);

(v) Supply of medical and surgical requisites forclinical forms of contraception (US$16.2 million);and

(vi) Construction and equipping of 1,000 additionalUHFWCs, upgrading of 73 rural dispensaries, a main-tenance demonstration program for health facilitiesfunded through the two previous projects and theones now proposed; and the costs of the ConstructionManagement Cell (US$44.4 million).

- 42 - ANNEX 3Page 4 of 5

(b) Maternal & Child Health Programs (US$3.3 million)

Development and integration of a national MCR pro-gram into the FP delivery system through workertraining and provision of vehicles and operatingcosts complementing around US$9.7 million in UNICEFsupport for immunization, diarrhea management andsafer child birth.

(c) Communications (US$9.0 million)

(i) Combined mass media and interpersonal approaches topromoting two-child norm, including training ofextension workers and community leaders, support toNGOs, production of materiale for radio and otheraudiovisual dissemination (US$8.2 million); and

(ii) Campaigns to promote acceptance of immunization anddiarrheal management program (US$0.8 million).

(d) Women's Program (US$14.9 million)

Strengthening of women's income-generating programs in100 upazilas through women's cooperatives (US$5.5 mil-lion); improved training, marketing, and design inMothers' Centers (US$4.4 million); and Women's VocationalTraining Programs (US$5.0 million) in 30 upazilas.

(e) Support to Non-Government Organizations and Innovative Programs(US$9.0 million)

(i) Support to population-related activities of NGOs,with particular emphasis on expanding their servicedelivery role in rural areas (US$4 million); and

(ii) Experimentation with measures to generate additionalFP demand, including bonuses for delayed marriage,longer birth intervals and family size limitations;testing district-based nutrition interventions;health financing studies, epidemiological survey;and preparation of the fourth phase of the nationalpopulation/MCH program (US$5 million).

(f) Research and Evaluation (US$2.9 million)

(i) Continued support to the Management InformationSystem and External Evaluation Unit, includingvehicles, equipment, training, special studies, andstaff support (US$2.0 million); and

43 - ANNEX 3Page 5 of 5

(ii) Support to research through the National Council forPopulation Control (NCPC) (US$0.9 million).

(g) Project Management Support (US$1.7 million)

Support, including vehicles, equipment and operatingcosts to project-related administrative groups, ProjectFinance Cell, MOHPC Procurement Unit and PopulationPrograms Office) to strengthen implementation capacity.

...-- y &

réa 4<re &/s 4

- 45 - ANNEX 4Page 1

PROJECT PERFORMANCE AUDIT MEMORANDUM

BANGLADESH (FIRST) POPULATION PROJECT(CREDIT 533-BD)

SUPERVISION OF BANK PROJECTS 1/ 2/CASE STUDY: BANGLADESH POPULATION PROJECT-/ -

I. THE PROJECT

1.01 The Bank became interested in assisting a population project inBangladesh in the early 1970s. A population sector survey, which was toprovide the background and foundation of this project, was carried out as partof its identification, preparation and appraisal.d/ An innovative and com-plex project to assist family planning through developing a national programand establishing a system of health delivery services emerged. The program tobe developed would be comprehensive and addressed equally to the creation ofdemand for and the delivery of family planning services. The project wasformulated by two appraisal missions; the first in May-June 1973 and thesecond in November 1973. The long period between the last appraisal missionand the signing of the credit agreement was primarily due to time required tofinalize arrangements with cofinanciers. The project was cofinanced by theBank and six other national donors (Canada, Australia, Germany, Norway, Swedenand Great Britain). Basic data of the project are given in Table 1.

1.02 The Population Planning Division of the Kinistry of Health andFamily Planning-! and the Health and Population Planning Section of the

1/ Taken verbatim from Operational Policy Review, The Supervision ofBank Projects, OEDReport No. 2858 dated February 22, 1980, Volume II,pages 148-160.

2/ This case study is based on a visit to Bangladesh by staff of the Opera-tions Evaluation Department (OED) during July 1978 and on interviewswith Bank personnel. Unless otherwise specified, all material includedherein reflects the analyst's view as of October 1978. Detailed commenton an earlier draft was received from the Population Control and FamilyPlanning Division, Ministry of Health, Population Control anr. FamilyPlanning, in conjunction with the Planning Commission.

3/ A Pepulation Sector Survey of Bangladesh was published Feb. 10, 1975.

4/ Presently the Population Control and Family Planning Division of theMinistry of Health, Population Control and Family Planning. For pur-poses of this case study the Ministry will be referred to as Healthand Population Planning (MOHPP).

ANNEX 4- 46 - Page 2

Ministry of Planning jointly were to have the major responsibility for imple-mentation of the project. Units within the MOHPP would be in charge ofconstruction and procurement/disbursement. In addition, five other ministrieswould participate in carrying out the project: (1) Local Government, RuralDevelopment, and Cooperation; (2) Agriculture; (3) Education; (4) Informationand Broadcasting; and (5) Labor and Social Welfare. Within each of theseministries, a Population Program Officer would be responsible for implementingspecific project components of that ministry. A condition of effectiveness wasthat these officers had been appointed and arrangements for their training hadbeen made. In fact, these officers had been appointed and given trainingoutside at the East-West Center before the credit was effective.

1.03 Although provision was made for a wide variety of facilities andprograms, nearly two thirds of the credit (excluding contingencies) wasallocated for constructing and furnishing facilities for training healthand family planning manpower (chiefly family welfare workers). This wouldinclude a nursing college, model clinics at several medical colleges andparamedical centers for treatment and training in both rural and urban areas.The rest of the funds were allocated for technical assistance in management,aid to the private sector, support for research and evaluation, and informa-tion and educational facilities for pilot programs to be established in theseveral agencies mentioned above. The thrust of this last component would beto influence as wide an audience as possible through the formation of grassroots groups (rural mothers' clubs); the mobilization of existing social orlabor groups (cooperatives, literacy or vocational training groups, organizedlabor, school teachers); and the use of seminars and the mass media (radioprograms, audio visual vans, films).

1.04 At the time of appraisal, the Government requested that a popula-tion specialist be appointed by the Bank and assigned to the resident missionto provide assistance in implementing the project. Although this was agreedto by the Bank and action was initiated in mid-1975, the appointment wasnot finalized and the specialist did not take up his duties in Dacca untilMarch 1976.

1.05 Although some of the components were implemented quite promptlyafter the agreement was signed, others, especially procurement of equipmentfrom abroad and the construction program, have been seriously behind appraisalexpectations. Because of the latter, disbursements have been much slower thanexpected with wide swings in performance. By 1978 the actual disbursementperformance appeared to stabilize at about 25% of appraisal expectations.At the writing of this case study it was doubtful that disbursement couldbe completed by the closing date of December 31, 19801/. Even so, a follow-onproject is in preparation with expected support from the same group of co-financiers and possibly other international organizations.

1/ Disbursements were US$14 million of total project cost by April 31,1979. The borrower expects that the disbursement rate will move rapidlyin the next few months.

ANNEX 4

- 47 - Page 3

1.06 Because the taka was devalued several times by the Government andsome buildings' costs have been less than estimated, the Bank's expectedcontribution is US$2.7 million less than the US$15 million granted for theoriginal project. Consequently, the Bank has agreed to allocate these savingsto expansion of several components of the original project and the addition ofother critical activities.

II. SUPERVISION OPERATIONS

A. Supervision Missions

2.01 The Bank decided at appraisal that because of the complexity of theproject and possible management problems within the Government that theproject would require a large amount of intense supervision. Consequently,until a population project officer had been assigned to the resident mission,supervision mission at three month intervals would be made; thereafter atintervals of six months.P This schedule was essentially followed. By thetime of the OED visit in July 1978 seven supervision missions had taken place.

2.02 Missions were planned well in advance and all concerned parties--the borrower, donors and Bank personnel--were informed long before the missionwent to the field. After each mission, arrangements were made for the follow-ing one, either while the present mission was still in the country or througha follow-up letter to the Government. Many times the supervision reportenumerated the issues to be addressed and actions taken through the nextmission. For a summary of supervision inputs see Table 2.

2.03 All supervision missions were exceptionally large, with a minimum offive and a maximum of seven members, including consultants. Staffing wasappropriate, missions usually including a demographer, communication special-ist, architect and occasionally a management specialist. Details of missionstaffing and arrangements are given in Attachment A. In addition, three tosix representatives of the cofinanciers and observers from USAID, UnitedNations Fund for Population Activities, UNDP and WHO participated in missiondiscussions or activities at various times. This intense effort by the Bankresulted in 355 man-weeks of supervision activity through FY1978 or an averageof two man-years for each year the project has been under supervision.

2.04 There has also been an unusually highly degree of continuity insupervision missions. One staff member who participated in the first apprais-al mission and led the follow-up mission has been the leader of all sevensupervision missions. In addition, one to three staff members or consultantswho participated in the project appraisal have also served on each supervisionmission. As of May 1978 this project had the rare continuity index of 100.

1/ The borrower comments that the frequency and strength of supervisionmissions was helpful in the initial stage of the program consideringthe numerous problems that had to be faced.

ANNEX 4- 48 - Page 4

2.05 One Program officer was extensively involved in the project fromidentification through -ppraisal and supervision until 1978. He participatedin many of the missions and prepared a considerable amount of correspondencethat went to the borrower and donors. There was a continuous exchange ofinformation between the Projects Division of CPS and the Programs Departmentand the responsible officer. The Program officer wrote -o the Governmentconcerning all facets of project implementation including procurement, hiringof consultants, compliance with covenant, etc. He also carried out mostcorrespondence with the donors.

2.06 The population project officer who was assigned to the residentmission in March 1976 participated in all supervision missions except thefirst. As the resident population expert, his general responsibilitiesincluded assisting the government in defining its population policy, analyzingthe demographic situation, monitoring the project, liaison with other donorsand providing assistance in procurement and disbursement matters.

2.07 This project officer was not given the responsibility for approvingconsultants, contracts or procurement procedures and procurement, however.As a result, a tremendous amount of correspondence took place between theofficer and Headquarters concerning these matters aad undoubtedly accountsfor a large part of the supervision input attributed to the project. Therewas some thought given in the Bank to assigning greater authority to theresident project officer on these matters if the Government or the residentmission requested such a decision, but apparently no such request was madenor was such an action suggested or discussed with the resident missionor the Government. A reason for not assigning the resident project officermore responsibilities was that he had not had Bank experience prior to hisappointment as population project officer in Bangladesh.

2.08 Cofinanciers (donors) of the project placed considerable additionaladministrative and supervision burden on the Bank which was the executingagency for four of them, approving disbursements and accounting for theirfunds. There was apparently no dissatisfaction with how this was done. Theother two donors handled their own disbursements. It was necessary andcustomary for the Bank to obtain the approval of all six donors for zhangesin project design and to inform them of progress and mission plans, andto invite them to participate in these missions. All of these tasks producedan unusual amount of correspondence, requiring a large amount of staff time.It is not surprising that the present chronological file amounts to 20volumes.

2.09 Reports of supervision missions were distributed on the averageof four weeks after the mission returned to Headquarters, which appearsto be less than the Bank norm. The reports followed accepted Bank formatand fulfilled general supervision requirements and more.

2.10 An aide-memoire or an extensively detailed list of actions to betaken during the next six months was prepared after each mission except thefirst and was followed up on during the subsequent mission. On the average,

ANNEX 4-. 49 - Page 5

five weeks after the mission returned to Headquarters, long follow-up letterswere sent to the borrower. Many of the points noted in these letters had beendiscussed with officials before the mission left the country or were includedin the aide-memoires. Follow-up letters as well as the abridged supervisionreports were sent to all six donors.

2.11 Most government officers associated with the project were verysatisfied with the Bank's supervision, and mentioned particularly the moraland technical support lent by missions. Only two criticisms were voicedby two different individuals interviewed: that missions had not spent enoughtime in the field, and that pressures put on the various agencies by theBank missions had led in some instances to haphazard implementation. Somestated that the upcoming arrival of missions provided a favorable incentive tomeet implementation targets. The resident project officer rated high marksfrom officials, who found that both he and the missions provided valuableassistance in getting things done. Only one official interviewed felt thatthe project officer's performance could have been augmented by the appointmentof a Bangladesh assistant.

B. Other Supervision Work

2.12 The borrower had agreed to send the Bank quarterly reports of theproject's progress, the first promised in November 1975. However, no progressreports of any kind were received (despite several reminders by the Bank)until August 1976 when the fourth mission was in the field. In additionto the incentive provided by the mission, the preparation of the progressreport at that time was due to assistance received from the recently arrivedresident project officer. No general quarterly progress reports were everreceived by the Bank; some monthly reports were received from one of the con-sultants and quarterly reports from the Ministry of Information and Broadcast.After August 1976, general progress reports were furnished by the Governmentevery time a supervision mission was in the country. These reports were usedfor discussion, planning, and follow-up work by the supervision mission. Eachof the four reports received to date followed a common format and generallycomprehensively covered all project elements, identified by implementingministries.

2.13 In addition to progress and quarterly reports, a program for moni-toring and evaluation was detailed in the Credit Agreement. It consisted ofseveral base line and follow-up surveys to obtain information on the currentpopulation, other vital statistics, attitudes, and population control achieve-ments of the participating ministries. This program was continuously behindschedule and noted by every supervision mission as a problem. Several advi-sors were employed to assist in developing this program, and a directoratefor Research and Service Statistics was set up in the Population Control andFamily Planning Division of the MOHPP to carry out much of this work. Atappraisal it was expected that the Population Planning Section of the Ministryof Planning would carry out the external evaluation of the project. At thewriting of this case study a system for monitoring the impact of the projecthad still not been satisfactorily established to support and augment the work

ANNEX 450 - Page 6

of the Population Planning Section and fulfill the covenant. Research andService Statistics had difficulty in obtaining data processing equipment,but the main factor behind lack of progress was a lack of personnel withsufficient knowleoge and experience to draw up questionnaires and establishsurvey programsY

2.14 A follow-up letter after the sixth mission in the fall of 1977suggested that it may also be worthwhile to arrange for a quick evaluationof a few successful and unsuccessful efforts under each of the pilot schemesin order to delineate factors responsible for differential performances,pending the completion of evaluation of the pilot schemes.

2.15 There was no exact accounting of the supervision activity of thecofinanciers or the borrower. A rough estimate, however, is that the 6 donorsmay have devoted about 100 man-weeks to supervision related activities, whilethe borrower spent at least another 150 man-weeks.

III. THE IMPACT OF SUPERVISION

A. Supervision of Obligations Under the Credit Agreement

3.01 The Draft Credit Agreement for this project was unique in that itprovided detailed implementation schedules for many components of the pro-ject. Although many of these performance goals or requirements relatedto initiation of action, others specified both starting and completion dates.The main purpose of the first supervision mission, which was in the fieldshortly after the credit was signed, was to encourage and assist the borrowerin carrying out the conditions of effectiveness. It was only partiallysuccessful in this respect and it was not until September after the second

1/ The borrower comments a response to this case study, that despite thedelays in setting up the service statistics section and the externalevaluation unit, the former has now devised and tested a system forestablishing service statistics; action is being taken to fill allvacant posts; and a mini-computer is expected to be installed by December1979. As well a national contraceptive prevalence survey is being carriedout presently and will be repeated annually, henceforth. The externalevaluation unit is now fully staffed; all follow-up surveys have beendesigned and the field work for three has been completed. Two fulltimeexpatriate consultants have been appointed, one to service statistics,the other to the unit, both on a long term basis. Other developmentsinclude preparation of a comprehensive plan for evaluation of the popula-tion program and the various project components supported by the Associa-tion and the cofinanciers. This should be ready before December 1979.A joint committee consisting of representatives from the services statis-tics section and the project implementation bureau of the PlanningCommission is being set up to monitor the sterilization program.

* 51 - ANNEX 4Page 7

mission had returned from the field that the Bank concluded that the condi-tions of effectiveness had been complied with. Each of the following missionsfollowed up on and sought to ascertain the status of fulfillment of allobjectives and covenants of the project. After each mission a scheduleof actions and achievements in line with project goals to be completed withinthe next six months was drawn up. During the following mission it wasdetermined if this schedule had been met and then the cycle was repeated.

3.02 Unfortunately, these interim objectives were not always linkedwith appraisal report project objectives; thus, it is not easy to determinewhat project objectives were completed and when. What is certain is thatmany of the project objectives and covenants were not completed within thetime frame expected at appraisal.

3.03 Some of the problems which delayed implementation had been antic-ipated at appraisal, and although measures were incorporated into the CreditAgreement, they were not complied within a timely fashion. These were problemsrelated to the lack of effective management and adequate technical personnel,and the acquisition of sites for project buildings. Although no indication ofborrower resistance to certain covenants surfaced at negotiations, thisappeared to be a major factor in at least some of the delays.

3.04 Originally, it had been envisaged that population planning and con-trol activities would take place outside the ministries, since six differentministries were involved and it was felt that placing the management under oneof them would create insuperable administrative conflicts. However, when itbecame apparent that the Government would insist that the primary executingagency (administratively speaking) be in the MOHPP, the Bank, at negotiations,obtained an agreement that the organizational arrangements affecting theproject would be subject to review-and possible alteration--one year afterthe date of effectiveness. Another covenant adopted to strengthen the admin-istrative services of the project was a management study of the MOHPP.

3.05 Both the review and study got underway slowly, and successivemissions noted that management was the continuing and major factor affectingthe project. The lack of cooperation between the two divisions within theMOHPP in terms of sharing medical staff was a serious drawback, in that thedoctors assigned to one division were not always available to participate inthe sterilization program and control activities of the other. Bank staffconsidered this a serious problem and attempted to get a procedural agreementbetween the two directorates involved.1/ The management study of MOHPP was

1/ The borrower confirms that an agreement has been reached which willmake medical staff available for the project. In a letter reactingto this case study, the borrower adds that details of the agreementhave been furnished to the Association, and that the working relation-ship between the two Divisions has already improved.

ANNEX 4Page 8

eventually initiated by local consultants in 1976 and a draft study wascompleted by a Bank management consultant who participated in the May 1977supervision mission. Generally speaking, Bank staff regard the study asinadequate and non-objective. The review of administrative arrangements wasalso completed in 1977, but its conclusions had not been implemented by thewriting of this case study.1/

3.06 Another covenant, forseeing the lack of trained manpower, requiredthe borrower to employ 13 specialist advisors, 4 management consultants, and aresearch associate. The borrower had great difficulty in finding suitablecandidates for all of these positions, despite the fact the Bank spent con-siderable time assisting in the process. All but two or three of thesepositions had been filled by the fall of 1978. As stated earlier, a localfirm undertook the management study, with the periodic assistance from threeconsultants from South Asia. A consortium of a British firm and two localfirms were employed for building design and management/consultation, andanother consultant was employed for intermittent periods to advise the collec-tion and analysis of population statistics.

3.07 Through Headquarters personnel and the resident project populationspecialist, the Bank was closely involved in both procurement and the hiringof advisors and consultants. Because of the complexity of the project and thenumber of advisors and consultants involved, the Bank spent a large amount oftime reviewing prequalification, tendering procedures, terms of reference,procurement procedures and reimbursement requests. This was done meticulouslyand expeditiously.

3.08 Bank staff interviewed noted that the Government has been unenthusi-astic about employing foreign consultants-not only for this project, butgenerally-and that it did so reluctantly. This attitude could explain theborrower's difficulty and delay.in hiring the numerous consultants and advi-sors required in the project.

