Document of rh

The World Bank

FOR OFFICIAL USE ONLY

Report No. 2762-IN

INDIA

STAFF APPRAISAL OF A NUTRITION PROJECT IN TAiMIL NADU

March 27, 1980

Population, Health and Nutrition Department

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

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CURRENCY EQUIVALENTS

US$1.00 = Rupees (Rs) 8.40 /1

GOVERNMENT OF INDIA FISCAL YEAR: April 1 - March 31GOVERNMENT OF TAMIL NADU FISCAL YEAR: April 1 - March 31

MEASURE (METRIC SYSTEM)

1 meter (m) = 3.28 feet (ft)1 kilometer (km) = 0.62 miles (mi)

/1 Until September 24, 1975, the Rupee was officially valued at afixed Pound Sterling rate. Since then it has been fixed againsta "basket" of currencies. As these currencies are floating, theUS Dollar/Rupee exchange rate is subject to change. Conversionsin this report have been made at US$1.00 to Rs 8.40 which repre-sents the projected exchange rate over the disbursement period.

FOR OFFICIAL USE ONLY

ABBREVIATIONS

ANM. - Auxiliary Nurse-MidwifeBDO - Block Development OfficerCARE - Cooperative for American Relief EverywhereCHW - Community Health WorkerCNC - Community Nutrition CenterCNW - Community Nutrition WorkerDANIDA - Danish Agency for International DevelopmentDCO - District Communication OfficerDDO - Divisional Development OfficerDNO - District Nutrition OfficerGOI - Government of IndiaGOTN - Government of Tamil NaduHRWD - Department of Highways and Rural WorksHSC - Health Sub-CenterIDA - International Development AssociationJCC - Joint Coordinator for CommunicationsLHV - Lady Health VisitorMCH - Maternal and Child HealthMO - Medical OfficerMPHW - Multipurpose Health WorkerNNMB - National Nutrition Monitoring BureauNSS - National Sample SurveyPHC - Primary Health CenterPEN - Public Health NurseFWD - Public Works DepartmentSAHSC - Sri Avinashilingam Home Science CollegeTNAIC - Tamil Nadu Agro-Industries CorporationTNNS - Tamil Nadu Nutrition StudyTNO - Taluk Nutrition OfficerTWAD - Tamil Nadu Water and Drainage BoardUNICEF - United Nations Children's Fund

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

!

INDIA

STAFF APPRAISAL OF A NUTRITION PROJECT IN TAMIL NADU

Table of Contents

Page No.

I. Introduction ............................................... ....... I

II. Nutrition in Tamil Nadu ................................. 3

A. Current Five-Year Plan ................. .......... . 3

B. Nutrition Conditions and Programs ................ .. 4

III. The Project . ........................................... .. 8

A. Goals, Strategy, Design and Objectives ............. 8B. Location ... . .......... 10

C. Phasing .............................................. ....... 10D. Description ........................................ 11

1. Summary and Main Features .................... 112. Detailed Project Features . ............ ........ 13

IV. Project Costs, Financing, Procurement, Disbursementand Audit ....................... ...................... 36

A. Costs and Financing ...................... .......... 36

B. Procurement . ....................................... 38

C. Disbursements .............. . .. . . ................ .... .0 39D. Accounts and Audits ....... o ...... o .. ....... 40

V. Project Organization and Management .... o......... .... o 40

Ao Overall Coordination ..o ............ o......... .oo..o 40

B. Programming and Budgeting ... .... .......... 41C. Project Execution ....... ooo ........ 41

VI. Justification and Risks .. o....o.. .. o. ....... .... .oo 42

A. Justification . ... ............. . .42

B. Risks ...... o ........-........ 44

VII. Recommendations ... . .. ................. ...... ..o. ... .. .. . 45

This report is based on the findings of an appraisal mission to Indiain July/August 1979. The mission consisted of: Mr. J. Greene, CPS (Chief),Mr. R. C. Carriere (CPS), Dr. K. V. Ranganathan (EDI), Mr. 0. Knudsen (CPS),Mr. E. Thomson (Nutrition Administration Consultant), Mr. S. da Cunha andMs. H. Perrett (Communications Consultants), and Mr. C. Jhabvala(Consultant Architect). A post-appraisal mission was made in January 1980by Mr. J. Greene and Dr. K. V. Ranganathan.

Table of Contents (Cont'd)

ANNEXES

1. Estimated Base Costs by Component and Expenditure Category2. Estimated Yearly Base Project Expenditures by Category3. Proposed Allocation of Credit4. Estimated Schedule of Disbursements5. Summary of Key Implementation Actions by Component6. Simplified Organizational Charts of Project Units

a. Nutrition Delivery Services Componentb. Rural Health Services Componentc. Project Coordination and Communications Arrangementsd. Project Evaluation Arrangements

7. Yearly Project Base Cost Estimates by Componenta. Nutrition Delivery Servicesb. Rural Health Servicesc. Communicationsd. Monitoring and Evaluatione. Project Coordination

8. Selected Documents and Data Available in the Project File

TABLES

1. Project Cost Estimates by Expenditure Category2. Project Cost Estimates by Component

MAP IBRD - State of Tamil Nadu: Project Districts

INDIA

STAFF APPRAISAL OF A NUTRITION PROJECT IN TAMIL NADU

I. INTRODUCTION

1.01 India remains a leader among developing countries in recognizingmalnutrition as a major concern. Initial Government interest from inde-pendence in 1947 intensified as a result of both the 1966-67 Bihar famine andthe growing recognition of the potential links between malnutrition and mentaldevelopment. Beginning with the Fourth Plan (1968-73), the Government ofIndia (GOI) began to expand feeding programs as an immediate way to helpbridge the nutrition gap, principally of children and pregnant and nursingwomen, while longer-term food production and income-generating measures tookhold.

1.02 Government concern for the nutrition and health of pre-schoolchildren was further reflected in promulgation of a "National Policy forChildren" in August 1974, followed later that year by establishment of aChildren's Board with the Prime Minister as President. The Government alsoincorporated supplementary feeding of pre-school children in the Minimum NeedsProgram which began under the Fifth Plan (1973-78) and includes nationaltargets for elementary and adult education; rural health, water supply, roadsand electrification; rural housing for the landless, and improvement of urbanslums.

1.03 India's commitment to nutrition has manifested itself on otherfronts as well. The National Institute of Nutrition, the Indian Council ofMedical Research and the All-India Institute of Medical Sciences are inter-nationally recognized for their work on nutrition problems. Moreover, theGovernment has undertaken a number of initiatives in such important nutritionareas as food processing and fortification. These efforts have includeddevelopment of balahar, 1/ a cereal-legume mixture developed for publicfeeding programs.

1.04 Public feeding programs steadily have expanded over the past 10years and now reach an estimated 20 million beneficiaries. Around 13 millionprimary school children receive balahar in a mid-day meals program for whichthe Cooperative for American Relief Everywhere (CARE) donates soy-fortifiedbulgur wheat. Other nutrition programs with feeding components include:(a) the Applied Nutrition Program, aided by the United Nations Children'sFund (UNICEF), which seeks to increase food production while providing nutri-tion and health education directed at nutritionally vulnerable groups; (b)the Special Nutrition Program, assisted by CARE, which provides supple-mentary feeding to mothers and pre-school children 2/ in urban slums, sociallydisadvantaged rural families and regions suffering repeated droughts andfloods; (c) the Food-for-Work Program, with World Food Program support, which

1/ A Hindi word meaning "child's food."

2/ Defined as children under six years of age.

reaches around 1.5 million beneficiaries in 16 states and territories, and(d) the Integrated Child Development Services program which on a pilot basis,combines health, nutrition and education measures for pre- and school childrenand their mothers using mainly local commodities.

1.05 The Central and State Governments share the costs of most feedingprograms. The GOI pays for the purchased inputs in balahar and its processingcosts. The states generally meet freight, port handling, storage and localtransport charges for donated commodities. They also provide local foods tosupplement balahar and the costs of cooking the ration and serving it tobeneficiaries. Over the last few years, the combined central and stategovernments' annual contribution to such feeding programs has risen substan-tially; for the CARE program alone, that support has almost tripled, risingfrom an estimated US$30 million in 1976 to more than US$81 million in 1979.The economic value of the donated soy-fortified wheat for India's schoollunch and pre-school feeding programs is currently estimated at around US$76million yearly. Inclusive of distribution, storage and administrative costs,the total economic cost of these feeding programs is estimated at more thanUS$160 million annually.

1.06 Recognizing that such feeding programs alone cannot provide anadequate solution to nutrition problems, the GOI's current nutrition strategycontinues to emphasize food production, income generation, and nutritioneducation accompanied by processing and fortification programs and morecareful targeting of supplementary feeding activities.

1.07 While national concern about nutrition is reflected to some degreein programs and priorities of all the Indian states, some have been moreaggressive than others in trying to identify the main causes of malnutritionand deal with them effectively. Among those, the southern state of TamilNadu is particularly prominent.

1.08 Tamil Nadu's population was estimated at 46.8 million in 1979, around7.4% of the estimated total Indian population. Almost one-third of its popula-tion lives in towns and cities, making Tamil Nadu the country's most urbanizedstate. It is also the third most densely populated state after Kerala andWest Bengal.

1.09 A relatively small agricultural sector accounts for about 40% ofstate income; manufacturing accounts for about 20% of state income. Almostsix million hectares, just under half the state's total land area, is culti-vated; over 20% of the cropped area is sown more than once yearly. Ricepredominates. It accounts for 35% of the cropped area, (around 80% of whichis planted in high-yielding varieties) and for over half the state's foodgrainproduction. Rice yields per hectare in Tamil Nadu are among the highest inIndia and hover at around twice the national average. Groundnuts account for13% of the total cropped area, followed by sorghum and millet at 11% each.Tamil Nadu's average compound growth rate of 2.7% yearly in cereals productionover the period 1964/65-1977/78 ranks ninth among Indian states. Its averageannual increase of 3.9% in pulse production, despite wide yearly fluctuations,

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ranks second only to Rajasthan over the same period. Overall food outputhas more than kept pace with the estimated 1.6% rate of natural increase inpopulation.

1.10 Tamil Nadu has the most fully developed irrigation potential of allthe Indian statiq. Surface and ground water irrigation covers around 75% ofthe state's potential of an estimated 3.7 million hectares. That percentageof coverage is almost twice the national average. In fertilizer consumption,the state ranks second only to Punjab with consumption per hectare of croppedarea at 37.1 kilos. Despite these high rankings in yields, fertilizerapplication and irrigation promotion, Tamil Nadu ranks fourteenth among 22Indian states in average foodgrains production per capita 1976-77 to 1978-79,because of the relatively small area under foodcrops production and the highdegree of urbanization of the state.

1.11 Agriculture continues to employ around 60% of the labor force,although an estimated half of the agricultural labor force is landless.Farm holdings are generally small due to high population density in ruralareas. Among Indian states, Tamil Nadu ranked ninth in per capita income,from 1973-74 to 1975-76, at an equivalent of US$118, according to the 1978report of the Finance Commission.

II. NUTRITION IN TAMIL NADU

A. Current Five-Year Plan

2.01 The State's main objectives for its current five-year plan endingin 1983 are to: (a) reduce economic and social inequalities of opportunityand income while substantially raising incomes and employment; (b) eliminatethe worst forms of poverty and appreciably reduce the numbers of those belowthe poverty line; 1/ and (c) improve the quality of life for weaker sectionsof the population, principally through the Minimum Needs Program, whichincludes basic services and rural housing for the landless. In conformitywith those objectives, the current plan stresses agriculture, rural develop-ment, irrigation and power. While decreasing as a share of previous planexpenditures, outlays for social services have almost doubled in absoluteterms since the last plan.

2.02 Through its plan program, Tamil Nadu projects an overall annual 3.8%growth rate in its six major sectors during the plan period, accompanied bythe creation of around 2.7 million jobs, which would reduce unemployment toaround 1.1 million persons, or around six percent of the labor force. Villageand small industries, fisheries and animal husbandry programs along with

1/ In 1977 an estimated 52% of the rural population lived below the absolutepoverty income level of US$73 per capita per annum. However, for theperiod 1957-58 through 1973-74 the average percentage of the ruralpopulation in absolute poverty was estimated at 58% relative to theall-India average of 50% for the same period.

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labor-intensive public works construction programs are to help improve condi-tions of the rural populace below the poverty line. However, the main bene-fits for this population would accrue through the Minimum Needs Program whichcontinues as a mainstay of the state's development effort, marked by animpressive record of social investments. Because of the gravity of theproblem, nutrition has played a continuing role in the state's developmentprogram during both past and present plans.

B. Nutrition Conditions and Programs

2.03 Various estimates over time show that Tamil Nadu continues to rankwell below the national average in per capita daily food intake. The NationalSample Survey (NSS) reported in 1978 that, according to 1973-74 data, TamilNadu ranked fifteenth among 16 major states with average per capita dailyenergy intake of around 2,036 calories against a national average of 2,263and estimated need of 2,400. Estimated per capita daily calorie intake inrural Tamil Nadu was around 2,012 calories against a national average of2,328. The urban situation was somewhat better, with average per capitadaily intake at 2,092 calories against a national average of 2,003. Estimatesof per capita protein availability in Tamil Nadu range between 36 and 42 gramsdaily, against the recommended daily allowance of 46 grams of proteinper capita. Anthropometric and food consumption surveys together with dataon morbidity and mortality provide overwhelming confirmation that protein-energymalnutrition is widespread and often severe in Tamil Nadu, particularlyamong pre-school children and pregnant and nursing women. Because of differ-ences in standards and techniques, the results of many of these studiesare not strictly comparable. Nevertheless, they indicate that up to anestimated 35% of rural households in Tamil Nadu and 40% of individuals consumeless than 80% of their calorie needs according to the most conservativecalculations of requirements.

2.04 The most complete picture of nutrition in Tamil Nadu resulted fromthe Tamil Nadu Nutrition Study (TNNS), carried out in 1970-73 under the jointauspices of the State and Central Governments and the United States Agencyfor International Development. The study concentrated on both operationalanalysis and applied research. It provides a unique data base derived fromthe most systematic effort yet undertaken in any developing country to analyzethe nutrition aspects of food production, distribution and consumption. Amajor TNNS objective was to identify intervention points to achieve signifi-cant changes in survival of children, who are recognized as the nutritionallymost vulnerable group. The study incorporated field collection and analysisof primary and secondary data as well as special studies. The multi-disciplinary TNNS team included economists, biologists, nutritionists, foodtechnologists, behavioral scientists, engineers and systems specialists. Itserved as the research arm of an interdepartmental group on nutrition whichthe State Government set up.

2.05 Principal TNNS conclusions were: (a) around half the families inTamil Nadu consume less than 80% of their calorie needs, calculated accordingto TNNS standards, which are marginally higher than those used by the Indian

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Council for Medical Research; (b) while some protein shortages occur, themost pressing need is for more calories; (c) generally increased food pro-duction is essential, but certain groups require special attention becauseof the gap between prevailing distribution patterns and their nutritionalneeds; (d) the highest priority target group for such specific interventionis the weaning child under three years of age, based on indications thatmalnourishment compounded by poor health is a major cause of pre-schoolmortality in Tamil Nadu and TNNS assertions that death rates for such childrenunder 18 months of age were more than ten times the composite rate for theirEuropean and North American peers; (e) pregnant and nursing women constitutethe next highest priority group because of their influence on health andgrowth of the infant; (f) food habits are major nutrition status determinantsfor Tamil Nadu pre-school children, whose nutrition falters dramaticallyduring weaning across all family levels of calorie intake and income; and(g) these habits are amenable to change, as demonstrated by TNNS testing ofa weaning supplement program in Coimbatore District.

2.06 These conclusions closely correlate with findings elsewhere inIndia that: (a) infectious diseases, diarrhea and unsatisfactory food habitsare major contributors to malnourishment, particularly among young children,and (b) changes in many undesirable food habits are within the financial reachof most families, including timely supplementation of breast milk with satis-factory home-made weaning foods, better feeding during pregnancy and nutri-tionally more effective food preparation and purchasing habits.

2.07 TNNS calculated that 45% of all Tamil Nadu children died beforethe age of five years and that over 50% of pre-school children in the statewere malnourished. Although based on careful sampling, TNNS mortality esti-mates are almost double those from official State health sources and probablyoverestimate present conditions by a considerable margin. However, a smallsample survey conducted in 1978 by the National Nutrition Monitoring Bureau(NNMB) found that 85% of surveyed children aged 1-5 years had weight for agelower than 90% of prevailing standard. A similar NNMB study five years earlierfound 89% of children surveyed to be malnourished by weight for age while 68%also were low weight for height. These NNMB studies tend to confirm TNNSconclusions in regard to numbers of malnourished children.

2.08 TNNS also tried to estimate the extent of nutrition-related mor-bidity and the financial cost of treating it at Government installations.The study found the cost of treatment of such morbidity to be around US$5.5million yearly or 31% of annual State expenditures at that time for medicalservices alone. Pre-school children with nutrition-related disordersaccounted for almost 23% of all patients then treated in Government installa-tions although they made up only 16% of the state population. Diarrhea,malnutrition and specific nutrient deficiencies, principally of vitamin A,were the leading forms of such pre-school morbidity. Among adults, a mainnutrition problem was anemia from shortages of iron and folate which studieshave estimated to affect more than half of Tamil Nadu's pregnant and nursingwomen.

