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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank FOR OFFICIAL USE ONLY INDIA STAFF APPRAISAL OF A NUTRITION PROJECT IN TAiMIL NADU March 27, 1980 rh Report No IN Population, Health and Nutrition Department This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

2 CURRENCY EQUIVALENTS US$1.00 = Rupees (Rs) 8.40 /1 GOVERNMENT OF INDIA FISCAL YEAR: April 1 - March 31 GOVERNMENT 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 a fixed Pound Sterling rate. Since then it has been fixed against a "basket" of currencies. As these currencies are floating, the US Dollar/Rupee exchange rate is subject to change. Conversions in this report have been made at US$1.00 to Rs 8.40 which represents the projected exchange rate over the disbursement period.

3 FOR OFFICIAL USE ONLY ABBREVIATIONS ANM. - Auxiliary Nurse-Midwife BDO - Block Development Officer CARE - Cooperative for American Relief Everywhere CHW - Community Health Worker CNC - Community Nutrition Center CNW - Community Nutrition Worker DANIDA - Danish Agency for International Development DCO - District Communication Officer DDO - Divisional Development Officer DNO - District Nutrition Officer GOI - Government of India GOTN - Government of Tamil Nadu HRWD - Department of Highways and Rural Works HSC - Health Sub-Center IDA - International Development Association JCC - Joint Coordinator for Communications LHV - Lady Health Visitor MCH - Maternal and Child Health MO - Medical Officer MPHW - Multipurpose Health Worker NNMB - National Nutrition Monitoring Bureau NSS - National Sample Survey PHC - Primary Health Center PEN - Public Health Nurse FWD - Public Works Department SAHSC - Sri Avinashilingam Home Science College TNAIC - Tamil Nadu Agro-Industries Corporation TNNS - Tamil Nadu Nutrition Study TNO - Taluk Nutrition Officer TWAD - Tamil Nadu Water and Drainage Board UNICEF - United Nations Children's Fund IThis document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

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5 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 B. Nutrition Conditions and Programs... 4 III. The Project A. Goals, Strategy, Design and Objectives... 8 B. Location C. Phasing D. Description Summary and Main Features Detailed Project Features IV. Project Costs, Financing, Procurement, Disbursement and Audit A. Costs and Financing B. Procurement C. Disbursements D. Accounts and Audits... o... o V. Project Organization and Management... o o 40 Ao Overall Coordination.. o... o....oo..o 40 B. Programming and Budgeting C. Project Execution... ooo VI. Justification and Risks.. o...o.... o oo 42 A. Justification B. Risks... o VII. Recommendations o This report is based on the findings of an appraisal mission to India in July/August 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 and Ms. H. Perrett (Communications Consultants), and Mr. C. Jhabvala (Consultant Architect). A post-appraisal mission was made in January 1980 by Mr. J. Greene and Dr. K. V. Ranganathan.

6 Table of Contents (Cont'd) ANNEXES 1. Estimated Base Costs by Component and Expenditure Category 2. Estimated Yearly Base Project Expenditures by Category 3. Proposed Allocation of Credit 4. Estimated Schedule of Disbursements 5. Summary of Key Implementation Actions by Component 6. Simplified Organizational Charts of Project Units a. Nutrition Delivery Services Component b. Rural Health Services Component c. Project Coordination and Communications Arrangements d. Project Evaluation Arrangements 7. Yearly Project Base Cost Estimates by Component a. Nutrition Delivery Services b. Rural Health Services c. Communications d. Monitoring and Evaluation e. Project Coordination 8. Selected Documents and Data Available in the Project File TABLES 1. Project Cost Estimates by Expenditure Category 2. Project Cost Estimates by Component MAP IBRD - State of Tamil Nadu: Project Districts

7 INDIA STAFF APPRAISAL OF A NUTRITION PROJECT IN TAMIL NADU I. INTRODUCTION 1.01 India remains a leader among developing countries in recognizing malnutrition as a major concern. Initial Government interest from independence in 1947 intensified as a result of both the Bihar famine and the growing recognition of the potential links between malnutrition and mental development. Beginning with the Fourth Plan ( ), the Government of India (GOI) began to expand feeding programs as an immediate way to help bridge the nutrition gap, principally of children and pregnant and nursing women, while longer-term food production and income-generating measures took hold Government concern for the nutrition and health of pre-school children was further reflected in promulgation of a "National Policy for Children" in August 1974, followed later that year by establishment of a Children's Board with the Prime Minister as President. The Government also incorporated supplementary feeding of pre-school children in the Minimum Needs Program which began under the Fifth Plan ( ) and includes national targets for elementary and adult education; rural health, water supply, roads and electrification; rural housing for the landless, and improvement of urban slums India's commitment to nutrition has manifested itself on other fronts as well. The National Institute of Nutrition, the Indian Council of Medical Research and the All-India Institute of Medical Sciences are internationally recognized for their work on nutrition problems. Moreover, the Government has undertaken a number of initiatives in such important nutrition areas as food processing and fortification. These efforts have included development of balahar, 1/ a cereal-legume mixture developed for public feeding programs Public feeding programs steadily have expanded over the past 10 years and now reach an estimated 20 million beneficiaries. Around 13 million primary school children receive balahar in a mid-day meals program for which the Cooperative for American Relief Everywhere (CARE) donates soy-fortified bulgur wheat. Other nutrition programs with feeding components include: (a) the Applied Nutrition Program, aided by the United Nations Children's Fund (UNICEF), which seeks to increase food production while providing nutrition and health education directed at nutritionally vulnerable groups; (b) the Special Nutrition Program, assisted by CARE, which provides supplementary feeding to mothers and pre-school children 2/ in urban slums, socially disadvantaged rural families and regions suffering repeated droughts and floods; (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.

8 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 children and their mothers using mainly local commodities The Central and State Governments share the costs of most feeding programs. The GOI pays for the purchased inputs in balahar and its processing costs. The states generally meet freight, port handling, storage and local transport charges for donated commodities. They also provide local foods to supplement balahar and the costs of cooking the ration and serving it to beneficiaries. Over the last few years, the combined central and state governments' annual contribution to such feeding programs has risen substantially; for the CARE program alone, that support has almost tripled, rising from an estimated US$30 million in 1976 to more than US$81 million in The economic value of the donated soy-fortified wheat for India's school lunch and pre-school feeding programs is currently estimated at around US$76 million yearly. Inclusive of distribution, storage and administrative costs, the total economic cost of these feeding programs is estimated at more than US$160 million annually Recognizing that such feeding programs alone cannot provide an adequate solution to nutrition problems, the GOI's current nutrition strategy continues to emphasize food production, income generation, and nutrition education accompanied by processing and fortification programs and more careful targeting of supplementary feeding activities While national concern about nutrition is reflected to some degree in programs and priorities of all the Indian states, some have been more aggressive than others in trying to identify the main causes of malnutrition and deal with them effectively. Among those, the southern state of Tamil Nadu is particularly prominent Tamil Nadu's population was estimated at 46.8 million in 1979, around 7.4% of the estimated total Indian population. Almost one-third of its population lives in towns and cities, making Tamil Nadu the country's most urbanized state. It is also the third most densely populated state after Kerala and West Bengal A relatively small agricultural sector accounts for about 40% of state income; manufacturing accounts for about 20% of state income. Almost six million hectares, just under half the state's total land area, is cultivated; over 20% of the cropped area is sown more than once yearly. Rice predominates. It accounts for 35% of the cropped area, (around 80% of which is planted in high-yielding varieties) and for over half the state's foodgrain production. Rice yields per hectare in Tamil Nadu are among the highest in India and hover at around twice the national average. Groundnuts account for 13% 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 production over the period 1964/ /78 ranks ninth among Indian states. Its average annual increase of 3.9% in pulse production, despite wide yearly fluctuations,