3.09 The potential problems posed by land acquisition were recognized atappraisal and the prompt selection and acquisition of sites was the subject ofone of the covenants. Nevertheless, it became apparent during implementationthat the acquisition of building sites was delaying the project in many loca-tions. According to one official interviewed the problem was due to thelengthy condemnation procedure that the Government undertook to obtain theland at the price it was willing to pay. Had the Government been willing

1/ Of the management study, the borrower comments that the two major recom-mendations have been Implemented, i.e., decentralization to districtlevel and a merger of the Directorate and the Division at Headquarters.As well, the National Institute of Population Research and Traininghas been set up for training officers at the middle and top levels inmanagement techniques. The borrower hopes, therefore, that with thesteps taken and those contemplated in the near future, that the manage-ment of the population program will improve considerably.

ANNEX 4Page 9

to pay the higher, market value, the land could have been obtained much moreexpeditiously. In the consultant's opinion, the problem in obtaining buildingsites was partly due to the Government changing the site location in nearlyone third of the cases. Despite the resulting delays in construction anddisbursement, the Bank took no action vis-a-vis land acquisition other thanmaking the borrower aware of the problem, apparently because it did not con-sider the building program seriously behind schedule. Government officials,for their part, also cited land acquisition as a serious problem, but statedthat they felt there was little the Bank could have done to expedite theprocess.

3.10 Despite the extent and detail of the covenants, the Bank was alsoflexible when the need arose to assist the borrower in implementing the pro-ject. For example, because of the difficulties in getting the civil worksstarted and completed, the Bank waived ICB and allowed the union councilsto carry out construction of the union health subcenters by force account,as they were doing for other construction.

3.11 For a project of the complexity of the Population Project, with itsmultiplicity of physical and program components, all being widely disbursedin a country with poor transportation and communication, it is extremelydifficult if not impossible for the Bank to be certain that Bank funds hadbeen used as agreed. In the final analysis it must rely on spot checkingand government controls.

3.12 There has been a general problem of the Government not providingthe Bank with audits of its projects in Bangladesh. The Population Projecthas been no exception. The Auditor Director-General's Office has the respon-sibility of carrying out these audits; but they are not done, they say,because of other pressing government work and lack of staff.

3.13 The first audit for fiscal 1976 was due in December 1976. Thiswas brought to the attention of the Government through a supervision missionfollow-up letter in November 1976. However, subsequent missions the follow-ing year noted that no audit had been received. Because all Bank projectswere not being audited, the Bank's Programs Department attempted to solvethe problem by general discussions with the Government. The Bank encouragedthe Government to employ private auditors to do the work, but to date theproblem remains unresolvedl/.

B. Implementation Assistance and Problem Solving

3.14 Considerable implementation assistance was provided by the Bankthrough the resident project officer and the large Bank supervision missions.

1/ The borrower confirms that the matter of audits is being pursued withthe Auditor General. It is opposed, however, to the appointment ofprivate auditors because it is believed they would only duplicate workand expenditures.

-54 - ANNEX 4Page 10

These inputs by the Bank, in the opinion of both Bank personnel and offi-cials in the government, contributed immeasurably to the implementation rateachieved under the project, even though this rate was less than anticipated.The close relationship that developed between the resident project officer andborrower officials was particularly useful in anticipating and solving prob-lems, such as getting the borrower to fulfill his reporting requirements (seepara. 2.13). The voluminous amount of correspondence that took place betweenthis officer and Headquarters also assured that the Bank was kept up to dateand could respond quickly to any problems that arose.

3.15 In addition to the problems over management, consultants, and landacquisition which were to some extent anticipated at appraisal and accom-modated in the Credit Agreement, there were also problems, unforseen atappraisal, which arose during implementation and had to be dealt with.

3.16 There were, for example, a series of difficulties over procurement.It is evident from the files that the Bank did get involved in many procure-ment issues throughout the project, but the Bank only began to note generalprocurement and disbursement problems in early 1978. Two special procurementand disbursement missions were sent to Bangladesh to look into this problemfor the Population as well as other projects, and some officials stated thatthis help with procurement was useful. Procurement and disbursement problemshave affected most projects in Bangladesh. One of the reasons is that underthe Population Project and a number of other projects in Bangladesh, it hasbeen necessary for all procurement to be made through the Supply Division ofthe Supply and Inspection Director, where all purchases of more than 10,000takas need to be made through tendering. Because of the complex procedures inthis agency, the tendering process could take up to six months or more. TheSupply Division contended that these delays were due to excessive work-loadand shortage of personnel. At one point, the Government suggested that theBank provide financing for more personnel, but this suggestion was apparentlyrejected.

3.17 Disbursements have been slow, partly because of the procurementproblems just noted and partly because the building program--which hingeson the acquisition of land--has been slow getting started. The Bank hadnot begun to consider disbursement delays as a serious problem at the writingof this case study.

3.18 The delay in hiring technical and managerial staff for the project(paras. 3.06-3.08) was exacerbated by the presidential limitation on thecreation of new posts, which prevented the appointment of personnel to themany posts established under the project. This problem came to the attentionof the first supervision mission, after which a memorandum was sent to theExecutive Director for Bangladesh in May 1975 requesting him to take up thematter with the Government. It is likely that this action was effected andeffective because the second appraisal mission noted that the presidentialrestriction on new government posts was lifted in July 1975.

ANNEX 4Page 11

3.19 There were problems, however, about which the Bank could do littleOne was the poor internal communication between the various levels of borrowerpersonnel. Another was the slowness in approving consultants, contractsor procurement. Because the resident project officer had not been given theresponsibility for approval, he was not only in a weak position in termsof oversight, but also had to rely more on communication with Headquarterswhich absorbed a great deal of supervision time (see para. 2.07).

C. Assistance with Institution-Building in the Country

3.20 The project itself was designed to expand and improve the populationplanning and implementation program of Bangladesh. The general awareness ofthe population problem was enhanced during the project identification andappraisal process when high level discussions were held by the Bank, theGovernment and potential donors. The existing Population Planning Division ofthe MOHPP was greatly expanded in terms of personnel and function. Throughthe project this division was renamed along with the MOHPP and was given, ineffect, ministerial status. In addition, population planning functions wereestablished in the five other participating ministries.

3.21 The project undertook to train nearly 4000 female family welfareworkers and five population planning officers, the latter who were to directthe population planning activities of the other ministries. Two groups ofthese officers have been trained, as some of the first appointees changed jobsor were promoted to higher responsibilities in their own ministry. In addi-tion, the large number of expatriate consultants provided informal training tomany who were involved in the project.

D. The Learning Process

3.22 The Second Population Project appraisal report had not been final-ized at this writing but it was likely on the basis of the Project IssuesPaper that at least two problems that occurred in the first project wouldbe corrected in the second. These were the lack of cooperation and coordina-tion between the two divisions in the ministry, and the need for greatercommunication among borrower personnel at various levels. The Second Projectwould very likely include a formal program of cooperation and support betweenthe divisions. On a smaller scale, communication among personnel in remoteareas was to be improved by provision of two-way radios.

3.23 Another lesson learned that should be reflected in the finalizedSecond Population Project is the need for simplification. One Bank staffmember thought that the project was too complex and thus too difficult tomanage to be effective. A simplier project focuse4 on one region or areawould be more manageable and effective, he thought.!Y

1/ The borrower's reaction to this view is firm: "The size of the country,spread of its population, and the urgency to solve the problem do notseem to justify an area-wise approach." Because of the seriousness ofthe population problem in Bangladesh, a simplest approach is ruled out."It is in recognition of this factor that a community-based, multisec-toral program was designed in the first instance."

ANNEX 4

- 56 - Page 12

IV. CONCLUSIONS

4.01 The level of supervision effort on this project has been tremendous.In a little over three years approximately 12 man-years have been devoted tothis project: 350 man-weeks of Bank supervision activities (by both missionsand the resident project officer who has spent almost all of his time onsupervision); 100 man-weeks by the various cofinanciers, and 150 man-weeks ofborrower-sponsored supervision activities.

4.02 There is little doubt that without this level of supervision,without the involvement of both resident and Headquarters staff of the Banktogether with a international group of cofinanciers, that there would not havebeen the level of population planning and control activities in Bangladeshthat there is today. The fact that the Bank was able to form and coordinate aproject with six cofinanciers has had a great impact on government populationpolicy. The size and frequency of supervision missions has kept the popula-tion issue continuously in the Government eye. The President of Bangladeshhas stated publicly that population is the country's number one problem.

4.03 Nevertheless, it is too soon to tell what impact, if any, theproject is having on the birth rate and population growth. No satisfactoryevaluation reports had been completed by October 1978.

4.04 Regarding the problems or delays of this project, two approacheshave been suggested as possibilities for improving its supervision: assigninggreater authority to the resident officer for approving tendering procedures,contracts, consultants and disbursements and employing a local citizen toassist the resident officer. Both of these suggestions have merit.

4.05 The Bank spent considetable time selecting the resident projectofficer, who was an individual with appropriate regional experience as well astechnical training. He had also participated in two supervision missionsbefore he was appointed. Thus with a little formal instruction in Bankprocedures and some support from other members of 'the resident mission, itshould have been possible to delegate more authority to him (even if theGovernment did not make such a request), with the result that much of thevoluminous correspondence would have been eliminated (para. 2.07) accompaniedby a considerable saving in staff, turnaround and execution time.1,

4.06 Whether a local assistant or counterpart to the resident officerwould have improved performance is debatable (para. 2.11). Although theofficer appointed was from a similar cultural background and has had a goodrapport with project authorities, an assistant with.experience in the ways and

operation of the Government could have been of considerable assistance ingetting things done.

I/ The borrower supports the proposition that greater responsibilityshould be delegated to the Resident Mission for supervision of theproject.

ANNEX 4- 57 - Page 13

4.07 Given the number of advisors and conaultants that were employedunder the project and that there was a resident officer, it is doubtful thatthe Headquarters missions needed to be so frequent and as heavily staffed.Nevertheless, as mentioned earlier, large frequent missions may have done anextra service in keeping the population issue in the forefront of Governmentattention.

俗‘ 喝

&k

·常 慫久么

瞬

59 SUPPLEMENT 1Page 1

Goverment of the People's Republic of BangladeshMinistry of Health and family Planning

family Planning VIM

No* Peo-i/044$85/ 3rd Juset 1986.

Subject t Project Performance Au&t to '--ort: langla&shfirst) Popp1jtion J!mJeO---(CI&!Ut 511=12I.

With teference, to World Bank, Wasbingto I letter dt* 14th

March,, 1986 on the above subject, I am directed to enclose herevith 1&-^

J Jtj -ED-eq -- -.- -aclit Report on the First Population Project - 533

for necusi-&447 action

Assistant Chief

Mro Faroque AhmedProarame OfficerVorld.*Bank local officeDhaka:-

60- . - SUiPLEETlPage 2

MSJe.t i Project Perfomanen adit asport- gasthe Uanglades Fixst pplation

Proleet ftredit fSm80

me OM has pointed øut that the pre"ant polulaties growing

at the rate of about *s% anmally, bat ln the mitroductory Para

. o' Poje t Perfornanc dit M rm the preMent ftpnlaticæ

Footnoted In Onwth rate stated to hav bM 2.6% anuall¥. Ihe Panning Cal-

key indiestorsssto* o£ the vt. of the People's Uepublic o£ Ungladesh on the

basis of natiohal census, intermensal reprt, PB surveys and rele.

vant studies have determined ln mid-1983, the population growth'

rate to b* 2.4% anually.

»e disrepancy rqire to b* re~onciled.

2. Prolect ebleetives

3. Prol eat. 3nlemnt atiå ida

løgardiag delay Ln dibursenent lt is stated that due to nonøn

sussen of eoxpediture statement alongwith bills/vouchers* In

Refer toPPK paras. ti, by the concerned impleenting agenies responsible fofir nur.

28 and 31 zing expunditur. and sendihg expnditure stat~ent to the Project.not

Pianuce Cø11, the redit could/be timely claled and disbursed

withi the original closing date o£ the Pir*t Population Projeat'.

lt is arther stated that the Project Pinance Cell is net

encarned with the delay ln start-iqp project activities dae to non-

ffit3et er delay Jn *lfiing the condigtons of the Credit

'*r ffc.tveness as pointed out ln t*e report.

4Pæoeæt ad Prorase r esuits

(a) a regardø soft-ware cosponents Ét is stated that part

o£ the sot0are o Npo nts w~leh were Inplefated earli

.. e.during the projOeat peri,,, vers effective as ';,caus

the. were Incorporated into the follo~.ap phases Of the

Pepalation Project.

*61- SUPPLD=ET 1Page 3

(b) 2he cause of substantial decrease in aterlisationowing to anctinal integration ifpoint that cannetbe agreed to. This needs In-depth Investigation.

Comment aserted B00 is looking Into all facters associated withIategration. 1he report may not identify integrationas the cause of decline and fall in performance.

5. As regards the trabifer of re-current cAst to Reve"oe

Bdget after 1990 the 00 delegation stated that the (bt.

Footnoted would be in a position to tae a decision in this matter

In PPAM after the study on heatth sector ad the projection of

resources during the Third Fiv Year Plan Period and beyond.

The OCS will absorb the recurrent cost of essential items

after 1990 to the extent possible,

6. 2MIL

As regards the maintenance of accounts, accounting

practice and procedure the OD itsion did not make W comment

-62-SUPPLENr1Page 4

Agriculture & Forests Division"OPULATION EDUCATION PROJECT I tGDio/ 9

Nemoo.Dats&~. a

National Project Director&

Deputy Secretary -1.. 4*

Ministry of Agriculture.

To a Mr. Parauve AbmedProgranae OfficerThe World Bank ResidentMission in Bangladesh,

. hakca.

Ieur 1'--# Abmed.#

Kindly refer to your letter dated 14-5-86 inviting comnents on

the draft " Project Performance Audit Report of Bangladesh Pirst Population

Project (Credit 533-BD) V We take this oppertunity to point out that the

Project Components under the Ministry of Agriculture the Annex - I, page

4 of 5 have perhaps been shown due to oversight which in fact should be as

under S-

While the I) To support the National Population Policy of the Government.appraisal reportdoes not describe II) To inform and educate farmers in understanding Populationthe component as Problem in proper perspective and its resultant advenee effeolelaborate,there was an error on food. production and standard of living.in Annex 1 thathas been corrected. III) To create avareness in the minds of the farmers the necessity

and urgency of adopting family planning practices to make thei

continuous users.

0onti-PAsL2POPULATION EDUCATION FOR AGRICULTURAL ExtENSION

WORNERS AND MOTIVATION OF FARMERSRear BuildIng 4th Floor, Khamarbarl, Farm Gate Doka, Banlade.

- 63 -

SUPPLEMENT 1Page 50

ZMEWZSW"W O J.GELZOE.WUaAgriculture & Forests Division

POPULATION EDUCATION PROJECT (8GD/80/P0I)

Item 3.23 in page 19 =nder ProJect CoUpletion Repor relates

to achievemets of project objectives onceimIng the Ministry of AgrioultuM.

We generally aree with the evaluation made under this project.

Thanking you.

National P ot at i

Deputy Secretazy(Admi 'Ministry of Apicultre.

POPULATION EDUCATION FOR AGRICULTURAL EXTENSIONW3RKERS AND MOTIVAVION OF FARMERS

Rear Building 4th Floor, Khamarbarl, Farm Gates Dhake, Bangladesh.

- 64 - SUPPLEMENT 1Page 6

TLX MSO NDtkI'b85 010tJ1NE 2 3JY986

INTNAFRADWASHINGU0IN

FOR M.OT1O MAIS ACTINO I'IRECTORs OED FROM ABDU. JAILKHAM(o,)REF ERD'$ TELEX NESSAOF DATED0 JUNF 7 ON PRO,JECITPERFORMANCE AUDIT REPORT ON RANO.ADESH IRSr POPtIATiONPROJECT()0080 VIEWS ON THIS ARE FURNXISHED HEL.OWt(1) ON PASI DATA SHEF1t IT NFF.8US I0 NE PROwFD WHY Bxplained

INSTITUTIONAL PERFORMANCE IS " MIXED" AND N01'' 0000"o throughoutmain report

(IT) (N VVAIUIATION SUMMARY:TH PRESEN1 kA*F OF OROWTH OF POPUIATIONQ48 ) Footnoted inDOES NOT FALL.Y WITH OUR ESHXAfE OF 2.4 AT )HE keyEND OF FY 85 (OVkNMN' NORANDUM FOR AID GROUP)(t) indicatorsAT PAGES I AND 4 OF THIS RFPORT THIS RATE HAS REFNSHOWN AS 246 ()

(II IE REPORI HAS RIONTLY OPSSRVED "MORE DELEGATIONOF AUTHORITY TO THE FI..D COUt.D HAVF S1STAN(YAI.LYFAC1IITATF0 PkOJEV1 ADMINISTRATION AND SIPERVISION(g)"( P,XV) AT PARA 53 OF THE REPORY 1f 6AYS'' XNSU1JF(1NT

DEIEATION OF AIIIHORITY WAS PROVIDED "10 IHE RESIIFNTOf;IE -TO HANDLE DAY TO DAY OPERAIXONAL DEXSX0NS(*)

VAI OF CONSIKI.IANI APP0jNT1HEN1Sr (;ONT1AC-S ANDMATTFRS RELA(ED TO PRO(UREENT HAD *0 8. REFERREDTO HEAD QUARTFkS(4) fHX8 VA1SD )JEI.AYS AND A 1RFMEN)11SANINT OF CORRC6PONDENCE HCTWEEN THE ft:SXDENT OFFX;EAND HFA)1VUAk1FRS "1 PP04-AN) ( ) IS HOPED THAT IDA HOSM0tUiD TAKE NOTE OF THIS (OMMENy Nor ONLY fOR THIS PROJ,TBUT FOR T1WHER PKIJECTS Ai WFL.(.4)

(IV) PN IMPORTANT COMMENT IN THE REPORT SAYSIXV MI0HT WELLB. THAT C(0tN1kY WIDE OVER-CAPACITY IN INA)NING FACH1Y'1IFS

IS BEIN CREATED THIS MAY &. A TRAININO IONSt910:11ONMORATORIUM "JOHI BE CONSIDERED UNTILI MOkF DkIAXI.E11

if HYt I1O THIS HAVE IIEEN OBTAINED '(PP XV-XVI) (1) THISEHERIUS FXAMINA TION BY ALL THOSF WHO ARE GONNFCT*-

(TH CONSTRUCION OF INFRASVRU1CtURE FACILITIES FOR VARIOUSTYPES (iF TkANIN4 PROGRAMMES UNDER DIFFERENT AIDED PROJECTS.

(V) CHAPTER-Ilt PROJECT ENVIROKMFNT Para. eTHk COMMFNT THAI "THE FFFF(TS OF 0130-ECONOMIC DEVELOPEN1 ia rela-ON THE .OWES* INCOME OROUP MAY RAISE THEIR FERTILIY" NEEDS iselaFURTHR PkONYNP (P-5)(i) tively

clearand sources have been footnoted.

- 65 - SUPPLEMENT 1Page 7

(VY)CHAPTFR-IV ISHUkSt THE COMMENT THAT THE LINKAOE OF THE WOMEN'S

COMPONFNI WITH See para.THE POPUtAlION PROURAMMEP WHERE THE MAIN PSJFCTIVE IS TO 18

IMPROVE THE ECONOMIC STATUS OF WOMEN9 IS OPEN TO QUESTIONsIS ITSFtF RUESTIONALBLE( 4 )

(VII) PROJECT AND PROGRAMME RESULTS%(A) AS REGARDS SOFI-WARE COMPONENTS IT IS STATED INAT PARIOF rHE 6OFT- WARE COMPONENTS WHICH WERE IMPLEMENTCD EARLIERI*.DURINO THE PROJhCT PERIODs WERE EFFFCTIVE AS THESEWERE INCORPORATED INTO THE FOLLOW-UP PHASES OF THEPOPULATION PROJECT(i)

(B) THE CAUSE OF SUBSIANTIAl D*CREASE IN STERILIZATION 0WIN6 10FUNCTIONAL INTEORATION IS A POINT THAT CANNOT BF AUREE0 T04.)THIS NFFDS IN-Df*PTH 3NW*STIBATION AND 008 IS LOOKING INTO INF Dis-OUESTION(,) THEERE [S NO UNIQUE AND DETERMINATE CAUSAL agree-REtATIONSHIP lKETWEEN ADMINSTRATIVE REORGANIZATION AND mentCl.IMIELES PREFERENCE FOR ONE OR ANOriR METHORO OF FERIXL(TY notedCONTROt(.)