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2.09 A subsequent study by the Institute of Child Health, Madras, foundthat nutrition was a leading or associated cause of 41.8% of the deaths ofpre-school children surveyed. The other leading causes were gastroenter-itis, principally manifested through diarrhea; respiratory infections, andother aiLuents which interact with malnourishment. Data from a 46-villagehealth program run through Erskine Hospital, Madurai, indicated prevalenceof vitamin A deficiency among pre-school children, which can lead to impairedvision or blindness, to be around 27%.

2.10 Both TNNS and later consumption data based on NSS estimatesstrongly point to inequalities of income distribution, rather than overallfood shortages, as a main cause of malnutrition in Tamil Nadu. NSS figuresalso indicate that, while the state as a whole is marginally self-sufficientin calorie availabilities, families in the lowest two income deciles consumearound 60% and 72%, respectively, of their estimated daily calorie needs.

2.11 Since the completion of TNNS, the State Government has continuedits long-term strategy of further increasing food production while tryingto raise the incomes of those living in absolute poverty. It considersinvestments in rural development essential to bring about sustainedreductions in malnutrition and morbidity levels. However, since nutritionimpact from such programs will occur slowly, the State Government hascomplemented them with a number of direct nutrition activities aimedspecifically at the most vulnerable groups.

2.12 Around 25 nutrition programs now operate in Tamil Nadu, largely

under Government auspices. Although sponsored by a number of differentagencies including the Departments of Social Welfare, Health and FamilyWelfare, Education, Labor and Rural Development, from 1971 these programshave been coordinated through the Department of Social Welfare which hasformal responsibility for nutrition activities in the state. This processhas taken place chiefly through a committee which is chaired by the Secretaryof the Department of Social Welfare and includes as members Secretaries of theother departments concerned. A number of these programs concentrate onpublicly-sponsored feeding, although their reach and scope vary considerably.The oldest of these is the school lunch program begun in 1956 which nowprovides mid-day meals, consisting mainly of balahar, 200 days a year foraround two million youngsters in more than 32,000 schools. A program offeeding at a total of around 4,000 child-care centers, or balwaddies, reachesaround 300,000 pre-school children, mainly aged 3-6 years.

2.13 Other nutrition programs have included operation of a nutritionrehabilitation center in Madurai District, assisted by the Royal CommonwealthSociety for the Blind, and three programs initiated by the Central Government:

(a) the Applied Nutrition Program, which has covered 61 ofTamil Nadu's 373 blocks;

(b) the Special Nutrition Program, which reaches around 130,000low-income beneficiaries in 33 municipalities and Madras, and

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(c) the Integrated Child Development Service program, whichnow operates experimentally in three Tamil Nadu blocksthrough around 300 child-care centers reaching an estimated24,000 pre-school children; coverage through an additional700 child-care centers recently was approved by theState Government.

2.14 The above efforts generally provide a daily meal, principallybalahar, to enrolled beneficiaries for 300 days a year.

2.15 However, all of Tamil Nadu's nutrition programs combined reachless than 10% of the state's pre-school children and an even lower proportionof pregnant and nursing women, and they appear to have had relatively modestnutritional impact on beneficiary groups. A number of studies have takenplace to assess both the outcome of such programs and the reasons for theirlimited success. The main constraints reported are:

(a) Feeding programs fail to reach intended beneficiariesbecause of weaknesses in setting or adhering to nutri-tional criteria with respect to target groups;

(b) Prolonged on-site feeding tends to substitute for foodwhich beneficiaries otherwise would consume at home;

(c) Take-home food is shared among other family members,thus diluting its impact on intended beneficiaries;

(d) Balahar is too coarse and bulky for very young childrento consume;

(e) Administrative shortcomings, including supervisiondeficiencies and optimistic expectations about theuse of workers' time, have inhibited effective nutri-tion education and promotion of home food productionactivities;

(f) Most nutrition activities are confined to centerswhich operate on a drop-in basis rather than throughactive and sustained efforts to identify and recruitthose at higher risk;

(g) Nutrition education campaigns have been neithersufficiently sustained nor oriented toward practicalbehavioral change; and

(h) Without adequate health care, infectious diseasesand diarrhea continue to exacerbate problems whichexisting programs are expected to resolve.

2.16 The State Government now spends around US$8.8 million yearly onnutrition, mainly from its revenue account. The school feeding program ofthe Education Department accounts for around three-fourths of that expenditure.Total State outlays on nutrition have remained relatively constant in recent

years, indicating both a sustained commitment to such efforts and continuing

Government concern that Tamil Nadu nutrition problems are too urgent forresolution only through the long-term process of satisfactory economic growth.

However, uncertainty about the impact and efficiency of its existing interven-tion efforts has acted as a brake on raising State Government budget alloca-tions for nutrition and led to the current request for IDA assistance. Inparticular, the State has become increasingly aware of the need to improve thetargeting and lower the unit cost of its interventions, to promote better

nutrition and health practices within families and to strengthen its maternaland child health (MCH) services to improve the utilization of availablenutrients by the most vulnerable groups.

2.17 Because of the magnitude of the problem and the scale of the re-sources required to combat it, the Government seeks IDA support to develop

and install an improved system which would achieve the foregoing aims. Whileinitially to get under way in rural areas because of plan priorities, the newsystem would be expected to be replicated throughout the state 1/ and lead toredesign and consolidation of current intervention programs.

III. THE PROJECT

A. Goals, Strategy, Design and Objectives

3.01 The main project goal would be to increase the efficiency, coverageand impact of Government of Tamil Nadu (GOTN) nutrition efforts. This would

be accomplished principally by systematic concentration for the first time onthe nutritionally most vulnerable group, children aged 6-36 months. However,the project also would improve the focus, quality and reach of nutrition-related services for other groups at high nutritional risk--pregnant and

nursing women and older pre-school children. The Government's decision tofocus on infants and younger children results from recognition that childrenunder three years of age account for an estimated 90% of pre-school mortalityin the state and that malnourishment is a leading or associated cause ofaround 75% of those deaths in the under-three age group.

3.02 The Government's strategy is to achieve results which would justifyhigher levels of nutrition expenditure through development of an effectivecombination of specific actions involving:

(a) expansion and restructuring of the State's nutritiondelivery program;

(b) education efforts to improve home nutrition of pre-school children; and

(c) expanded MCH care.

1/ The nutrition and health component of the Madras Urban Project IIrecently appraised by IDA is expected to be run along the lines proposedin the Project.

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Monitoring and evaluation would have a key role in the strategy since, throughthe project, the Government expects to reduce the unit costs of nutrition ser-vices, thereby increasing efficiency and easing the fiscal burden of expandingthe program state-wide and extending its full services to all pre-schoolchildren. Nutrition surveillance data generated monthly through Lhe nutritiondelivery component would provide early warning of the onset of nutritionemergencies from causes such as crop failures. These findings would helpenable the Government to avert further nutritional deterioration by timelytargeting of stand-by emergency food supplies to affected areas. Evaluationwould help identify ways of refining the project activities to improve theircost-effectiveness, while monitoring would assure timely implementation of keyactivities. An important feature of the project strategy is its explicitemphasis on trying to get families themselves to do a better job of providingappropriate food and nutrition-related care for young children through anintensive and carefully planned new program of nutrition and health education.

3.03 The Government's approach draws on its own experience combined withlessons learned from programs elsewhere in India and in other developing coun-tries. The project results from 16 months of intensive dialogue with theState and Central Governments. Particularly close collaboration between IDAand the GOTN during preparation resulted in substantial refinement and simpli-fication of the original project design. The Government initially had pro-posed incorporating village water supply and agricultural interventions inthe project, including rainfed pulse production, improved on-farm storageand modernization of rice and oil processing facilities. These componentsultimately were excluded because it was felt they would complicate projectmanagement and could best be tackled through programs exclusively directed tothe agriculture and water supply sectors. Other results of the preparationprocess included considerable reorientation of the proposed roles of fieldworkers in the nutrition and health delivery systems and development ofsuitable arrangements for coordination of their work. Another outcome wasthe deve'lopment of explicit criteria and operational procedures. for a newproject-assisted food supplementation program which departs from the existingstate pattern of prolonged supplementation, mainly for children over threeyears of age, generally with scant regard to nutrition criteria.

3.04 Two innovative features distinguish the proposed project'sapproach to food supplementation from current Tamil Nadu programs. First,child beneficiaries would be identified and monitored through a nutritionsurveillance system to be set up in project villages. Second, supplementa-tion would continue only as long as required for a child to achieve adequatenutritional recovery and would be accompanied by intensive nutrition educationof key family members to promote permanently-improved home feeding practices,within the financial reach of most project families.

3.05 The main objective of the project would be to improve the nutritionand health conditions of pre-school children, with emphasis on those aged6-36 months, and pregnant and nursing women. After four full years ofproject operation in each district, (see para. 3.06) the Government anticipates

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a 50% reduction in the currently estimated 60% incidence of protein-energymalnutrition 1/ among children under three years of age. Additionally, theproject would contribute to the Government's goal of achieving the followingobjectives after five operational years in each project area: (a) around a25% reduction in the infant mortality rate, now estimated at 125 per 1,000 2/and in the currently estimated mortality rate of 28 per 1,000 children betweenthe ages of one and four years; (b) reduction to 5t of the incidence ofVitamin A deficiency in children under five years of age, currently estimatedat up to 27%; and (c) reduction to 20% of the currently estimated 55%incidence of nutritional anemia in pregnant and nursing women. Whileambitious, these objectives are considered attainable as part of the State'soverall development effort.

B. Location

3.06 The project would take place in the rural areas of six districtswhere nutrition conditions are among the most precarious in the state,according to TNNS analysis--Chengalpattu, Madurai, North Arcot, Pudukottai,Ramanathapuram, and Tirunelveli. These districts contain the largest numberof taluks 3/ where TNNS reported nutrition conditions to be least satisfac-tory in terms of calorie needs met by the population. The districts aregrouped geographically in two areas: Madurai, Pudukottai, Ramanathapuramand Tirunelveli blanket the southern third of Tamil Nadu; in those districtsaverage calorie intake is estimated at 76-84% of requirements. Chengalpattu,which has similar nutrition characteristics, and North Arcot, where calorieintakes are estimated to average below 74% of requirements, adjoin each otherin the northeast. The project area consists of all 170 rural blocks in thosedistricts. Average rural population per block varies widely by projectdistrict, ranging from 56,700 in Chengalpattu to 94,300 in North Arcot.

C. Phasing

3.07 The project would be implemented on a block-by-block basis and phasedin gradually over five years, with final evaluation to take place during thesixth year. Implementation in the first year would be confined to KottampattiBlock of Madurai District, where the basic project design would be tested andrefined as necessary. Another 33 blocks in Madurai and Chengalpattu Districtswould come on stream in the second year, followed by 43 blocks in the thirdyear. A review of project operations also would take place toward the end

1/ Mission estimate based on TNNS and other data.

2/ This government estimate is about 45% lower than TNNS conclusions butwill be verified through baseline studies in project areas.

3/ Districts are divided into taluks containing an average of 12 blocks.In project areas, average block size is 78,000 population.

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of the third operational year to guide the final two years of implementatiorwhen 43 and 50 blocks, respectively would become operational. During negoti-tions, the State Government gave assurances that the terms of reference forthe Kottampatti pilot block review and for the mid-term review would be sati-factory to IDA .n-d that the project design and implementation schedulewould be adjusted according to their findings as feasible, taking i11to accotnitIDA comments on the reviews.

D. Description

1. Summary and Main Features

3.08 The project would consist principally of linked programs of nutritionand health services delivery. These would be implemented simultaneously andcombined to produce substantial nutritional improvements in the target group.Intensive informal education of mothers and other key family members toimprove child-feeding practices and management of diarrhea among youngsterswould support and reinforce the nutrition and health components.

3.09 An outreach system initiated under the nutrition services componentwould promote regular nutrition surveillance of participating children underthree years of age in project villages. It also would serve as a conduit forselective interventions to counter malnutrition among target groups, includingshort-term food supplementation for vulnerable children aged 6-36 monthsand prophylaxis against specific nutrient deficiencies. Strengthened basichealth care delivery would emphasize MCH services and prevention and cure ofnutrition-linked health disorders. Since this innovative approach involvesthe development and implementation of new and as yet untested deliverysystems, the project would place heavy emphasis on monitoring and evaluation.Evaluation would continue through a sixth project-financed year to analyzeproject impact and cost-effectiveness as fully as possible and to provide thebasis for future modification of the program and its subsequent expansion toother parts of the state. Project coordination would be managed by a smalloffice set up for that purpose.

3.10 The project would finance:

(a) Construction, furnishing and equipping of:

(i) about 1,600 health sub-centers (HSCs);

(ii) 60-bed hostels at nine institutions to train femalemultipurpose health workers (MPHWs);

(iii) a training facility to accommodate 150 female healthsupervisors (lady health visitors);

(iv) training and hostel wings at 39 primary health centers(PHCs) where field training of female MPHWs and ladyhealth visitors (LHVs) would take place; and

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(v) a 100-place facility for in-service training of healthworkers, block extension educators and medical officers(MOs).

(b) Training costs consisting of incremental staff, materials andstudent stipends for the training of about:

(i) 2,500 female MPHWs, 800 LHVs, 75 public health nurse(PRN) instructors and 830 MOs; and

(ii) 9,000 community nutrition workers (CNWs), 900 of theirimmediate supervisors and 250 other supervisory staffinvolved in nutrition delivery at block, taluk anddistrict levels.

(c) Vehicles, consisting of a total of about:

(i) 102 sedans and station wagons, including 81 for nutritionsupervision, 16 for health supervision, three for projectcoordination use, and one each for communications andmonitoring and evaluation;

(ii) Nine buses for project-assisted health training institutions;

(iii) 212 motorcycles, including 191 for health supervision, sevenfor communications work, and 14 for monitoring and evaluation;and

(iv) 3,200 bicycles, including 2,600 for use by MPHWs and 600 foruse by supervisory and office staff responsible for projectnutrition, health and communications monitoring and evaluationactivities.

(d) Upgrading, furnishing and equipping of:

(i) about 9,000 community nutrition centers (CNCs); and

(ii) the project coordination office.

(e) Furniture and equipment for:

(i) a small micro-biology laboratory to monitor the qualityand safety of the supplement and other foods, and tocarry out serum analysis as part of impact evaluation;

(ii) a communications campaign and monitoring and evaluationoffices in each of the six project districts;

(iii) a nutrition supervisory office in each of the 170 projectblocks, 68 project taluks, the six project districts andat state headquarters; and

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(iv) a health supervisory office in each of the 14 project divisions.

(f) Costs of designing, producing and disseminating films, filmstrips,radio broadcasts, folk plays, manuals, posters, charts, and relatedmaterials for nutrition and health education campaigns and fortraining neighborhood leaders.

(g) Costs of technical assistance for communications and monitoring andevaluation.

(h) Costs of food supplements for beneficiary children and selectedpregnant and nursing women.

(i) Drugs, vaccines and supplies for MPHW, LHV, PHC and CNW use.

(j) Project evaluation activities, including baseline and specialstudies, surveys, and data processing costs.

(k) Incremental operating costs of the project, including:

(i) salaries of health and nutrition workers and supervisors,communications staff, monitoring and evaluation and projectcoordination personnel;

(ii) rent and running costs of CNCs, taluk nutrition offices,the project coordination office and communications andmonitoring and evaluation field offices;

(iii) running costs of project-financed HSCs; and

(iv) supplies for CNCs, HSCs and other facilities includedin the project.

(1) Funds for innovative activities to be developed during the project onthe basis of criteria to be agreed upon between the State Governmentand IDA.

2. Detailed Project Features

Nutrition Delivery Services

3.11 This component would concentrate on strengthening the State'scapacity to identify children under three years of age at high nutritionalrisk, to monitor their nutritional status and to reach them, as well as olderpre-school children and pregnant and nursing women with specific measures tocorrect or prevent protein-energy malnutrition and other nutrition problemssuch as vitamin A deficiencies and iron deficiency anemia. This would takeplace through a network of CNCs, each staffed by a full-time female CNW and ahelper, recruited and trained under the project. The component would includedevelopment of a nutrition surveillance system for pre-school children, withemphasis on those aged 6-36 months, and a new program of short-term foodsupplementation for children in that age group identified as being at highestnutritional risk.

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3.12 Community Nutrition Workers and Centers. The CNW-CNC network isthe key to the project's nutrition delivery system. One CNC, staffed by a CNWand helper, would be established per 1,500 population, roughly equivalent tothe average size of a Tamil Nadu village. In this respect, the new systemresembles existing pre-school nutrition delivery patterns in the state. Theaverage target population per CNW would be 250 pre-school children, includingaround 100 aged 6-36 months, and 45 pregnant or lactating women. CNWs wouldbe recruited from the village they would serve.

3.13 However, the role of the CNW and project recruitment procedures,as well as the functions of the CNC, also mark a substantial departure fromthose existing patterns. A selection committee including a senior nutritionsupervisor and a representative of the village council would choose the localCNW. CNWs would have a primary education. Whenever possible they would berecruited from among the most disadvantaged village groups, which have a highpropensity for malnourishment. Preferably, these women would have well-nourished children of their own.