9 - 3 - ranks second only to Rajasthan over the same period. Overall food output has more than kept pace with the estimated 1.6% rate of natural increase in population Tamil Nadu has the most fully developed irrigation potential of all the Indian statiq. Surface and ground water irrigation covers around 75% of the state's potential of an estimated 3.7 million hectares. That percentage of coverage is almost twice the national average. In fertilizer consumption, the state ranks second only to Punjab with consumption per hectare of cropped area at 37.1 kilos. Despite these high rankings in yields, fertilizer application and irrigation promotion, Tamil Nadu ranks fourteenth among 22 Indian states in average foodgrains production per capita to , because of the relatively small area under foodcrops production and the high degree of urbanization of the state 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 rural areas. Among Indian states, Tamil Nadu ranked ninth in per capita income, from to , at an equivalent of US$118, according to the 1978 report 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 ending in 1983 are to: (a) reduce economic and social inequalities of opportunity and income while substantially raising incomes and employment; (b) eliminate the worst forms of poverty and appreciably reduce the numbers of those below the poverty line; 1/ and (c) improve the quality of life for weaker sections of the population, principally through the Minimum Needs Program, which includes basic services and rural housing for the landless. In conformity with those objectives, the current plan stresses agriculture, rural development, irrigation and power. While decreasing as a share of previous plan expenditures, outlays for social services have almost doubled in absolute terms since the last plan Through its plan program, Tamil Nadu projects an overall annual 3.8% growth rate in its six major sectors during the plan period, accompanied by the creation of around 2.7 million jobs, which would reduce unemployment to around 1.1 million persons, or around six percent of the labor force. Village and small industries, fisheries and animal husbandry programs along with 1/ In 1977 an estimated 52% of the rural population lived below the absolute poverty income level of US$73 per capita per annum. However, for the period through the average percentage of the rural population in absolute poverty was estimated at 58% relative to the all-india average of 50% for the same period.

10 -4- labor-intensive public works construction programs are to help improve conditions of the rural populace below the poverty line. However, the main benefits for this population would accrue through the Minimum Needs Program which continues as a mainstay of the state's development effort, marked by an impressive record of social investments. Because of the gravity of the problem, nutrition has played a continuing role in the state's development program during both past and present plans. B. Nutrition Conditions and Programs 2.03 Various estimates over time show that Tamil Nadu continues to rank well below the national average in per capita daily food intake. The National Sample Survey (NSS) reported in 1978 that, according to data, Tamil Nadu ranked fifteenth among 16 major states with average per capita daily energy intake of around 2,036 calories against a national average of 2,263 and estimated need of 2,400. Estimated per capita daily calorie intake in rural Tamil Nadu was around 2,012 calories against a national average of 2,328. The urban situation was somewhat better, with average per capita daily intake at 2,092 calories against a national average of 2,003. Estimates of per capita protein availability in Tamil Nadu range between 36 and 42 grams daily, against the recommended daily allowance of 46 grams of protein per capita. Anthropometric and food consumption surveys together with data on morbidity and mortality provide overwhelming confirmation that protein-energy malnutrition is widespread and often severe in Tamil Nadu, particularly among pre-school children and pregnant and nursing women. Because of differences in standards and techniques, the results of many of these studies are not strictly comparable. Nevertheless, they indicate that up to an estimated 35% of rural households in Tamil Nadu and 40% of individuals consume less than 80% of their calorie needs according to the most conservative calculations of requirements The most complete picture of nutrition in Tamil Nadu resulted from the Tamil Nadu Nutrition Study (TNNS), carried out in under the joint auspices of the State and Central Governments and the United States Agency for International Development. The study concentrated on both operational analysis and applied research. It provides a unique data base derived from the most systematic effort yet undertaken in any developing country to analyze the nutrition aspects of food production, distribution and consumption. A major TNNS objective was to identify intervention points to achieve significant changes in survival of children, who are recognized as the nutritionally most vulnerable group. The study incorporated field collection and analysis of primary and secondary data as well as special studies. The multidisciplinary TNNS team included economists, biologists, nutritionists, food technologists, behavioral scientists, engineers and systems specialists. It served as the research arm of an interdepartmental group on nutrition which the State Government set up Principal TNNS conclusions were: (a) around half the families in Tamil Nadu consume less than 80% of their calorie needs, calculated according to TNNS standards, which are marginally higher than those used by the Indian

11 -5- Council for Medical Research; (b) while some protein shortages occur, the most pressing need is for more calories; (c) generally increased food production is essential, but certain groups require special attention because of the gap between prevailing distribution patterns and their nutritional needs; (d) the highest priority target group for such specific intervention is the weaning child under three years of age, based on indications that malnourishment compounded by poor health is a major cause of pre-school mortality in Tamil Nadu and TNNS assertions that death rates for such children under 18 months of age were more than ten times the composite rate for their European and North American peers; (e) pregnant and nursing women constitute the next highest priority group because of their influence on health and growth of the infant; (f) food habits are major nutrition status determinants for Tamil Nadu pre-school children, whose nutrition falters dramatically during weaning across all family levels of calorie intake and income; and (g) these habits are amenable to change, as demonstrated by TNNS testing of a weaning supplement program in Coimbatore District These conclusions closely correlate with findings elsewhere in India that: (a) infectious diseases, diarrhea and unsatisfactory food habits are major contributors to malnourishment, particularly among young children, and (b) changes in many undesirable food habits are within the financial reach of most families, including timely supplementation of breast milk with satisfactory home-made weaning foods, better feeding during pregnancy and nutritionally more effective food preparation and purchasing habits TNNS calculated that 45% of all Tamil Nadu children died before the age of five years and that over 50% of pre-school children in the state were malnourished. Although based on careful sampling, TNNS mortality estimates are almost double those from official State health sources and probably overestimate present conditions by a considerable margin. However, a small sample survey conducted in 1978 by the National Nutrition Monitoring Bureau (NNMB) found that 85% of surveyed children aged 1-5 years had weight for age lower than 90% of prevailing standard. A similar NNMB study five years earlier found 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 TNNS conclusions in regard to numbers of malnourished children TNNS also tried to estimate the extent of nutrition-related morbidity and the financial cost of treating it at Government installations. The study found the cost of treatment of such morbidity to be around US$5.5 million yearly or 31% of annual State expenditures at that time for medical services alone. Pre-school children with nutrition-relate disorders accounted for almost 23% of all patients then treated in Government installations 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 main nutrition problem was anemia from shortages of iron and folate which studies have estimated to affect more than half of Tamil Nadu's pregnant and nursing women.