(VIII) AS REGARDS THE TRANSFER OF RECURRENT COST TO REYFNU.BUDGCT AFTER 1990 THE 008 DEL.E0ArlON WHILE NEOOTIATING

THIRD POPULATION AND FAMILY HEALTH PROJECT SIATED THATTHE GOVT WOULDOE IN A POSITION TO TAKE A DECISION IN THIS FootnotedMATIER AFTER THE STUDY OF HEALTH SECTOR AND THE PROJECTIONOV RESOURCES DURING THE THIRD FIVE YEAR PLAN PERIOD ANDAND HEYON() lH SIZE OF THE PERSONNEL9 ITEMS OF THEEXPENXFTURE7 UNIT RATES ETC, WERE DETERMINED FROM TIMEAT THE INSIANCF OF DONORS ON 1HE UNDFRSTANDIN THAT PROORAME

WOUtD CONTINUE T0 RECEIVE SUPPORT FROM DONORS(t) WHtLEGOB WOU.1D LIKE 1O PROVIDE RESOURCES FOR THIS HIbN PRIORITYPROXRAMMEP IT WOULD DONOR SUPPORT FOR IT.

SETO DHAKAPLS CORRECT) ON IAST LINE PRIPRl*lY PROAMME9

244423 WOR.B9ANK642226 SETU BJMMMM

=0623O942

一 乙 る ー

1 で』 ノ停介 多み v/&

- 67 -COMMS FROM COPINANCIERS SUPPLEMENT 2

Page 1

AUSTRALIAN *-*-IOEVELORMENT

6 P 0 Box $07

ASSISTANCE = 013. 619111

,=*SWWT Of VAM

BUREAUDEPARTMENT OF FOREIGN AFFAIRS

ACTION OFFICERREFERENCE 84/0729

22 May 1986

Mr Yukinori WatanabeDirectorOperations Evaluation DepartmentThe World Bank1818 H Street, NWWASHINGTON, DC 20433USA

Dear Mr Watanabe

RE: PROJECT PERFORMANCE AUDIT REPORTtBANGLADESH (FIRST) POPULATION PROJECT (CREDIT 533-BD)

Thank you for your letter to Dr Dun of 14 March andthe opportunity for ADAB to comment on the draft ProjectPerformance Audit Report for the above project. In relation tothis particular report, however, ADAB does not wish to make anyspecific comments.

As you are aware, ADAB is continuing to support thisproject into its third phase.In the earlier phases, the Australiancontribution was a financial one to the World Bank to assistthe full range of activities covered by the projects. Some ofthe comments in the draft audit report concern relations betweenthe World Bank and those of its bilateral partners who unlikeAustralia chose to operate discrete components under the generalcoordination of the Bank. We are not in a position to commenton these arrangements.

We believe, of course, that lessons learned from theearly phases of the project as identified in the Report shouldbe taken into account in the implementation of the current thirdphase. For example, such issues as problems of long-term sustain-ability and the need for a more focussed approach, should bepursued to enable the effective implementation of the project'snew phase. We have already indicated to you that we would wishour contribution to the third phase to be associated with specificcomponents of the project. We will monitor these components ingreater detail and this will enable us to comment more easilyin future on specific aspects of the project.

THE OVERSEAS AID UNIT OF THE DEPARTMENT OF FOREIGN AFFAIRS

-68- SUPPLENENT 2Page 2

We look forward to receiving a copy of the final reportwhen it becomes available.

Yours sincerely

Helen WareActing Deputy Director General

Country Programs Branch

- 69 -Brfts Nigh ConmisionAbu rdw NousnPlot 7 Road 64 Guim Ohake SUPPLEMENT 2Postal Address: PO Box 60?9 Gulshmn Dhaka 12 Page 3

Telephone 600tS33*7e 2 ay18

Mr Paruque Ahmed Your retm

222 New Eskaton Road ourrofuromG20 BOX 97Dhaka au 29 May 1986

AUDIT REPORT OF FIRST POPULATIO'N PROJECT

Thank you for sending me a copy of this interesting report.I have had time to look in detail only at the summary; but thisis sufficient itself to raise several important questions fordonors to the current Family Planning Project. I noted the following:

a. The evaluators consider it clear that the GOB will not beable to absorb the programme costs by the end of the ThirdPo4lation Project. Ithink this comes es no surprise h ofus; and we all attempt to see the Family iianning Programme in along-term perspective which implies a long-term committment.Nonetheless, it is vital that the GOB demonstratd its committmentto its declared family planning goals; and the most tangiblecommittment one can think of is a budgetary one. Provision inthe current five year plan is practically the same as that inprevious periods for family planning: -which is to say, risible,given the scale of the problem. Donors should insist that theGovernment make adequate provision to take on a greater shareof the cost by the end of the third project.

b. Donors have now committed themselves to the agreed projectdesign and will thus make every effort to make the Third PopulationProject successful. Nonetheless, it is difficult not to agreewith the Auditor's comments on the dangers of too complex a projectdesign, on the risk that too ambitious an integrated project ofthis sort will fail to achieve its objectives, and on the needfor a scaled approach to development of the project facilities.

I hope .-.. e : are of some use.

JHS DFirs Secre (Aid)

c.c. Mr Wickstead ODA (references are to ank ProjectPerformance Audit Report on First Population Project: credit5'.x, - BD)

-.y!>

- 71 -

PROJECT COMPLETION REPORTBANGLADESH POPULATION I PROJECT

Credit 533-BD

September, 1984

Population, Health and Nutrition Department(Revised October 1985)

M

s

- 73 -

I. PROJECT FORMULATION

A. Context of Project Formulation

1.01 Bangladesh is one of the least economically developed countriesin the world. In 1974, when the Project was appraised, per capita incomewas estimated to be about US $ 72 per year. The literacy rate was about23%. Unemployment was high and persistent at over one-fourth of the totallabor force. As of January 1973, the Planning Commission estimated a totalpopulation of 74 million and a natural rate of increase of 3% per annumresulting from a crude birth rate of 47 per thousand and a death rate of 17per thousand. Accounting for a small net emigration, the growth ofpopulation was estimated to be about 2.9%. The low standard of living hadled to wide spread malnutrition and low life expectancy, estimated at lessthan 47 years. The infant-mortality was high, about 16% of all live bornchildren, according to one estimate in early sixties, died within theirfirst year.

1.02 The Population growth had a serious effect on the development.The rate of growth of population was estimated to have exceeded the rateof growth of GDP during the period 1940 - 1960. During the sixties, thoughthe GDP was reported to have increased at twice the rate of the previousdecade, more than 70% of the increase was offset by an acceleration in therate of population growth. About 90% of the population was rural with 80%engaged in agriculture. The main natural resource was agricultural land,of which the average farm family had only 0.45 acres for each of itsmembers, an extremely low ratio. Continued high rates of population growthat prevailing levels, it was estimated, would result in a doubling ofpopulation in about 23 years. With no significant amount of additionalland available for cultivation, the prospects for a pesantry already at themargin of subsistence were grim.

Family Planning Activities

1.03 The Family Planning (FP) program in Bangladesh (then EastPakistan) had evolved through several phases. Early attempts by a group ofvolunteers to arouse interest and concern over rapid growth of thepopulation led to formulation of a voluntary FP association in 1952. TheAssociation provided FP services and education through private clinics andvoluntary activities. The Government support for FP came very slowly; anation-wide government program was started in 1960 under the Ministry ofhealth as part of health services but it made little headway. The programwas predominantly clinic-oriented, with no outreach activity. A revisedand more comprehensive program was launched in 1965; after a reorganizationthat took the program out of the Ministry of Health and established it asan independent, single-purpose program with its own staff and facilities.FP boards were formed at the national, district and thana levels. Threeother supporting organizations were formed -- Directorate of Training,Research, Evaluation and Communication (called TREC), InspectionDirectorate (responsible for supervision) and Postpartum Directorate.

- 74 -

1.04 The main feature of this program was its extensive reliance onsubstantial incentive payments to both personnel involved in administeringthe program and acceptors. Doctors and Lady FP visit-rs played animportant role in sterilization and IUD insertion, respectively. Theprogram increased the number of acceptors but the demographic impact wasnegligible. In 1975, the contraceptive prevalence of modern methods wasestimated to be only 4.7%. However, about 80% of the people became awareof FP methods and services. The program also demonstrated the utility ofthe field support staff and the efficacy of paramedical FP staff.

1.05 Several improvements in the program -- introducing oralcontraceptives, strengthening the post-partum program and launching a pilotproject of couple registration for systematic motivation -- were planned in1970. However, the liberation war which resulted in the creation ofBangladesh in December 1971 severely disrupted the FP program.

1.06 Subsequently the FP Board (renamed the National Family PlanningBoard) along with the three supporting directorates was placed under theMinistry of Health, which was renamed as the Ministry of Health and FamilyPlanning. By 1973, 426 specialised FP clinics were functioning asautonomous units. A total of 2,586 full time personnel including 52medical officers, 547 Lady FP Visitors, 418 FP officers, and 1254 fieldassistants were employed in the program. In addition about 6,000 part-timefield workers served as village organizers; about two-thirds were women,mostly traditional mid-wives. The Non-Governmental Organizations (NGOs)also became active. However, the level of FP activities had beendrastically reduced since the war due to abolition of incentives, lack ofclear program policy and weak organisational infrastructure.

1.07 The IDA-aided project was, therefore, formulated under conditionsof uncertainty prevailing in 1973 in environment and program policy.Although there was a general agreement that reducing population growth wascritical for economic development, the extent of religious support orresistance to the population program was not certain. There was alsodivergent points of view about the nature of the future populationprogram. Among the donors, some preferred a v6rtical FP program, some feltthat a narrow vertical approach to FP program would not suffice and that abroad sectoral program would be needed, and a few felt that emphasis shouldbe placed on MCH activities and other developmental aspects in preferenceto FP activities.

B. Process of Project Formulation

1.08 The First Five Year Plan (1973 - 78) of Bangladesh drawn up bythe Planning Commission set the target of reducing Population growth ratefrom an estimated 3% in 1973 to 2.8% by 1978. It was envisaged that at theend of the plan period the crude birth and death rates would decline to 43and 15 from the present level of 47 and 17 per thousand population,respectively. The long term goal was to reduce the net reproduction rateto one in the next 25 to 30 years in order to achieve zero populationgrowth in the next century. The Plan recognized the seriousness of thepopulation problem by stating that no civilised measure would be toodrastic to keep the population of Bangladesh on the smaller side of 150million for sheer ecological viability of the nation.

- 75 -

1.09 The Plan proposed that the delivery of FP services should beintegrated with the health services under the Ministry of Health. A homevisiting scheme should be launched employing about 12,000 teams of a maleand female worker. A rural center and 3 subcentres 3hould be establishedin each thana for the delivery of health and FP services. Variousministries, such as the Ministries of Local Government, Rural Development,and Cooperatives, Agriculture, Education, Labor and Social Welfare, andInformation and Broadcasting, should be involved in educational andmotivational efforts. The Plan also stated that all voluntaryorganizations involved in PP should be given adequate encouragement andsupport and that the Government should consider instituting a strongdisincentive after the second child, legalizing abortion, and undertakingsocial measures for the emancipation of women.

1.10 For implementation of the above policies the Plan proposed thatthe Ministry of Health and FP should play an important role in the deliveryof services, that other relevant ministries should develop requiredcapability for education and motivational efforts, and thatinter-ministerial coordination committees should be set up at all levels-- national, district and thana. Furthermore, a high-level NationalPopulation Council consisting of heads of relevant ministries and otherpublic leaders chaired by the Prime Minister, was to be set up to formulatepopulation policy and direct population activities.

1.11 The World Bank which was a major donor and the coordinator of theBangladesh Consortium for economic aid, was invited by the PlanningCommission in October 1972 to assist in formulaLion of the plan forpopulation activities in the First Plan and a population project. Inresponse to this invitation, and IDA mission visited Bangladesh in May 1973for identification and sector review-cum-appraisal. During thesediscussions, the outline of a project emerged consisting of broad basedpopulation activities, closer relationship between FP and health,multi-sectoral activities on a pilot basis and development of manpower. AnIDA appraisal mission visited Bangladesh in November 1973.

1.12 It was generally agreed among donors and the Government thatexternal assistance needed effective coordination. Therefore, as a firststep, a Bank staff member had participated in UNFPA mission in 1973.

However, differences of opinion arose among the Bank, UNFPA, and USAID, themajor donors in the population field. The Bank's relationship with UNFPAbecame sensitive on the issue of who should play the leadership role.Differences also arose with USAID on the issue of the organization of the

FP program. USAID favoured a separate organization for the program whilethe Bank favoured a program having close relationship with the healthsystem. This strained the relationship at headquarter level for some time,but the in-country relationship remained cordial and active. Consequently,the Government coordinated the efforts of UNFPA, USAID, and the Bank.

1.13 While the IDA-assisted project was being appraised, theGovernment signed an agreement with UNFPA'for a 3-year project of US $10million. USAID provided US $6.5 million during 1972 - 1973 for manpowerretraining, medical equipment, and contraceptive supplies. USAID was also

- 76 -

expected to make available another US $ 8-10 million during the period 1974- 77. In addition, several other donors such as the Ford Foundat:on andthe Pathfinder fund were active.

1.14 Five donors - Overseas Development Administration (ODA) of theUK, Norwegian Agency for International Development (NORAD), CanadianInternational Development Agency (CIDA), Swedish International DevelopmentAuthority (SIDA), and KEW Germany -- were contacted by the Bank and theGovernment and expressed interest in participating in the project.Meanwhile, because of rapid price increases within Bangladesh, the cost ofthe project increased to an estimated US $ 45 million from about US $ 20million when prepared. However, it was felt that the physical size of theproject as prepared was necessary for impact on the population problem andshould not be reduced. The donors co-sponsoring the project with IDA hadmajor reservations on three issues -- Government commitment to thepopulation program; organizational structure to implement the program andthe cost of facilities. Two rounds of visits were made by the Bank staffto various capitals in Europe to discuss these issues during the period1973-1974.

1.15 Several concerns were expressed by various departments in theBank during the project preparation. The project duration was planned tobe four years but it felt that the project might take about seven years toimplement given that several preparatory activities such as site selectionand building design for the facilities were needed and that the capabilityfor project -- implementation was weak. It was also felt that buildingswere costly, the project had too many components and too many pilot schemeswere included.

1.16 During this period (1973 - 74) the Government made severalorganizational changes. In October 1974 it decided to establish thePopulation Planning Division (later called Population Control and FPDivision PCFPD) in the Ministry of Health and Population Planning (MDHPP)as a separate division with a full-time secretary as its head. Thisdivision was to be responsible for coordinating and monitoring thepopulation programs of different ministries and agencies as well asproviding technical support to these agencies. The staff of the NationalFamily Planning Board and the supporting directorates were transferred tothis division. In December 1974, the Government constituted a CentralCoordination Committee on Population Activities comprised of secretaries ofinvolved ministries with the Minister of Health and Population Planning asChairman and the Secretary of the Population Planning Division as Secretaryof the Committee.

1.17 Several issues, however, remained unresolved. The donors haddoubts as to whether the Population Planning Division would be able tocoordinate population activities of the other ministries. Several otherdetails such as sites and drawings for facilities, terms of reference forthe study of national laws, and appropriate organizational structure of thePopulation Planning Division needed to be worked out. Rather than delaythe project, these were included as conditions of credit effectiveness.

- 77 -

1.18 The project was presented to and approved by the Board inFebruary 1975 The project documents acknowledged the risks associated withthe project, both in terms of its implementation and impact. The creditwas signed on March 10, 1975, about two years after the first mission hadvisited Bangladesh. The arrangements for funding with all the other donorswere completed only by December 1975.

II. PROJECT CONTENT

Project Objective

2.01 The project was designed to assist the development of acomprehensive national fertility control program. Expansion of facilitiesand staff were planned under the project to serve the existing demand forFP services and a wide range of information, education and motivationactivities were planned to create additional demand for such services. Inall, six ministries were involved in the project. Specific demographicobjectives were not set for lack of adequate data. Nevertheless it wasestimated that project would directly avert about 1.3 million births.

Project Components

2.02 The project had six major components -- technical assistance tostrengthen program organization; facilities; staff; information; educationand motivation activities through multi-sectoral pilot programs andman-media; support for research and evaluation; and support to NGOs andinnovative activities. The details of these components are as follows:

(a) Technical assistance and general support for strengthening thepopulation program organization:

i) Obtaining the services of a management firm to assist theMinistry of Health and Population Planning in improvingits internal organization;

ii) Conducting a national seminar on population problem forpolitical leaders; and

iii) Conducting studies on building utilization.

(b) Constructing, furnishing, equipping and supporting the followingtraining and service-cum-training facilities for the Ministry ofHealth and Population Planning:

i) One nursing college in Dhaka to graduate 60 tutorsannually to train nurses and public health nursing staff;

ii) Eight Family Welfare Visitor training schools, each totrain 60 students annually;

- 78 -

iii) Eight new Thana Health Complexes with (a) a 25-bedmaternity ward unit, (b) dormitories for 25 trainees, (c)an outpatient clinic and (d) staff housing to serve asrural field training centres for medical and paramedicalpersonnel in health and family planning services;

iv) Twenty-four union health subcentres with dormitorycapacity for two trainees for union-level field training(three per health complex described above); and

v) Four model clinics in medical colleges for familyplanning training of medical students, and the retrainingof 50 medical students annually.

(c) Training and subsequent employment for four years for 3,700female family welfare workers as members of male/femalehome-visiting teams in rural areas.

(d) Provision of audiovisual equipment, vehicles and operating costsfor three years for the establishment and support of nineeducation/motivation pilot schemes in 61 thanas and generalprogram support to the designated ministries as follows:

Ministry of Local Government, Rural Development and Cooperatives:

i) A pilot scheme for the use of model farmers and cooperativemanagers as change agents for family planning; and

ii) A pilot scheme for the rural womens functional literacy programas a means of acceptance of family planning.

Ministry of Labor and Social Welfare:

i) A pilot scheme for the formation of rural mothers' clubs forfamily planning motivation;

ii) A pilot scheme for the women's vocationaltraining programs as a means of acceptance offamily planning; and

iii) A pilot scheme for the family planning programfor organized labor.

Ministry of Agriculture:

i) A pilot scheme for the use of agriculturalassistants for population education.

Ministry of Education:

- 79 -

i) A pilot scheme for the use of a mobilepopulation education team to hold seminars onpopulation problems for school teachers toobtain their support in influencing thecommunity;

ii) Curriculum development and teacher trainingfor the introduction of population educationin the primary and secondary school curricula;and

iii) A national seminar on population education.

Ministey of Information and Broadcasting:

i) A pilot scheme for the use of audiovisual vansfor family planning films;

ii) Establishing a Population Program Cell forRadio Bangladesh;

iii) Expansion of the film producing capacity ofthe Department of Films for producing familyplanning films;

iv) Setting up a Population Feature WritingBureau; and

v) Training the public relations officers inpopulation problems.

Ministry of Health and Population Planning:

i) A pilot scheme for the use of family planningmotivation kits by family welfare workers.