3.14 Each month the CNW would weigh all children aged 6-36 months inher village. Where appropriate, child-weighing would begin at four months ofage. These children also would continue to be weighed quarterly through theirfifth year. Weighing would take place both at the CNC and in village neighbor-hoods in accordance with a regular schedule reflecting prevailing patterns ofwomen's work both at and away from home. CNWs would use a portable bar scalesupplied by the project and would record children's weights on both a chartwhich mothers would retain and a form kept at the CNC which also would containhealth data, including records of immunization and other services providedby MPHWs. The CNW would use the weighing process both to convey nutritioneducation and to identify candidates for the short-term food supplementprogram which she and her helper would administer at the CNC. These weightrecordings would be central to the nutrition surveillance system to beinitiated through the project. About 30% of the CNW's time would be spenton surveillance and supplementation activities.

3.15 CNWs would have four additional important responsibilities. Theywould give talks and demonstrations to groups of women, promoting betterweaning and child-feeding practices, and would discuss other topics relatingto good nutrition. They would provide prophylaxis against specific nutrientdeficiencies through semi-annual vitamin A dosage for pre-school childrenand regular administration of iron and folate supplements for pregnant women.They would be responsible for tri-annual administration of deworming medicinefor pre-school children and a program of diarrhea management which wouldinclude supplying of a pre-packaged glucose-electrolytes mixture and arrowrootpowder for oral rehydration and for continued feeding of pre-school childrenwho fail to respond to home treatment. Supplies for these activities wouldbe provided by the Health Department, stocked at PHCs and distributed throughnutrition supervisors to CNWs. Finally, CNWs would organize women and childrenfor village immunization and health clinics carried out by MPHWs and wouldrefer pre-school children for MPHW services when indicated.

3.16 The CNC would be the site of four major activities:

(a) weighing of children aged 6-36 months;

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(b) nutrition education;

(c) distribution of food supplements for on-site consump-tion by eligible young children and selected pregnantand nursing women; and

(d) maintenance of village nutrition and health records.

3.17 CNCs would be existing buildings with a minimum room space of 30 mselected in accordance with agreed criteria by a committee consisting of theBlock Development Officer (BDO), a local government engineer, a representa-tive of the village council and a senior nutrition supervisor. Selectioncriteria include proximity to disadvantaged populations, access to water, andcertain construction characteristics. It is anticipated that suitable CNCspace readily would be available in all but a small fraction of project vil-lages at a yearly rental averaging around US$36. A cement floor and latrinewould be installed at each CNC, which also would be equipped with simplefurniture, including a desk and chair, three cupboards, shelves, mats, akerosene stove, a blackboard and utensils for cooking demonstrations andserving children who require semi-solid supplementation.

3.18 CNC activity patterns would be flexible to accommodate those ofvillage women. Typically, the CNC would open early in the morning when themost severely malnourished children would arrive for supplementation. Theywould remain at the CNC long enough to consume two rations. Later in themorning, weighing would take place; eligible pregnant and nursing women andother children would arrive for on-site supplementation. Arrangements fordistribution of vitamin A and iron supplements and deworming medication wouldbe worked out by individual CNWs and their supervisors; in most cases, the CNCis expected to be the focal point for such activities.

3.19 Initially, mothers or grandmothers would be required to bringeligible children to the CNC, observe weighing activities and feed theirchildren, mixing the rations with boiled water when semi-solid supplementationis required. However, once the program is established, older siblings couldcontinue to deliver and collect children to be supplemented, particularlyduring times of peak demand for agricultural labor. The above activitiesprobably would take an average of 6 hours daily. However, the CNC wouldreopen frequently for nutrition education talks, demonstrations and relatedactivities led by CNWs, who also would make home visits and reach women atwater taps and other places where they gather.

3.20 The State Government plans to develop a statewide CNC-CNW programdepending upon the experience from the proposed Project and to cover olderpre-school children as warranted. Communities themselves would be encouragedduring the project to take increasing financial and operational responsibilityfor such activities. The Government would hope to phase down its contributionwherever the CNC-CNW system has operated for four years. Ultimately theGovernment would seek to limit its financing to equipment and food costs, withCNCs either donated or rented by village councils or other groups and the work

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of the CNW either being paid for by a local source or performed by volunteers.The gradual phasing out of CNCs would be feasible, particularly if nutrition

education succeeded in substantially reducing the risk that food supplementswould be shared among all children - which now appears likely - if taken home.Shifting to a take-home supplement, which might then be made available throughthe village fair-price shop, would reduce the need for CNCs if -7rangementscould be made for weighing and nutrition education to take place elsewhere.The project would encourage neighborhood participation in these activities:orientation sessions would be held for neighborhood leaders and the CNWswould also encourage mothers themselves to weigh their children. With theforegoing objectives in mind, the Social Welfare Department would developprospective modes of such participation, discuss them with IDA and beginapplying them during the project.

3.21 The post-project role of CNWs (contract workers), would be determinedpartly by Government success in obtaining local financing for their continuedservices or their replacement by village volunteers. Over time, CNWs might

be absorbed into the health system as community health workers (CHWs) inaccordance with the suggested national pattern of primary health care.Tamil Nadu so far has not recruited CHWs, experimenting instead with severalalternate ways of providing combined village nutrition and health coverage.Should the state ultimately accept CHWs, CNWs would be logical candidates forsuch recruitment because of their skills and experience and would be expectedto receive preferential consideration for such work.

3.22 Supervision, Training and Management. A cadre of around 900 nutri-tion supervisors would oversee CNW performance. Each would supervise 10 CNWs,mainly through twice-monthly visits. Supervisors would be women with B.S.degrees, preferably in home science. Around 400 would be chosen from existingSocial Welfare extension staff; the others would be new recruits. Supervisorswould verify the accuracy of CNW weighings and make final selection of childrento be admitted to the food supplement program and discharged from it. Super-visors also would distribute vitamin A, iron and folate, deworming and diarrheamanagement supplies monthly to CNWs and monitor their use. They would obtainthese medications from the nutrition instructress to be recruited, trained andposted in each project block, who would collect supplies from PHCs.

3.23 Initial training of CNWs would consist of two-month training coursesat block headquarters in groups of 25-30 and in-service training thereafter.Such training would be organized and carried out by an instructress in eachblock. The 170 instructresses would have postgraduate degrees in nutritionor home science, preferably with teaching or field work experience. The finalweek of initial CNW training also would be attended by female MPHWs from thesame area because of the complementarities of their roles. In-service trainingsessions would take place twice monthly at selected CNCs in the afternoon forbatches of ten CNWs. At that time, supervisors would discuss problems andprogress with their full CNW complement. The instructress also would holdmonthly in-service training sessions for all block CNWs and supervisors atblock headquarters.

3.24 Supervisors and instructresses would receive two months' initialtraining; Sri Avinashilingam Home Science College (SAHSC), which has the expe-rience and capacity to run such programs, has agreed to do so. SAHSC would

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develop special curricula for this purpose in consultation with an advisorycommittee to be set up by the Social Welfare Department. Instructresses'curricula would be derived partly from the specific content of CNW trainingbut also would emphasize teaching methods. Supervisors' curricula wouldstress personnel management and supervision. Assurances were recetved duringnegotiations that training curricula for CNWs, supervisors and instructresseswould be furnished to IDA for review by August 31, 1980, and would thereafterbe implemented taking IDA comments into account.

3.25 The rest of the component's management structure would be as follows(see Annex 6a): A taluk nutrition officer (TNO) and support staff would overseeCNW-CNC operations in each taluk, averaging 12 per district. TNOs would begraduates with degrees in nutrition, social work or related fields, preferablywith practical experience in community development. Since taluks contain anaverage of three blocks each, each TNO would supervise around three instruc-tresses and 15 supervisors, as well as a superintendent in each block respon-sible for food supplement distribution to CNCs. TNOs would spend 20 days permonth in the field and would hold regular monthly meetings with supervisorsand instructresses. Around two-thirds of TNOs would be new recruits, requiringa minimum of three weeks' training in Government procedures which the SocialWelfare Department would organize and carry out. All TNOs also would requirein-service training in personnel and basic financial management, organizationalmethods and other executive skills. These programs would be developed duringthe first project year by local management training institutions in consulta-tion with the Social Welfare Department.

3.26 A district nutrition officer (DNO) with the rank of Assistant SocialWelfare Director would supervise and manage the component in each districtassisted by a section superintendent and support staff. Each DNO would reportto the Collector in charge of the district and to the Joint Director of SocialWelfare in Madras, who would have project-wide responsibility for the operationof the component in the Directorate of Social Welfare. Component supportstaff at block, taluk and district levels would be responsible for operationallogistics including payment of salaries, accounts and auditing, and the regularflow and analysis of data for performance monitoring.

3.27 To facilitate supervision, the component would finance the costs ofone sedan each at state and district levels, one 4-wheel drive vehicle andone bicycle for each taluk nutrition office, and furniture and equipment forblock, taluk, district and state project nutrition offices.

3.28 Food Supplement. The food supplement would be designed specificallyto be acceptable and beneficial to younger malnourished children who cannotconsume or readily digest enough balahar for their needs. It would consistprincipally of a rice-pulse mixture, with added sugar, vitamins and minerals.The supplement was developed in collaboration with the Protein Foods andNutrition Development Association of India and pretested for palatabilityat the Institute of Child Growth in Tamil Nadu. Through simple technologyalready in common use, the supplement would be pre-cooked and shaped into20-gram briquettes containing around 70 calories for beneficiaries to consumeeither directly or in semi-solid form by dilution in water. Its shelf lifewould be 90 days. The raw material mix could be varied to take advantage of

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food price changes. The usual ration would be 40 grams for children undertwo years of age and 80 grams for beneficiaries aged 2-3 years. Severelymalnourished children, estimated at 10% of beneficiaries, would receivedouble rations. Around 30% of pregnant women, totaling around 275,000beneficiaries, also would receive a daily supplement of 80 grams for the lasttrimester of pregnancy and the first four months of lactation. They would beselected by health workers according to criteria agreed on with IDA designedto identify women at high risk of giving birth to underweight babies (that is,less than 2500 grams).

3.29 The supplier would pack and distribute the supplement to the blocklevel. The 32 metric tons of supplement for the Kottampatti test would beproduced at its existing pilot plant by Gandhigram Rural Institute in Madurai.Gandhigram's plant has a capacity of 500 kg daily and has produced variousweaning foods which the Institute has used in its own experimental programs.The project would provide Gandhigram with some replacement equipment toproduce the supplement which also would be used in later project-financedtrials of alternative supplement formulations. The supplement for the secondand third project years would be supplied by the parastatal Tamil Nadu Agro-Industries Corporation (TNAIC) at a negotiated annual contract price based onreviews of input and production costs in accordance with standard Governmentprocedures. By the fourth year, the food supplement requirement would beexpected to be large enough--around 4,000 tons--to attract competitiveinterest. If so, local competitive bidding would replace negotiated sales forthe two final project years. Otherwise, TNAIC would continue to supply thesupplement requirements for the final two project years at a fair and reason-able price. The appraisal mission concluded that Gandhigram and TNAIC wouldbe able to provide the supplement at an economic price. Although costs of thefood supplement are included in the project, IDA would not disburse againstthem. Based on expected processing costs and currently-averaged input pricesreflecting seasonal swings in availability, the delivered cost of the supple-ment at block headquarters was estimated at appraisal at Rs 3.75 per kilo, orRs 0.30 per 80 gram ration delivered to each CNC. This works out to an averageestimated ration cost of Rs 33 per child beneficiary or Rs 65 per maternalbeneficiary. Food requirements for the project are estimated to total around13,000 metric tons over five years, or a negligible offtake of Tamil Nadu'soverall production of the commodities involved.

3.30 Calculations of estimated project food requirements resulted fromdevelopment of a program model which takes into account a wide range ofvariables influencing demand. These include initial malnourishment ratesand differential supplementation rates by age group and nutrition status,assumptions as to relapse -;ates, the numbers of women to be supplementedand estimated beneficiary participation rates. Project management woulduse the model to adjust ration requirements as these variables changeduring the project.

3.31 Supplement Eligibility Criteria. A particularly innovative featureof this component would be the use, initially on a pilot scale, of weight gainas a basis for identifying children aged 6-36 months at high nutritional risk.Current nutrition surveillance systems rely on weight for age alone, as is

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common in India, or combined with weight for height, height for age or armcircumference. Some combination of those measures is generally preferableto identify active malnourishment since a child's low weight for age couldreflect the stunting effect of previous malnutrition, which only a combinationof other indicate.-s would detect. The use of body weight changes, whenapplied effectively, is simpler and more dynamic than combinations of theother procedures since a child's failure to put on adequate weight overseveral months unmistakably would indicate either the presence of activemalnourishment or the increasing risk of its onset. The weight gain methodwould be tested in Kottampatti and compared with the weight for age method.If found operationally feasible and effective, the weight gain method would beadopted for the rest of the project. Pending analysis of these test results,selection criteria for child beneficiaries of the food supplement under theperiod would conform to existing GOI policy.

3.32 The use of weight gain criteria would permit a sharper targetingof the food supplement: it would exclude stunted children gaining adequateweight and it would provide preventive therapy for those most likely to becomemalnourished. Admission criteria for the supplement therefore are designedboth to exclude children who do not need supplementation and to ensure theinclusion of virtually all those at high nutritional risk. Because of theirexponentially higher risk of mortality, all severely malnourished childrenaged 6-36 months would be enrolled at once in the supplementation program.Other children in that age group would enter the program after failing to gainadequate weight over two months in the case of children aged 6-12 months orthree months in the case of children between the ages of 1-3 years. The CNWwould weigh children; supervisors would carry out verification weighingsbefore enrolling children into the food supplement program or discharging themfrom it. Multiple weighings would reduce measurement errors resulting fromthree factors: children's normal daily weight fluctuation, the + 50 gramaccuracy of the bar scale, and errors in recording the reading of the scale.

3.33 All child supplementation would be daily for an initial period of90 days. The supplement would serve both to help restore children to adequaterates of weight gain and to demonstrate the importance of better home-feeding.Current data on food intake by income class indicates that, for all but thepoorest families, the estimated average calorie gap for children underthree years of age could be met by redistribution to them of less than 5%of the total amount of food consumed by adult family members. CNWs wouldstress this aspect of nutrition education both at CNCs and in their homevisits. Experience in Tamil Nadu and elsewhere indicates that 90-120 days ofadequate feeding generally is sufficient to reverse the nutrition decline inmost children, although relapses appear common in the subsequent absence ofimproved health care and family food practices. However, a partial assessmentof a 46-village nutrition program in Madurai district, which combined nutritioneducation with feeding for about 90 days, indicated that as many as 70% of theparticipating children in particular villages surveyed managed to retain theirnutritional momentum as long as four years after completion of the program.

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3.34 Most children would be expected to gain 500 grams, the acceptableminimum, during the first 90 days of supplementation and would then bedischarged. The rest would be referred for examination at the nearest PHC,since their failure to gain sufficient weight probably would indicate serioushealth disorders, unless home feeding had declined or remained grosslyinadequate. These children then would continue in the program in 30-dayincrements while the CNW, assisted by neighborhood leaders, made a specialnutrition education effort with the family, subject to a maximum of sixmonths' continuous supplementation. Such a restriction is considered essen-tial to: (a) ensure that only children who can benefit from the supplementreceive it, and (b) reduce the likelihood that families would use the supple-ment as a long-term substitute for food which the child otherwise wouldconsume at home. Assurances were obtained during negotiations that criteriafor entry into and discharge from the food supplement program for children andwomen would be satisfactory to IDA.

3.35 On-site feeding involves substantially less risk of sharing withother family members than take-home rations. However, some families at firstmight perceive the supplement as small in relation to the opportunity cost ofdaily visits to the CNC, limiting participation by some children and eligiblewomen. Steps to deal with this in advance include siting the CNC in asaccessible a location as feasible and specific CNW emphasis on continuedface-to-face recruitment of those eligible for the supplement, particularlythe most disadvantaged. The monitoring and surveillance systems also wouldprovide clear signals on participation rates. Moreover, flexibility regardingthe time of ration delivery is built into the project and modest changes inration size also could be considered if circumstances warrant. These aspectsof the project would be scrutinized carefully during the Kottampatti andmid-term reviews and would receive regular attention from project management.The annual recurring cost of the supplement program, including the ration andall applicable overhead, would be US$2.96 per village child aged 6-36 monthsand US$3.75 for each pregnant lactating woman.

Rural Health Services

3.36 This component would improve the quality, efficiency and coverageof rural health care in project areas through installation of an MPHW systeminvolving the deployment of one male and one female worker to an HSC servinga population of 5,000. Tamil Nadu already has an adequate number of maleworkers in place for that purpose and a satisfactory program for retrainingthem already is under way. However, the State would have virtually to doublethe present number of female health worker posts and more than double thenumber of HSCs to achieve suitable coverage ratios.

3.37 Basic rural health care in project areas is now provided mainlyby a network of one PHC and an average of 6 HSCs per project block. PHCsbasically are out-patient facilities but usually contain up to six beds foremergencies, obstetrical cases and vasectomies. Each has a small operatingroom, a small pharmacy and a laboratory, along with housing in separatebuildings for its three medical officers and support staff. Each HSC isstaffed by an auxiliary nurse-midwife (ANM), who concentrates on postpartumcare and deliveries, performing an average of ten deliveries per month.