12 A subsequent study by the Institute of Child Health, Madras, found that nutrition was a leading or associated cause of 41.8% of the deaths of pre-school children surveyed. The other leading causes were gastroenteritis, principally manifested through diarrhea; respiratory infections, and other ailuents which interact with malnourishment. Data from a 46-village health program run through Erskine Hospital, Madurai, indicated prevalence of vitamin A deficiency among pre-school children, which can lead to impaired vision or blindness, to be around 27% Both TNNS and later consumption data based on NSS estimates strongly point to inequalities of income distribution, rather than overall food shortages, as a main cause of malnutrition in Tamil Nadu. NSS figures also indicate that, while the state as a whole is marginally self-sufficient in calorie availabilities, families in the lowest two income deciles consume around 60% and 72%, respectively, of their estimated daily calorie needs Since the completion of TNNS, the State Government has continued its long-term strategy of further increasing food production while trying to raise the incomes of those living in absolute poverty. It considers investments in rural development essential to bring about sustained reductions in malnutrition and morbidity levels. However, since nutrition impact from such programs will occur slowly, the State Government has complemented them with a number of direct nutrition activities aimed specifically at the most vulnerable groups Around 25 nutrition programs now operate in Tamil Nadu, largely under Government auspices. Although sponsored by a number of different agencies including the Departments of Social Welfare, Health and Family Welfare, Education, Labor and Rural Development, from 1971 these programs have been coordinated through the Department of Social Welfare which has formal responsibility for nutrition activities in the state. This process has taken place chiefly through a committee which is chaired by the Secretary of the Department of Social Welfare and includes as members Secretaries of the other departments concerned. A number of these programs concentrate on publicly-sponsored feeding, although their reach and scope vary considerably. The oldest of these is the school lunch program begun in 1956 which now provides mid-day meals, consisting mainly of balahar, 200 days a year for around two million youngsters in more than 32,000 schools. A program of feeding at a total of around 4,000 child-care centers, or balwaddies, reaches around 300,000 pre-school children, mainly aged 3-6 years Other nutrition programs have included operation of a nutrition rehabilitation center in Madurai District, assisted by the Royal Commonwealth Society for the Blind, and three programs initiated by the Central Government: (a) the Applied Nutrition Program, which has covered 61 of Tamil Nadu's 373 blocks; (b) the Special Nutrition Program, which reaches around 130,000 low-income beneficiaries in 33 municipalities and Madras, and

13 - 7 - (c) the Integrated Child Development Service program, which now operates experimentally in three Tamil Nadu blocks through around 300 child-care centers reaching an estimated 24,000 pre-school children; coverage through an additional 700 child-care centers recently was approved by the State Government The above efforts generally provide a daily meal, principally balahar, to enrolled beneficiaries for 300 days a year However, all of Tamil Nadu's nutrition programs combined reach less than 10% of the state's pre-school children and an even lower proportion of pregnant and nursing women, and they appear to have had relatively modest nutritional impact on beneficiary groups. A number of studies have taken place to assess both the outcome of such programs and the reasons for their limited success. The main constraints reported are: (a) Feeding programs fail to reach intended beneficiaries because of weaknesses in setting or adhering to nutritional criteria with respect to target groups; (b) Prolonged on-site feeding tends to substitute for food which 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 children to consume; (e) Administrative shortcomings, including supervision deficiencies and optimistic expectations about the use of workers' time, have inhibited effective nutrition education and promotion of home food production activities; (f) Most nutrition activities are confined to centers which operate on a drop-in basis rather than through active and sustained efforts to identify and recruit those at higher risk; (g) Nutrition education campaigns have been neither sufficiently sustained nor oriented toward practical behavioral change; and (h) Without adequate health care, infectious diseases and diarrhea continue to exacerbate problems which existing programs are expected to resolve The State Government now spends around US$8.8 million yearly on nutrition, mainly from its revenue account. The school feeding program of the Education Department accounts for around three-fourths of that expenditure. Total State outlays on nutrition have remained relatively constant in recent

14 years, indicating both a sustained commitment to such efforts and continuing Government concern that Tamil Nadu nutrition problems are too urgent for resolution only through the long-term process of satisfactory economic growth. However, uncertainty about the impact and efficiency of its existing intervention efforts has acted as a brake on raising State Government budget allocations for nutrition and led to the current request for IDA assistance. In particular, the State has become increasingly aware of the need to improve the targeting and lower the unit cost of its interventions, to promote better nutrition and health practices within families and to strengthen its maternal and child health (MCH) services to improve the utilization of available nutrients by the most vulnerable groups Because of the magnitude of the problem and the scale of the resources required to combat it, the Government seeks IDA support to develop and install an improved system which would achieve the foregoing aims. While initially to get under way in rural areas because of plan priorities, the new system would be expected to be replicated throughout the state 1/ and lead to redesign 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, coverage and impact of Government of Tamil Nadu (GOTN) nutrition efforts. This would be accomplished principally by systematic concentration for the first time on the nutritionally most vulnerable group, children aged 6-36 months. However, the project also would improve the focus, quality and reach of nutritionrelated services for other groups at high nutritional risk--pregnant and nursing women and older pre-school children. The Government's decision to focus on infants and younger children results from recognition that children under three years of age account for an estimated 90% of pre-school mortality in the state and that malnourishment is a leading or associated cause of around 75% of those deaths in the under-three age group The Government's strategy is to achieve results which would justify higher levels of nutrition expenditure through development of an effective combination of specific actions involving: (a) expansion and restructuring of the State's nutrition delivery program; (b) education efforts to improve home nutrition of preschool children; and (c) expanded MCH care. 1/ The nutrition and health component of the Madras Urban Project II recently appraised by IDA is expected to be run along the lines proposed in the Project.

15 -9- Monitoring and evaluation would have a key role in the strategy since, through the project, the Government expects to reduce the unit costs of nutrition services, thereby increasing efficiency and easing the fiscal burden of expanding the program state-wide and extending its full services to all pre-school children. Nutrition surveillance data generated monthly through Lhe nutrition delivery component would provide early warning of the onset of nutrition emergencies from causes such as crop failures. These findings would help enable the Government to avert further nutritional deterioration by timely targeting of stand-by emergency food supplies to affected areas. Evaluation would help identify ways of refining the project activities to improve their cost-effectiveness, while monitoring would assure timely implementation of key activities. An important feature of the project strategy is its explicit emphasis on trying to get families themselves to do a better job of providing appropriate food and nutrition-related care for young children through an intensive and carefully planned new program of nutrition and health education The Government's approach draws on its own experience combined with lessons learned from programs elsewhere in India and in other developing countries. The project results from 16 months of intensive dialogue with the State and Central Governments. Particularly close collaboration between IDA and the GOTN during preparation resulted in substantial refinement and simplification of the original project design. The Government initially had proposed incorporating village water supply and agricultural interventions in the project, including rainfed pulse production, improved on-farm storage and modernization of rice and oil processing facilities. These components ultimately were excluded because it was felt they would complicate project management and could best be tackled through programs exclusively directed to the agriculture and water supply sectors. Other results of the preparation process included considerable reorientation of the proposed roles of field workers in the nutrition and health delivery systems and development of suitable arrangements for coordination of their work. Another outcome was the deve'lopment of explicit criteria and operational procedures. for a new project-assisted food supplementation program which departs from the existing state pattern of prolonged supplementation, mainly for children over three years of age, generally with scant regard to nutrition criteria Two innovative features distinguish the proposed project's approach to food supplementation from current Tamil Nadu programs. First, child beneficiaries would be identified and monitored through a nutrition surveillance system to be set up in project villages. Second, supplementation would continue only as long as required for a child to achieve adequate nutritional recovery and would be accompanied by intensive nutrition education of key family members to promote permanently-improved home feeding practices, within the financial reach of most project families The main objective of the project would be to improve the nutrition and health conditions of pre-school children, with emphasis on those aged 6-36 months, and pregnant and nursing women. After four full years of project operation in each district, (see para. 3.06) the Government anticipates