(e) Salary support, operating costs, support forinstitutions capable of conducting researchstudies and evaluation:

i) The establishment of an Evaluation Unit at theHealth and Population Planning Section of thePlanning Commission for program evaluation;

ii) Special evaluation studies of the pilot schemesto be conducted by the PPD through the concernedministries;

iii) A study on the determinants of reproductivebehavior by the Bangladesh Institute ofDevelopment Studies; and

- 80 -

iv) A study of national laws to assess theirpronatality impact to be conducted by PopulationPlanning Division through a special committee.

(f) Support to the Population Planning Division to assist theprivate sector in family planning activities and for thedevelopment of innovative activities in the public sectorduring the life of the project.

2.03 Organizational Arrangements. The Project relied primarily onexisting agencies for implementation and provided assistance forstrengthening them appropriately. PCFPD if the MDHPP was responsible foroverall implementation and coordination. As the functions andresponsibilities of PCFPD and its relationship with the health divisionwere not clear, a comprehensive management study of MDHPP was planned and areview of the organizational arrangements was scheduled one year after thecredit-effectiveness. As PCFPD did not have the capability forimplementing large scale construction r*ojects, a new small full-timetechnical group -- Building Planning and Design Unit (BPDU) -- was to beset up to coordinate all construction activities. The technical assistanceto BPDU at Bank insistence was to be provided by consultants. For purposesof centralizing project-financial responsibility, a Project-Finance Cell,headed by a Project-Finance Officer on loan from the Ministry of Finance,was established in PCFPD. The implementation of all new schemes was theresponsibility of the concerned ministries who were to appoint populationProgram Officers (PPDs) for this purpose. An External Evaluation Unit(EEU) in the Population Planning section of the Planning Commission was tobe responsible for external evaluation of the project-components. ThePopulation Planning Section was to form advisory groups for IEC and forresearch and evaluation. To strengthen the Population progr2m, setting upof the national Population Council envisaged in the First Five Year Planwas a condition of credit-effectiveness. A seminar of political leaderswas also planned to strengthen political commitment to the populationprogram.

Cost at Appraisal

2.04 At appraisal the total project cost, including contingencies, wasestimated at US $ 45.7 million equivalent (Table - '). The foreignexchange component was about 53% and Construction accounted for about 50%of costs. As there were large uncertainties in likely price escalation,contingencies including physical were estimated at 38% of the total projectcosts.

Project Financing

2.05 The project was financed by seven donors and the Government of

Bangladesh (table - 2 shows the breakdown). The percentage share of total

- 81 -

project cosLs was as follows -- Australia 5.7%, CIDA 4.4%, IDA 32.7%, KFW13.1%, NORAD 18.3%, ODM 6.9%, SIDA and GOB 18.9%. The type of financingarrangements also varied. IDA and Australia had joint financing, SIDA andGOB had joint financing and all other donors had parallel financing forspecified components (Annex - 1).

Changes in Project Content

2.06 The Project costs at appraisal were more than double theestimated costs when the project was first prepared because of priceincreases in Bangladesh. However, by June 1975, the Taka was devalued. Asaving of about US $ 17.3 million was estimated to have resulted by 1980due to price increases being less than estimated, changes in the Takaconversion rate and changes in currency values of other donors as comparedto US dollar. In 1978, this estimated decrease in costs was reallocatedfor the following: retraining of fie'd workers, extension of salarysupport to 8000 Family Welfare Assistants, transport for field workers,construction of 80 Ur.ion Family Welfare Centres, support to NationalInstitute of Population Research and Training, support to NGOs and purchaseof films (Annex 2). The support to existing schemes was extended by twoyears to June 1980.

- 82 -

Table - 1

Project Cost

US $ (in thousands)

Category Local Foreign Total % of totalbase cost

Program Orgaaization 148 130 278 1.0Rural Health/FP Services 2,717 - 2,717 9.6Training Health/FP Manpower 6,996 10,897 17,893 62.9Ministry of:

Local Government, RuralDevelopment and Cooperation 688 899 1,587 5.6

Labour & Social WelfareActivities 977 330 1,302 4.6

Agriculture 68 58 126 0.5

Education 400 70 470 1.6

Information & Broadcasting 677 1,216 1,893 6.6

Health & Population Planning - 57 57 0.2

Support to Private Sector/Innovative Activities 350 - 350 1.2

Research 223 228 451 1.6

Evaluation 1,011 304 1,315 4.6

Contingencies 7,410 9,855 17,265 -

TOTAL 21,660 24,044 45,704 100.00

- 83 -

Tab, 2.Imry.aiah Ptpulation Ilro>et: Appra~s Finanirg Plan

(d$ 00n)

Federa1 B. ard oBcIma/ Republicof ~@Aif a/ Astralia &nd btal

~ 0eren?Ï/ - ~~SIDA

I. Ostructio Cænpanp~Nuraing College 1,091 700 1,791Ydel Family Plannig Clincs 1,132 725 1,857FWlV Trainim Schools 8,342 1,192 9,5341%na tiealth C~plexs 1,944 8,293 5,315 15,552Union Bealth Subenters 248 1,666 1,067 2,981

Subtotal - 1 248 8,342 3,136 12 , 182 e/ 7 ,8 07f/ 31,715

11. NM-COstruction OmpnentsPPS of the PanMng c=assio 604 604Nenistry of L Gover~ent, Rural

Developent and Corstives 1,747 91 1,838snistry of Labor and Socal welare 1,6" 1,6æ

Mnistry of Agriculture 160 160inistry of Fuction 589 589nistry of Infortio and Brodcting 2,316 2,Y6

Ministry of ealth and Popilation PlanimngPopulatim Planning Division 534 534Mel ClinP 636 636Training Se 1s 320 320

~hana Bealth plex 405 405Family Welfare Workers 3,320 3,320Uae of >ltivation Kits 70 70Service Statistics System 359 359Study of Building UtlJization 220 220Internal Evaluatio 87 87

Subtotal for 0lPP 4,376 1,575 5,951

Bangadesh Institute of Developent Studies 475 475Support to Private Sector and IU ative Activities 387 387

Subtotal - II 1,747 5,985 5,417 840 13,989

Total 1,993 5,95 8,342 3,136 17,599 8,647 45,704Per~et of Total 4.4 13.1 18.3 6.9 3B.5 18.9 100.0

'/ CID's contributio of CS2.0 a111im will cover ftnanci% of 2 pilot sdhn under tle linistry of ocal Gomernmnt,~ ural Develpent and Cooperativs and emstruction cf to unon health amners.

b/ ?ederal Republic of Germnys contributio of 1115.0 millio vill cover the trainiv ani arlaris of Fl" for idih the~ederal Republic of Germn bas expresed a xdsh to finrme; also it vi over ftnrmir of vehiclas, special equpment

for 1M trine schools; motiimt Idts, a serviæ statstics systez, a buiding utilimation study, internal study,internal evaluation cf ptlot ce under the Mnstry cf Health and lopulation Plann~ arnd pilot ~s s ~mIer theMinistry of labor an Social Welfare.

/ For contruction of en 1a training schools./ For conmtructio of ome 1M trainirM schol ind ome thna health c .plex./ Reprsentire forei8~ exax8e ~ -m nte for tle mrsng college, mndel family planning linics, seven th -hpealth

complex 22 uni~ health subcnters.f/ epresentint ocal epenitures for the mnrsing c~ , model fanly plpannig clinis, seven thane health cmpl~xs ard

22 uion health subcenters.

Type of finanMitg arr PrallParaU al Parallel Parallel ParalL1 Jolnt Joint

- 84 -

III PROJECT IMPLEMENTATION

A. OVERVIEW

3.01 Initial implementation of most project components was delayed byabout a year, because credit effectiveness was delayed and the formalapproval for each component (Project Proformas) had to be obtained from thePlanning Commission. Except for construction, however, other components ofthe project largely proceeded on schedule after the start and wereimplemented reasonably well. The construction component was delayed formore than two years by several factors: Inadequate pre-projectpreparation, procedural problems, dispersed nature of facilities,difficulties in staffing BPDU, multiplicity of organizations, shortages ofmaterial and negligence of contractors. A price increase was less thananticipated at appraisal, several new activities consistent with the spiritand objections of the project were added and the project closing date ofDecember, 1980was extended by two years. However, many of the facilitieswere not completed by the extended closing date. Due to delay in claimingreimbursements and in the construction component which accounted for 60% oftne original cost, disbursements lagged considerably behind originalestimates. Only about 35% of the IDA credit t.ad been disbursed by December1979 (the project completion date at appraisal). The credit was fullydisbursed by June 1983.

B. CREDIT EFFECTIVENESS

3.02 Expeditious actions were taken by the GOB to meet condition ofcredit effectiveness. Within two months of signing the credit, theNational Population Council was established, a revolving fund was created,terms of reference of the study of national laws were finalised,acquisition of sites was started, the Building Planning and Design Unit(BPDU) was established and PPOs were designated. The responsibilities ofthe Population Planning Division were revised and its name was changed toPopulation Control and Family Planning Division (PCFPD). The PCVPD wasmade responsible for provision of FP and maternal and child health services

- 85 -

and for coordination of population activities. As substantial progress hadbeen made on fulfilling the remaining conditions of credit-effectiveness(signing of agreements with NORAD and KFW, filling key positions in PCFPD,formally appointing PPOs, finalizing a contract with project managementconsultants and approval of National Economic Council for activities ineducation, IRDP and BIDS) the credit was declared effective on September25, 1975, about 6 months after signing of the credit agreement. Theseconditi.ons were met within 4 months of credit effectiveness.

C. IMPLEMENTATION OF THE PROJECT

COMPONENTS

Technical Assistance to

Strengthen Program Organization

3.03 Management Study. A local irm, P & M Consultants, was selectedin February 1976 for a management study of internal organisation of theMinistry. A draft report was ready by early 1977, which was revised incollaboration with a group of expatriate consultants. The report wasdiscussed by the World Bank Supervision Mission with the Government inApril 1977.

3.04 The principal recommendations of the consultants were as follows:(a) Strengthening internal organization by merging the population and thehealth and by adopting a new system of personnel administrAtion; (b)Strengthening field level activities by delegating program tesponsibilitiesto district administration, creating additional positions of FP officers atthe sub-divisional level, involving newly elected local bodies (UnionParishads) in monitoring the village program, and training field levelstaff (Family Planning Assistant, Family Welfare Assistant, Dais) to workas a team; greater decentralization of financial powers, and programbudgeting; (c) Improving coordination between health division and PCFPD bytransferring PCFPD medical officers to health division for bettercoordination and career prospects of these persons, and coordinatingpopulation aczivities at the district level by civil administration; takingsteps so that in the long term health division would provide FP and MCHservices integrated with health services on a contractual basis from PCFPD;and (d) Improving coordination with other ministries by having projects inthese ministries funded by PCFPD.

3.05 Although the study was carefully done and was based upon anunderstanding of existing problems, the knotty issue of relationshipbetween the health division and PCFPD could not be satisfactorily resolvedand has continued to absorb attention of program personnel to date (para7.08). MCH and FP services are still only gradually being integrated withhealth services. The Government implemented some of the recommendations

- 86 -

quickly, a few others with some delay and did not implement the rest. Thedirectorate and the division was merged. The district level wasstrengthened and greater decentralization occured but devolution offinancial authority was inadequate. Although civil administration was notinvolved, other steps suggested to strengthen field level operations weretaken. The coordination with other ministries continues to be weak.

3.06 Seminar. A national population seminar for political leaders wasplanned to generate political support for the population program. Insteadseveral small meetings were held for district coordinators and womenmembers of Union Parishads because of uncertalnty of response from anational gathering. These meetings helped generate increased awareness ofpopulation problems and partially met the original objective.

3.07 Building Utilization Study. BPDU did not carry out a buildingutilization study as facilities were completed only by the end of theproject. It would be useful to conduct such a study at an appropriatetime.

Training

3.08 Nursing College. As planned, about 60 missing tutors graduatedeach year for the first two years (1978 - 79). Then the output deviatedconsiderably from the target for two reasons. First only 96 tutors wereneeded for Family Welfare Visitor Training Institutions (FWVTIs) and amajority of these were trained. Second the categories of Lady HealthVisitors and Lady FP visitors were merged into a common category of FWVsand the college contended that Lady PP visitors did not have requisitebasic qualifications to be trained as tutors. In 1982, only 33 nursingtutors and 10 public health nurses graduated. The missing college buildingwas ready only by December 1980, about l' months behind appraisalestimates. There are still problems with the building -- water leakage andincomplete electrical fittings -- and about half of the planned equipmentis yet to be received. However, the facility is fully utilized as thenursing college offers several other nursing courses (B.Sc. in nursing andvarious Diplomas in nursing). The residential space is crammed ascurrently about 120 students reside in an area designed to accomodate about80 students.

3.09 Family Welfare Visitor Training Institutes. The Project supportedconstruction of 8 FWVTIs attached to district hospitals to train FWVs.pending completion of construction of new schools, Government started thetraining program in rented, though inadequate, facilities. By 1979, 11schools were functioning and had graduated about 2000 FWVs. UNFPA and WHOalso provided assistance for training. During the period 1980 - 82, eightof these schools moved into new facilities as they became ready. However,these facilities continued to suffer from defective water and electricalconnections, poor workmanship and inadequate maintenance. Residentialfacilities during field training remain poor and need to be improved.Because of rapid expansion, the quality of FWV field training was poor andtheir field performance was less than satisfactory. Several steps havebeen taken to improve the quality of training -- voluntary organizationsprovided tutors for vacant positions resulting from out-migration,

- 87 -

curricula was revised to place more emphasis on MCH/FP and rural healthservices and on practical training, textbooks were translated from Englishto Bangla and a manual was prepared. Despite their deficiencies, theseinstitutions nevertheless made a significant contribution to development offield manpower.

3.10 Field Training Thana Health Complexes. Eight FTTHCs, each THCwith three union centers, were planned to service-cum-training facilitiesfor doctors and paramedical staff. These facilities were completed onlyduring 1982 - 83 as compared to the appraisal estimated dates of mid 1979and have begun to function as service facilities. Although the bedutilization was low in previously existing THCs, 30 beds were provided inview of the long term need. So far there is no field training taking placeat these complexes although plans are being made to utilize them fortraining purposes in the future.

3.11 Model FP Clinics. One Clinic for each medical school, wasplanned to provide practical training to intern medical students inclinical FP Services. Of the eight clinics, four were funded by USAID andthe remaining four were funded by the Project. These facilities werecompleted in 1980 - 81, about 15 to 24 months behind schedule and havebecome fully operational despite minor construction defects. Though someof the clinics are underutilized from service delivery perspective, theyare providing training to interns and FWVs, and have exceeded theperformance expectations set at appraisal.

3.12 Field Workers. Although the Government had not yet developed adefinite structure for field services, the project had included salarysupport for 3700 female Family Welfare Assistants (FWAs). UNFPA had agreedto provide support for an additional 1500 FWAs. By October 1975, PCFPDdeveloped a plan to recruit 13500 FWAs (3 female workers per union) and4500 FP Assistants (one male FPA per union) during the period 1975 - 78.Although the Bank mission expressed reservations about rapidly deploying alarge number of inadequately trained workers, the Government felt that theproblem could be overcome by retraining. By May 1976, about 3,360 workerswere given 4 weeks training and were posted. Because of the difficultiesin getting adequate number of candidates both educational qualificationsand age requirements were lowered. By 1978, about 16,700 workers had beenposted and the savings in the project costs were used to fund 8000 of them(Annex 3). Thus a substantial expansion of field infrastructure took placeduring the project period.

3.13 The Planning Commission evaluated the first batch of trainees.Only about 60% of the FPAs and FWAs reported that they were trained intheir specific duties and responsibilities. The workers were generally notwell aware of the side effects of the FP methods. The unmarried FWAs facedseveral social problems, initially but their acceptance by the communityincreased overtime. Supervisory support was almost nonexistent becausesupervisory staff was not properly trained and did not carry out theirfield visits regularly. Inspite of these deficiencies, the workersreported to have visited about 550 couples and motivated about 21 couplesper month. By 1978, the Government formed 19 district level training teamsfunded with the savings in the project cost. Transport support in the form

- 88 -

of bicycle for FPAs, motorcycles for Thana FP officers (TFPOs) andambulances at THCs were also provided from the savings in project cost. Arecently prepared evaluation of the field workers found that only about 54%of all couples reported receiving FP and MCH advice from them. FWAs alsoseemed to maintain records of eligible couples and supply contraceptivesregularly. The supervision seems to have improved with an average of 3.3supervisory visits by FPA per month to each FWA. However, FPAs did notappoint depot holders in the unions on a regularly basis. The poorperformance of field workers continues to adversely affect performance ofthe program and remains a cause of concern. An action plan to strengthentraining, supervision and logistics was prepared to improve performance ofthe workers and formed a part of the credit agreement of the secondproject.

Union Family Welfare Centres.

3.14 As there was no static facility at the union level to support thefield work, the government developed a plan to construct Union FamilyWelfare Centres (UFWC) for the delivery of integrated basic health, MCH andFP services. A pilot program of construction of 80 UFWCs was funded fromthe savings in the project. (The Second Project includes support for about700 UFWCs). these 80 facilities were constructed by Union Committeesheaded by the Parishad Chairman. The experience of construction wasuneven. Generally, difficulties were experienced due to fund shortagesbecause of procedural delays in release of funds and inflexible accountingprocedures to deal with escalation of prices. 70 UFWCs are reported tohave been completed, staffed, equipped, furnished and were functioning byJune 1981. It took more than 6 months to staff and provide supplies tosome of the UFWCs after they were completed. The low utilization of UFWCshas also been a cause of concern and remedial measures (preparation of amanual of operations, supply of drugs) are being taken.

MINISTRY OF LOCAL GOVERNMENT, RURAL DEVELOPMENT AND COOPERATIVES.

Model Farmers and Cooperative Managers

3.15 The project provided support for cooperative managers and modelfarmers in 19 pilot thanas to receive education in FP so that they couldorganize groups to listen to programs on population and FP topics fromRadio Bangladesh. This scheme was implemented by female Deputy ProjectOfficers with the assistance of male inspectors in 1311 village societiesin 12 thanas. The program was started in May 1976 but the attendance atthe program was thin as the farmers were busy and perhaps not interested.In an evaluation, only about 22% of the mens' cooperative member said theywere given FP education through their cooperatives.

3.16 Womens Cooperatives. In contrast to the above, the pilot schemeof rural womens cooperatives was highly successful. In this scheme theIntegrated Rural Development Program (now Bangladesh Rural developmentBoard) was assisted in involving women in cooperatives, providing skill ofreading and writing and simple training in home economics (includingsewing, poultry, farming, kitchen gardening) and family planning.

- 89 -

The project began in July 1975, and the staff was appointed intime. The staff participated in several training programs includingtraining in foreign countries. All of the equipment was procured althoughthe baby taxis arrived after the project period vas over and often therewere delays in release of funds. Transport problems and limited staff atheadquarter were cited as major constraints for increasing effectiveness.By October 1979, 680 cooperatives were formed with 28000 members in 28thanas exceeding the target of 190 cooperatives in 19 thanas. Loanstotalling Taka 1.9 million were distributed. This scheme was furtherexpanded in the second project.

3.17 An evaluation of womeu's cooperatives in 1980 by EEU found thatknowledge and use of contraception among cooperative members was higherthan nonmembers; 34.2% of the members reported use of contraception ascompared 18.5% in the general population (Contraceptive Prevalence Survey1981). However, the impact on fertility was not clear. The highcontraceptive use rate among members may be due to their high literacy rate(62.9%) but the trend in use showed a shift from the use of modern methodsto the use of less reliable traditional methods. Most of the members (81%)received loans through the cooperatives and about 48% reported making aprofit. Slightly over one-fifth of the women's cooperatives members earnaround TK 100 per month whereas only 4% of nonmembers reported receivingthis amount. However, the members did not generally motivate or providecontraceptive supplies to other women in the area.