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ANMs carry out around 30% of all deliveries, the highest service coverage ofany part of the state health system, and some HSC-based activities. However,ANMs do not adequately penetrate villages with other services. This is duepartly to their large area of crverage, which now runs from an average of36 km in Chengalpattu to 50 km in North Arcot. In addition to thin coverage,problems impeding more effective ANM performance include training and supervi-sion deficiencies and inadequate supplies of drugs and medicines. Male healthworkers are segregated into cadres each responsible for a single program suchas malaria control, tuberculosis control, immunizations and health inspection.One LHV supervises three ANMs. One male supervisor oversees the work of fivemale field workers. A PHC medical officer supervises all block health staffwith the help of an extension educator and health inspector.

3.38 Under the MPHW system, which the Government intends to introducewidely by the end of 1985, each male MPHW would carry out the combined immuni-zation, communicable disease control and other tasks formerly implementedthrough separate cadres. ANMs or new recruits to be trained as female MPHWswould concentrate on pre- and postnatal services, deliveries, infant and childcare, treatment of minor ailments and referrals to higher levels of healthcare. The female MPHW would be required to cover an average of no more thanhalf of the previous HSC geographic area, thereby permitting more intensivecontact with beneficiaries. Both male and female workers would continue tomotivate individuals and groups to take part in family welfare activities,distribute contraceptives and provide follow-up services to acceptors.

3.39 The HSC team would deliver a comprehensive package of basic healthservices available to those who need them. These changes also would permiteach LHV to supervise four instead of three female workers while increasingthe frequency of her contact with them because of the reduced geographic areainvolved. After four years of operation in each project area, the componentwould be expected to raise antenatal registrations to 80% and tetanus toxoidimmunization and the number of assisted deliveries to 60% of pregnant womenreached by health services. This is a significant jump from existing coveragelevels estimated at 54%, 30% and 30% respectively. It also would triple theaverage number of contacts between pregnant women and female health workers.

3.40 Each MPHW would be expected to spend around four hours dailyin field visits. The MPHW team schedule would ensure that one member isalways available at the HSC. The team thus would pay an average of 2-3visits weekly to each village in its area of coverage. Job descriptionsagreed with IDA for MPHWs and supervisors stress the importance of village-level performance, its supervision and monitoring.

3.41 Village visits are espcecially important because the MPHW is theprincipal contact point between individuals and the State's rural healthdelivery system. In this respect, Tamil Nadu differs from patterns of health

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delivery in many other states through which the initial contact point is apart-time community health worker (CHW) in each village. Tamil Nadu has yetto adopt the concept of CHWs. Presently, it is experimenting with severalalternate ways of providing health care at the village level. One is asystem through which an additional physician is posted to the PHC and threeof its four doctors spend part of each working day in villages to provideon-site health care. The mobile medical team concept, for which an evaluationby the National Institute of Health and Family Welfare is nearing completion,operates in 28 blocks. Another approach now getting under way on a limitedscale is the provision of matching funds to voluntary agencies which agree toorganize their own community health services and hire a part-time physicianand paraprofessional staff. A health project for Danish aid (DANIDA) financ-ing is under preparation in two districts--Salem and South Arcot. Whilespecific details remain to be worked out, both the Health Department andDANIDA intend to include some approach to community-based health care.

3.42 Field observations before and during appraisal indicated that,despite Government expectations to the contrary, the mobile medical teamsystem probably would prove expensive and difficult to administer effectively.Furthermore, applicability of the matching grants concept would appear to belimited by the shortage of voluntary groups at the village level and thepoverty of those who most need access to health care. Thus, neither of thetwo approaches now being tried would seem to provide a cost-effective way ofgetting health care to the village.

3.43 The appraisal and previous missions felt that integration of villagenutrition and health services through a single department would be the mosteffective and efficient way of providing village nutrition and health care,rather than continuing the division of these responsibilities between SocialWelfare and Health. In addition to facilitating administrative and technicalsupervision, establishment of a single cadre of community workers under Healthwould promote optimal delivery of a fully-integrated package of village-levelcare to improve rural nutrition and health conditions. However, the StateGovernment believed it premature to consider a major reorganization of itsestablished nutrition and health delivery systems until after the mobilemedical team and additional options had been fully studied. Moreover, theState Government considers the deployment of CNWs combined with MPHWs as aparticularly promising way of providing effective nutrition and MCH care atthe community level for several reasons. First, community health workers arealmost exclusively men under the all-India pattern which results in limitedattention to MCH and nutrition activities, despite the priority importance ofthese subjects at the village level. Second, CNWs recruited from "successful"mothers are likely to have high credibility with their clientel. Third,nutrition and MCH services, which make up the basic health care needs of youngchildren and pregnant and lactating women, are likely to be carried out betterunder the project because of fewer competing demands on female MPHW time. TheState Government expects the incorporation of certain nutrition-related healthtasks into the work of the CNW to result in a functionally integrated servicepackage, while preserving the administrative responsibility of the SocialWelfare Department for nutrition delivery in Tamil Nadu, a pattern whichaccords with national policy. When the results of ongoing and planned

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experiments have been evaluated, some expansion of CNW functions to includeother common health problems may be considered together with a decision on themost effective organizational and administrative structure and procedures0

3.44 To facilitate consideration of a possible shift to a fully-integratedcommunity nutrition and health system, the Kottampatti review would include anassessment of the extent to which the combined services of CNWs and MPHWs meetthe need for community nutrition and health care. If significant gaps wererevealed, a modified nutrition-health delivery system would be worked out andtested during the second project year. The State Government gave assurancesduring negotiations that the results of the various experiments with ways ofproviding health care at the village level in the State would be taken intoaccount during the mid-term project review (para. 3.07). Assurances also werereceived during negotiations that, should the State modify its health systemin project areas during the Project, the State Government, after consultationwith IDA, would take all necessary measures to maintain the efficiency, qualityand level of nutrition and health services and ensure appropriate use of CNWsto avoid duplication of effort.

3.45 Health Sub-Centers. The 1,600 HSCs to be built and equipped include166 to replace inadequate facilities, currently rented. Each 65 m HSC wouldbe a one-story building of simple brick or stone construction with an asbestossheet roof. The use of factory-made materials such as cement and glass wouldbe minimized; locally-available wood would be used in place of steel whereverpossible. The HSC would consist of a clinic room, an examination room, alatrine and living quarters for the female MPHW in accordance with designs andworking dra'ings already approved by IDA. Construction costs would run aboutUS$55 per m . HSC sites in each project block would be selected by a teamconsisting of the PHC medical officer, the BDO, a local government engineerand the president of the panchayat union, representing village councils in theblock. Locational criteria for HSCs agreed on with IDA include proximity togood roads, public transport, electric supply and other public facilities,and adequate drainage. Each site would be less than half a kilometer from aperennial source of 500 gallons of potable water daily for HSC use.

3.46 Around 50% of HSC sites would be donated or already publicly owned.Based on rural land prices in project districts, the average purchase costof a site would run around US$161. Construction schedules would allow anaverage of 10 months for acquiring purchased sites after their identification;HSCs would be ready for use in the first three months of their scheduledimplementation year.

3.47 Training Requirements and Facilities. Achievement of health trainingtargets under the project would require a major increase in the numbers oftrained female MPHWs. Eight female MPHW training institutions operate in thestate. These consist of four Government schools, each with an annual outputof 30 students, and four private ones, which annually graduate 40 studentseach. The curriculum for the Government institutions is being revised and thecourse duration has been shortened from 24 to 18 months. The new curriculumis more operationally oriented and includes six months' field training. Mostof those trained in Government schools accept MPHW jobs. The private sectorabsorbs around 50% of those trained elsewhere. That level of private demandis expected to continue during the project.

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3.48 Government institutions would have to step up their output of femaleMHPWs to meet project requirements combined with targets for introducing thesystem in Salem and South Arcot districts. Around 476 additional female MPHWswould be needed there through 1985 as part of the health project now beingprepared for DANIDA financing.

3.49 The component would finance construction and equipping of a 60-bedhostel to expand accommodation at each of the four existing Government traininginstitutions for female MPHWs and at five new female MPHW training centers atdistrict hospitals, which the Government is to open early in 1980, for whichclassroom facilities2already are available. Each hostel would have a plintharea of around 950 m and would contain 15 four-bed rooms, lavatory andbathing facilities, a dining and recreation area, a kitchen and a warden'squarter. The component also would finance construction of 10-bed dormitory-cum-classroom units at each of 27 PHCs where female MPHW field training wouldtake place. These facilities would permit the Government to meet requirementsfor additional female MPHWs in project and DANIDA districts, as well asreplacement needs for existing female health workers in the state.

3.50 Tamil Nadu also would have to increase its output of LHVs to meetsupervision targets for female MPHWs. Only two LHV training schools nowoperate in Tamil Nadu. One is an over-crowded Government institution inMadras where 325 students are accommodated in space designed for 200. Theother is a private institution which takes in 35 trainees per year. FreshLHV recruits receive 30 months' training; those promoted from the ANM cadrereceive 18 months' training. The LHV training curriculum would be revisedto reflect the new role of female MPHWs and would include a 6-month fieldtraining module for Government trainees at selected PHCs. In addition totraining new LHVs, Tamil Nadu also must provide refresher courses and orien-tation for about 550 already working in project areas. However, the Staterequires additional facilities for this purpose.

3.51 To help meet the above initial and in-service LHV training needs,the component would finance construction and equipment for a new LHV trainingfacility, probably in Madurai. The new institution would handle all LHVpromotion training of ANMs as well as all in-service training for existingLHVs. The existing Madras facility would concentrate on initial training offresh LHV recruits. The new LHV school would accommodate 150 trainees,including two annual batches of 50 who would be trained for 18 months each,and 50 existing LHVs who would receive 16 weeks' refresher training. Alsofinanced would be a 10-bed dormitory and classroom block for each of the 12PHCs where LHVs would receive field training from both the existing Madras andplanned new school. These training facilities would be built during the firstyear of the project and begin operating from the start of the second projectyear.

3.52 In-service orientation to the MPHW system also would be requiredfor MOs in line with major changes in their role resulting from introductionof the MPHW system. First, the MO in charge of block operations would haveincreased managerial responsibilities as leader of an expanded block health

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delivery service team, and would have a substantial role in providing in-service training for its lower-level workers. Second, the PHC's workloadwould change with the addition of complicated deliveries, sputum examinationsfor TB and other services. Furthermore, PHCs can anticipate a substantialincrease in daily contacts, now averaging around 300, from MPHW referrals.Tamil Nadu would organize a program of nine weeks' training to upgrade MOcapabilities for the MPHW system; those specializing in obstetrics and familyplanning services would receive an additional three months' training. Becauseof high attrition rates, a state-wide total of about 400 MOs would requiresuch training annually.

3.53 Currently Tamil Nadu has three institutions for in-service train-ing of health workers, block extension educators and MOs. They are locatedin Chengalpattu, Madurai and Salem. Each has a training capacity of 100 andtrains around 300-500 persons per year, depending on the length and typeof course. However, these three family health and welfare training centersalready are stretched to full capacity and cannot take on the additionalin-service load which the project requires. To meet the shortfall, theGovernment would set up a fourth 100-bed training center in another part ofthe state. Its establishment would provide better geographic distribution ofsuch training than could be achieved by expanding existing facilities. Italso would prove more suitable in the long run than the temporary option ofsetting up special programs for these personnel at existing teaching hospitalsand other facilities. Construction and equipment for hostel and classroomspace at the new facility would be financed under the component during thefirst year of the project.

3.54 The per student cost of civil works averages around US$72 per mfor classrooms and hostels. Tamil Nadu would continue to need these facilitiesafter the project to expand the MPHW system state-wide, to replace personnellost by attrition and to provide in-service training for its growing cadre ofLHVs and other professional staff. Estimated annual demand for female MPHWsand LHVs would remain steady at 500 and 125, respectively, for the first fewpost-project years as MPHW implementation took place in the rest of Tamil Naduand then would rise and level off at around 1,000 and 250, respectively, forreplacement needs.

3.55 The Department of Highways and Rural Works (HRWD) would be respon-sible for HSC construction. HRWD relies on a well-established network ofrural contractors. The supervision system extends to the block level, wherea full-time engineer and overseer are stationed, supervised at the taluklevel by an executive engineer. Additional HRWD staff, including short-termhelp, is routinely recruited and posted to the block level as necessary. Theblock engineer and staff would be responsible for civil works procurement andconstruction supervision for HSCs and PHC hostel-classroom facilities. Blockengineers are allotted 1.5% of construction costs yearly for maintenance ofeach building erected under their supervision. Major repairs require HRWDsanction. Additionally, each user department at the block level can approve

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at least Rs 700 for minor repairs to any building. The State Public WorksDepartment would be responsible for construction and maintenance of the othertraining facilities through its established organizational and contractingsystem, which are satisfactory.

3.56 While under preparation, appropriate training curricula stillneed to be made available for MOs, PHN instructors, LHVs and female MPHWs.Assurances were received during negotiations that training for the aboveworkers would be carried out according to curricula which would be furnishedto IDA for review by August 31, 1980, and would thereafter be implementedtaking IDA comments into account.

3.57 Lack of adequate supplies of drugs and medicines at PHCs and theperiphery is one problem which the project would help correct. The yearlyPHC allocation for drugs and medicines would be raised to Rs 25,000 fromits present level of Rs 14,000, while that for male and female supervisorsand MPHWs would be raised to Rs 1,800, a 50% increase over present levels.The component would finance the incremental cost of these drugs and medicines.Under the MPHW system, the Health Department would have exclusive responsi-bility for the supply of drugs and medicine to supervisors and MPHWs. Atpresent, the BDO purchases such supplies on the basis of technical recommen-dations from the physician in charge of the PHC. However, even with suppliesnow ordered directly through the Health Department, serious shortages continueto affect the health care system. Persistence of these difficulties wouldhamper the effectiveness of MPHWs. For that reason, during the first projectyear a study would be carried out to determine the reasons for these prob-lems as well as to rationalize the choice of drugs based on epidemiologicalprevalence of specific diseases in the area of coverage of HSCs and PHCsand to identify corrective measures. Assurances were received during negotia-tions that the study would be completed by June 30, 1981 under terms ofreference satisfactory to IDA, and that the GOTN would furnish the report toIDA for comment.

3.58 The component would finance a bus for each of the seven new traininginstitutions receiving project support and two for existing medical officers'training centers, a station wagon for each of the 14 divisional health officesin the project area and two for use by State Health headquarters. Alsofinanced would be a motorcycle and two bicycles for each project divisionalhealth office and PHC, as well as bicycle loans, recoverable over 18 months,for the estimated 50% of all male and female MPHWs in project areas who wouldtake them up.

3.59 Managerial Arrangements - A Senior Deputy Director of Public Healthin the Directorate of Public Health and Preventive Medicine, Madras, wouldhave overall responsibility for the component. Assurances were receivedduring negotiations that a post of Deputy Director (Training) would be estab-lished in the Directorate and filled by a suitable officer by August 31, 1980;that official would have special responsibility for ensuring the appropriate-ness and timeliness of project-financed training. A Divisional Health Officer

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would be in charge of each of the 14 divisional health offices in the sixproject districts, reporting both to the Collector concerned and to the SeniorDeputy Director of Public Health in Madras through the District Health Officer.The staff of each divisional health office would include a PHN, a senior malehealth inspector and support personnel. Each office would supervise anaverage of 12 PHCs, 188 HSCs and their staff. The establishment of thedivisional health offices without incremental staff recruitment would bepossible through realignment of current managerial functions and transfer ofexisting health personnel.

3.60 Management of the component would include operation of its monitor-ing system. Information on participation rates, kinds of services offeredand utilization of supplies would flow monthly from HSCs for consolidationat the PHC, where it would be combined with supervisors' information onMPHW activities. As head of the MPHW team in that block, the responsible MOwould forward these materials to division headquarters along with reports onmonthly PHC activities, and actions planned and taken to correct problems inthe MPHW system. A similar process of consolidation and analysis would takeplace at the divisional level. Those reports would go both to the Collectorand the Senior Deputy Director of Health in Madras, where a monthly reportalong similar lines would be prepared for dissemination to those most directlyconcerned with the project. The Senior Deputy Director and his support staffwould keep track of corrective actions planned or under way and would provideguidance to Divisional Health Officers or other levels of the system asnecessary.

3.61 Coordination with Nutrition Delivery System - Although they work fordifferent Government departments, MPHWs and CNWs and their supervisors wouldhave to collaborate with one another effectively. CNWs would be expected toorganize communities for clinics to be held by MPHWs. MPHWs would be expectedpromptly to examine, and, if necessary, refer for PHC scrutiny those childrenfailing to gain weight during supplementation or otherwise exhibiting diseasesymptoms noted by the CNW. The MPHW would enroll eligible women for foodsupplementation to be provided through the CNC. In village visits and otherwork, the MPHW would be expected to reinforce nutrition education themes andencourage families to take part in the child-weighing program. Equallyimportant, all family health records would be maintained at CNCs, therebyencouraging both MPHWs and their supervisors to spend more time in villages.The significance of these complementarities would be stressed during theinitial training of nutrition and health workers and this would be reinforcedby monthly inter-department meetings at the block level. Moreover, informalcontact between health workers and their nutrition counterparts would beencouraged along with joint in-service training programs which either sponsor-ing department could propose.