16 a 50% reduction in the currently estimated 60% incidence of protein-energy malnutrition 1/ among children under three years of age. Additionally, the project would contribute to the Government's goal of achieving the following objectives after five operational years in each project area: (a) around a 25% 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 between the ages of one and four years; (b) reduction to 5t of the incidence of Vitamin A deficiency in children under five years of age, currently estimated at up to 27%; and (c) reduction to 20% of the currently estimated 55% incidence of nutritional anemia in pregnant and nursing women. While ambitious, these objectives are considered attainable as part of the State's overall development effort. B. Location 3.06 The project would take place in the rural areas of six districts where 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 number of taluks 3/ where TNNS reported nutrition conditions to be least satisfactory in terms of calorie needs met by the population. The districts are grouped geographically in two areas: Madurai, Pudukottai, Ramanathapuram and Tirunelveli blanket the southern third of Tamil Nadu; in those districts average calorie intake is estimated at 76-84% of requirements. Chengalpattu, which has similar nutrition characteristics, and North Arcot, where calorie intakes are estimated to average below 74% of requirements, adjoin each other in the northeast. The project area consists of all 170 rural blocks in those districts. Average rural population per block varies widely by project district, 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 phased in gradually over five years, with final evaluation to take place during the sixth year. Implementation in the first year would be confined to Kottampatti Block of Madurai District, where the basic project design would be tested and refined as necessary. Another 33 blocks in Madurai and Chengalpattu Districts would come on stream in the second year, followed by 43 blocks in the third year. 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 but will 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.

17 of the third operational year to guide the final two years of implementatior when 43 and 50 blocks, respectively would become operational. During negotitions, the State Government gave assurances that the terms of reference for the Kottampatti pilot block review and for the mid-term review would be satifactory to IDA.n-d that the project design and implementation schedule would be adjusted according to their findings as feasible, taking i11to accotnit IDA comments on the reviews. D. Description 1. Summary and Main Features 3.08 The project would consist principally of linked programs of nutrition and health services delivery. These would be implemented simultaneously and combined to produce substantial nutritional improvements in the target group. Intensive informal education of mothers and other key family members to improve child-feeding practices and management of diarrhea among youngsters would support and reinforce the nutrition and health components An outreach system initiated under the nutrition services component would promote regular nutrition surveillance of participating children under three years of age in project villages. It also would serve as a conduit for selective interventions to counter malnutrition among target groups, including short-term food supplementation for vulnerable children aged 6-36 months and prophylaxis against specific nutrient deficiencies. Strengthened basic health care delivery would emphasize MCH services and prevention and cure of nutrition-linked health disorders. Since this innovative approach involves the development and implementation of new and as yet untested delivery systems, the project would place heavy emphasis on monitoring and evaluation. Evaluation would continue through a sixth project-financed year to analyze project impact and cost-effectiveness as fully as possible and to provide the basis for future modification of the program and its subsequent expansion to other parts of the state. Project coordination would be managed by a small office set up for that purpose 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 female multipurpose health workers (MPHWs); (iii) a training facility to accommodate 150 female health supervisors (lady health visitors); (iv) training and hostel wings at 39 primary health centers (PHCs) where field training of female MPHWs and lady health visitors (LHVs) would take place; and

18 (v) a 100-place facility for in-service training of health workers, block extension educators and medical officers (MOs). (b) Training costs consisting of incremental staff, materials and student 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 their immediate supervisors and 250 other supervisory staff involved in nutrition delivery at block, taluk and district levels. (c) Vehicles, consisting of a total of about: (i) 102 sedans and station wagons, including 81 for nutrition supervision, 16 for health supervision, three for project coordination use, and one each for communications and monitoring and evaluation; (ii) Nine buses for project-assisted health training institutions; (iii) 212 motorcycles, including 191 for health supervision, seven for communications work, and 14 for monitoring and evaluation; and (iv) 3,200 bicycles, including 2,600 for use by MPHWs and 600 for use by supervisory and office staff responsible for project nutrition, health and communications monitoring and evaluation activities. (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 quality and safety of the supplement and other foods, and to carry out serum analysis as part of impact evaluation; (ii) a communications campaign and monitoring and evaluation offices in each of the six project districts; (iii) a nutrition supervisory office in each of the 170 project blocks, 68 project taluks, the six project districts and at state headquarters; and

19 (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 related materials for nutrition and health education campaigns and for training neighborhood leaders. (g) Costs of technical assistance for communications and monitoring and evaluation. (h) Costs of food supplements for beneficiary children and selected pregnant and nursing women. (i) Drugs, vaccines and supplies for MPHW, LHV, PHC and CNW use. (j) Project evaluation activities, including baseline and special studies, 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 project coordination personnel; (ii) rent and running costs of CNCs, taluk nutrition offices, the project coordination office and communications and monitoring and evaluation field offices; (iii) running costs of project-financed HSCs; and (iv) supplies for CNCs, HSCs and other facilities included in the project. (1) Funds for innovative activities to be developed during the project on the basis of criteria to be agreed upon between the State Government and IDA. 2. Detailed Project Features Nutrition Delivery Services 3.11 This component would concentrate on strengthening the State's capacity to identify children under three years of age at high nutritional risk, to monitor their nutritional status and to reach them, as well as older pre-school children and pregnant and nursing women with specific measures to correct or prevent protein-energy malnutrition and other nutrition problems such as vitamin A deficiencies and iron deficiency anemia. This would take place through a network of CNCs, each staffed by a full-time female CNW and a helper, recruited and trained under the project. The component would include development of a nutrition surveillance system for pre-school children, with emphasis on those aged 6-36 months, and a new program of short-term food supplementation for children in that age group identified as being at highest nutritional risk.

20 Community Nutrition Workers and Centers. The CNW-CNC network is the key to the project's nutrition delivery system. One CNC, staffed by a CNW and helper, would be established per 1,500 population, roughly equivalent to the average size of a Tamil Nadu village. In this respect, the new system resembles existing pre-school nutrition delivery patterns in the state. The average target population per CNW would be 250 pre-school children, including around 100 aged 6-36 months, and 45 pregnant or lactating women. CNWs would be recruited from the village they would serve However, the role of the CNW and project recruitment procedures, as well as the functions of the CNC, also mark a substantial departure from those existing patterns. A selection committee including a senior nutrition supervisor and a representative of the village council would choose the local CNW. CNWs would have a primary education. Whenever possible they would be recruited from among the most disadvantaged village groups, which have a high propensity for malnourishment. Preferably, these women would have wellnourished children of their own Each month the CNW would weigh all children aged 6-36 months in her village. Where appropriate, child-weighing would begin at four months of age. These children also would continue to be weighed quarterly through their fifth year. Weighing would take place both at the CNC and in village neighborhoods in accordance with a regular schedule reflecting prevailing patterns of women's work both at and away from home. CNWs would use a portable bar scale supplied by the project and would record children's weights on both a chart which mothers would retain and a form kept at the CNC which also would contain health data, including records of immunization and other services provided by MPHWs. The CNW would use the weighing process both to convey nutrition education and to identify candidates for the short-term food supplement program which she and her helper would administer at the CNC. These weight recordings would be central to the nutrition surveillance system to be initiated through the project. About 30% of the CNW's time would be spent on surveillance and supplementation activities CNWs would have four additional important responsibilities. They would give talks and demonstrations to groups of women, promoting better weaning and child-feeding practices, and would discuss other topics relating to good nutrition. They would provide prophylaxis against specific nutrient deficiencies through semi-annual vitamin A dosage for pre-school children and regular administration of iron and folate supplements for pregnant women. They would be responsible for tri-annual administration of deworming medicine for pre-school children and a program of diarrhea management which would include supplying of a pre-packaged glucose-electrolytes mixture and arrowroot powder for oral rehydration and for continued feeding of pre-school children who fail to respond to home treatment. Supplies for these activities would be provided by the Health Department, stocked at PHCs and distributed through nutrition supervisors to CNWs. Finally, CNWs would organize women and children for village immunization and health clinics carried out by MPHWs and would refer pre-school children for MPHW services when indicated The CNC would be the site of four major activities: (a) weighing of children aged 6-36 months;