Ministry of Labour and Social Welfare

3.18 Mother's Clubs. The project supported formation of Mother'sClubs in each of the 760 villages of the 19 rural social service thanas of19 districts. The main objectives of the Mother's Clubs are to bring womentogether for gainful economic activity through training in various crafts,education in various aspects of social life, and population and familyplanning activities inside and outside the club. The headquartersadministrative structure was set up with the PPO in place by July 1975.Thana social welfare officers and about 380 trade instructors were trainedby the inservice training institute of the Ministry of Social Welfare.The training in trade was also imported by Bangladesh Small and CottageIndustries Corporation and other similar organizations, but on a smallerscale. The system for supply of local equipment had to be streamline asprocurement of equipment was delayed up to March 1978. Technical supportfor the scheme was provided by expatriate consultants. By June 1098, about760 clubs comprising about 28000 members in 19 thanas were set up,exceeding membership targets. The total income generated was reported tobe Taka 2.4 million.

3.19 An evaluation by EEU showed that members of the clubs hadimproved knowledge about MCH and FP than nonmembers. About 83% of themembers also know three or more trades compared to only 25% of those whodid not participate in income-generating activities. 37% of these memberswho were eligible were reported to be using contraception as compared to18% of nonmembers in the program area. The impact on fertility andmortality was not clear.

- 90 -

3.20 The main difficulty with the clubs was that only a small quantityof the articles produced there could be sold. The support for design,quality control and marketing was very weak. The quality of tradeinstructors was also low as the salary levels were low and most of them didnot receive special training in crafts. Wherever other organizations, suchas International Union for child welfare, were involved the incomegenerating activities progressed better. However, generally incomegeneration activities continued to remain weak. Several actions wereidentified to strengthen those activities -- adequate linkages with designand marketing organizations, skilled trade instructors, financial supportfor economic activities, and strengthened organizational capability. Thereactivities were included in the second project when the component wasextended.

3.21 An evaluation of the women's vocational training program by EEUin September 1979 found that trained women were younger, somewhat bettereducated and had lower incomes compared to the other women in programvillages or those residing in non-program villages. 65% of the trainedwomen had an income of Taka 100 or less per quarter from the trades whereas9% had an income of Taka 400 or more. More trades known, more trades werepractised and the income earned also was generally higher. Poultry raising(49%), sewing (32%), kitchen gardening (31%) and embroidery (30%) were themost known trades. The FP knowledge and use among trained women wasconsiderably higher than the other women surveyed. 31% of the trainedwomen were currently contracepting as compared to about 12% in the generalpopulation. However, trained women did not visit other village women forFP education after their training. This scheme was included in the secondprojeict. However several problems need to be resolved for securing themaximum benefits from the vocational training activities -- inadequatemaintenance of facilities, inadequate utilization of equipment, poorquality of trade instructors, improper mix of craft training, andinadequate skills in commercial activities. Therefore a careful thinkingon strategy for vocational training is necessary.

3.22 Labour Welfare Centres for Organized Labour. The projectprovided support for introducing FP education and services at three labourwelfare centres operated by the Ministry of Labor and Social Welfare inselected industrial units and a system of home and follow-up visitscovering in all about 50,000 workers. The UNFPA also provided similarassistance for 3 additional labour welfare centres. A population planningunit was established at the Directorate of Labor, Dhaka, and LaborManagement Population Committees were set up at the units covered formanaging the program. Because of freq!ent resignations resulting from lowsalaries, a full quota of field motivators was never available for theprogram. Clinical facilities were not well organised at the labour welfarecentres and the audio visual equipment remained unutilised during theproject period. The monitoring system was weak. By June 1980, a total ofabout 19,000 new FP acceptors were recruited, about 50 per cent of thetarget set in the project proforma and 96 per cent of the target set in theappraisal report. For ease of implementation, these activities togetherwith with remedial measures were consolidated under an UNFPA assistedproject and this component was not included in the second project.

- 91 -

Ministry of Agriculture

3.23 The project assisted the Ministry of Agriculture in involvingAgricultural Assistants in FP motivation activities through training andprovision of bicycles and motivation kits. The scheme covered 19 thanas,one each from 19 districts were Mother's Clubs were started. A PPO wasappointed in the Ministry of Agriculture for implementing this pilotscheme. All the project personnel (50 officers and 34 staff) wereappointed in time and all the equipment was produced. The agriculturalassistants contacted about 180,000 farmers and claimed to have motivatedabout 93,000 farmers to adopt FP methods as compared to the target of about79,000 acceptors. However, the recording and reporting system was poor andcontinuation rates are not available. An evaluation showed that although70% of the farmers knew about Union Agricultural Assistants, only 47% hadbeen visited during last 6 months and about a half of those visited haddiscussed FP with them. Only 31% of the Agricultural Assistants and 50% ofthe Thana Agriculture Officers interviewed had received training. Most ofthe farmers who were contracepting had been motivated by PP workers. Thiscomponent was also consolidated with the similar UNFPA supported projectand UNFPA continued to provide assistance.

Ministry of Education

3.24 The project provided for 19 mobile population education teams in19 pilot thanas to provide orientation courses in population problems forteachers of primary schools. This scheme was approved only by December1975. All the staff position were filled but it took some time to procurevehicle and audio-visual equipment due to procedural difficulties. Theperformance of the project officials improved gradually as they acquiredexperience. The consultancy services also helped the project personnel indeveloping expertise in population education. A total of about 3,300teachers were oriented in population education compared to the target of7,000 teachers and these teachers are reported to have motivated about14,000 FP acceptors. The short fall in the number of teachers oriented wasbecause school authorities did not send the required number of teachers tothe courses. An evaluation of the mobile population education teams by theEEU in 1979 found that there was no direct impact on the fertility in thearea where this scheme operated. However, an immediate demographic impactperhaps should not be expected.

3.25 The project also provided assistance in developing curricula onpopulation education for primary and secondary schools and trainingteachers to use such curricula. During negotiations an agreement wasreached that population education would be systematically introduced in theregular primary and secondary school curricula by January 1979. Apopulation education curriculum was developed and was accepted by thenational curriculum committee. This curriculum was introduced in classes 4and 5 in January 1979 and was to be introduced in other classes in phases.Total expenditure on the project was Taka 2.7 million, only about 50 percent of the cost estimated at the appraisal, due to the short fall inconsultancy services and difficulties in utilizing funds because ofGovernment financial rules.

- 92 -

A national seminar on population education to focus attention onthe need for population education among the young school age population andto gain support from the educators was held in December 1978 and was wellattended. The population education activities were merged with suchactivities supported by UNFA and were expanded with assistance from UNFPA.

Ministry of Information and Broadcasting

3.26 Audio-Visual Vans. The scheme provided for 16 cinema vans withthe necessary equipment and personnel to be used by the department of masscommunication for disseminating population and FP information in 8 thanascovering a population of about 1.6 million. Actual field operations beganoaly in February 1977 as there was a dispute about the award of procurementcontract. A total of about 3,500 film shows were held in the 8 selectedthanas by February 1980. The program operated satisfactorily but sufferedfrom a lack of adequate quality films and a few important positions couldnot be filled due to recruitment rules. A 1979 EEU evaluation found thatonly about 2% of the current users in the program area cited audio visualvans as a source of information on FP. Fertility behaviour in the programareas was not different from the non-program areas. As the program of themobile vans was not coordinated with other multi-sectoral components or theactivities of the MORPP, they may not have had intended impact. By nowmost of the audio visual vans have become unserviceable due to heavy useand poor maintenance. Because of the difficulties in maintenance and useof sophisticated costly vehicles only jeeps were included in the secondproject for mass education.

3.27 Population Program Cells. The project assisted the Ministry ofInformation and Broadcasting in establishing population program cells inRadio Bangladesh for producing and broadcasting population programs inDhaka and 5 regional stations. Support was provided for personnel,equipment, and 1,900 radio sets to test the effectiveness of theseprograms. The staff was appointed and received training both in Bangladeshand abroad by November 1975. The scheme initially experienced somedifficulties because of the lack of premises, slowness of the regionalstations to accept the cells and a lack of transport. Two of the regionalstations began producing population programs in November 77 and threeothers from April 1978. A 20 minute program every day (except Sunday)under the title "Happy Family" was put on the air. Subsequently, two otherprograms of 20 minutes each and every day were added.

An evaluation showed that regular radio listeners have muchbetter understanding of the concept of FP compared to those who listen toradio occasionally or seldom. A little over half (55%) of the respondentswere regular listeners and an overwhelming majority (86%) of the listenerslistened to FP programs. Only about 16% respondents found the program veryuseful, most of the remaining claimed that they did not need thisinformation. Listeners, however, rarely provided any feedback to stations.

3.28 Support was also provided to the Ministry of Information andBroadcasting in strengthening generally the capacity of its department offilms and specifically population related activities. The objective was toset up a modern laboratory to process locally produced films based on

- 93 -

population themes. There was some delay in starting the department becauseof a freeze on staff hiring and, during the project period, only 11 of the30 positions planned at appraisal could be filled. Although a new buildingwas available only by June 1980, most of the equipment had been procuredand installed in old premises. The film department produced 15 short films(of 20 minutes each) and one training film as compared to the target of 15short films and one full length feature film. A total of 236 copies in 35mm and 475 copies in 16 mm of the local and foreign films were made anddistributed for public showing in the cinema houses and different agenciessuch as the department of mass communication, Bangladesh Television and IEMdepartment of PCFPD. Their impact has not been evaluated but Bank missionsjudged the films to be of good quality.

3.29 Feature Writing Bureau. A Feature Writing Bureau was establishedwithin the Press Information Department and it completed 90 features, 82articles, 54 short stories, 46 cartoons, 82 illustrations, and 83photographs for publication in national dailies and periodicals. A book onFP methods was also published. Although planned at appraisal, the bureaudid not provide any matter for broadcast or for films. The GOB supportedthe Bureau after 1980.

3.30 Training of Public Relations Officers. The project providedsupport for training Public Relations Officers posted at the district andsub-divisional levels through two-week seminars on population programs,policies, and motivation techniques. About 100 officers were trained andwere also given reorientation training. As all the officers had beentrained, this component was discontinued in the second project.

Ministry of Health and Population Planning

3.31 The project provided support for MOHPP to provide 380 kitscontaining flip charts and slides, 190 cassette tape recorders and 190slide projectors to provide audio visual support for the motivationalactivities of FWAs. Subsequently it was found that the FWAs could not betrained in use of tape recorders and slide projectors. Therefore, it wasdecided to produce 90,000 copies of flash cards and 100,000 copies ofbooklets on population. These materials were produced and distributed.The IEM unit also was equipped to produce simple audio-visual materialslike filmstrips, slides, flashcards, etc.

3.32 Other Activities. Several other smaller activities -- purchaseof transport, study tours of religious leaders, drug feasibility study, andradio feasibility study -- were funded from the savings of the FirstProject. These were generally performed well.

Research and Evaluation

3.33 Monitoring and Internal Evaluation. The Project providedassistance to the erstwhile Research, Evaluation, Statistics and PlanningUnit of PCFPD for development of FP service statistics system. However,technical problems arose in the design of the system and the limitedmanpower of the unit got involved in research and evaluation functions.Towards the end of 1979, the research and evaluation functions were

- 94 -

transferred to NIPORT and a Management Information System (MIS) unit wasestablished in PCFPD. The MIS unit also received support from the FordFoundation and USAID. A simplified service statiatics system wasimplemented in 50 unions in 50 thanas where contraceptive prevalence anddemographic surveys were either underway or contemplated. The MIS unitprepares reports on monthly contraceptive acceptance/distribution with thehelp of a minicomputer and circulates them widely. The project assistancehelped in establishing a MIS but the feedback system needs to bestrengthened further to increase use of information for improving programperformance and the simplified service statistics system needs to beextended to cover the whole country.

3.34 External Evaluation Unit. The EEU was established in thePlanning commission towards the end of 1976. The unit did not have a headfor nearly half the project period and personnel changed frequently. By1980, the unit had a professional staff of about 15 research assistants.Meanwhile other agencies carried out baseline surveys of target groups ofpilot schemes, but the data-tape was inadvertently destroyed disallowingits comparison with the latter evaluation surveys. EEU carried out about10 of various project components as compared to 25 planned at appraisal.These studies, by and large, assess program impact but do not seem to havebeen used by the implementing ministries to improve and further developtheir population activities. Some officials apparently reacted to theseevaluations as negative and critical of their performance. Therefore, thefeedback process needs to be strengthened and should be more smoothlymanaged in the future.

3.35 The project provided support to the Population Study Centre atthe Bangladesh Institute of Development Studies for a study of determinantsof reproductive behaviour. The study was to provide information aboutpeople's attitude to FP and focus on two questions -- how many childrenpeople want to have and why do they want that many children. the surveyalso included data on income and expenditure; ownership of productiveassets; use of water, sanitation, health and nutrition services; genealogyfor families; and an anthropological study of a few villages. Aconsiderable amount of field work was completed by May 1978,, however;processing, analysis and interpretation of the data did not make muchprogress. Unfortunately, no formal completed reports were producedalthough 2 interim reports were prepared. The results of these efforts areunsatisfactory.

3.36 The project also provided support for a study of existingnational laws on population growth. The principal topics of the study werecontraception, sterilization, minimum age of marriage, registration ofvital statistics, employment of women and children, and incentives anddisincentives. Although an interim report on this study was available byApril 1977, its review and revision was substantially delayed. A copy ofthe revised report was submitted to the National Council on PopulationControl in 1980. Three bills relating to age of marriage, vitalregistration and inheritance were drafted by the Ministry of Law.Although, the laws have not yet been enacted, this study is a forerunner ofattempts to harmonize the population policy and the national laws.

- 95 -

Support for Private Sector and Innovative Activities

3.37 The project included a fund of US $350,000 to support innovativepopulation projects in the public and private sector. A subventioncommittee was established within PCFPD to approve schemes to be financed.Under this component, the largest support was provided to Bangladesh FamilyPlanning Association for Development of small NGO organizations active inFP and MCH activities. A variety of organizations (about 43 in all)received support for population activities under this scheme includingcommunity development organizations such as Swanirvar, TeachersAssociations, Women's and Youth organizations, FP, MCH, and health and folkart organizations, social service providers, and welfare organizations.PCFPD set up a Family Planning Services and Training Centre to providepromotional, technical and other services to voluntary organizationsengaged in MCH, nutrition and FP services. This Centre carried out a fewevaluations of the organizations receiving support from PCFPD, the resultsof which showed generally a satisfactory performance. As this componentachieved its objective of stimulating and supporting non-governmentactivities in the population field, it was included in the Second Project.

D. Project Execution

Organizational Arrangements

3.38 BPDU was established quickly and its director joined in January1975. However, the Unit suffered from several problems throughout theproject period. Its staff, on deputation from PWD, was never adequate.The performance of the unit was also adversely affected by inadequateoffice space, facilities and transport. Administratively it was a new unitattached to health division and could not fit well into PCFPD structure,leading to some confusion. It assisted at various phases of theconstruction component of the project including furnishing and equippingthe facilities and liaised with the consultants, PWD and the Bank.

3.39 A consortium of two local and one foreign consulting firm (HESConsultants) was selected after a careful scrutiny. However, thenegotiations were protracted because the Government wanted only a minimaltime commitment from the foreign consultants. The contract was finallysigned in January 1976. The consultants were to carry out financial andtechnical study of FTTHCS, prepare master plan, assist in site selectionand analysis, prepare designs, and document and supervise theconstruction. The consultant firm carried out their tasks diligently.Later on, as PWD was responsible for supervision, the consultant'sinvolvement in design was increased and involvement in supervision wasreduced. All the requirements of the individual sites could not beforeseen by the consultants and some remaining work had to be done laterthrough contractors. The initial designs did not take all theenvironmental conditions into account. Consequently, ventilation was poor,water leaked into some buildings and concealed wiring and water pipes posedproblems in repair. There also were construction defects from poorsupervision.

- 96 -

3.40 The overall organizational arrangement for construction was notoptimal. Multiple parties were involved -- Pwt, BPDU, consultants and theBank -- and, therefore, many decisions were delayed. BPDU and theconsultants were seen as unnecessary by PWD. PWD's site supervision was,however, weak. Several problems were encountered in coordination among themultiple parties involved. A coordination committee was set up and metfrequently to resolve outstanding issues. However, higher officials oftenhad to be involved in expediting decision making. For the construction ofUFWCs, Union Committees were made responsible. The experience with thismode of community participation was also mixed. The organizationalarrangements were modified in the Second Project to include a ConstructionEngineering and Management Cell (CMC) in PCFPD to provide field levelservices. A Population Project Cell was also created in PWD for the SecondProject. These arrangements came into existence by 1981 and expedited thecompletion of construction work for the First Project.

3.41 As planned, six PPOs were appointed by 1975. These PPOs weregiven training which included in country training, field visits andtraining abroad. PPOs generally performed well and were instrumental inimplementation of multi-sectoral activities. During the life of theproject only four changes in PPOs occurred. These changes caused somedisruption. A second round of training was organized in 1977. The PPOscould not carry out internal evaluation and field supervision suffered froma lack of staff and adequate transport. Field-level activities also werenot coordinated well. A need was subsequently felt to add marketing designand quality control support for women's programs. This could not beprovided during the First Project. Although included in the AppraisalReport of the Second Project, this cell was never established. Therefore,income-generation activities of these programs suffered adversely.

3.42 For the first few years the Project Finance Cell did not functioneffectively because of frequent transfer of Project Finance Officers, lackof staff and lack of training in disbursement procedures of the Bank andother donors. Consequently, disbursements fell behind schedule by 1978.The Cell could not expedite applications from other ministries anddisbursements considerably lagged the expenditures throughout the life ofthe project. The cell also could not inspect facilities, personnel, andequipment in the field for lack of staff. Although the functioning of thecell improved considerably over time, financial management of the projectremained weak throughout.

3.43 In addition, project management suffered from two common problemsof project implementation in Bangladesh -- frequent transfer of staff, andcumbersome procedures for recruitment, internal and external financing andadministration. Consultants were hired to advise PCFPD on simplificationof procedures. Some procedures such as cost reimbursement were simplifiedduring the project implementation. However, much remains to be done inremoving procedural bottlenecks. While the absence of a unit to implementthe project may have slowed down projeLL implementation and resulted ininadequate coordination, it perhaps helped institutionalise projectactivities in the different ministries.

- 97 -

Construction

3.44 It was felt at appraisal that a considerable amount ofpreparatory work for the design of buildings and identification ofeffective modes of construction was needed. These were the first tasksgiven to the consultants after an agreement with them was signed in 1976.The consultants carried out a THC study assessing user requirements andinvestment requirements of alternative designs and construction methods.These studies and a master plan were completed and finalized by December1976. The study did not reveal any lower-cost alternatives. At appraisal,total gross area of the project facilities was estimated to beapproximately 700,300 sq.ft. The master plan suggested a gross area ofabout 893,000 sq.ft., 27% higher than appraisal estimates. Subsequentdiscussions resulted in a plan with gross areas of about 673,000 sq.ft.,about 9% below appraisal estimates. By February 1977, standard designswere approved. Almost all the sites had been acquired by that time,although litigation later arose in several cases. The FTTHC and itsassociated three union subcentres were combined into one contract andtherefor 21 contracts were awarded (1 Nursing college, 8 FWVTIs, 8 FTTHCcomplexes, 4 MFPCs).

3.45 Delays occurred at almost all stages of construction and it tookabout five years for the facilities to be completed once initialpreparation was ready (Annex 4). The signing of the consultant's contractwas delayed. IniLial delays in tendering also occurred due tounfamiliarity with IDA tendering, procurement and reimbursementprocedures. The other reasons for delay and the number of facilitiesaffected were as follows: site related (5), revision of design (1),disputes and legal injunctions (3), need to find second contractor becauseof failure of first contractor (6), additional unforeseen work (4),material shortages (generally during the period 1977 - 79), slowness bycontractors (8), and delay in finishing (3). Organizational difficultiesof supervision were mentioned earlier. Out of 45 sites, 17 sites weredisputed. Consequently work on 5 contracts was initiated in 1977, on 8contracts in 1978, on 7 in 1979 and on the remaining one in 1980.