Nutrition and Health Communications

3.62 The central element of this component would be activities en-couraging families to adopt a limited number of specific practices to improvenutrition conditions of young children. These would include timely intro-duction of semi-solid foods to supplement breast milk, feeding instead ofwithholding food from the sick child, increasing the home food ration for

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children under three years of age and home rehydration of children withdiarrhea. Such changes are considered feasible within existing family incomeand food availability constraints for most participating families since,according to TNNS findings, they could be accomplished by small shifts incurrent intrafamily food distribution patterns. The component's approach tonutrition education would differ from most previous efforts in Tamil Nadu byconcentrating on a few practical and specific actions and practices likelyto produce significant nutrition and health benefits for the target group.Additionally, the nutrition education program would stress worker use ofemotional appeals and mobilization of group pressures for change rather thanthe more customary emphasis on scientific argument.

3.63 The component also would: (a) provide teaching materials for pre-service and in-service training of project nutrition and health personnel;(b) prepare communities and their leaders for the introduction of projectservices through a combination of person-to-person contact and mass mediacampaigns; and (c) encourage local participation in project activities suchas child weighing and supplementation, use of oral rehydration supplies,compliance with deworming procedures and regular use of iron and vitamin Asupplements; and (d) motivate field staff through regular newsletters andpublic recognition of outstanding performance.

3.64 Through these combined activities, the component would: (a) improvethe quality of training of CNWs and MPHWs and their supervisors; (b) preparepopulations and community leaders for introduction of project activities;(c) help maintain high morale and motivation among health and nutrition fieldstaff, thereby contributing to their improved performance; (d) increase theprobable effectiveness of nutrition and health field worker performance byproviding support media for their activities; (e) improve the pace of communityresponse to project activities, and (f) speed up the likely rate of nutritionimprovement by promoting self-help and at-home measures outside the directcontrol of project staff, thereby improving the chances that nutritionalmomentum generated by project activities will be maintained through thefamily's own efforts.

3.65 In support of training activities, the component would financearound 250 sets of film strips and 13,000 training manuals for use duringpre-service and in-service sessions. CNW training would include practicalcommunications training focusing mainly on developing expertise in using printmedia, such as flip books and charts to be financed under the component.Field staff also would learn how to develop self-made materials and duringtraining would produce at least one set of flash cards, food charts or othersimilar materials. Each CNW would receive a project-financed field manual atthe close of training for use during home and other visits.

3.66 The component would finance films for use by officials in pre-activity visits to prepare area leaders and villagers for introduction ofproject nutrition services. The first visit to a project village would takeplace around three months before the nutrition delivery component went intolocal operation. Each supervisor would probably have to make an additional

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two visits to each of the 15 villages for which she would be responsible.These meetings would involve leaders of village councils and other organiza-tions such as womens' groups. One meeting would be for the entire populationand would include a film show for selected project villages through projectorsalready available to the Collector's office augmented by six others, includinggenerators, which the component would finance, to be used later for screeningsof other nutrition messages. During this period, an average of 10-15 womenleaders would be identified in each project village. Every six months theywould receive one day's orientation training from the CNW at the CNC. Theywould be expected to support her efforts by ensuring that children are broughtfor weighing regularly, that beneficiaries continue in the supplementationprogram and that other forms of desirable participation also take place.Efforts would be made for them to weigh children themselves or to superviseweight-taking by mothers or other responsible family members.

3.67 Printed materials, including posters and other visual aids, wouldbe financed and disseminated to reinforce educational and motivational workby CNWs. Among the topics would be: (a) explaining the project's selectiveapproach to food supplementation and entry and exit criteria; (b) encouragingregular participation in weighing; (c) promotion of management of childdiarrhea through home-made oral rehydration therapy; (d) encouraging contin-uation of breast-feeding and increased home feeding of children receivingnutrition supplements, and (e) encouraging participation in vitamin A andiron supplementations and deworming activities.

3.68 The component would finance about three major campaigns annually topromote a few implementable nutrition and health practices affecting youngerchildren. The principal audiences would be women, particularly mothers andtheir mothers-in-law, who are the key figures in early childrearing. However,reinforcing messages also would be directed at husbands and older siblings,because of their collateral roles in that regard. Each campaign would lastfor about three months separated by a one-month interval for analysis ofmonitoring data and design modifications resulting from it. Campaigns wouldconsist of 5-minute films to be shown in Tamil Nadu's extensive network ofrural movie houses, averaging four per project block; short radio programs;newspaper and magazine advertisements; and on-the-ground efforts of nutritionand health workers, reinforced by flip-books, charts, posters and self-madematerials. The component would finance the design, production and dissemina-tion of all materials for these campaigns, including multiple copies of sixdifferent films, 3,200 radio spot advertisements, 10,000 wall paintings and50,000 posters.

3.69 Each campaign would focus on one important idea or change and isexpected to be repeated at least three times unless monitoring data suggestotherwise. Among the topics already identified for probable campaign focusare:

(a) the introduction of low-cost, locally available semi-solid foods to the child from the age of four months,with parallel continuation of breast-feeding;

(b) generally increasing the amount of food given to theyoung child;

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(c) continued feeding rather than withholding food fromchildren with diarrhea and the use of home-made oralrehydration mixes; and

(d) improvement of environmental hygiene with emphasis oncontrol of common disease vectors such as flies.

Current plans call for a maximum of six campaign topics during the project.

3.70 Traditional folk theater as well as modern media would have a rolein this component. In recent years, one such form popular in rural areas,Villu Pattu, has shifted from its original historic-heroic focus to morecontemporary themes. It has been used successfully to convey developmentmessages in such fields as agriculture and family planning. The projectwould finance the identification of around 20 Villu Pattu troupes; develop-ment of sample scripts for troupes to adapt; training to use these scripts,through apprenticeship to a master troupe, and the cost of around 20 educa-tional performances monthly by each troupe in project villages which, becauseof poverty or isolation, have less access to films. On the basis of estimatedcosts per target person reached, the efficiency of traditional folk theaterunder these circumstances is comparable to that of rural cinema.

3.71 Managerial Arrangements - Because this component provides supportto both the Social Welfare and Health Departments, it would be managed throughthe project coordination office. A Joint Coordinator for Communications(JCC) would direct the component. The staff of the communications unit wouldinclude an assistant communications officer, a news bulletin editor, an artdirector, a monitoring officer, a media officer, a production officer, atraining officer, a photographer and support staff, most of whom would berecruited specifically for the project. The unit also would post one DistrictCommunication Officer (DCO) to each project district to coordinate fieldactivities as they began to phase in. Incremental salary costs of thesepersonnel would be financed by the component, along with around 10.5 person-years of local consultants to provide technical assistance in mass and inter-personal communication and other fields such as monitoring. Job descriptionsfor all communications staff and terms of reference for all technicalassistance have been prepared for the component and are satisfactory toIDA.

3.72 The communications unit would set up a technical working groupto provide ad hoc advice as needed on content or design or to solve specialproblems in specialized fields not covered by staff or technical assistance.It would consist of around six experts from both the public and privatesectors including a nutritionist, a pediatrician, an anthropologist, aspecialist in public health administration and the State Directors of SocialWelfare and Rural Development or their nominees. The JCC would convenemeetings and act as the Member-Secretary. Alternates also would be named forall members to ensure availability on short notice. The component wouldfinance modest honoraria for remuneration of non-Government members of theworking group. Management, distribution and control systems to disseminatecommunications materials as well as contracting procedures for each of themedia elements have been worked out.

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3.73 Also financed by the component would be around one month of pre-service communications training for the JCC; one staff car, a motorcycle andthree bicycles for the communications unit; one motorcycle for use by each ofthe six DCOs; furniture and equipment for headquarters and district offices,and the costs of small background studies on socio-cultural constraints tochanging food and health practices, media access and traditional media infra-structure, which are of direct use for finalizing decisions on communicationstrategy and message content.

3.74 Monitoring of the component by its management would focus on whethermessages get out as planned, reach the right people, are understood andremembered by them and are found interesting and relevant. Regular feedbackfrom field staff on how well nutrition education and other activities seemto be working, and how response develops to project activities would provideuseful qualitative indications of how the component is progressing. Limitedinquiries in regard to specific practices before and after each mass mediacampaign would reveal trends and problems in the communications interventions.Additionally, monthly health and nutrition reports consolidated at the districtlevel would provide DCOs and component management with necessary informationon the use of communications material disseminated under the component.

Monitoring and Evaluation

3.75 This component would support the regular collection, interpretationand appropriate dissemination of analytic information required by project andcomponent managers: (a) for timely and effective physical and financialimplementation; and (b) to determine the extent, pace and cost of progresstoward achieving project objectives.

3.76 Project monitoring and evaluation would cover seven areas:

1. Input delivery (monitoring)

2. Contact with the target group (monitoring)

3. Input utilization (monitoring)

4. Adoption of recommended behavior (monitoring and evaluation)

5. Nutritional status changes (surveillance and evaluation)

6. Health status changes (evaluation)

7. Death rate changes (evaluation)

. ~MONITORING - --. vei

Delieryj Cntat |Utilization ReoinnainlStatsu hags Death Rate

t . EVALUATION

World Bank - 21073

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3.77 Monitoring and evaluation would measure concurrently, at varyinglevels of depth, the degree to which nutrition, health and communicationservices are producing desired results. If the delivery of inputs, messagesand services are satisfactory and if they are relevant, acceptable and accessi-ble to the target population (measured by monitoring), positive effects on thenutrition and health status of the beneficiaries should take place (measuredby evaluation). This underscores the fundamental continuity between bothkinds of activities.

3.78 Component monitoring would be undertaken by the executing agenciesconcerned. A list of what type of component data would be collected, at whatintervals, by whom, and by what method would be worked out between the manage-ment of each component and the monitoring division of the project coordinationoffice, which would have overall responsibility for project monitoring.

3.79 Project monitoring would draw upon data regularly generated byexecuting agencies. This flow of information would be supplemented by on-the-spot field checks as well as a total of around 15 special monitoring surveysduring the project. Those would include studies on drop-outs from the foodsupplement program, degree of supplement substitution for food consumed athome, changing patterns of intra-family food distribution, media penetrationand the reliability of data generated by the nutrition and health deliverysystems. Also included would be studies in the first, third and fifthproject years of the efficacy of nutrition and health training, and costs perperson reached and per service rendered. Annual surveys of leakages in thesupplementary food distribution system also would take place through projectmonitoring.

3.80 Based on data from each component, the monitoring division wouldprepare consolidated monthly reports on project progress and would make theseavailable to component and project management. These would include statusreports on corrective measures previously undertaken or identified for eachcomponent. The monitoring group also would prepare quarterly and annualreports on project progress. Both would contain comparative information onprogress to date against scheduled targets and progress during the reportingperiod. Using data generated by the monitoring division, the project communi-cations unit would prepare summaries of these reports for distribution toproject field personnel.

3.81 Additionally, during the first project year, a detailed monitoringstudy to refine the mix of project activities as necessary would be carriedout in Kottampatti Block, where the project first would be implemented. TheKottampatti study would test:

(a) the acceptability and shelf-life of the food supplementunder field conditions and verify the number of feeding-days required to bring malnourished children back tonormal growth;

(b) the practicality and effectiveness of criteria and pro-cedures for selection of children and pregnant andlactating women to be enrolled in the feeding program;

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(c) the adequacy of the curricula proposed for variouscategories of nutrition and health trainees, andthe feasibility and appropriateness of the staffworkload, targets and schedules as presently conceived;

(d) coordination arrangements proposed for the health andnutrition staff at various levels;

(e) the proposed monitoring and supervision systems, confirmminimum information requirements, and identify priorityareas for further in-depth studies;

(f) the accessibility and acceptability of project facilitiesand services; measure the initial utilization andparticipation rates; determine who actually benefitsfrom the services rendered and analyze determinants ofrelapse, dropping-out, absenteeism and non-participation;

(g) teaching materials to be used in communication activities;

(h) technical aspects of the program, including methodsfor providing oral rehydration therapy for diarrhea,maintenance of the cold chain for vaccines, use of thegrowth chart, suitability of scales, use of anemiarecognition card;

(i) logistical channels for the supply of inputs such asdrugs and the most appropriate frequency and methodsof re-supply; and

(J) aspects of the proposed evaluation system, includingtraining of field investigators, pre-testing of surveyinstruments, and communications survey methods.

Evaluation staff would be posted in the field to facilitate collection andanalysis of Kottampatti data.

3.82 The nutrition surveillance system would provide project managementwith a monthly account of the numbers and percentages of children weighed,children not gaining adequate weight and children in the feeding program.These key indicators would reveal the project's changing coverage over time,show the monthly variations in nutritional status, and indicate trends infeeding program participation of children with faltering growth. They wouldprovide timely identification of villages, blocks, and districts which mayrequire special attention because of continuing or emerging nutrition problems.Complementing this surveillance system would be another information-generatingscheme operating in control districts outside the project. A sample ofrandomly selected children would be weighed each month using anthropometriccriteria. Measurements would be done by specially recruited investigatorswho would report directly to project headquarters in Madras. This scheme

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would provide sensitive early warning information on creeping and acute nutri-tional deterioration elsewhere in the state, and also would enable projectauthorities to isolate favorable effects attributable to project actions.

3.83 Evaluation of the impact of the project would concentrate on changesin levels of malnutrition, morbidity and mortality among target groups inproject areas compared to changes elsewhere in Tamil Nadu. This will beaccomplished principally through baseline and annual re-surveys in projectdistricts and certain other areas which would serve as controls. Samplingwould take place for a total of around 14,000 households during the projectperiod. The initial baseline survey would get under way six months before theimplementation of project activities in each district. Data collection andanalysis would take about six months. Other evaluation topics would includeefforts to determine changes in intra-family food distribution habits after theintroduction of project nutrition activities and an assessment of the feasi-bility of making the food supplement available through fair-price shops andother commercial channels. Additional studies would seek to relate the costsand impact of project activities to other programs in Tamil Nadu aimed atsimilar target groups.

3.84 A major study of project achievements and their costs would takeplace in the year following the last year of project implementation. Thestudy would include a sectoral review of Tamil Nadu's nutrition and ruralhealth policies and programs, experience with the State's various modes ofdelivering nutrition and health services at the community level and theirimpact and managerial and budgetary implications; IDA would receive a copy ofthe report. Assurances were received during negotiations that terms ofreference for this study would be satisfactory to IDA.

3.85 Evaluation would be carried out by a group under the overallsupervision and technical guidance of the Director of Evaluation and AppliedResearch in the Finance Department. The Evaluation Division would be headedby a special officer with the rank of Joint Director. Three sectionswould report to him: evaluation and surveillance, special studies andadministration.

3.86 The evaluation and surveillance section and the special studiessection each would be staffed by a Deputy Director, one research officerand two research assistants. The special studies section also would recruitgraduate students to be stationed for longer periods of time in selectedvillages as participant observers. A specialized staff consisting of anutrition expert, a statistician, a social anthropologist, and a healthspecialist/epidemiologist would be available for consultation with bothsections; they would work under the direct control of the head of specialstudies. In addition, a total of about 110 field investigator-years would berequired to carry out the sample surveys as well as to contribute to datacollection for the special studies. The administrative support section, whichhandles payments and logistical matters, would be headed by a research officerwho would also undertake work in the evaluation and surveillance section. The

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non-technical support staff would include one junior accounts officer, onesuperintendent, two assistants, two junior assistants, one record clerk andfour steno-typists.

3.87 A field unit would be established in each project district as themain arm for data collection. Each unit would be headed by a research officersupported by junior research assistants and investigators, whose number wouldvary somewhat between districts depending upon the number of sample householdsto be covered. To ensure both objectivity and widest possible application offindings from the project, an Advisory Panel on Evaluation would be set upconsisting of representatives of the State Government, the GOI and appropriateresearch institutions. The panel would be established by December 31, 1980and would continue through the project period. The panel chairman would bethe State Director of Evaluation. The head of the Project Evaluation Divisionwould be its Member-Secretary. Assurances were received during negotiationsthat such a panel would be set up and would meet as necessary throughout theproject period to review and comment on the evaluation of the project.

3.88 The component would finance the costs of monitoring and evaluationstudies; furniture and equipment for the evaluation office and its field units;one four-wheel drive motor vehicle, one motorcycle and three bicycles for theevaluation office; one motorcycle and four bicycles for each of the seven fieldunits, and incremental operating costs for the component including the salariesof agreed staff.

Project Coordination Office

3.89 A small office to coordinate the project was set up in the StateSecretariat prior to negotiations. Its professional staff already consists ofa Project Coordinator and the Joint Coordinator for Communications; others tobe assigned would include a monitoring officer, a senior accounts officer, anadministrative officer, and two computer programmers. The Project Coordinatorreports to the Secretary of the Social Welfare Department, who is the ChiefProject Coordinator. However, the Project Coordinator also is a member andsecretary of an interdepartmental project oversight committee, chaired by theChief Secretary of Tamil Nadu, whose other members include the Secretaries ofSocial Welfare, Health, Agriculture, Rural Development and the heads of otherinterested government agencies.

3.90 The Project Coordination Office would review annual and quarterlybudgets and work programs from each project district and executing agencyto ensure their consistency with project schedules and operational criteria.It also would review proposed annual project budget submissions from thesetwo sources, identify differences between such proposals and approved projectimplementation schedules and annual financing plans, seek to reconcile thesewith the agencies concerned and report on the outcome to the high-level com-mittee. Remaining issues would be resolved there and the results communicatedback to component managers through the coordination office. Final proposedannual budgets for each component would be forwarded to the Finance Departmentby the coordination office for inclusion in the annual state budget.