21 (b) nutrition education; (c) distribution of food supplements for on-site consumption by eligible young children and selected pregnant and nursing women; and (d) maintenance of village nutrition and health records CNCs would be existing buildings with a minimum room space of 30 m selected in accordance with agreed criteria by a committee consisting of the Block Development Officer (BDO), a local government engineer, a representative of the village council and a senior nutrition supervisor. Selection criteria include proximity to disadvantaged populations, access to water, and certain construction characteristics. It is anticipated that suitable CNC space readily would be available in all but a small fraction of project villages at a yearly rental averaging around US$36. A cement floor and latrine would be installed at each CNC, which also would be equipped with simple furniture, including a desk and chair, three cupboards, shelves, mats, a kerosene stove, a blackboard and utensils for cooking demonstrations and serving children who require semi-solid supplementation CNC activity patterns would be flexible to accommodate those of village women. Typically, the CNC would open early in the morning when the most severely malnourished children would arrive for supplementation. They would remain at the CNC long enough to consume two rations. Later in the morning, weighing would take place; eligible pregnant and nursing women and other children would arrive for on-site supplementation. Arrangements for distribution of vitamin A and iron supplements and deworming medication would be worked out by individual CNWs and their supervisors; in most cases, the CNC is expected to be the focal point for such activities Initially, mothers or grandmothers would be required to bring eligible children to the CNC, observe weighing activities and feed their children, mixing the rations with boiled water when semi-solid supplementation is required. However, once the program is established, older siblings could continue to deliver and collect children to be supplemented, particularly during times of peak demand for agricultural labor. The above activities probably would take an average of 6 hours daily. However, the CNC would reopen frequently for nutrition education talks, demonstrations and related activities led by CNWs, who also would make home visits and reach women at water taps and other places where they gather The State Government plans to develop a statewide CNC-CNW program depending upon the experience from the proposed Project and to cover older pre-school children as warranted. Communities themselves would be encouraged during the project to take increasing financial and operational responsibility for such activities. The Government would hope to phase down its contribution wherever the CNC-CNW system has operated for four years. Ultimately the Government would seek to limit its financing to equipment and food costs, with CNCs either donated or rented by village councils or other groups and the work

22 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 supplements would be shared among all children - which now appears likely - if taken home. Shifting to a take-home supplement, which might then be made available through the village fair-price shop, would reduce the need for CNCs if -7rangements could 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 CNWs would also encourage mothers themselves to weigh their children. With the foregoing objectives in mind, the Social Welfare Department would develop prospective modes of such participation, discuss them with IDA and begin applying them during the project The post-project role of CNWs (contract workers), would be determined partly by Government success in obtaining local financing for their continued services or their replacement by village volunteers. Over time, CNWs might be absorbed into the health system as community health workers (CHWs) in accordance with the suggested national pattern of primary health care. Tamil Nadu so far has not recruited CHWs, experimenting instead with several alternate ways of providing combined village nutrition and health coverage. Should the state ultimately accept CHWs, CNWs would be logical candidates for such recruitment because of their skills and experience and would be expected to receive preferential consideration for such work Supervision, Training and Management. A cadre of around 900 nutrition 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 existing Social Welfare extension staff; the others would be new recruits. Supervisors would verify the accuracy of CNW weighings and make final selection of children to be admitted to the food supplement program and discharged from it. Supervisors also would distribute vitamin A, iron and folate, deworming and diarrhea management supplies monthly to CNWs and monitor their use. They would obtain these medications from the nutrition instructress to be recruited, trained and posted in each project block, who would collect supplies from PHCs Initial training of CNWs would consist of two-month training courses at block headquarters in groups of and in-service training thereafter. Such training would be organized and carried out by an instructress in each block. The 170 instructresses would have postgraduate degrees in nutrition or home science, preferably with teaching or field work experience. The final week of initial CNW training also would be attended by female MPHWs from the same area because of the complementarities of their roles. In-service training sessions would take place twice monthly at selected CNCs in the afternoon for batches of ten CNWs. At that time, supervisors would discuss problems and progress with their full CNW complement. The instructress also would hold monthly in-service training sessions for all block CNWs and supervisors at block headquarters Supervisors and instructresses would receive two months' initial training; Sri Avinashilingam Home Science College (SAHSC), which has the experience and capacity to run such programs, has agreed to do so. SAHSC would

23 develop special curricula for this purpose in consultation with an advisory committee to be set up by the Social Welfare Department. Instructresses' curricula would be derived partly from the specific content of CNW training but also would emphasize teaching methods. Supervisors' curricula would stress personnel management and supervision. Assurances were recetved during negotiations that training curricula for CNWs, supervisors and instructresses would be furnished to IDA for review by August 31, 1980, and would thereafter be implemented taking IDA comments into account The rest of the component's management structure would be as follows (see Annex 6a): A taluk nutrition officer (TNO) and support staff would oversee CNW-CNC operations in each taluk, averaging 12 per district. TNOs would be graduates with degrees in nutrition, social work or related fields, preferably with practical experience in community development. Since taluks contain an average of three blocks each, each TNO would supervise around three instructresses and 15 supervisors, as well as a superintendent in each block responsible for food supplement distribution to CNCs. TNOs would spend 20 days per month in the field and would hold regular monthly meetings with supervisors and instructresses. Around two-thirds of TNOs would be new recruits, requiring a minimum of three weeks' training in Government procedures which the Social Welfare Department would organize and carry out. All TNOs also would require in-service training in personnel and basic financial management, organizational methods and other executive skills. These programs would be developed during the first project year by local management training institutions in consultation with the Social Welfare Department A district nutrition officer (DNO) with the rank of Assistant Social Welfare Director would supervise and manage the component in each district assisted by a section superintendent and support staff. Each DNO would report to the Collector in charge of the district and to the Joint Director of Social Welfare in Madras, who would have project-wide responsibility for the operation of the component in the Directorate of Social Welfare. Component support staff at block, taluk and district levels would be responsible for operational logistics including payment of salaries, accounts and auditing, and the regular flow and analysis of data for performance monitoring To facilitate supervision, the component would finance the costs of one sedan each at state and district levels, one 4-wheel drive vehicle and one bicycle for each taluk nutrition office, and furniture and equipment for block, taluk, district and state project nutrition offices Food Supplement. The food supplement would be designed specifically to be acceptable and beneficial to younger malnourished children who cannot consume or readily digest enough balahar for their needs. It would consist principally of a rice-pulse mixture, with added sugar, vitamins and minerals. The supplement was developed in collaboration with the Protein Foods and Nutrition Development Association of India and pretested for palatability at the Institute of Child Growth in Tamil Nadu. Through simple technology already in common use, the supplement would be pre-cooked and shaped into 20-gram briquettes containing around 70 calories for beneficiaries to consume either directly or in semi-solid form by dilution in water. Its shelf life would be 90 days. The raw material mix could be varied to take advantage of