3.46 Contractor-related difficulties were the most numerous and causedmost of the delay. These difficulties were largely related to procedures.The contracts were combined for all work - civil works, electricalfittings and sanitary facilities -- to be done in each facility, contraryto the usual Bangladesh practice of awarding separate contracts for eachwork. The construction industry was able to respond to this change onlyslowly. Many contractors faced financial difficulties and had difficultyin procuring costly materials for doors, windows, plumbing and electricalfittings. The most serious procedure causing the slowdown of the work wasthe price-escalation clause. Not only was this not the practice of thePublic Works Department, but the lack of a satisfactory price index gaverise to endless dissention with contractors, delayed decision on claims,large numbers of pending bills and inevitably a slow-down of actualconstruction. In the case of one Thana Health Center, the contractor made5 claims for price escalation, which were processed between December 1981and July 1982 without a settlement being reached on any of them. In somecases, contractors deliberately slowed down the work so as to be able toclaim price increases. The Public Works Department, for its part, couldnot enforce discipline because of its own failure to fix satisfactory pricelevels. The price escalation clause was discontinued in the SecondProject.

- 98 -

3.47 Most of the construction materials (except cement in 1979) wasprocured locally. In the earlier contracts, in 1977, material procurementwas the responsibility of the contractors. Material shortages during 1977- 1979 caused considerable delay in construction. Finally PWD issued thesematerials to many contractors and replenished its stock of cement bypurchasing about 11,000 tons through international bidding.

3.48 Many of these difficulties were only resolved by frequentmeetings of the coordination committee, intervention by senior officialsand expediting by The Bank's population specialist located at Dhaka andSupervision missions. Despite the above difficulties, the technicalquality and workmanship of the construction was judged by the Bank missionsto be adequate. The facilities were completed about 3 years behind theappraisal estimate of June 1979.

3.49 Considerable difficulties were also experienced in making thefacilities functional. Almoct all facilities seem to suffer from minordefects due to design problems, lack of electrical and plumbing fittingsand lack of equipment. In the earlier designs concealed water supply pipesand electrical wiring, and ruled pointings were used. This led to leakageof rain water and difficult maintenance. Wooden windows and doors,wherever used, faced problems because of poor quality of timber andinadequate paint. Rimlock system was used in the earlier stages which iscostly to repair; simple padlock systems were later used. Many facilitiessuffer from poor and inadequate plumbing and electrical fittings. In viewof the above, it is now necessary to inventory all the defects and takeprompt corrective actions either through original contractors or byappointing new contractors. In the absence of such measures thefunctionality of the buildings in the short term and their life in the longterm will be considerably reduced. On a long term basis adequate financialand organizational arrangements need to be made to maintain thesefacilities.

Procurement

3.50 The requirements of furnishings and equipment for the facilitieswere determined by the consultants and scrutinised by the concernedagencies and the Bank. These were procured through tenders. In addition avariety of equipment needed for other components of the project (vehicles,vans, ambulances, bicycles, radios, sewing machines, duplicw'ing machines,computing equipment, etc.) was procured by the Supplies Directorate. Byand large standard IDA procedures were used. Procurement went reasonablywell except for some initial delays due to unfamiliarity with proceduresand was reasonably well synchronised with the completion and handover ofthe facilities concerned.

- 99 -

E. Projects Costs and Disbursements

Costs

3.51 The actual expenditure on civil works and furniture was higherthan appraisal estimates in Takas. In dollar terms, however, constructioncosts were only 71% of the base costs at appraisal. It is difficult tomake a similar comparison in the costs of non-construction components. Atappraisal, construction was 69.4% of total project costs; the actualconstruction costs were estimated to be about 41.8% of total project costs(Annex 5). A major reason for cost changes was fluctuations in relativevalues of currencies. Cost estimates were also based upon a limited pastexperience. The price situation at the time of forwulation of the projectwas unclear and marked by economic uncertainties. As it turned out, atdisbursement the original project components accounted for only 76% oftotal costs.

Disbursements

3.52 Project disbursements lagged behind by about 2.5 years from theoriginal estimates (Annex 6). Four factors contributed to this delay.Initially the project started slowly and credit effectiveness was delayedby about 5 months. The construction component was delayed by about 3years. The original cost estimates were too high and the utilization ofsavings began only in 1979. Finally the Project Finance Cell haddifficulty in getting reimbursement applications from various ministries intime in addition to its own delays in processing them. By December 1979,the original closing date, only about 35% of IDA credit was disbursed. Theproject closing date was extended and the credit was fully disbursed byJune 1983. The experience was similar for other donors (Annex 5). At theclose, their allocations were disbursed only partially -- NORAD (80%), CIDA(64%), ODM (100%), and KFW (100%).

IV. PROJECT CONTRIBUTION

Project Performance

4.01 The Project met most of its quantitative targets, particularly interms of inputs. The output of each component was reviewed along with itsactivities in the previous section. The construction component wascompleted but with a considerable delay (para 3.44 to 3.49). Othernon-construction components performed reasonably well (para 3.02 to 3.47).As measured by activity indicators, most of them achieved their objectivesby June 1980 after extension of the Project (Annex 8). Multi-sectionalcomponents were the first organized effort to involve personnel from otherministries in population matters. Although the coordination of fieldactivities was inadequate, these activities were institutionalized duringthe First Project. The Second Project included most of these componentsand further strengthened them whereas other components were consolidatedwith similar efforts supported by UNFPA. The issues related to quality ofactivities became visible as their implementation proceeded. As mentionedin the previous section, some actions were taken during the First Projectperiod to improve quality and efforts are continuing in this direction inthe Second Project.

- 100 -

Project's Contribution to Program Development

4.02 By 1973, activities in the population field had come to a standstill. The Project was a major attempt to re-establish the nationalpopv'%tion program. The ingredients of a national population policystarted emerging from 1973 when the First Five Year Plan was formulated.The program during the period 1973 - 80 derived from a broad based strategyto improve health; reduce infant, child and maternal mortality; raise thesocio-economic status of women; change the outlook of the rural populationby the use of mass media; deliver contraceptive services within easy reachand mobilize community support for population planning. The Projectcontributed directly and indirectly to program development in several ways-- technical assistance to strengthen progran organization; delivery of PPservices; training; IEC activities; multi-sectoral activities; monitoring,evaluation and research; and support for non-government organizations. Thedevelopment of the program and the project's contribution toward it arereviewed below.

Program Organization

4.03 The organizational framework for the delivery of health and FPservices is located within the MOHPC, but has changed several times overthe years. Currently, the Ministry, headed by a Minister has two wings;the health wing has responsibility for planning and implementing the healthprogram and the. population control wing has responsibility for planning andimplementing MCH and FP services of the Government and supportingpopulation-related work of voluntary agencies (Annex 9). The wings werecreated in April 1983, when a MOHPC reorganization merged the former HealthDivision and PCFPD. The National Council for Population control, headed bythe President of the country, was established in 1975, fulfilling one ofthe conditious of credit effectiveness; and is responsible for policyplanning and program review.

4.04 In pursuant of the recommendations of a management study carriedout under the First Project, several actions were taken to strengthen PCFPD(para 3.03 - 3.05). Efforts to improve relationships between PDFPD and thehealth division were the subject of considerable attention of programadministrators and donors (para 7.08). While the Second Project was beingprepared, a plan for phased integration of health and FP services wasworked out and approved by the Government. However, the Government decidedto integrate those services at and below the thana level from July 1980, asa part of the Second Five Year Plan. While considerable attention, so far,has been paid to structural issues, the processes of planning, control,personnel and budgeting have remained weak and need to be strengthened bydeveloping better systems and staff skills.

Service Delivery Infrastructure

4.05 The institutional framework, consisting of the THC, the UFWC, anda team of male and female workers at the periphery, has been developed fordelivery of both health and FP services in rural areas. When fullyestablished, each THC will have 31 beds, provide outpatient and inpatientservices and manage outreach activities. The THC is headed by a ThanaHealth and FP Office and is staffed by 5 medical officers, 3 health and FPinspectors, one sanitary inspector and other nursing and clinical staff. AUFWC, one planned for each union, is to serve a population of about

- 101 -

20,000. It is staffed by a medical assistant, a FWV, a pharmacist andsupporting staff. Under the integrated set up, at the periphery servicesare to be delivered to the rural population by a ward-level team of a maleand a female worker, each team serving about 6,000 population. OneAssistant Health Inspector will supervise the male workers of four teams,while a FPA supervises three female workers.

4.06 Considerable progress has been made in putting the aboveinfrastructure in place. The number of PCFPD staff increased considerablyduring the period 1974 - 79 (Annex 10) and more than 90% of FWA, FPA andThana FP officers were in place by 1979. However, only about 50% of FWVand 35% of Thana medical officer positions were filled by that time. Thenumber of facilities offering FP services also increased considerablyduring this period. Although only 8 THCs and 80 VFWCs were constructedunder the Project, it contributed considerably to expansion of fieldworkers; about 8,000 FWAs were supported by the Project. Several actionswere also tak3n to improve worker performance but low worker productivitycontinues to be a concern (para 3.13). the FWA also provides a limitedrange of services (motivation for contraception, supply of pills andcondoms); her role needs to be expanded to make FP and MCR services morewidely available. Although a considerable quantitative expansion inservice delivery has occurred, the quality of services needs improvement(para 7.11). Finally MCH services have lagged behind FP services. In1980, it was estimated that while about 30% of the population had access tohealth services, only about 1 per cent of children had been immunized forDPT and rural mothers receiving ante-natal care at least once beforedelivering was less than 2%. Now plans are being made to implement some oft%e priority elements of an MCR program such as training traditional birthattendants, diarrhoea management and an expanded program of immunization.

4.07 Training. The program has developed a considerable capabilityfor pre-service and inservice training of field workers at various levels.Each of the 8 medical colleges now has one field area for orienting medicalundergraduates towards community health, MCH and FP activities. The outputof the schools of medical assistants will provide about 3,YOO trainedpersons for staffing all VFWCs by 1985. Twelve FWV schools have becomefully functional with annual output of 600 FWVs. About 5,000 FWVs areexpected to be available by July 1985, adequate to fill the sanctionedpositions now available. 19 district teams are now functioning for theteam training of field workers. NTPORT has been set up to coordinate alltraining activities and meet training needs of middle level managers. TheProject supported 4 FP clinics at medical colleges, 8 FWVTIs and 19district training teams; thus providing for a considerable portion oftraining infrastructure. The program has taken several steps to improvequality of training (para 3.13) but much more is needed in terms ofinstitutional strengthening, curriculum improvements and development oftraining material.

4.08 Information, Education and Communication Activities. Theinfrastructure for the communication program, consists of various units ofthe Ministry of Information and Broadcasting, field workers and the IEMunit of PCFPD, the Health Education Bureau of the Health Division andvoluntary agencies. Units were set up in Radio Bangladesh under the First

- 102 -

Project for producing and broadcasting programs related to population. Afilm processing laboratory and feature writing bureau were alsoestablished. In addition, the Project supported a variety of othercommunication activities such as seminars of political leaders, study toursof religious leaders and distribution of motivational kits. Thecommunication activities have resulted in a substantially increased levelof knowledge of FP and have created social support for FWAs. TheContraceptive Prevalence Survey of 1979 showed that 955 of ever marriedwomen under 50 years of age knew of at least one method of FP and nearlyhalf knew five or more methods. In view of the large gap between knowledgeand practice of FP, the IEC activities should now focus on impartinginformation about specific methods, supporting service delivery at thanalevel and below and generating community participation.

4.09 Multi-sectoral Activities. All the activities carried out byother ministries under PDFPD coordination were supported by the Project ona pilot basis; many of them also received assistance from other donors(para 3.15 to 3.31). As pilot programs, they provided implementationexperience and resulted in their expansion with funding from other donorsor in the Second Project. Three women's programs together represent acomprehensive effort to improve women's status but their coverage is verylimited, synergistic interaction among them is lacking and they need to bemade more cost-effective.

4.10 Monitoring, Evaluation and Research. Considerable progress hasbeen made in setting up a monitoring, evaluation and research system; themain elements include the MIS Directorate, EEU, the operational researchactivities of NIPORT, the Population Study Center and the HealthInformation Unit. The activities of the MIS Directorate and EEU supportedunder the Project were discussed earlier (para 3.33 to 3.34). NIPORT hascompleted about ten operational research studies. To increase therelevance and utilization of research, this system needs to be furtherstrengthened by focussing research effort on priority areas, training ofresearchers on methodology and by better coordination between programadministrators and researchers.

4.11 Involvement of Non-government Organizations. PCFPD set up asubvention committee under the First Project to screen and support fundingrequests from voluntary agencies (para 3.37). It has developed goodworking relationships with voluntary organizations. Urban areas have beenearmarked for NG0s and innovative projects of NGOs in rural areas are alsoencouraged. The Social Marketing Project has undertaken commercialmarketing of contraceptives with USAID support.

4.12 Financial Resources. The expenditure on population activitieshas increased considerably. The total allocation and utilization of fundson population program in 1978 - 79 was US $ 31.16 million and 72%,respectively, as compared to US $ 4.66 million and 57%, respectively, in1973 - 74 (Annex 11). Although difficult to estimate accurately, theProject may have provided about 45% of all program resources to FP duringthe period 1975 - 80.

- 103 -

4.13 Contraceptive Acceptance and Use. Program performance asmeasured by contraceptive acceptance has increased considerably. In 1980 -81, the number of sterilization and IUD acceptors were 12 times and thenumber of condoms and pill cycles distributed were about 6 times that in1974 - 75 (Annex 12). Injectables and MR also are becoming increasinglypopular. Couple years of protection offered in 1980 - 81 was about 1.68million as compared to about 0.17 million in 1975; the direct contributionof the Project is, however, difficult to estimate. The use of modernmethods of contraception is estimated to have increased to 10.7% from 4.7%during the same period (Contraceptive prevalence Survey 1981). Of thecurrent users, about 50% obtained services from government facilities andan additional 25% from government FP workers. By 1981, about 21.7% of thecurrently married women under 50 years of age had ever used at least onemodern method. Despite a considerable increase in contraceptive use,rather ambitious national targets have not been met and had to be reviseddownward on several occasions. Most recently a target of reaching NRR of 1by year 1991 was envisaged; which in turn required reaching a contraceptiveprevalence level of 35% by 1985. Now a prevalence level of 38% is plannedto be achieved by 1990.

Project Contribution

4.14 In summary, the Project was instrumental in supporting thequantitative expansion and institutionalization of the national populationprogram. Although its direct demographic impact is difficult to measure,contraceptive prevalence increased considerably during the project period.Most of the quantitative targets for project components were met, albeitwith delay. By involving many major donors directly, by offeringopportunities for coordinating with UNFPA and USAID and by becoming avehicle for ongoing dialogue with Government, it contributed to keepingattention focussed on the population program. When viewed in this context,the Project was successful.

V. COVENANTS AND THEIR FULFILMENT

5.01 The borrower implemented the project with due diligence andefficiency within the limitations of the project implementation capabilityarising out of lack of trained personnel, difficulties in acquiring sites,problems with contractors and material shortages.

5.02 A large number of covenants were written into the creditagreement since this was the first population project in Bangladesh and the

borrower's implementation capability was judged as "weak".

5.03 Many evaluations of specific project activities were carried outbut the Building Utilization Study was not done as the buildings were

completed very late (section 3.04-b).

5.04 A specific study was not made to ensure that FWAs devoted 50% of

their time on FP motivation activities (section 3.01-b) as they were full

time employees engaged in FP activities.

- 104 -

5.05 The audit accounts/reports to be sent not later than 6 monthsafter the end of the financial year were always late (section 4.01). TheProject funds have not yet been audited.

5.06 The study groups on information, education and motivation, and onresearch and evaluation were established (section 3.07) but do not seem tohave remained active.

5.07 The imported goods were not insured (section 3.11-a) followingthe general practice of the Government as it considers insurance moreexpensive than the replacement of the damaged equipment.

5.08 The other covenants, by and large, were met. A revolving fundwas established (section 3.02), consultants were appointed (section 3.03)sometimes latter than planned due to the non-availability, a study of theeffect of national laws on population growth was carried out (section3.06), and population education was introduced gradually (section 3.08).

VI. ROLE OF BANK

6.01 Project Formulation. The Bank responded quickly to the PlanningCommission request to formulate a project assisting the Government inlaunching a population program. The donors were concerned about a highrate of population growth and felt that quick action was required, eventhough a clear line of action had not emerged. Donors were also concernedabout the Government's commitment to and organization arrangements for apopulation program. The Bank helped define the project and mobilizesupport for it. The Bank also took the lead in conducting a sector reviewwhich led to identification of project components. As preparatory workcould not be done and many details had to be resolved, these were includedas covenants in the credit agreement. While the documentation for theFirst Project was prepared by Bank staff, the preparation of the SecondProject had much larger involvement from Government personnel.

6.02 Donor Coordination. The World Bank is the largest donor agencyto Bangladesh. Therefore, it took lead in formulating the project andcoordinating donor activities. Initially there were some difficulties.USAID forward a vertical organization for the program and UNFPA felt thatit had an organizational mandate to coordinate the population activities.These differences were resolved over time. The resident representatives ofthe Bank in Bangladesh took an active part in coordinating donor effortthrough several in country meetings. Thus Bank assisted in raisingfinances, harmonizing the relationships among donors and between donors andthe Government and in expediting project implementation. It was theexecuting agency for four donors, approving disbursements and accountingfor their funds.

6.03 The involvement of donors kept focus on population issues; thelevel of Government commitment in the absence of donor involvement isdifficult to predict. Donors also influenced project content -- largebuildings and neglect of simultaneous development of MCH services on thenegative side and rapid growth of program and multi-sectoral populationactivities on the positive side.

- 105 -

6.04 Supervision. Considerable implementation assistance was providedby the Bank through the resident population specialist and large Banksupervision mission which normally included a demographer, a communicationspecialist and an architect. In all, there were 18 supervision missionswith about 183 man-weeks in the field. In addition, other donor agencieswere represented by either their resident representative or headquarterpersonnel Considerable supervision effort was spent and, both theGovernment and the Bank feel that this effort helped in resolving manyimplementation problems and in expediting implementation. By 1979, it wasestimated that about a total of 350 man-weeks had been spent by Bank staffto supervise the project.

6.05 The Bank maintains a resident population specialist only inBangladesh. The role of the resident specialist was envisaged to be one ofpolicy dialogue with the Government. However, in addition to this role,the resident specialist became a trouble shooter and facilitator andprovided a focal point for the donors. The resident specialist, it isagreed by all, provided valuable services. In view of his involvement inimplementation of the project, he could have been delegated moreauthority. Whether this would have resulted in increased pressure on himfor agreeing to changes in project procedures or content is not certain,but the supervision effort needed from headquarters would have been less.

6.06 Procedural Problems. Some of the procedures used by the Bank(guarantee for contractors, price escalation clause, material procurementbeing the responsibility of the contractors) resulted in delays inconstruction during the initial years and were gradually changed. Theprocurement and disbursement problems for all Bangladesh projects werediscussed with the Government by a special mission in 1978. Bank approvalwas needed at several stages which resulted in a considerablecorrespondence between Dhaka and Washington and contributed to delays.Availability of a trained Project Finance Officer with Government andcontinuity of personnel would have resulted in reducing the lag betweenexpenditure and disbursements. Although the familiarity with theprocedures increased, the project implementation capability continues toremain weak.