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3.91 The coordination office would review monthly monitoring reportsfrom each project district in respect to each component and prepare consoli-dated summaries. It also would keep track of corrective actions proposedor under way in each component and carry out extensive field observation ofproject activities to verify the accuracy of such reports. Additionally,the Project Coordinator would be in frequent contact with District Collectorsin regard to the pace and quality of project implementation. To facilitatedata management, interpretation and analysis, the project's evaluation unitwould be located in the Project Coordination Office, although it would remainunder the administrative control of the Finance Department.

3.92 The coordination office also would operate a US$500,000 equivalentmanagement fund to support innovative activities relating to project objec-tives which implementing agencies would propose from time to time. Approvalof the high-level project committee would be required for such expenditures;assurances were received during negotiations that advance IDA approval wouldbe obtained for expenditures of US$50,000 or more from the project managementfund.

3.93 For the coordination office the project would finance three vehicles;furniture and equipment, including a desk computer; staff salaries and otherincremental operating costs; and the project management fund.

IV. PROJECT COSTS, FINANCING, PROCUREMENT, DISBURSEMENT AND AUDIT

A. Costs and Financing

4.01 The total estimated project cost is US$66.4 million equivalentfor five years of project operation and evaluation in the sixth year. Totalproject costs may be broken down into base costs of US$49.7 million equivalentand contingencies of US$16.7 million equivalent. The foreign exchange compo-nent is estimated at US$8.7 million, 13% of total project costs. Costs ofcivil works, vehicles, furniture and equipment account for US$15.5 million,or 33% of base costs. Food costs are US$6.0 million, 13% of base costs.Training costs account for US$2.8, 6% of base costs. Technical assistanceand mass media contracts total US$2.4 million, 5% of base costs. Incrementaloperating costs total US$19.6 million, or 42% of base costs. Duties and taxesare estimated at US$1.9 million. All costs are based on calculations at thetime of appraisal. Salary costs are based on standard Government pay andallowances scales in effect at that time. Local technical assistance costestimates are based on prevailing rates for such services. Table 1 summarizescost estimates by expenditure category. Table 2 provides cost estimates bycomponent.

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nDKIA: TAM.rL NADU NUTRITION PROJECT - Table 1Project roSc Estimates by Expenditure Category

(In Rs 'eoo) (ln USS 't000) 2 I ofLocal Foreign Total Local Foreign Total FE Base Costs

A. Civil Works 52,985 22,708 75,693 6,308 2,703 9,011 30 19

D. Vehicles, Equipment 39,959 14,462 54,421 4,757 1,722 6,479 - - 14and Furniture

1. Vehicles 8,665 2,888 11,553 1.031 344 1,375 25 32. Equipment and 31,294 1.1,574 42,868 3,725 1,378 5,103 27 11

PUrniture

C. Training 23,670 - 23,670 2,818 -- 2,818 - 6

D. Contract Services 18,998 - 18,998 2,262 - 2,262 - 5

1. Coruunications 17,558 - 17,558 2,090 - 2.090 -2. Ivaluation 1,440 - 1,440 172 - 172 -

r. Technical Assistance 1,522 - 1,522 181 - - -

P. Food Supplements 50,747 - 50,747 6,041 - 6,041 - 13

C. Project M.anagement Fund 4,200 - 4,200 500 - 500

IL Incremental Operating Costs

1. DJrugs and Supplies 33,977 11,326 45,303 4,045 1,348 5,393 25 122. Salaries and 96,386 - 96,386 11,475 - 11,475 24

- Allovances3. Veh. op. Costs 3,033 2,108 5,141 361 251 612 41 14. Other Op. Costs 17,705 -- 17.705 2,1 -- 2,108 5

Subtotal 151,101 13.434 164,535 17,989 1599 19,587 42" aase Costs 343,182 50,604 393,786 40,855 6,024 46,879 12.9 100

ContingenciesPhysical 23,828 2,837 6.1Price L40.158 16,685 35.5

Subtotal Con.inzencies 163,986 19,522TOTAL 557,772 66,401

INDIA: TAMIL NADU NUTRITION PROJECT Table 2

Project Cost Estimates by Comoonent(in '000)

Rutees us __ 'S5$ 5 Foreign 2 BaseLocal Foreign Total Lccal Foreign Total Excbanee C"st

Yutrition Delivery Services 172,764 11,662 184,426 20,567 1,389 21,956 6.3 46.8

Rural Health Services 130,295 38,076 168,371 15,511 4,533 20,044 22.6 42.8

Nutrition Coamunicactins 23,950 325 24,275 2,851 39 2,890 1.3 6.2

Monitoring and Evaluation 8,159 171 8,330 971 20 991 2.0 2.1

t Iect Coordination 8,014 370 8,384 954 44 998 4.4 2.1

base Costs 343,182 50,604 393,786 40,854 6,025 46,879 12.8 100.0

Physical Contingencies 19,267 4 L561 23 828 2.294 542 2,837 6.1

SUB-TOTAL 362,449 55,165 417,614 43,149 6,567 49,716

Price Continsencies 122,17 17,94 158 14.550 2,135 16,685 35.6

TO'AL PROJECT COSTS 484,666 73,106 557772 57,699 8,702 66,401

- 38 -

4.02 The foreign exchange component of base costs is estimated at 30%for civil works, at 27% for equipment and furniture and at 25% for vehicles,materials, drugs and supplies. Physical contingencies were calculated at10% against estimated base costs of civil works, furniture and equipment.A similar allowance has been made for drugs and supplies, training, and foodsupplements because of possible variations in the numbers of beneficiariesinvolved. Price contingencies averaging 33.6% of base costs and physicalcontingencies were calculated on the basis of anticipated expenditure schedulesand expected price increases from the end of appraisal currently estimated at10% in 1981, 7% per year 1981-83 and 5% in 1984 and thereafter.

4.03 Recurring State expenditures for nutrition are about US$8.8 million1979-80, and for health, about US$82 million. These represent around 0.9%and 8% respectively, of the State's estimated 1979-80 revenues of US$1,011million. By 1995, conservatively assuming continued 3% annual budget growthin real terms (although such State expenditures have been rising at around4.3% yearly), State revenues would run around US$1,622 million. Using 1995population projections, the state-wide recurring costs in real terms of theproject's nutrition services for both rural and urban areas would be US$28million at present malnourishment levels, which are, however, expected to fallsignificantly, and ignoring savings to the State budget as communities beginto absorb a share of CNC-CNW costs. Assuming that other nutrition programsremained constant, although it is expected that existing pre-school activitieswould be absorbed into the CNC-CNW system, total State spending on nutritionin 1995 would run around US$37 million in real terms, or around 2.3% of annualstate revenues anticipated at that time. Incremental recurring costs ofstate-wide health coverage under the MPHW system would be around US$15.7million in 1995 in real terms. State health expenditures in that year wouldrise to around US$127 million in real terms if other health costs kept pacewith population growth and would account for around 8% of total state revenuesprojected for 1995.

4.04 An IDA credit of US$32 million would finance 50% of total projectcosts net of duties and taxes. The GOTN would finance the balance. Retro-active financing of up to US$300,000 would be provided for expenditures fromSeptember 1, 1979, for baseline studies, development of nutrition and healthworkers' training curricula and training of communications and other personnelneeded to get the project under way according to schedule.

B. Procurement

4.05 Civil works contracts (US$9.0 million) would be small and dispersedboth geographically and over time, which would not be suitable for interna-tional competitive bidding. They would be awarded on the basis of local com-petitive bidding through standard GOTN procedures, which are acceptable to IDA.

4.06 An estimated 102 sedans and station wagons, 9 buses and 212 motor-cycles (US$1.1 million) would be procured under the project. They would bepurchased mainly in small quantities over five years and dispersed principally

- 39 -

in rural areas. Maintenance facilities and ready availability of spare partswould be essential, requiring purchase of types of locally made vehiclesalready used by Government departments. Vehicle procurement thus would beby local competitive bidding under existing GOTN procedures which are satis-factory. Bicycles (US$0.3 million) would be purchased mainly by individualstaff from loan funds provided by the GOTN; the purchase price would berecovered over 18 months from each buyer.

4.07 Orders for drugs, furniture, equipment and supplies (US$10.5 million)would be bulked whenever possible and purchased according to established localcompetitive bidding procedures, except where valued at less than US$50,000,when they would be procured through prudent local shopping. Drugs to beprocured would include arrowroot powder and glucose-electrolytes (US$0.9million), which would not attract foreign bidders. Other drugs and medications(aggregating US$3.3 million) would be of disparate types and procured overtime due to limited shelf life of some items. They would represent an incre-ment of less than 15% over drugs now procured by the State under establishedprocedures which are satisfactory, ensure equitable, reasonable prices, andare provided through local manufacturers which include a number operating incollaboration with foreign companies from IDA countries. Contracts for mediaproduction, data processing of evaluation studies and technical assistance(US$2.4 million) also would be procured through prudent local shopping becausethe specialized nature of services to be provided makes competitive biddingunsuitable for those purposes. All the above costs exclude contingencies.All proposed tender documents for civil works, vehicles, drugs, equipment,furniture and supplies, estimated to cost US$100,000 or more, would bereviewed by IDA before bids are invited. All proposed contracts estimated tocost US$100,000 equivalent or more would be furnished for review by IDA beforesigning and, when based on local competitive bidding, would be accompanied bya copy of the relevant bid evaluation. Signed copies of other contracts alsowould be furnished to IDA along with copies of the relevant bid evaluations,where competitive procurement is involved.

C. Disbursements

4.08 Disbursements would be made for 80% of the costs of civil works,vehicles, equipment, furniture, training, contract services, technical assis-tance, drugs, supplies and the project management fund.

4.09 Disbursements expenditures for civil works payments not exceedingRs 300,000, for payments for vehicles, equipment, contract services, drugsand supplies not exceeding Rs 150,000 and for training would be made on thebasis of certificates of expenditure. The State Government would retainrelevant documentation for inspection in the course of project review missions.Disbursement against all other items would be made against evidence of receiptof and payment for civil works, goods and services.

- 40 -

D. Accounts and Audits

4.10 The Government would maintain separate accounts for expendituresmade under the project. These would be audited annually for each fiscalyear in accordance with sound auditing principles consistently applied. Suchaudit reports would be furnished to the Association within nine months afterthe close of a fiscal year. Certificates of expenditure would be auditedinternally at least once every six months and audit reports furnished to IDA.Those reports would show, inter alia, that the funds withdrawn were used forthe purposes intended, the goods had been received, work performed and thatpayments had been made.

V. PROJECT ORGANIZATION AND MANAGEMENT

A. Overall Coordination

5.01 At the state level, an inter-departmental committee chaired bythe Chief Secretary of the State, would meet quarterly to review projectprogress and decide on desirable budgetary and implementation adjustments.The Project Coordination Office, headed by the Project Coordinator, (paras.3.89-3.93) would serve as Secretariat to the committee. Other members ofthat high-level committee would include the Secretaries of Finance, SocialWelfare, Health, Rural Development, Agriculture and the managing directorsof the Tamil Nadu Water Supply and Drainage Board (TWAD) and the Tamil NaduAgro-Engineering Cooperative Federation. Wihile the latter agencies are notdirectly involved in project implementation, their participation in thecommittee is important because of recognized linkages between nutrition andtheir areas of responsibility. Moreover, the Government intends to provideimproved water supplies on a priority basis to the estimated 30% of habitationsin project areas where no public or protected source is available within onekilometer. Inclusion of a TWAD member on the high-level committee would helpensure coordination of that program with project activities.

5.02 Inter-agency coordination at other levels would take place throughdistrict and block project committees. The district committee would be chairedby the Collector. Its membership would include the District Assistant Directorof Social Welfare, the District Health Officer and the District AssistantDirector of Rural Development. District committees would meet monthly tomonitor project progress and resolve difficulties arising at that level.

5.03 At the block level, the DDO would chair a monthly meeting of thenutrition instructresses, the MO, the BDO, the TNO and the concerned divi-sional health officer. These meetings would provide a forum for identifica-tion and resolution of local problems and for suggested improvements in theconduct and content of the program, which would be forwarded to the high-levelcommittee and respective implementing agencies in Madras through the Collectors.Notices and minutes of meetings would be copied to Agriculture, Rural Develop-ment and TWAD staff and their presence requested when items of mutual interest

- 41

are on the agenda. The Collector would meet regularly with these committeeswhile on tour and at least twice yearly with DDOs for the express purpose ofdiscussing progress and direction of the nutrition project.

B. Programming and Budgeting

5.04 Block and district committees would collaborate on the formulationof quarterly project work programs under the currently approved budget anddevelopment of annual program proposals for the coming financial year. Theproject coordination office would review these proposals, reconcile them withannual project cost estimates and approved or requested departmental budgetsand work programs and recommend suitable action by the high-level committee.The project coordinator would notify both district committees and executingagencies of decisions by the committee, and would forward approved proposalsfor the next fiscal year to the Finance Department for incorporation in theannual budget. After budget approval, the project coordinator would adviseconcerned departments and district collectors of details of programs andoperations approved for the next fiscal year. Notification of approved workprograms and budgets would be made at least 60 days before the start of thefollowing quarter. The flow of funds would follow established Governmentprocedures.

C. Project Execution

5.05 Existing Government agencies would carry out project activitiesas indicated below:

Agency Activity

Directorate of Public Health, Health Services Operation,Department of Health and Family Welfare Management, Monitoring

Directorate of Social Welfare, Nutrition Services Operation,Department of Social Welfare Management, Monitoring

Bureau of Evaluation and Project EvaluationApplied Research, Departmentof Finance

Tamil Nadu Agro-Industries Food Supplement ProductionCorporation

Highways and Rural Works Department Civil Works

Public Works Department Civil Works

Project Coordination Office, Project Coordination,Department of Social Welfare Communications, Monitoring

- 42 -

5.06 Annex 5 provides an implementation schedule of key project activi-ties. Annex 6 provides simplified organizational charts for each component.

VI. JUSTIFICATION AND RISKS

A. Justification

6.01 The nutrition component, at 80% coverage of eligible children, whichthe project is expected to reach, would provide nutrition protection for anestimated 780,000 children under three years of age, including 470,000 cur-rently deemed to be actively malnourished. It would also provide selectivefood supplementation for about 275,000 pregnant and lactating women. Thehealth component, at 75% coverage of the project population, which is arealistic four-year goal, would improve the availability and quality ofbasic services to an estimated ten million persons, including an estimated950,000 families and an estimated additional 1.25 million women and theirchildren who are not now adequately served by the system. Although theproject's specific objectives concern women and children, improved quality andreach of health services is likely also to improve overall health conditionsof the labor force in project areas. Resulting morbidity reductions wouldincrease the number of work days available per adult beneficiary, includingduring times of peak demand for agricultural labor. Through combined nutri-tion, health and communications interventions, the project would contributeto increased young child survival rates and would help such beneficiaries toreach full genetic potential, raising many to higher levels of educability andpotential performance, enhancing the rate of return of Government investmentsin education, and providing a more favorable climate for acceptance of familyplanning.

6.02 These changes would help improve the quality of rural life; whilenutrition is only one organizing principle for such efforts, the projectoffers an important opportunity to do so at district and local levels.Through its combined services, the project also would provide a focused andeffective alternative to long-term feeding programs which now characterizethe state's pre-school nutrition efforts and reach only a small proportionof those at greatest risk. Rationalizing the structure of direct nutritionintervention would help the state realign its other nutrition programs andimprove their reach and effectiveness.

6.03 The program supported by the Project would require considerablyless food supplement than the existing feeding programs. Under the Project,children 6 to 36 months would receive an average of about 110 days' supple-mentation, including allowance for relapse. Under existing programs, suchchildren would receive supplementation for 300 days yearly for the full2-1/2 years. Thus, considerably larger populations could be covered witha given volume of food supplement under the program supported by the Project.

- 43 -

6.04 The proposed project would reduce malnutrition through the stageof infant and young child development (where current evidence suggests thatits effects are most harmful for human development) and would reduce peri-natal, infant and child mortality. In quantitative terms, our expectation isthat the program would: (a) reverse or avert around 570,000 cases of moderateto severe malnutrition among children under three years of age and (b) reducethe mortality rate among infants and pre-schoolers by some 25%, resultingin (short run) increases in five-year-olds entering the school-age cohortof about 37,000 per year. The per capita cost of achieving improved nutri-tional status through the nutrition delivery component, averaged over 570,000direct child beneficiaries of the food supplement program (around 80% of thosetaking part), would be about Rs 220. These costs are incurred primarily inthe pre-birth and infant stages when the mother and child feeding programs areutilized.

6.05 The potential economic benefits depend largely on the impact ofimproved nutritional and health status (as realized during this early child-hood state) on productivity and earnings in adult life. In the present stateof the art, estimates of such benefits are necessarily highly speculative. Itis, of course, well known in a general sense that children whose early nutri-tional status is satisfactory tend to be substantially more productive andhave higher earnings capacity in later life. What is difficult, however,is to separate out the specific "nutritional factor" associated with thisdifference from a host of other factors that tend to be highly correlated withnutrition status in early life--parental incomes, education, and position insociety being some of the leading ones.