24 food price changes. The usual ration would be 40 grams for children under two years of age and 80 grams for beneficiaries aged 2-3 years. Severely malnourished children, estimated at 10% of beneficiaries, would receive double rations. Around 30% of pregnant women, totaling around 275,000 beneficiaries, also would receive a daily supplement of 80 grams for the last trimester of pregnancy and the first four months of lactation. They would be selected by health workers according to criteria agreed on with IDA designed to identify women at high risk of giving birth to underweight babies (that is, less than 2500 grams) The supplier would pack and distribute the supplement to the block level. The 32 metric tons of supplement for the Kottampatti test would be produced at its existing pilot plant by Gandhigram Rural Institute in Madurai. Gandhigram's plant has a capacity of 500 kg daily and has produced various weaning foods which the Institute has used in its own experimental programs. The project would provide Gandhigram with some replacement equipment to produce the supplement which also would be used in later project-financed trials of alternative supplement formulations. The supplement for the second and third project years would be supplied by the parastatal Tamil Nadu Agro- Industries Corporation (TNAIC) at a negotiated annual contract price based on reviews of input and production costs in accordance with standard Government procedures. By the fourth year, the food supplement requirement would be expected to be large enough--around 4,000 tons--to attract competitive interest. If so, local competitive bidding would replace negotiated sales for the two final project years. Otherwise, TNAIC would continue to supply the supplement requirements for the final two project years at a fair and reasonable price. The appraisal mission concluded that Gandhigram and TNAIC would be able to provide the supplement at an economic price. Although costs of the food supplement are included in the project, IDA would not disburse against them. Based on expected processing costs and currently-averaged input prices reflecting seasonal swings in availability, the delivered cost of the supplement at block headquarters was estimated at appraisal at Rs 3.75 per kilo, or Rs 0.30 per 80 gram ration delivered to each CNC. This works out to an average estimated ration cost of Rs 33 per child beneficiary or Rs 65 per maternal beneficiary. Food requirements for the project are estimated to total around 13,000 metric tons over five years, or a negligible offtake of Tamil Nadu's overall production of the commodities involved Calculations of estimated project food requirements resulted from development of a program model which takes into account a wide range of variables influencing demand. These include initial malnourishment rates and differential supplementation rates by age group and nutrition status, assumptions as to relapse -;ates, the numbers of women to be supplemented and estimated beneficiary participation rates. Project management would use the model to adjust ration requirements as these variables change during the project Supplement Eligibility Criteria. A particularly innovative feature of this component would be the use, initially on a pilot scale, of weight gain as 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

25 common in India, or combined with weight for height, height for age or arm circumference. Some combination of those measures is generally preferable to identify active malnourishment since a child's low weight for age could reflect the stunting effect of previous malnutrition, which only a combination of other indicate.-s would detect. The use of body weight changes, when applied effectively, is simpler and more dynamic than combinations of the other procedures since a child's failure to put on adequate weight over several months unmistakably would indicate either the presence of active malnourishment or the increasing risk of its onset. The weight gain method would be tested in Kottampatti and compared with the weight for age method. If found operationally feasible and effective, the weight gain method would be adopted for the rest of the project. Pending analysis of these test results, selection criteria for child beneficiaries of the food supplement under the period would conform to existing GOI policy The use of weight gain criteria would permit a sharper targeting of the food supplement: it would exclude stunted children gaining adequate weight and it would provide preventive therapy for those most likely to become malnourished. Admission criteria for the supplement therefore are designed both to exclude children who do not need supplementation and to ensure the inclusion of virtually all those at high nutritional risk. Because of their exponentially higher risk of mortality, all severely malnourished children aged 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 gain adequate weight over two months in the case of children aged 6-12 months or three months in the case of children between the ages of 1-3 years. The CNW would weigh children; supervisors would carry out verification weighings before enrolling children into the food supplement program or discharging them from it. Multiple weighings would reduce measurement errors resulting from three factors: children's normal daily weight fluctuation, the + 50 gram accuracy of the bar scale, and errors in recording the reading of the scale All child supplementation would be daily for an initial period of 90 days. The supplement would serve both to help restore children to adequate rates 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 the poorest families, the estimated average calorie gap for children under three 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 would stress this aspect of nutrition education both at CNCs and in their home visits. Experience in Tamil Nadu and elsewhere indicates that days of adequate feeding generally is sufficient to reverse the nutrition decline in most children, although relapses appear common in the subsequent absence of improved health care and family food practices. However, a partial assessment of a 46-village nutrition program in Madurai district, which combined nutrition education with feeding for about 90 days, indicated that as many as 70% of the participating children in particular villages surveyed managed to retain their nutritional momentum as long as four years after completion of the program.

26 Most children would be expected to gain 500 grams, the acceptable minimum, during the first 90 days of supplementation and would then be discharged. The rest would be referred for examination at the nearest PHC, since their failure to gain sufficient weight probably would indicate serious health disorders, unless home feeding had declined or remained grossly inadequate. These children then would continue in the program in 30-day increments while the CNW, assisted by neighborhood leaders, made a special nutrition education effort with the family, subject to a maximum of six months' continuous supplementation. Such a restriction is considered essential to: (a) ensure that only children who can benefit from the supplement receive it, and (b) reduce the likelihood that families would use the supplement as a long-term substitute for food which the child otherwise would consume at home. Assurances were obtained during negotiations that criteria for entry into and discharge from the food supplement program for children and women would be satisfactory to IDA On-site feeding involves substantially less risk of sharing with other family members than take-home rations. However, some families at first might perceive the supplement as small in relation to the opportunity cost of daily visits to the CNC, limiting participation by some children and eligible women. Steps to deal with this in advance include siting the CNC in as accessible a location as feasible and specific CNW emphasis on continued face-to-face recruitment of those eligible for the supplement, particularly the most disadvantaged. The monitoring and surveillance systems also would provide clear signals on participation rates. Moreover, flexibility regarding the time of ration delivery is built into the project and modest changes in ration size also could be considered if circumstances warrant. These aspects of the project would be scrutinized carefully during the Kottampatti and mid-term reviews and would receive regular attention from project management. The annual recurring cost of the supplement program, including the ration and all applicable overhead, would be US$2.96 per village child aged 6-36 months and US$3.75 for each pregnant lactating woman. Rural Health Services 3.36 This component would improve the quality, efficiency and coverage of rural health care in project areas through installation of an MPHW system involving the deployment of one male and one female worker to an HSC serving a population of 5,000. Tamil Nadu already has an adequate number of male workers in place for that purpose and a satisfactory program for retraining them already is under way. However, the State would have virtually to double the present number of female health worker posts and more than double the number of HSCs to achieve suitable coverage ratios Basic rural health care in project areas is now provided mainly by a network of one PHC and an average of 6 HSCs per project block. PHCs basically are out-patient facilities but usually contain up to six beds for emergencies, obstetrical cases and vasectomies. Each has a small operating room, a small pharmacy and a laboratory, along with housing in separate buildings for its three medical officers and support staff. Each HSC is staffed by an auxiliary nurse-midwife (ANM), who concentrates on postpartum care and deliveries, performing an average of ten deliveries per month.