6.07 Overview. Overall the Bank's role appears to have beenpositive. Notwithstanding the problems of limited flexibility and need forseeking approval at several stages, involvement of the Bank in providingadvice based upon its experience elsewhere and keeping population issues infocus was considered an asset. In view of the need to keep the lendingmomentum and continue the growth of program, Bank was asked again to takethe lead in formulating the Second Project. The Second Project, appraisedin 1978, was largely a continuation of the First Project with support fordifferent types of facilities (Annex 13). The Second Project consisted ofproviding salary and other support for FWAs, construction of 700 UFWCs and19 THCs, drug supply, strengthening the training activities started in theFirst Project, starting training of Medical Assistants, strengthening IECactivities in MDHPP and Ministry of Information and Broadcasting women'sprograms, research and evaluation, and innovative and non-governmentactivities. Currently the Government and the donor group are in theprocess of formulating a third possible project.

- 106 -

VII. MAJOR ISSUES

7.01 The major concerns at the time of project formulation wereproject content and design and an appropriate form of organization forpopulation activities. Construction and utilization of facilities, quantumof supervision effort and financial uncertainties received considerableattention during project implementation. Program management, quality ofservices and the rule of donors also affected project performance.

Project Content and Design

7.02 It was realised by the donors that something had to be quicklydone to control population growth if other aid was to be effective.Therefore, donors were willing to put a large amount of money in thepopulation program even though its direction and efficacy were not clearlyestablished. The availability of FP services was very limited and neededto be improved. Given the low level of economic development, effectivemotivational activities also had to be started. The logic for the projectcomponents was derived as follows: manpower needed to be developed,therefore, training facilities had to be created; efficacy of female fieluworkers had been established, therefore, the number of such workers had tobe increased; demand for FP was low, therefore, broad based IEC activitieswere needed; the exact nature of the demand generation activities was notcertain, therefore, many activities had to be tested on a pilot basis.Thus the project strategy was to support development of a broad basedcomprehensive program.

7.03 Choices regarding type of program, geographic dispersal offacilities and pilot schemes and construction of facilities for trainingwere made in designing the project. These were three alternatives for thetype of program -- a vertical FP program alone, parallel MCH and FPprograms and an integrated rural health program. In the first stage, aparallel MCH and FP program was favoured over either of the otherapproaches although MCR services did not receive much attention. Thischoice was made with a view ultimately to integrate health and FP servicesbecause of the cost-effectiveness of integrated programs. The complexitiesare discussed further in 7.08. The facilities and schemes had to bedispersed as the Government could not afford politically to concentrate theprogram in any given area. Finally the construction component wasconsidered necessary by the Government to develop infrastructure fortraining and health services. The facilities were perceived as too largeand costly by many observers. Studies done to develop appropriate designand adopt cheaper methods of construction, however, did not reveal anybetter alternatives.

7.04 The project was complex; it involved 7 donors and 6 ministries,initiated 19 schemes on a pilot basis, considerably increased the numberfield workers, and added many new activities to the functions of existingorganizations. The Project was also to assist in evolving a programorganization and in institutionalizing it. This complexity contributed toboth the slow pace of implementation and the difficulty of coordination.It also was thought to have strained the implementation capability of thenew Government. A simpler project would have been easier to implement andsupervise. However, serious implementation delays were experienced only inconstruction. Perhaps simple and smaller buildings, not so widely

- 107 -

dispersed, would have reduced civil works implementation problems and moreattention to management issues would have led to a better fit betweenimplementation needs and capabilities.

7.05 A small project might have been easier to manage but wasconsidered less desirable given the urgency of the problem and the largepopulation base of Bangladesh, while a large project provides anopportunity to influence policy and program development, it also distractsattention from some of the critical issues. For instance, a large fieldforce was quickly trained and put in place. The alternative of posting asmaller number of field workers and perfecting training, supervision andlogistics system before a large scale expansion was not followed. It isnow difficult to change structure, skills and work habits of large fieldstaff.

7.06 Was the design of the project appropriate? It is difficult toestablish causal relationships between input and output in a populationprogram. Therefore, the project components were devised in response toperceived problems and needs. The design was an act of faith in view ofthe lack of prior experience in the population field in Bangladesh. It wasfelt that doing something imperfect was better than not doing it. Thecomplexity of the project arose from the jugdement that the best approachwas to rapidly develop the sector, respond to initial problems and testseveral new schemes. In retrospect, it might have been possible to phasein the delivery system more slowly. However, it would have been - andremains - difficult to resist the temptation to set up a widely operationaldelivery system and improve it as implementation proceeds, particularlywhen there are significant levels of demand waiting to be absorbed by evenan imperfect service delivery framework. The project design did not changesignificantly from the First to the Second Project, indicating that onbalance the project design was considered the most appropriate responseafter weighing the likely options of other approaches.

Organizational Issues

7.07 At the project formulation stage, the donors felt that divisionin MOHPC would not be able to coordinate the activities of otherministries; instead an organization should be set up in the PlanningCommission. This view was not accepted by the Government which preferredto work through PCFPD. Although the National Council for Populationcontrol and the Coordination Committee were formed, coordination amongmulti-sectoral activities is weak. The field programs of differentministries involved in population activities have not been knitted into aneffective network for mutually synergistic interaction.

7.08 Integration between health and population in the context ofBangladesh has attracted considerable attention. PCFPD was formed in 1975and assigned responsibility for delivery of MCH and FP services. Basichealth care and MCH/FP services were separated functionally although theyremained under a single ministry. Subsequent to this change, the healthdivision literally gave up responsibility to deliver FP services. InFebruary 1978, the Secretaries of Health and PCFPD signed a memorandum ofunderstanding in regard to a working relationship, the main features ofwhich were to deploy medical officers from the health division of PCFPD, toestablish common facilities at union level, and to share the physical

- 108 -

facilities at thana health complexes. These decision resulted in separatecadres of field workers for PCFPD and Realth, complete dependence of PCFPDon the Health division to fill up positions of medical officers, andseparate organization at thana level. Poor quality of medical services incase of complications arising out of FP acceptance and lack ofunderstanding and cooperation at headquarters level between the twodivisions continued. In 1979, a phased program of integration was drawnup. In the first phase, medical colleges and districts in sub-divisionalhospitals were to be integrated for providing health, MCH, and FPservices. In the second phase, the thana level facilities were to beintegrated as they were developed. To Improve utilization of field staffand to conserve field resources, the Government decided to integrateservices at and below thana level from July 1980, as part of the SecondFive Year Plan. The Health Staff and the Thana FP Officers opposedintegration and began go-slow tactics reducing performance levels. Thecivil surgeon on health side asked for immediate integration at thedistrict level and the health division staff boycotted the team training ofheaith and PP staff. Through several review committees and personalefforts of the ministers the plan for integration continues to beimplemented. However, several problams remain, including conflictingsignals from some donors who prefer vertical organization and others whofavor full integration with more emphasis on health rather than familyplanning services. These problems have distracted the attention of topadministrators from the need to Improve program performance. Too muchattention has been devoted to changing structures to the detriment oforganizational processes. The Bank took an essentially pragmatic role inthis complex situation. It felt that in the Bangladesh context, MCHservices are necessary to help generate demand for smaller families butthat abrupt formal integration would create insurmountable opposition byfield staff and administrators. Therefore, moving gradually towardfunctionally integrated services was, on balance, the most practical courseof action, despite the recognized coordination difficulties. The Bank alsohas steadily urged the Government to maintain a stable structure andconcentrate on specific management and supervision problems at theperiphery rather than seek to correct these problems by nationalreorganization.

Project Implementation Capability

7.09 Three issues arose during project implementation -- delays inconstruction of facilities (para 3.45), financial uncertainties (para 3.51)and quantum of supervision effort required (para 6.04). Several factorscontribute to delays in implementing projects in Bangladesh -- economicproblems facing the country, political changes, administrativedifficulties, lack of trained personnel, difficulties in coordination andvarious approvals required by different donors. The quality of projectactivities suffered because of generally low skill levels of personnel andrigid budgeting procedures. Although actions were taken in the project totrain PPOs and simplify procedures, specific attention is needed onincreasing project implementation capability by training and systemsdevelopment and designing projects in ways which do not overburden suchcapabilities.

- 109 -

Program Management

7.10 Although the program developed a considerable infrastructure andbuilt its organizational capability, many isoues remain. Clarity oforganization goals and structure, appropriate job descriptions of staff,motivation, improved supervision and appropriate supplies are necessary forthe program to work effectively. Strengthened supervision, logistics,quality of training, coordination of activities at the field level, andmonitoring are needed for full utilization of the infrastructure (para 4.02to 4.13).

Quality of Services.

7.11 While gradually improving, the quality of services has remained aproblem. Earlier the quality of services was poor for lack of facilitiesand trained personnel. Some of these constraints continue. However, thequality of services depends both upon technical assistance and attitude ofstaff. Lack of supervision also affects quality of services. Considerableemphasis has been placed in the program on motivating staff to achievequantitative targets but no incentives have been built in the program forquality. Concerned with the initially poor quality of services forsterilization, the Government has set up a special project with donorassistance to monitor and improve its quality, which has had some success.Additionally, the Government has moved to tighten supervision of fieldstaff.

Role of Donors

7.12 The donors, in addition to providing financial support,contributed considerably towards development of the program. Populationissues were discussed in annual Aid Consortium meetings of donors. Thefunding of various donors was coordinated so as to be complementary andcoordination among donors for the most part remained excellent. however,given the nature of the program, there was not always agreement on specificcomponents. Occasionally donors pressured the Government into differentdirections and contributed to lack of consistency in program development.On the whole, however, donors played a positive role in emphasizingpopulation as an issue and in developing the program.

VIII LESSONS LEARNT AND RECOMMENDATIONS

8.01 Learning from implementation experience and evaluation of projectcomponents took place during Implementation of the First Project and wasincorporated in design of the Second Project. However, a few lessonsemerge for overall project design and implementation, as presented below.

a) A conscious choice of project complexity should be made (para7.04) and steps taken to increase implementation capabilityconsonant with that complexity. For instance PPOs weretrained before their posting and worked well. But a similarapproach was not used for the Project Finance Officerresulting in implementation difficulties;

- 110 -

b) Project elements should be pilot tested before their largescale expansion (para 7.05). Therefore, projects should alsoconsciously identify the likely future program directions andinclude support for their pilot experimentation;

c) In social sectors, development of infrastructure and programshould receive equal emphasis. Smaller and more appropriatefacilities and a more moderate pace of expansion of fieldstaff will not unduly distract attention away from criticalissues of program development (para 7.04);

d) The resident specialist is a useful position where projectsencompass the whole sector and several donors are involved(pars 6.05); and

e) Crisis response to population issues does not suffice. Thepopulation problem has to be viewed in a longer time frameand persistent efforts are required to achieve results. Thegoal setting processes and program development should takeinto account the long term nature of population program (para4.13).

IX CONCLUSION

9.01 At the time of project formulation, the availability of FPservices was very limited, health staff delivering FP services wasdemotivated, field structure was nonexistent and organizational capabilityfor program implementation was weak. Although considerable progress hasbeen made in each of the abo7e areas -- quality of services, integrationwith health productivity of field staff, and program management, theycontinue to absorb attention of program administrators. In view of thenature of these problems, it may take several more years beforesatisfactory solutions to the above problems is reached.

9.02 The Project assisted in a considerable expansion and broadeningof the program. The project was too short, particularly as some of thedetails were not finalized at the time of appraisal, but provided for asectoral approach and participation of several donors. The Bank played aproductive and positive role in the evolution of the sector.

-111- Annex 1Page 1 of 2

ANNEX - 1

Project Components Financed by Different Donors

DonorsComponent

IDA/Australia CIDA NORAD KFW ODM SIDA/GOB

Construction X X X - X X

PCFPD X -

PLAN COM - -

I RD P - X -

Ministry of Labour &Social Welfare - - - X - X

Ministry of Agriculture - - X

Ministry of Education -- -

Ministry of Informationand Broadcasting X -

Model Clinics Operation X -

Vehicles for TrainingFacilities X - - X - -

Field Workers X - X X - -

Motivational Kits - X - -

Service Statistics System - - -

Building Utilization Study -X - -

Study of ReproductiveBehaviour X -

Private Sector/InnovativeActivities X -

Training Teams - - X - - X

80 UFWC X - K - X x

NIPORT - - X - - -

Special Films X - - X -

Bicycles & Motorcycles - - - X

- 112 - Annex 1Page 2 of 2

ANNEX - 1 (Continued)

DonorsComponents

IDA/Australia CIDA NORAD KFW ODM SIDA/GOB

Ambulances - - - - X -

Visits of religious leaders X

Drug Feasibility Study X

Drug Supplies -X

Radio Feasibility Study X

Project Finance Cell X -

Christian Health Care - - X - - -

Master Plan X -

Nursing College Auditorium X - - - - -

Project Officer X X X X X -

Doctor's Quarters -- - -

-113 - Annex 2Page 1 of 2

ANNEX - 2

USE OF SAVINGS

US $ 000

Appraisal Actual RemarksBase Coat

A. Original ProjectConstruction 16,671 11,843

Non-Construction

PDFPD 547 267

PPs of PLANCOM 482 390

IRDP 1,747 1,059

Ministry of Labour &Social Welfare 1,456 1,358

Ministry of Agriculture 146 205

Ministry of Education 536 187

Ministry of Information &Broadcasting 2,085 2,485

Ministry of Health &Population 4,913 10,313

BIDS 433 381

Private Sector/InnovativeActivities 350 1,006

TOTAL A 28,439 29,494

B. Utilization of Project Savings (Nov. 78 estimates)

Retraining of Field Workers 317 360

Salaries of 8000 FWAs 3,840 - included in MDHPP

80 UFWCs 3,257 4,269

Support to NIPORT 310 255

Purchase of FP films 10 17

Support to Voluntary Agencies 125 - included in

private sector

Purchase of 5,350 bicycles and300 motorcycles 621 571

-114 - Annex 2Page 2 of 2

ANNEX - 2 (Continued)

Appraisal Actual RemarksBase Cost

Purchase of 17 ambulances 272 -

Training of Additional PPOs 57 58

Study Tours of religious leaders 60 75

Drug Feasibility Study 50 20

Supplies of Drugs 400 NA

Radio Feasibility Study 30 14

Strengthening of PFC 100 33

Christian Health Care Project 50 NA

Professional Fees for Master Plan 158 68

Support to Private Sector 230 NA

Construction of auditorium inNursing College 100 NA

Functional Analysis ofFP/Realth 30 10

Construction of Doctor'sQuarters 1,600 NA

Extension for another yearof schemes 3,518 - included in the

schemes

TOTAL B 15,135 5,750

Project Officer 346 346

- 115 -

ANNEX - 3

Field Workers of PDFPD

Dates Employed FINANCED BY TotalFWAs KFW UNFPA IDA NORAD TOTAL BALANCE1 FPAs Field

Workers

May 1976- Nov. 1976 1997 197 1800 - - 1997 - 1368 3365

December 76- Dec. 1977 5900 3700 1800 - - 5500 400 2850 8750

Jan. 1978- March 78 10554 3700 1800 2527 2527 10554 - 7298 14852

April 1978- Dec. 1978 13500 3700 1800 4000 4000 13500 - 7892 18392

January 79- June 1979 13500 - 1800 4000 4000 9800 3700 NA NA

lBalance for Government of Bangladesh financing.

SOURCE: IDA Supervision Reports.

Amfex 4- 116 - Page 1 of 2

ANNEX - 4

Construction Schedule for Facilities

Average Period in Months

Facility Jan. 1977 Issue of Actual Due date Actual Date of Totalto tender -worker order-invitation- of completion commission

of work completion date -ing

NursingCollege (1) 1.0 5.0 13.0 11.0 16.0 11.0 59.0

FWVTS (8) 17.1 8.4 1.8 14.4 19.8 2.9 64.4

FTTHC (8) 13.9 17.1 3.3 11.3 21.6 5.0 72.2

MFPC (4) 8.5 21.5 - - 28.5 2.8 61.3

- 117 - Annex 4Page 2 of 2

ANNEX - 4 (Continued)

Completed by Quarter

1980 1981 1982 1984

4 1 2 3 4 1 2 3 4 1 2 3 4

Number of NursingCollege - - 1 - - - - - -

FWVTI - - 3 1 1 - 3 - - - -

FTTRC -- 1 - 2 - - -5--

MFPC 1 --- 1 1--- -1--

SOURCE: IDA Supervision Reports

Annex 5: Disbursement of Other Donors(First Population Project, Credit

No. 533-BD)

Amount claimed for reaibursenient/diabursement from differentdonor agencies upto 30.6.1983 (in thousand US S)

- - - - aaaaaaaaaaa - - -- - - a a fla a - a - C C - a . - - .

Amount claimed ror reimbursement/disbursement Percn.

Loan/ - - a a a - a - a * - - * a a a a a * a a a a a a * a a * a * a a * a a a a * * a * * tageAgency Loan! Equipment Recurring Innovative Technical

grant and local projects Assistancevehicles expenditure

-- a a -. a a - a a a a a a a a a a a a a a a a a a a a a a a a a a a a a 0 a aM. a* 0 M a0 0 go ap a0 a aa

IDA & 17320.00 3007.16 5749.25 1006.08 1226.86 2227.17 5808.61 19025.0 100 %Australia

NCRAD 8032,00 83.49 1818.41 - 137.60 703.72 3694.80 6438.01 80 %

CIDA 1746.00 70.95 891.34 a 148.31 * 1110.60 64 %

ODM 2520.00 17.34 - a 49.20 961.20 1492.26. 2520.00 100 %KFW 6577.0 1525.67 4924.76 - 126.57 a a 6577.00 100 % *

SIDA 3000.00 648.32 309.94 a 759.14 272.17 1010.43 3000.00 100 %

-a aa - -a - a -aaa- - - a a a w a - a a a a 0 -a a 0 a a a a a 0 a a a0 a a a S a - a a a a0 a a a

Crand*Total 39195.00 5352.92 13693.70 1006.08 2447.68 4164.26 12006.10 36670.74 98.66%

Excluding GOB.

Source: Project Finance Cell, Population Control Wing

* 00 '

SI 0 A

Adjustment against SIDA Grant upto 50.6.83 (In '000 US $)* - a* ----- - - *a* * *- - - ** - **b ** -a - - - - -- a --- a a a .. .

Amount claimed for reimbursement/adjustment* * * a a a * * * a a a a -- * a a a a - - a * - - a a a

Ministry/Division Equipments Recurring Technical F.W.C. CivilWorks Total& Vehicles local Assistant

expenditurea a a a a a - a a a a a a a a a a a a - - a a * -a * a a a * - a * a a a a a * * - * *

Ministry of Education 12.79 169.13 4.95 * a 186.87

Ministry of Agriculture 64.13 140.81 * * a 204.94

Ministry of Health (8PDU)Local Consultance (services) * a 754.19 a a 754.19

Women's Welfare Division(Civil Works Canstructionof Training Centres) *259. 259.66

Civil Works (Balance afterClaiming 80 % from IDA a - a * 750.77 750.77

Purchase of Motor cyclesand bicycles 571a40 * * * a 571.40

F.wC. * 272.17 - 272.17

Grand Total 648.32 309.94 759.14 272.17 1010.43 3000.00- a a a a a a a a " a a a a a a a - a r a a a a a a a * a - a a a a a *- * * a * a a a a a a a a a a a a a *a

Oowb

K. F. W.

Reia,bursement/disbursemsnt on account of various Projectfinanced by K.F..J. upto 30.6.83 (In thousand US S)

. . .- - -- - - - - - .- - - - - - * *- *-. * * - * * a * * -- - - -

Amount claimed for reimbursement/disbursement on

- - - - .- - - - - Totalministry/Projects Equipments Recurring Innovative Technical F.W.C. Civil Works

& Vebbeles local project Aseistantexpenditure

, . . - . . . . . . . .a . . . ..... - -- -*- * - -a -Ofal * * * * *. * * * * * * * *

"other's Club 67.37 323.00 . . - * 390.37

Labour 29.77 85.57 11.14

Women's Vocational Trg. 38.24 554.61 * 592.85 I

FWV Training School &Vehicle for Nursing College 182.27 . * 182.27

r.W.A. (PC & FPDiviason) - 1951.07 . - 3951.0?