6.06 What can be demonstrated, however, is that the economic benefits,in terms of enhanced adult productivity and earnings, need not be very largeto provide a healthy economic justification for the proposed nutrition deliveryprogram. A conservative estimate for the present value of the prospectivelifetime earnings of an Indian agricultural laborer, discounted at 10%, issome Rs 4,500. 1/ On the assumption that about 47% of the beneficiariesfrom the nutrition program would be full-time agricultural laborers at anyone time during the forward period, 2/ the per capita present "value" of a1% increase in productivity resulting from improved nutritional status duringthe formative childhood period would be some Rs 21. The present value of theestimated cost of nutrition services is Rs 187 per capita (the estimate ofnutrition costs given above, after discounting). To earn 10% on the invest-ment in improved nutrition status, therefore, requires an increase in adultproductivity of less than 9% among fewer than half of those children whoreceive nutrition services through the project.

1/ The calculation is based on an annual earnings stream of Rs 1300 (260working days at Rs 5 per day) and an earnings span of some 42 years,from age 12 to age 55.

2/ Assuming that about 10% of the 5-year old cohort will die before real-izing the earning span and that, on average, about 85% of the women arenot employed as paid workers (versus about 10% of the men).

- 44 -

6.07 The required increase in productivity, while in itself reasonable,would be still less with: (a) a less restrictive assumption about prospec-tive earnings, since the one above is equivalent to arguing for zero realincreases in agricultural wages over the next 60 years and that all prospec-tive workers become agricultural laborers, typically among the lowest earninggroups in Indian society; and (b) the addition of a reasonable valuation ofwork done by those outside the formal employment sector, in particular thevalue of work done by women in the home, and an expectation that earningsprospects for women also will improve over the next 60 years.

6.08 The economic value of reduced child mortality would constitutean additional benefit from the project's nutrition and health services.Among other things the scale of this benefit would depend importantly onthe ultimate impact on desired and achieved family size among the householdsaffected by reduced child mortality. Thus, if reduced mortality bringsforward in time attainment of desired family size--and there is some plausi-bility in this argument based on recent demographic studies--the impact islargely to advance the realization of the future income streams of the currentgeneration of children who die in infancy and are replaced by others, but onaverage some four years later. In that case, the income stream of the survivoris realized rather than that of his/her "replacement," and is realized, onaverage, four years earlier. Using the agricultural laborer income stream asdescribed above, such a four-year advancement would be "worth" Rs 1,400 interms of present value. Assuming that 60% of the 37,000 whose deaths areaverted by the project become full-time workers, this element alone would payfor more than half the recurring costs of the health components

B. Risks

6.09 The project faces the fundamental risk that the determinants ofmalnutrition may be so complex that even effective implementation of theproject as designed would not produce the anticipated results. However, theproject has been designed on the basis of extensive research in Tamil Nadu andelsewhere, takes into account the most relevant experience available, and, ifproperly implemented, is expected to have pronounced effect. With respect toactual implementation, as opposed to design, the project faces five basicrisks as outlined below.

6.10 The first is the usual risk of pioneering efforts associated withmajor training programs and the installation of new systems: possibleproblems with quality control and adherence to implementation schedules.A second risk is that CNWs may find it difficult to apply project criteriafor the food supplement program. However, both of the above risks are reducedby the extensive performance monitoring built into the project, particularlythrough detailed reviews of the Kottampatti Block experience and again afteranother 69 blocks have become operational. The risk of distortion of thefood program is further reduced because entry and exit are controlled by thesupervisor.

- 45 -

6.11 A third such risk is that participation in the food supplement pro-gram would be less than expected because of the relatively modest size ofthe daily ration, its limited duration and difficulties in reaching the mostdisadvantaged. This risk is offset by the intensive surveillance, monitoringand nutrition education efforts designed to promote and sustain participationby eligible beneficiaries. Additionally, flexibility is built into thesystem in regard to both entry and discharge criteria and adjusting rationsizes as appropriate.

6.12 A further risk is that maintenance of separate administrativecontrols for nutrition and health delivery might hamper both project manage-ment and the emergence of an optimal package of village health and nutritionservices. However, this risk is offset both by training and supervisionarrangements which stress field coordination between the departments concernedand the willingness of the State to continue to address the organizationalquestion through project reviews and evaluation.

6.13 Additionally, positive changes in intrafamily food distribution andfamily food habits may occur later or to a lesser extent than anticipated.In that case, more children would relapse than expected, the costs of foodsupplementation would rise and fewer beneficiaries would retain nutritionmomentum during their later pre-school years. However, even in that event,the project would have made a significant contribution in helping the Govern-ment achieve its goal of substantially reducing mortality rates of youngerpre-school children and in boosting their nutrition during the most criticalyears.

VII. RECOMMENDATIONS

7.01 During negotiations, agreements were obtained from the StateGovernment that:

(a) reviews of project operations would take place after a year'soperation in Kottampatti Block and after about 70 blocks hadbecome operational but no later than the end of the thirdproject year, under terms of reference satisfactory to IDA,and that the project design and implementation schedulewould be adjusted according to review findings as feasible,taking into account IDA comments on the reviews (para 3.07);

(b) the above reviews would take account of: (1) the currentevaluation of mobile redical teams in Tamil Nadu carriedout by the National Institute of Health and Family Welfareand (2) the results of other pilot projects and studies ofways to introduce community health and nutrition servicesin the State (para. 3.44);

- 46 -

(c) curricula for the training of staff under the project wouldbe prepared and furnished to IDA for its comments and that suchtraining would be carried out in accordance with these curricula,taking into account IDA comments;

(d) criteria for entry into and discharge from the food supplementprogram for children and women would be satisfactory to IDA(para. 3.34);

(e) should the State modify its health system in project areasduring the project, after consultation with IDA, Tamil Naduwould take all necessary measures to maintain the efficiency,quality and level of nutrition and health services and ensureappropriate use of CNWs to avoid duplication of effort(para. 3.44);

(f) a study to identify ways of improving procurement, delivery andchoice of drugs and medicines to PHCs and HSCs would be carriedout under terms of reference satisfactory to IDA by June 30,1981 and that the report would be furnished to IDA for comment(para. 3.57);

(g) the post of Deputy Director (Training) would be established inthe Directorate of Public Health with special responsibilityfor assuring appropriateness and timeliness of project-financedtrai.ing, and a buitable officer appointed thereto, by August 31,1980 (para. 3.59);

(h) an evaluation study of project achievements and their costswould be carried out in the year following the last year ofproject implementation, including a sectoral review of TamilNadu's nutrition and rural health policies and programs,experience with the State's various modes of delivering nutri-tion and health services at the community level, and theirimpact and managerial and budgetary implications, in accordancewith terms of reference satisfactory to IDA (para. 3.84);

(i) an Advisory Panel on Evaluation consisting of representativesof the State Government, the GOI and appropriate researchinstitutions, would be set up by December 31, 1980 and meet asnecessary throughout the project period to review and commenton evaluation of the project (para. 3.87); and

(j) advance IDA approval would be obtained for any expenditures ofUS$50,000 or more from the project management fund (para. 3.92).

7.02 Subject to the above assurances, the project is recommended for anIDA credit of US$32 million to the Government of India on standard terms.

INDIA; TAMIL NADU NUTRITION PROJECT

Estimated Base Costs by Component and Expenditure Category (Rs '000)

Nutrition Communi- Monitoring Coordi-Delivery Health cations and Evaluation nation Total

A. Civil Works 5,285 70,408 -- -- -- 75,693

B.. Vehicles, Equipment and Furniture 26,640 25,654 654 425 1,048 54,421

1. Vehicles 5,044 5,956 141 256 156 11,5532. Equipment and Furniture 21,596 19,698 513 169 892 42,868

C. Training 8,065 12,300 2,496 809 -- 23,670

D. Contract Services -- -- 17,558 1,440 -- 18,998

E. Technical. Assistance 80 -- 1,227 215 -- 1,522

F. Food Supplements 50,747 -- -- -- -- 50,747

G. Project Management Fund -- -- -- -- 4,200 4,200

H. Incremental Operating Costs

1. Drugs and Supplies 4,782 39,847 475 147 52 45,3032. Salaries and Allowances 69,429 18,684 1,138 5,013 2,122 96,3863. Vehicle Operation 4,365 451 79 59 187 5,1414. Other Operating Costs 15,033 1,027 648 222 775 17,705Subtotal 93,609 60,009 2,340 5,441 3,136 164,535

TOTAL BASE COSTS 184,426 168,371 24,275 8,330 8,384 393,786

TOTAL BASE COSTS (US$ '000) (21,956) (20,044) (2,890) (991) (998) (46,879)

INDIA: TAMIL NADU NUTRITION PROJECT

Estimate of Yearly Base Cost Expenditure by Category(Rs 1,000)

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Total

A. Civil Works 20,798 12,359 10,994 15,642 15,900 75,693

B. Vehicles, Equipment and Furniture1. Vehicles 3,298 2,148 2,193 2,758 1,156 11,5532. Equipment and Furniture 9,976 8,107 9,030 10,984 4,771 42,868Subtotal 13,274 10,255 11,223 13,742 5,927 54,421

C. Training 4,329 4,332 5,814 6,048 3,147 23,670

D. Contract Services1. Communications 1,257 2,989 3,727 5,355 4,230 17,5582. Evaluation 140 200 250 200 250 400 440Subtotal 1,397 3,189 3,977 5,555 4,480 400 18.998

E. Technical Assistance 182 190 269 381 500 1,522

F. Food Supplements 122 4,173 8,699 15,091 22,662 50,747

C. Project Management Fund 210 630 1,050 1,050 1,260 4,200

11. Incremental Operating Costs1. Drugs & Supplies 1,705 5,233 8,333 12,557 17,475 45,3032. Salaries & Allowances 2,847 9,646 17,286 26,944 39,014 649 96,3863. Vehicle Operating Costs 140 510 976 1,442 2,068 5 5,1414. Other Operating Costs 420 1,736 3,290 5,034 7,199 26 17,705Subtotal 5,112 17,125 29,885 45,977 65,756 680 164,535

TOTAL 45,424 52,253 71,911 103,486 119,632 1,080 393,786

1

- 49 -

ANNEX 3

INDIA: TAMIL NADU NUTRITION PROJECT

PROPOSED ALLOCATION OF CREDIT

Percentage ofAmount of the Credit Expenditure to

Category Allocated (US$ '000) Be Financed

1. Civil Works 10,600 80%

2. Vehicles, Furniture, Equipment 7,500 80%

3. Training Costs, Contract Services 5,900 80%and Technical Assistance

4. Project Management Fund 500 80%

5. Drugs and Supplies 6,300 80%

6. Unallocated 1,200

T 0 T A L 32,000

-50- ANNEX 4

INDIA: TAMIL NADU NUTRITION PROJECT

ESTIMATED SCHEDULE OF DISBURSEMENTS

IDA FinancingAmount Cumulative

FY 1981

September 30, 1980 500 500

December 31, 1980 700 1,200March 31, 1981 800 2,000June 30, 1981 900 2,900

FY 1982

September 30, 1981 900 3,800December 31, 1981 950 4,750March 31, 1982 975 5,725June 30, 1982 1,075 6,800

FY 1983

September 30, 1982 1,100 7,900December 31, 1982 1,250 9,150Miarch 31, 1983 1,550 10,700

June 30, 1983 1,750 12,450

FY 1984

September 30, 1983 1,900 14,350December 31, 1983 2,000 16,350March 31, 1984 2,200 18,550June 30, 1984 2,400 20,950

FY 1985

September 30, 1984 2,550 23,500December 31, 1984 2,700 26,200March 31, 1985 2,850 29,050June 30, 1985 2,950 32,000

-51

AXNEX 5

F,~~~~~~cilit(uunievrySo ie

•stu lc 'utritice office

* aet up taluk nutrition offices r

* procure ar.d supply velhiclesfurnishings, supplies and equipment_Kas appropriate to: I

- CNCa ____

- Block nutritIcn offices - Taluk niutrition o"fices r- District nutrition uffices I- State headquarters

set up food supplement plants- deject anki acquire aitas Om I- construct buildings

-rouead irstall equipienenStaffLn, and tann

* recrit or post

- Dis'qtrict Assistant D.rectors- 'Zaluk Nutrition Officers (Th0s)- Thatructresses and Superintendants- Supervisors m r- CI4Ws and helpers = - -m

•comsplete development of curriculac andprepare training manuals for CN¶s,supervisurs and instructresses

5 develop in-service traini4g program forThOs and cotduct training

* select trainers of instrnictresses

* organize and carryout trainers workshop

and field trial teaching

* carry our initial training of supervisorsand instructresses

•carry ot pre-service C(W training a : :-~- --

training~~~~~~~~~ I -

services mm .-•supervi!oe CN4Ws - m - m -I

e concract for food supolementt

precurement and deliveryI

-aarrange interim food del±very toI

Kottampatti

* conduct organoleiptic tests of supplementin clinic and in field

*to develop local financing arrangementsfor CNWs and CNCslm m , u

Loni-torinj

* * ~~ref ine key mnontoring indicators inconsula.titon ~,:th orcject coordinationoffi.ce and Ev a.Qaaicn ZivIiain andd;velor, monItoring pr ocedures

* r,r nd dtssiaemonthlv,quarterly and annual imple~mentationreportsm m es m im m

teat nutrition delivery system In

Kottczmpocti

rcviqe iuirterLy estLnateA of food

reluLte--nts <idcnt lv cpv(u t-i es or

-52-

~Qv ,>.r,a:on .k:torsAYN1EX 3b

Activity . Year1 Year 2 Year 3 r4 Yeat 4

Physical Facilities

* construct dormitory and 1a~classroom facilities in ' 0.1r

existing female, K-0W schnools• oven five new female bPHW schools, 1 Tone LWV school and one HFTC andIconstruct dormitories

* improve one existing HFI7Cf -

* construact dormitory, classroom andtesidential facilities for field training of female ŽfPTWs

* renovate and expand exist:ing micro-

•procure fu-niture, equipment, vehicles 'and supplies for I

- State headquarters- Division Health Offices - PHCs- Health subcenters

*site, construct, equip, furnish and Ioperate new neal:h subcenters andupgrade existing ones- - -

Staffing and Training

* appoint State headquartera staffincluding senior deputy director anddeputy director (training)

• recruit or post

- Divisional Health O fficers - Puiblic Health Nurses- Female KHP1Ws- Female supervisors Im--

* complete develooment of curriculae and

* organize and carry out preser-vice trainingj fof female ~{aand female, supervisors - -- - -

* retrain 1-- HNs --

Other Key, Act±on 7.*operate new training instit,tto,ns

*operate health subcenters and MCH '

*supervise ~P~fws m

onitori'nP and- Sz:dies

establish b.ealtn mcn.itor4ing unit and ~E~ lVrevievw existing& monitoring tndlcato)rs andprocedures in consultatIon with proiectcoMMUnication o;ffiCe n vautDivision

*conduct tests on var cus cnis

aspects of health. D;-ogram

*tes-t healt- delivery svste~, in Kottanpatt an eie agt

* arry oult st'-dy Of wavs to ~prove drug Ip r ocz r enentan'd delry 5lystm

-53-

ANNEX 5c

Summary of Key Implementation Actions.

Communications Activities

Mctivitr Year I | Year 2 Year 3 Year 4 Ye4r

Physical Flacillties - _* set up district communicationoffices NW

* procure vebicles, furnishings andequipment for

- state headquarters- district communication offices ___I

Staffing and Training

* appoint headquarters staff

* recruit local consultants

* establish techniccl working groupon communicatinns

* recruit and post district communicationofficers

Other Kev Actions

* refine behavioral cbj:ctives foruutritioa and health communications

* design, pretest and produce learnLingmaterials for coordinated face-to-face || ||and mass media communication activities I

* design, test and produce growth charts I* establish management information unit

* organize project support communication |activities m - -Li

* darry out mass media campaigns (radio _and film) m m -| r _ _ um .n1

* utilize tradi,tional media (folk theatre) I | | I Iii* develop and implement procedures for Iii

involvIng local formal and informal I IlIlaaders in project implementation| L

Monitoring

* establish communications monitoring unitan'i tefine mnitrcrn° intdicators in con-sultation with, Project coordinati-on ofofficc and evaluation division

uncdertake ad hoc monitoring surveys * U U* ..