27 ANMs carry out around 30% of all deliveries, the highest service coverage of any part of the state health system, and some HSC-based activities. However, ANMs do not adequately penetrate villages with other services. This is due partly to their large area of crverage, which now runs from an average of 36 km in Chengalpattu to 50 km in North Arcot. In addition to thin coverage, problems impeding more effective ANM performance include training and supervision deficiencies and inadequate supplies of drugs and medicines. Male health workers are segregated into cadres each responsible for a single program such as malaria control, tuberculosis control, immunizations and health inspection. One LHV supervises three ANMs. One male supervisor oversees the work of five male field workers. A PHC medical officer supervises all block health staff with the help of an extension educator and health inspector Under the MPHW system, which the Government intends to introduce widely by the end of 1985, each male MPHW would carry out the combined immunization, communicable disease control and other tasks formerly implemented through separate cadres. ANMs or new recruits to be trained as female MPHWs would concentrate on pre- and postnatal services, deliveries, infant and child care, treatment of minor ailments and referrals to higher levels of health care. The female MPHW would be required to cover an average of no more than half of the previous HSC geographic area, thereby permitting more intensive contact with beneficiaries. Both male and female workers would continue to motivate individuals and groups to take part in family welfare activities, distribute contraceptives and provide follow-up services to acceptors The HSC team would deliver a comprehensive package of basic health services available to those who need them. These changes also would permit each LHV to supervise four instead of three female workers while increasing the frequency of her contact with them because of the reduced geographic area involved. After four years of operation in each project area, the component would be expected to raise antenatal registrations to 80% and tetanus toxoid immunization and the number of assisted deliveries to 60% of pregnant women reached by health services. This is a significant jump from existing coverage levels estimated at 54%, 30% and 30% respectively. It also would triple the average number of contacts between pregnant women and female health workers Each MPHW would be expected to spend around four hours daily in field visits. The MPHW team schedule would ensure that one member is always available at the HSC. The team thus would pay an average of 2-3 visits weekly to each village in its area of coverage. Job descriptions agreed with IDA for MPHWs and supervisors stress the importance of villagelevel performance, its supervision and monitoring Village visits are espcecially important because the MPHW is the principal contact point between individuals and the State's rural health delivery system. In this respect, Tamil Nadu differs from patterns of health

28 delivery in many other states through which the initial contact point is a part-time community health worker (CHW) in each village. Tamil Nadu has yet to adopt the concept of CHWs. Presently, it is experimenting with several alternate ways of providing health care at the village level. One is a system through which an additional physician is posted to the PHC and three of its four doctors spend part of each working day in villages to provide on-site health care. The mobile medical team concept, for which an evaluation by the National Institute of Health and Family Welfare is nearing completion, operates in 28 blocks. Another approach now getting under way on a limited scale is the provision of matching funds to voluntary agencies which agree to organize their own community health services and hire a part-time physician and paraprofessional staff. A health project for Danish aid (DANIDA) financing is under preparation in two districts--salem and South Arcot. While specific details remain to be worked out, both the Health Department and DANIDA intend to include some approach to community-based health care Field observations before and during appraisal indicated that, despite Government expectations to the contrary, the mobile medical team system probably would prove expensive and difficult to administer effectively. Furthermore, applicability of the matching grants concept would appear to be limited by the shortage of voluntary groups at the village level and the poverty of those who most need access to health care. Thus, neither of the two approaches now being tried would seem to provide a cost-effective way of getting health care to the village The appraisal and previous missions felt that integration of village nutrition and health services through a single department would be the most effective and efficient way of providing village nutrition and health care, rather than continuing the division of these responsibilities between Social Welfare and Health. In addition to facilitating administrative and technical supervision, establishment of a single cadre of community workers under Health would promote optimal delivery of a fully-integrated package of village-level care to improve rural nutrition and health conditions. However, the State Government believed it premature to consider a major reorganization of its established nutrition and health delivery systems until after the mobile medical team and additional options had been fully studied. Moreover, the State Government considers the deployment of CNWs combined with MPHWs as a particularly promising way of providing effective nutrition and MCH care at the community level for several reasons. First, community health workers are almost exclusively men under the all-india pattern which results in limited attention to MCH and nutrition activities, despite the priority importance of these 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 young children and pregnant and lactating women, are likely to be carried out better under the project because of fewer competing demands on female MPHW time. The State Government expects the incorporation of certain nutrition-related health tasks into the work of the CNW to result in a functionally integrated service package, while preserving the administrative responsibility of the Social Welfare Department for nutrition delivery in Tamil Nadu, a pattern which accords with national policy. When the results of ongoing and planned

29 experiments have been evaluated, some expansion of CNW functions to include other common health problems may be considered together with a decision on the most effective organizational and administrative structure and procedures To facilitate consideration of a possible shift to a fully-integrated community nutrition and health system, the Kottampatti review would include an assessment of the extent to which the combined services of CNWs and MPHWs meet the need for community nutrition and health care. If significant gaps were revealed, a modified nutrition-health delivery system would be worked out and tested during the second project year. The State Government gave assurances during negotiations that the results of the various experiments with ways of providing health care at the village level in the State would be taken into account during the mid-term project review (para. 3.07). Assurances also were received during negotiations that, should the State modify its health system in project areas during the Project, the State Government, after consultation with IDA, would take all necessary measures to maintain the efficiency, quality and level of nutrition and health services and ensure appropriate use of CNWs to avoid duplication of effort Health Sub-Centers. The 1,600 HSCs to be built and equipped include 166 to replace inadequate facilities, currently rented. Each 65 m HSC would be a one-story building of simple brick or stone construction with an asbestos sheet roof. The use of factory-made materials such as cement and glass would be minimized; locally-available wood would be used in place of steel wherever possible. The HSC would consist of a clinic room, an examination room, a latrine and living quarters for the female MPHW in accordance with designs and working dra'ings already approved by IDA. Construction costs would run about US$55 per m. HSC sites in each project block would be selected by a team consisting of the PHC medical officer, the BDO, a local government engineer and the president of the panchayat union, representing village councils in the block. Locational criteria for HSCs agreed on with IDA include proximity to good roads, public transport, electric supply and other public facilities, and adequate drainage. Each site would be less than half a kilometer from a perennial source of 500 gallons of potable water daily for HSC use Around 50% of HSC sites would be donated or already publicly owned. Based on rural land prices in project districts, the average purchase cost of a site would run around US$161. Construction schedules would allow an average of 10 months for acquiring purchased sites after their identification; HSCs would be ready for use in the first three months of their scheduled implementation year Training Requirements and Facilities. Achievement of health training targets under the project would require a major increase in the numbers of trained female MPHWs. Eight female MPHW training institutions operate in the state. These consist of four Government schools, each with an annual output of 30 students, and four private ones, which annually graduate 40 students each. The curriculum for the Government institutions is being revised and the course duration has been shortened from 24 to 18 months. The new curriculum is more operationally oriented and includes six months' field training. Most of those trained in Government schools accept MPHW jobs. The private sector absorbs around 50% of those trained elsewhere. That level of private demand is expected to continue during the project.