Hotivation Kits 350.74 . . . a 350.74

Service Statistics(PC & VP Division) 125.00 3.07 1 48. * a76

PC & r P Division 14.00 - * * * * . i4.0

Internsh Evaluation "7.44 * * * *44

D.OD.S. Kits 718.20 * * 716*20

Project Officer * * 78*00 * .00

.. . w . . V

I52M.67 4924.76 * 7 126.57 - 6577.00a a a a a a a a a a a a a a a a a a wea a a a a a * * * a * * * a * * a * * * a a * a a * * * a * a * * * * a a * *

C 1 0 A and 0 0

Reibursement/Disburse.Icnt on account of various ProjectsFinanced by CtDA, G)M upta 30.6.83 (in thousaw US 8)

-------- - -.... e- -aS -e m -. .. - -e - .. .. - -

V Amount claimed for reiabursement/disbursement.Ministry/Project * * * - * * m * * * * em * * * * * * * . .0. . . a . . . . . .

Equipments Recurring Innovative Technical F. M. C. Civil Total& Vehicles local Projects Assistance Works

xpwendture

EC U (Planning Commissionconsultathon fe) * * 26.27 * 28.2?I D P (L.G.R.0.C) 70.95 691.34 * 57.04 1059.3

Project Officer - * 23.00 233.00em ~ ~ I -M M- - -w aM ear a0 mM 40 a amwaam mc

Total 70.9 691.34 - 148.31 * * 1110.60

96 ...P...B.0 ..

File for PapulationControl Division 17.34 e - m a17034

Civil Marks * * * a a 1492.26 149226

Engineering Consultant * * a 12.20 * * 12.20

f*w*C* * * * a 961.20 m 261.20 ame

Project Officer * 7.00 MOO5.0 *a* * a* * a a a * e * * a a ae ae on em ** a -ma e - e * a a * * a a wee

Total 17.34 - a 49.20 961.20 1492.26 2520.00 o%------------- * a e * a a * a * - m * e a a a a * a a e a * a a e a a - - a - a - a - a a * a a a * a a a a

I

MORAD

Reimbursement/Disburse.ment on Account of various projectsFinanced by NORAD upto 30.6.8 (In thousand US $)

. . -.-. . . . . ... a . . . . . . .. - C ".* - a * O* * a * - * - * w * * -* * * e - * *

Amount claimed for reaibursement/Disbursementa .... a - a a a a d * a *a * * -a a a * a - * a ** ** Remarke

Project/Kinistry Equipments Recurring Innovative Technical Civil& Vehicles local Projects Assistance Works

expenditure.-. - a . .. . a . .- . . . . ... - * . --- - a - - * * *a* a a a a * ** ** ** * * * a * * * *a*

Civil borks * * a * 3694.80 3694.80 Includiigcost of cemnt

Engineering Consultant . a a 36.60 a a 36.60

Ir.w.c. aa701,72 a703.72

19 FPA Training a 359.95 * a * * 359.95

FNA (PC & FP) DiviLsion * 1265.60 * a a * 1285.60

UIPORT 83.48 172.66 a a a * 255.14

Project Finance Officer * * a 101.00 M a 101.008 a a a a a a a a a a - a a a a a a a a a * a a a a a a a a - a a a a a a a83.48 1818.61 * 137.00 703.72 3694.80 6438.01

- -- a--a aa----a--a- - a--a-a--a--a--a-aa-aa-aa-a--a--a--a-aa-a -- a -*a **a aa -a - a * a

0

. o'

IDA & AUSTRALIA

Amount claimed for reimbursement rrom IDA & Australia upto 30.6.83(In thousand US 5) (First Population Project, Credit ko.533-60)

-. - - - - - - - - - - - - - - - - - - - ----- - * * f -* - - - - -w - - - -* - --- - - *Amount claimed for reimbmrsement/disbursement

Project/Cinistry civilC Equipments Technical Recurring Innovative Total' RemarksWorks & vehicles Assistance local Exp. Projects- - -- -- -- -- -- - - a a - - -- - - - - - - - a a - a - a Q - a a a a a a a a . - -0 a a a af .0 M a a-a

Construction 9808.61 - a 367.79 - * 6176.40PC&FP Division (including 48.23 115.40 103.26 - 266.89 Added cost ofI SR T) .ana

Planning Commission - - 32.43 61.41 295.66 M 39.72Ministry of Information 1552*9 932.50 248509and BroadcastingModel Clinic (Veh. & IRC) a a 316.71 a a 316.71Nursing College a a a * * *T.H.Ca. a a 1028.71 a a * 1028.71B.I.D.S. - - 28.49 67.55 284.93 " 360.97Private Sectors and 0 1006.8 Added TVInnovative activities Ia6*0 *FWC a 2227.17 - 105.16 * * 2332.33F P 0 Training S a a 58.20 a a 58.20F.W.As a a a * 4021.00 4021.00Ulemas * a * 75.01 * a 75.01Drug feasibility a a a 19.94 - a 19.94Radio feasibility a a * 14.28 a a 14.26Strengthening of PFC 1 a a 12.03 21.13 . 33.21Fee for Master Plan * a a 68.00 a . 68.00functional Analysis a a a 5.88 4.54 a 10.42Services Statistics a a a 149.14 86.03 a 235.17Project Officer a * * 107.00 - a 107.00

0

5808,61 2227*1? 3007.16 122686 5749.25 1006*08 19025.13 a*a a a - a a at a a - a a a a a a - a a a a a a a a a a a - - a a6 a a a a a a a a at. at - - - - - -a a a a a -a a a -% a;aJ

Annex 6: Bangladesh Population ProjectDisbursement Provile

App aisal Actual Actual in PERCENT

$M _ % $M _ % % of Appr. 10 20 30 ' 0 50 60 70 80 90 1002/75 Board Presentation 2/2/75 -

6/7510.10 0.7 9/75 Effetive Le 925/750.54 3.6 0.01 0.1 3.7 12/750.39 5.9 0.01 0.1 2.2 3/76 '1.32 8.8 0.28 1.9 21.2 6/762.48 16.5 0.34 2.3 13.7 9/76 N

2.82 18.8 0.83 5.5 29.4 12/763.27 21.8 1.23 8.2 37.6 3/774.09 27.3 1.29 8.6 31.5 6/774.84 32.3 1.32 8.8 27.3 9/775.87 39.1 1.81 12.1 30.8 12/777.13 47.5 1.83 12.2 25.6 3/788.60 57.3 2.01 13.4 23.4 6/78

10.13 67.5 2.32 15.5 22.9 9/7811.53 76.8 2.85 19.0 24.7 12/7812.81 85.4 3.26 21.7 25.4 3/7913.19 91.9 3.98 26.5 28.8 6/7914.34 95.6 4.76 31.7 33.2 9/7914.59 97.3 5.06 33.7 34.7 12/79 Appraised o le ion Date 12 31/79 %14.77 98.5 6.19 41.3 41.9 3/8014.94 99.0 7.68 51.2 51.7 6/8014.94 99.6 9.43 62.8 63.1 9/8015.00 100.0 9.80 65.3 65.3 12/80

10.38 69.2 69.2 3/81 Appraised losin Date 12/3110.73 71.5 71.5 6/8110.77 71.9 71.9 9/8110.84 72.3 72.3 12/8110.92 72.8 72.8 3/8211.09 73.9 73.9 6/8211.57 77.1 77.1 9/82 Closing Da e 9/311/8212.56 83.7 83.7 12/8213.59 90.6 90.6 3/8315.00 100.0 100.0 6/83 1_ (Dat of F nal Payment 6/30/ 3)

- 125 -

Annex 7: Training Output

Category No. of Schools Annual Output

Family Welfare Visitors 12 600

FWA 19 Retraining

Doctor 8 1,200

Medical Assistants 8 800

- 126 -

Annex 8: Achievement of Multi Sectoral Components

Targetted and Actual Number of Acceptors Recruited by the Multi SectoralComponents during the First Project

Total 1975-80Target1 Actual

1. Women's CooperativesNumber of Cooperatives 190 680

Total acceptors recruited (000s) 5.6 8.5

2. Mothers' ClubsNuaber of clubs 760 760Total acceptors recruited (000s) 10.6 NA

3. Women's Vocational TrainingNumber of trainees 3,380 3,400Total acceptors recruited (000s) 33.8 54.0

4. Labor Welfare CentersNumber of Centers 3 3Total acceptors recruited (000s) 19.8 19.0

5. Mobile Education TeamTotal acceptors recruited (000s) 16.6 14.0

6. Use of Agricultural Extension WorkersNumber of Villages 1,400 1,900Total acceptors recruited (000s) 99.0 93.0

1 Targets were set for the period 1975-78

- 127 -

Anex 9: Organization Structure of theHealth and Population Program

ORGANIZATIONAL STRUCTURE OF THE HEALTHAND POPULATION PROGRA..INE

MINISTEROF HEALTH & oTHER 41INISTER OFPOPUI, ATION MINISTRIES PLANNINGCONTROL GII

MINISTEROF STATEIAI

SECRETARY SECRETARY SECRETARIES CHIEF SLCRETARYHEALTH DIVISION POPULATION 4ND DIVISIONS STRUCURE EXTERNAL

FAMILY PLAN.NING DIVISIO RESOURCEUIVISION PLANNING DIVISION

COMMISSIONJOINT SECRETARIES JOINT SECRETARIES JOINT

StCRETARIES CHIEF.HEALIN AND(o0 I POPULATION

iTH * PLA"1'flGDIRECIOR DIRECTOR GENFRAL SECRETAPY(PREVENTIVE) PC & ID DIRECTORATE 11sKLCTOPS

RFGIONAL PtPVLATION ASSISTANTDEPUTY PROGRAMME CHIEF EXTERNAL

OFFICERS EVALUAION UNITI I4 CIVIL SLkGEON * TECH1wI-At. POPULATION oisTit

C OFFICER CONTROL OFFICRSBADITIONAL CIVIt IMEDICALs & F.P.

SCRGEONS OFFICEIt CORDWATIO0I IcannaT

HEALTH MEDICAL PC & FP THANAADMINISTRATOR OFFICER OFFICERS OFFICERS oSTRICT

MCal FP CooDINATIONICALOFFICERMTTEE

rCMEDICAL ASShTANT FAMILY TAA

IV I DASSITANTIHEALTH FAMILY FAMILY 1UNION UDoa

jI%SECTOR WELFARE PLANNING OFFICERS CountVISITOR ASSISTANTCOMM

(PARAMEIICS)

IFAMILY WELFARE EAILY ELRECIL~ 4~4~(~j5 ~ASSISTAhTS COUNCILI(HORKERS (.WALEIt=u- -* sWEMALEz COWMITSER

1, I.. . . 1* h' l, '.pi , lq WI "H

*frnostue of Wnterne 4 SMeOMWrfus. Ag.*cltut. Labour & So.e-1teast Logo Gove"aot swai 0swoepent & Coopearei so.1"a's

SeaVe M6nie'Y of Haab 4 A.asusinConto dnme Govwmt.

- 128 -

ANNEX *1

Facilitis.-nd.Saff in POMulation Proaram

** - * * W M * * ft *- * * M- * * * *.. *

racilities About 1974 About 1982

Sterilization 447

I U D 426 clinics 2,449Pills/Condoms I

Commercial outlets - 70,000

Porsonnel

f1edicel Personnel 52 (in FP alone) 6,200

Medical Assistants * 3,700 (by 1985)

Family Welfare Visitors 457 3.500

F PA 2 4,900F WA ( 1512,350

Parttime workers 6,000 *

* - * * * * * * * * m 0&m * *M ft M 40 *** *

- 129 -

ANNEX -1

Financial Aeources of Population Program

(in million US $)- 4- * * *o * * * Ob G * * * * * * b * O * *

AllocationYear w - *D * *t Op UP * * t Ob Utilization $ of

Govt. Aid Total

1973-74 2.0 2.7 4.7 2.7 57.1

1974-75 3.2 2.0 5.2 4.1 79.6

1975-76 5.6 7.4 13.1 10.9 82.9

1976-77 10.5 4.0 14.4 12.9 69.7

1977-78 11.5 9.9 21.3 18.0 84.6

1978-79 12.7 18.5 31.2 22.8 73.0

1979-80 14.7 24.8 39.5 NA NA

.w.. -w M M o o - w M a M d * *0M *. m M a 0 d t In s W * f

Sourcel Planning Commission - Second Five Year Plan of Bangladesh.

- 130 -/*

ANNEX - 12

Acceptance of selected VP Mathody

(in thousands)

. . . . . . . . . a a . a * a * * * * * * * * * * * * * - a * * * *

Vasec- Tube- Injec- Condom Pills tako Couple

tomy tomy tion pieces cycles Vials pr ofprotection

. . f a . . . . a * - f * * W a M - a0 M * * * * a f a * a a * * a * a * a a a* .

1972-73 0.2 0.1 * * 15.7 20.J 139.8 72.8 216.0

197374 0.4 1.0 V 27.6 11.2 441.0 99.7 183.0

1974-75 14.5 4.7 - 0.7 50.4 9.3 1,288.5 99.1 266.7

1975-76 37.8 11.1 1.9 4.4 77.8 54.7 5,943.1 124.7 1,064.4

1976-77 75.1 41.3 2.6 6.7 59.4 35.3 4,638.6 59.5 834.4

1977*78 32.6 44.7 4.5 6.1 40.6 65.4 7,487.3 32.2 1,242.7

1978-79 24.7 81.7 11.0 4.4 22.6 57.5 7,120.6 39.1 1,168.8

1979-80 27.5 171.3 26.00 10.5 21.8 58.4 6,227.7 39.1 1,205.8

1980-81 26.0 232.5 112.0 28.0 41.6 67.0 8,103.4 59.8 1,704.5

* The basis for calculation of couple years of protection (CYP) is as followes

I CYP = I Vasectomy a I Tubectomy a 1,33 IUD - 0.33 Vial Emko a 3.33 Injection/MR

120 pieces condoms m 1) cycles oral pieces.

Source4 MIS Directorate, PCFPD.

- 131 -

Annex 13: A Comparison of Contents of First and Second Project

Included inFirst Project Second Project

Item Appraisal Subsequent Appraisal ReportReport Additions

ConstructionNursing College 1 -FWVTI X -FTTC + 24 Subeentres - XMFPC X --UFWC - XDoctors Quarters XTraining School for MAs - X

Non-ConstructionTraining X - XField Workers X -PCFPD, MIS X - XPPS, Planning Commission I -IRDP X - XMinistry of Labour and

Social Welfare X -Ministry of Agriculture X -Ministry of Education X -Ministry of Information &

Broadcasting I - IMOHPP - IEM Unit X - IBids X -Health Education Bureau - IPvt. Sec./Innovative Projects K - XTransport X -

Drugs - XProject Implementation I -Project officer I - K

BANGL ADESH

POPULATION PROJECT LOCATIONSIN D l A

ThakurgOn D PHYSICAL FACILITIES•

26 "NUHSING COLLEGE

r NiIphaimar, o0 MODEL FAMILY PLANNING CLINtCFAMILY *ELFARE VISITOR TRAJNING SCHOOL

THANA RURAL HEAL1H COMPLbX AND THREE HEALTH SUB--CENTERS

ngpif PILOT SCHEME THANAS.

1) RURALWOMANS lUNCIIONAL IITERACY 2 TRAINING OF MODEL FARMER ANDCOOPERATIVEMANAGERS

(31 MOTHERS CLUS 141 USE OF AGRICULTURE ASSISTANTS

(Si MOSILE POPULAlION EOUCATION TEAMS 6D MOTIVATION KITS FOR FAMILY WELFARE WORKERS

f7 USE OF AUDIOVISUAL VANS

<81 LABORWE.FARE CENTERS

91 WOMENS VOCATIONAL TRAINING

1HANAS WITH 'ON'ENTRATION OF SCHEMES 1 TO 7

22

-25t C o~a-2* SvRSYl 25'

s LHET

YMENSNG

-Øl' Kashm

Gotor

G r

TNGAI

rr

Dattttnagå

Ra-Laksam~<

23 ~~~~oarnada t.aksh impur hoony ~

Pdtfrbo - OosMaIildt

calla

Jiba "Aon

Ma1 CHiTTACAL~ ~

2r j T2r-

Bay ohf Beng al

89'____ Roads Cox's Bazar

-'~~----- Roads under construction(<Not alt shown) Jhilonja 1r.DIA DHAKA.r -/ Railwaysi N i ARivers

BURMA Deisrici boundorhas-- International bousndaries

BANG ADE SH0 l S 20 30 40 0

*M2es 2r-

Boa oo eego n2 a0

Soy ofSengo O 20 40 -IIS PPA MAP 15 BASED ON 18RD) 10939R.-a n a K,In.e** JANUARY' 1975 MA? H AS EEN UPDA TED TO*

RFFUICT NAME AND POUITICAL CHANGESSsil.ANKA

wanes 90° 91r9

BANGLADESH

SECOND POPULATION AND FAMILY HEALTH PROJECTl N D l A PHYSICAL FACILITIES

0 1 HANA HEALTH COMPLEXES

26' J + MEDICAL ASSISTANTS TRAINING SCHOOLS(MATS)THAK TuAON : \1>Au \-0 FIELD TRAININC, FACIUITIES FOR MATS

-76'~ FWA TRAINING CENTERSRANg L A G4*4-e WOMEN'S VOCATIONAL TRAINING CENTERS4 FWV SCHOOL EXTENSION. BARISAL

A RAiNING FACILITIES IN PCFPDHEADOUARTERS

KRAN et nFAMILY WELFARE CENTERS4.4f4R - RiVERS

* " 4THANA BOUNDARIESDIVISON BOUNDARIES

SUBDIVISION BOUNDARIES* " DIST RICT BOUNDARJES

cr" INTERNATIONAL BOJNDAR!ES

i0 LA sRIMM .. 4W ~ri7,1I -

a- Gv rAxt44 S

n AeT e N wt Aa u A AMNAAH BA0(A AJ PA CN44 3RMAA

nuy GADAR

r ~ ~~~ D^.l A-Nl

TA~ o, slig V ONGA,i4 0Å4.4,~44 * 44444484 GA ATARtAO, 4, A7..1CAUNANÖA1,444 t ~ -'c' 4 4~~

GAm, M 0-~4P'CA r4TA.4 om. fÅ34 _ros C,

uu-.",RA KAMAMA4 TIIL4

OA0 RAGR' i - - o 9 - A A

un R44R4 A <A ',**

o ,*4 FRA 4-1<~ 0

rkVIN.GA DkAh#ft.4*f IJÅNJ

SA. Nu**44 't.I A ~ I'4 A

户

万

：价

9ýr 911. 9ýr

BANGLADESHINDIA THIRD POPULATION AND FAMILY HEALTH PROJECT

Number of UHFWC Facilitiesper 100 Unions in District.-

.26* Less then 40

40-50

50-60

More than 60

District Headqvarters District Boundaries

Division Heodquarters Division Boundaries

National Capital International Boundaries

SERPLI

25* NE SYLHETNAOGýON SLINAMGANJ

i LpuRA

1ý5,N 0 A 9 MJ

MYkEýýNGH

RAJSHA lSERA.10 HARldANJ DAZARTANG ýL

l HQRGýNJNýfäff

QAZIP

-24* PA8NA DA~ - 24*-INDIA

D x

付