* prepare and dissurainate ad hoc brochur.-:: I * and aress releares and periodic news-leLtet mmm -~mn mmuuu

- 54 -

Su-asv of Key Lole entation ActionsANNEX 5 d

F.valuacion

Activity Ycar 1 | 'ear 2 Year 3 Year 4 Year 5

Physical- Facilities

5 set up District field units

* procure equipment, supplies and

vehicles for

- State headquarters i

- Dlistrict field units

Staffinf ard Training

* appoint component manager and

state headquarters staff

* establish evaluation technical

advisory committee

* organize in-service training for

state and district level staff 7.- -elect and train investigators

3 assist in development of curriculum7for traininZ of C3qWs, MPHWs andsupervisory staff in monitoring andrinorting procedures

F_valuation and Studies

* design, procest and administer

questionnaires for baseline and impactsurveys in project and control areas

* conduct mid-term and terminal (6th year)

evaluation

* cartv out evaluation of nutrition and

health training activities

3 undertake background studies for design

of communication messages

- conduct mortality survey I I I - - t - _

* undertake or cossnission other studies,as needed; including MoniCoring sury'y ona

- comunications activities- supplementary feeding- weighing exercise and beneficiary

selection

* establish procedures for dissemination of

findings, conclusions and decisions

*organize annual evaluation conferences

Other Key Activities

* test operation and adminiscration of

?re.ect activities in Korcampatti

* initiate nutrition surveillance scheme

in project and concrol areas - - - - -

* conduct longitudinal village surveys I I r , r* identify and set priorities fot in-depth

studiesm m

idencify research agencies for sub-

conttraced selected special studies L L*review oeriodically overall project

7allocations and expenditures K

I I I I I I I I I I 1

- 55 -

A-NNb. Se

Summary of Key implementation Actions

Project Coordination Office

mctivity | Tea, Tea 2 Tea, 3 Tear 4 Year 5

Physical Facilities

* select and rent headquarters office

* procure furnishings, equipment, suppliesand vehicles

Staffing and Training

* recruit and appoint headquarters staff

* organize management training course

Other Key Actions

* prepare detailed annual projectimplementation schedule

* set up project accounting system

* prepare annual budget

* review periodically overall projectbudget allocations and expenditures

* formalize coordination arrangements

* fund innovations to be pilot tested _ -_ -_ _ -_ -_ -

* insure proper maintenance of projectequipment, buildings and vehicles I -_ _ _ - - _ _ _ - _

Monitoring

* establish project monitoring division

* review and refine key monitoring indi-cators for use in coordinated health,nutrition and communications monitoringsystem in consultation with EvaluationDivision and component management

* develop proceduras for regular andtimely receipts analysis and presen-tation of selected indicators of keyproject activities

* arrange for speedy feedback anddissemination of implementationexperience in Kottampatti

* prepare quarterly reports for consi-deration in decision meetirgs of HighPower Committee | o H a I _

TAMIL NADU NUTRITION PROJECTNUTRITION DELIVERY SERVICES

SIMPLIFIED ORGANIZATION CHART

State Leve~l Directorate of Social Welfarer Joint Director of Social Welfare

IDistrict Coletr

Madilrall ~~~Chenrgelpattu flanmanathaouram North Arcot Pudukottai Tirunelveli

| Assistat lt Assistant Assistant Assistant Assistant Assistantl)istl it i evet Durectoi Director Director |Director Director, Oirector

ollectors cr

Taltikh Taluk Taluik Taluk Taluk TalukTahlik Nutrition Nuutiiion Nutrition Nutrition Nutrition NutritioniLevel Offiicl-rs Offiicer s Officer-s Officers Officers Officers

/12 TaluksJ (1 2 Talu.ks (12 Taluks) |(13 Tulaks) 114 Taluks) 15 l-aluks)

Block lI"strilctress Istructress hsistructress lfistructress | Instructress InstfructressLe-vel (33 Blocks) 1,27 Blocks) (22 Blocks) (36 8locks) | 31 Blocks) j (10 Blocks) |

Is-evsti A Sipetvisors | | Supervisors | | Supervisors | | Supervisors Supervisors

II- I I -1I II i i|g

} Co lit&mity qe Coinmunitvep t Cora munittVua ComrunitV ArcComtunity |rComunitVLeel ) Nutrition Nutrition Nutrition Nutrition Nutrition Nutrition

w Ofrkers Woriers Workers Workers Workers Workers

World Bank -21072

TAMIL NADU NUTRITION PROJECTRURAL HEALTH SERVICES COMPONENT

SIMPLIFIED ORGANIZATION CHART

Directorate of Public HealthState Senior Deputy Director of Public Health

i evJel Deputy Director of Public Health (Ttaining)

District I lealIth DistHici Flealth District Health District Health District Health District Health

Disuict Otlicer, Officer Officer, Officer, Officer, Officer,

Level Madurat Chengelpattu Ramanathapuram North Arcot Tirunelveli Pudukottai

District District District District District District

3 Divisional 2 Divisional 3 Divisional 3 Divisional 2 Divisional Divisional

Dlealth Health| Health Health Health Health

DLviseonal Offices Offices Offices Offices Offices Offices

Leavel Divisional Divisional Divisional Divisional Divisional Divisional

Health Officer Health Officer Health Officer Health Officer |Health Officer Health Officer

Primaty Primary Primary Primary Primary Primary

Health| Health Health Health Health Health |_n

llock Centers Centers Centers Centers Centers Centers

Level (33 Blocks) 12| Blocks1 | 122 Blocks) (36 Blocks) (31 Blocks) (10 Blocks)

Medical Officers Medical Officers Medical Officers Medical Officers Medical Officers MedicaJ Officers

LadyV Health y ealth Lady -Iealh | Lady Health Lady Health Lady Health

Visitors Visitors Visitors Visitors Visitors Visitors

Male Health Male Hfealth Male Health Male Health Male Health Male Health

Supervisors Supervisors Supervisors Supervisors Supervisors Supervisors

| Flesltli | Health Health Health Hlealth Health

Sub Ceriters Sub Centers Sub Centers |Sub Centters Sub Centers Sub Centers

Vfillaje Male arI Femnale Male and Female Male and Female Male and Female Male and Female Male and Female |

Level Multipurpose Multipurpose Multipurpose Multipurpose Multipurpose Multipurpose

Health Workers Health Workers Health Workers Health Workers Health Workers Health Workers

World Bank - 21069

crS

TAMIL NADU NUTRITION PROJECTPROJECT COORDINATION AND COMMUNICATION ARRANGEMENTS

High-Powered Comirittee

Chief Secretary, ChairmanProject Coordinator. Member-

Secretary

Secretaries of Fiiance.Social Welfare. Health,Agriculture, Rural

Development; managinigdirectors of Tamil NadoiWaler and Drainage Boardandl Agro-engineeringServices CooperativeFederation, Ltd.

| Chief Project Coordinator |

| (Secretary, Social Welfare)|

.

Commupnications Oec ration Moritoring rEvalati°I

J SCordinatoWlfr, CoPnctosAmnsration StatstidlnOficeon

Joint Coordnator, Comunicationsand FinanceStiscaOfce

Assistait Communications Otficer Administrative Officer 2 Computer Programrners I See separate char INewslihloletin Editor Senior Accounts Officer 5 Statistical AssistantsAit Direciot Section OfficerMottitolifi) Offlicer Senior Assistai IMedia Officer 4 Accounts AssistantsProductioni Officer 2 Junior AssistantsTrcamring Otflicer

Pholoofar.pher,

__._L_ _ _ _ __ _ _~~

Technical Working G-rip

World Bank 21070

TAMIL NADU NUTRITION PROJECTEVALUATION ACTIVITIES

SIMPLIFIED ORGANIZATION CHART

Directorate of Evaluation

and Applied Research

Exte inal Consultants jDept. of Finance) Technical Advisory Committee

National Institute of Nutrition.

. - - -_ _ __ _- _ _f - - - - - HyderabadInstitute of Child Health, Madras

Sri Avinashilingan College

CoimbatoreJoint Director Gandhigram Rural Institute

Tamil Nadu Nutrition Study,

MadrasErskine Hospital, Madurai

Evaluationi and( Sui veillansce iA

Section Specialist Staff Special Studies Section Administrative Stippiort Section ia

Deputy Directolr 4 Nutritionist Deputy Ditector Research Officer1

-

Heseaicli Officer Health Expert Research Officer Jr. Accounts Oflicer

2 Research Assistarits Epirlemiologist 2 Research Assistants Office SuperintendentRural Sociologist 6 PhD Students 2 Assistants

Anthropologist 2 Jr. Assistants

Statistician Steno

Computer Programmer Driver

6 District Field Units 20 Investigators Test & Pilot Block Record clerk

Field Unit iLGGS

each stafted by

Research Officer Research Officer

3 Jr Research Assistatits 2 Jr. Research Assistants

15 Investigators 10 Investigators

1] Also undertakes work in Evaluation & Surveillance Section World Bank - 21071

February 1, 1980

INDIA: TAMIL NADU NUTRITION PROJECT

Nutrition Delivery Component

Estimated Yearly Base Cost by Categor(In Rupees)

Year 1 Year 2 Year 3 Year 4 Year 5 Total

Civil Works 1,142,400 1,152,600 1,347,600 1,642,200 -- 5,284,800

Vehicles, Equipment and Furniture

1. Vehicles 887,800 1,343,500 1,191,700 1,620,900 -- 5,043,9002. Equipment and Furniture 4,615,200 4,797,300 5,454,800 6,729,100 -- 21,596,400Subtotal 5,503,000 6,140,800 6,646,500 8,350,000 -- 26,640,300

Training 1,597,636 1,750,919 2,008,312 2,431,951 276,365 8,065,183 s

Technical Assistance 80,000 -- -- -- -- 80,000

Food Supplement Costs 122,000 4,173,000 8,699,000 15,091,000 22,662,000 50,747,000

Incremental Operating Costs

1. Supplies 16,000 398,000 900,000 1,402,000 2,066,000 4,782,0002. Salaries and Allowances 727,810 6,522,120 12,797,800 19,739,280 29,642,380 69,429,3903. Vehicle Operating Costs 50,000 400,000 825,000 1,250,000 1,840,000 4,365,0004. Other Operating Costs 100,620 1,405,440 2,786,300 4 6,359,280 15,032,900Subtotal 894,430 8,725,560 17,309,100 26,772,540 39,907,660 93,609,290

TOTAL 9,339,466 21,942,879 36,010,512 54,287,691 62,846,025 184,426,573

--4

February 1, 1980

INDIA: TAMIL NADU NUTRITION PROJECT

Rural Health Services

Estimated Yearly Base. Bost by Category(In Rupees)

Year 1 Year 2 Year 3 Year 4 Year 5 Total

Civil Works 19,655,500 11,206,000 9,646,000 14,000,000 15,900,500 70,407,500

Vehicles, Equipment and Furniture

1. Vehicles 2,022,800 758,800 958,600 1,080,400 1,135,600 5,956,200

2. Equipment and Furniture 3,972 368 3,285,812 3,466,024 4,242,860 4,731,100 19,698,164

Subtotal 5,995,168 4,044,612 4,424,624 5,323,260 5,866,700 25,654,364

Training 2,490,080 2,131,400 3,059,450 2,783,810 1,835,710 12,300,450

Incremental Operating Costs

1. Drugs and Supplies 1,527,473 4,716,837 7,311,490 11,028,428 15,262,389 39,846,617

a. Drugs 835,423 3,588,437 6,456,240 10,066,278 14,116,739 35,063,117

b. Supplies 692,050 1,128,400 855,250 962,150 1,145,650 4,783,500

2. Salaries and Allowances 1,025,394 1,605,186 2,616,015 5,291,083 8,146,137 18,689,315

3. Vehicle Operating Costs 29,400 49,000 88,200 127,400 156,800 450,800

4. Other Operating Costs -- 5,970 174,060 318,660 528,660 1,027,350

Subtotal 2,582,267 6,376,993 10,189,765 16,765,571 24,094,48 60,009,082

TOTAL 30,723,015 23,759,005 27,319,839 38,872,641 47,696,896 168,371,396

ul

INDIA: TAMIL NADU NUTRITION PROJECT

Communications

Estimated Yearly Base Cost by Category(In Rupees)

Year 1 Year 2 Year 3 Year 4 Year 5 Total

Vehicles, Equipment and Furniture

1. Vehicles 91,300 -- 20,000 10,000 20,000 141,300

2. Equipment and Furniture 386,756 19,800 35,800 30,800 40,000 513,156

Subtotal 478,056 19,800 55,800 40,800 60,000 654,456

Training 162,974 370,982 543,522 629,522 788,700 2,495,700

Contract Services 1,337,276 3,009,033 3,736,867 5,195,200 4,279,972 17,558,348

Technical Assistance 566,785 255,000 135,000 135,000 135,000 1,226,785

Incremental Operating Costs

1. Supplies 125,000 80,000 80,000 85,000 105,000 475,000

2. Salaries and Allowances 209,208 218,534 227,089 236,705 246,798 1,138,334

3. Vehicle Operating Costs 13,400 13,400 15,800 17,000 19,400 79,000

4. Other Operating Costs 129,670 129,670 129,670 129,670 129,670 648,350

Subtotal 477,278 441,604 452,559 468,375 500,868 2,340,684

TOTAL 3,022,369 4,096,419 4,923,748 6,468,897 5,764,540 24,275,973

INDIA: TAMIL NADU NUTRITION PROJECT

Monitoring and Evaluation

Estimated Yearly Base Cost by Category

(In Rupees)

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Total

Vehicles, Equipment and Furniture

1. Vehicles 141,000 46,000 23,000 46,000 -- -- 256,000

2. Equipment and Furniture 109,500 24,000 12,000 24,000 -- 169,500

Subtotal 250,500 70,000 35,000 70,000 -- -- ,

Training and Conferences 78,200 78,200 203,000 203,000 189,800 56,600 808,800

Contract Services 60,000 180,000 210,000 230,000 360,000 400,000 1,440,000

Technical Assistance 38,000 38,000 38,000 38,000 38,000 25,000 215,000

Intremental Operating Costs

1. Supplies 36,000 37,000 42,000 42,000 42,000 -- 199,000

2. Salaries and Allowances 307,556 720,411 928,427 1,136,765 1,270,583 649,000 5,012,742

3. Vehicle Operating Costs 8,300 11,100 11,300 11,300 11,300 5,500 58,800

4. Other Operating Costs 17,325 37 125 40,838 45,169 54,633 26,000 221,090

Subtotal 369,181 805,636 1,022,565 1,235,234 1,378,516 680,500 5,491,632

TOTAL 795,881 1,171,836 1,508,565 1,776,234 1,966,316 1,162,100 8,380,932

INDIA: TAMIL NADU NUTRITION PROJECT

Project Coordination Costs

Estimated Yearly Base Cost by Category(In Rupees)

Year 1 Year 2 Year 3 Year 4 Year 5 Total

Vehicles, Equipment and Furniture

1. Vehicles 155,000 - -- 155,0002. Equipment and Furniture 892,000 -- _ 892,000Subtotal 1,048,000 -- -- -- -- 1,048,000

Project Management Fund -- 420,000 840,000 1,260,000 1,680,000 4,200,000

Incremental Operating Costs

1. Supplies 10,000 10,000 10,000 11,000 11,000 52,0002. Salaries and Allowances 406,192 412,020 422,007 435,056 446,724 2,122,0003. Vehicle Operating Costs 37,500 37,500 37,500 37,500 37,500 187,5004. Other Operating Costs 155,000 155,000 155,000 155,000 155,000 775,000Subtotal 608,692 614,520 624,507 638,556 650,224 3,136,499

TOTAL 1,656,692 1,034,520 1,464,507 1,898,556 2,330,224 8,384,499

65 -

ANNEX 8Page 1

INDIA: TAMIL NADU NUTRITION PROJECT

Selected Documents and Data Available in the Project File

Section A

A.1 The Tamil Nadu Nutrition Study: An Operations-Oriented Study ofNutrition as an Integrated System in the State of Tamil Nadu,Sidney M. Cantor Assoc. Inc. (1973), 6 volumes.

A.2 Nutrition as a Function of Public Health: Nutrition-RelatedMorbidity in Tamil Nadu, Sidney M. Cantor Assoc. Inc. (1973).

A.3 "The Tamil Nadu Nutrition Project," S. Rajagopalan (1974).

A.4 Nutrition Atlas of India, C. Gopalan and K. Vijaya Raghava,National Institute of Nutrition (1969).

A.5 "National Nutrition Monitoring Bureau -- Report for the Year 1978,"National Institute of Nutrition (1979).

A.6 "Health and Nutrition in India: Recommendations for Ford FoundationSupport," D.R. Gwatkin (1974).

A.7 Food Habits Survey, Operations Research Group (Baroda) forProtein Foods Association of India [no date] 2 volumes.

A.8 "UNICEF Annual Report for India" (1979).

A.9 "USAID Evaluation of Title II Program: India" (1979) [extract].

A.10 "Report of the Seminar on the Pre-School Child" [no author] (1970).

A.11 Nutrition in Tamil Nadu, R.P. Devadas (1972).

A.12 Selected Nutrition Intervention Programs in Tamil Nadu,R.P. Devadas [unpublished draft] (1979).

A.13 "Rural Health Services in Tamil Nadu," Department of Public Healthand Preventive Medicine (1978).

A.14 Nutrition and Family Planning in India, B. Wickstrom (1977).

A.15 The Feeding and Care of Infants and Young Children, S. Ghosh (1976).

A.16 "Tamil Nadu, An Economic Appraisal 1976-77," Finance Department (1978).

- 66 -

ANNEX 8Page 2

Section B

B.1 "Tamil Nadu Integrated Nutrition Project," Department ofSocial Welfare (1979).

B.2 "Tamil Nadu Integrated Nutrition Project," Department of Public Healthand Preventive Medicine (1979).

B.3 "World Bank Nutrition Project: Pilot Block Project Design,"Department of Social Welfare (1979).

Section C

C.1 Working Papers on Nutrition, Health, Communications, andMonitoring and Evaluation.

c.2 Working Paper on "The Number of Direct Beneficiaries of the Supple-mentary Feeding Program and Project Food Requirements."

c.3 Working Paper on "Criteria for Enrolling Children in and DischargingThem from the Supplementary Feeding Program."

c.4 Working Paper on "The Economics of Supplemental Feeding of Mal-nourished Children: A Case STudy of Leakages, Benefits and Costs."

A ~ ~ ~~~~~~~~~~~A P~~~~~~~~~~~RD 14748

INDIA

TAMIL NADU NUTRITION PROJECT A NDHRA 'PR'A DFSH 2

PROJECT DISTRICTS ~ ~

1,1. 11 IT -TI Ill ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ N.VA AN

N NAtN ATNH A R 'NOT,

IA~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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KARNA)AKA NAN /

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K,RA I A~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ANI

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