30 Government institutions would have to step up their output of female MHPWs to meet project requirements combined with targets for introducing the system in Salem and South Arcot districts. Around 476 additional female MPHWs would be needed there through 1985 as part of the health project now being prepared for DANIDA financing The component would finance construction and equipping of a 60-bed hostel to expand accommodation at each of the four existing Government training institutions for female MPHWs and at five new female MPHW training centers at district hospitals, which the Government is to open early in 1980, for which classroom facilities 2 already are available. Each hostel would have a plinth area of around 950 m and would contain 15 four-bed rooms, lavatory and bathing facilities, a dining and recreation area, a kitchen and a warden's quarter. The component also would finance construction of 10-bed dormitorycum-classroom units at each of 27 PHCs where female MPHW field training would take place. These facilities would permit the Government to meet requirements for additional female MPHWs in project and DANIDA districts, as well as replacement needs for existing female health workers in the state Tamil Nadu also would have to increase its output of LHVs to meet supervision targets for female MPHWs. Only two LHV training schools now operate in Tamil Nadu. One is an over-crowded Government institution in Madras where 325 students are accommodated in space designed for 200. The other is a private institution which takes in 35 trainees per year. Fresh LHV recruits receive 30 months' training; those promoted from the ANM cadre receive 18 months' training. The LHV training curriculum would be revised to reflect the new role of female MPHWs and would include a 6-month field training module for Government trainees at selected PHCs. In addition to training new LHVs, Tamil Nadu also must provide refresher courses and orientation for about 550 already working in project areas. However, the State requires additional facilities for this purpose To help meet the above initial and in-service LHV training needs, the component would finance construction and equipment for a new LHV training facility, probably in Madurai. The new institution would handle all LHV promotion training of ANMs as well as all in-service training for existing LHVs. The existing Madras facility would concentrate on initial training of fresh 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. Also financed would be a 10-bed dormitory and classroom block for each of the 12 PHCs where LHVs would receive field training from both the existing Madras and planned new school. These training facilities would be built during the first year of the project and begin operating from the start of the second project year In-service orientation to the MPHW system also would be required for MOs in line with major changes in their role resulting from introduction of the MPHW system. First, the MO in charge of block operations would have increased managerial responsibilities as leader of an expanded block health

31 delivery service team, and would have a substantial role in providing inservice training for its lower-level workers. Second, the PHC's workload would change with the addition of complicated deliveries, sputum examinations for TB and other services. Furthermore, PHCs can anticipate a substantial increase in daily contacts, now averaging around 300, from MPHW referrals. Tamil Nadu would organize a program of nine weeks' training to upgrade MO capabilities for the MPHW system; those specializing in obstetrics and family planning services would receive an additional three months' training. Because of high attrition rates, a state-wide total of about 400 MOs would require such training annually Currently Tamil Nadu has three institutions for in-service training of health workers, block extension educators and MOs. They are located in Chengalpattu, Madurai and Salem. Each has a training capacity of 100 and trains around persons per year, depending on the length and type of course. However, these three family health and welfare training centers already are stretched to full capacity and cannot take on the additional in-service load which the project requires. To meet the shortfall, the Government would set up a fourth 100-bed training center in another part of the state. Its establishment would provide better geographic distribution of such training than could be achieved by expanding existing facilities. It also would prove more suitable in the long run than the temporary option of setting up special programs for these personnel at existing teaching hospitals and other facilities. Construction and equipment for hostel and classroom space at the new facility would be financed under the component during the first year of the project The per student cost of civil works averages around US$72 per m for classrooms and hostels. Tamil Nadu would continue to need these facilities after the project to expand the MPHW system state-wide, to replace personnel lost by attrition and to provide in-service training for its growing cadre of LHVs and other professional staff. Estimated annual demand for female MPHWs and LHVs would remain steady at 500 and 125, respectively, for the first few post-project years as MPHW implementation took place in the rest of Tamil Nadu and then would rise and level off at around 1,000 and 250, respectively, for replacement needs The Department of Highways and Rural Works (HRWD) would be responsible for HSC construction. HRWD relies on a well-established network of rural contractors. The supervision system extends to the block level, where a full-time engineer and overseer are stationed, supervised at the taluk level by an executive engineer. Additional HRWD staff, including short-term help, is routinely recruited and posted to the block level as necessary. The block engineer and staff would be responsible for civil works procurement and construction supervision for HSCs and PHC hostel-classroom facilities. Block engineers are allotted 1.5% of construction costs yearly for maintenance of each building erected under their supervision. Major repairs require HRWD sanction. Additionally, each user department at the block level can approve

32 at least Rs 700 for minor repairs to any building. The State Public Works Department would be responsible for construction and maintenance of the other training facilities through its established organizational and contracting system, which are satisfactory While under preparation, appropriate training curricula still need to be made available for MOs, PHN instructors, LHVs and female MPHWs. Assurances were received during negotiations that training for the above workers would be carried out according to curricula which would be furnished to IDA for review by August 31, 1980, and would thereafter be implemented taking IDA comments into account Lack of adequate supplies of drugs and medicines at PHCs and the periphery is one problem which the project would help correct. The yearly PHC allocation for drugs and medicines would be raised to Rs 25,000 from its present level of Rs 14,000, while that for male and female supervisors and 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 responsibility for the supply of drugs and medicine to supervisors and MPHWs. At present, the BDO purchases such supplies on the basis of technical recommendations from the physician in charge of the PHC. However, even with supplies now ordered directly through the Health Department, serious shortages continue to affect the health care system. Persistence of these difficulties would hamper the effectiveness of MPHWs. For that reason, during the first project year a study would be carried out to determine the reasons for these problems as well as to rationalize the choice of drugs based on epidemiological prevalence of specific diseases in the area of coverage of HSCs and PHCs and to identify corrective measures. Assurances were received during negotiations that the study would be completed by June 30, 1981 under terms of reference satisfactory to IDA, and that the GOTN would furnish the report to IDA for comment The component would finance a bus for each of the seven new training institutions receiving project support and two for existing medical officers' training centers, a station wagon for each of the 14 divisional health offices in the project area and two for use by State Health headquarters. Also financed would be a motorcycle and two bicycles for each project divisional health 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 would take them up Managerial Arrangements - A Senior Deputy Director of Public Health in the Directorate of Public Health and Preventive Medicine, Madras, would have overall responsibility for the component. Assurances were received during negotiations that a post of Deputy Director (Training) would be established in the Directorate and filled by a suitable officer by August 31, 1980; that official would have special responsibility for ensuring the appropriateness and timeliness of project-financed training. A Divisional Health Officer

33 would be in charge of each of the 14 divisional health offices in the six project districts, reporting both to the Collector concerned and to the Senior Deputy Director of Public Health in Madras through the District Health Officer. The staff of each divisional health office would include a PHN, a senior male health inspector and support personnel. Each office would supervise an average of 12 PHCs, 188 HSCs and their staff. The establishment of the divisional health offices without incremental staff recruitment would be possible through realignment of current managerial functions and transfer of existing health personnel Management of the component would include operation of its monitoring system. Information on participation rates, kinds of services offered and utilization of supplies would flow monthly from HSCs for consolidation at the PHC, where it would be combined with supervisors' information on MPHW activities. As head of the MPHW team in that block, the responsible MO would forward these materials to division headquarters along with reports on monthly PHC activities, and actions planned and taken to correct problems in the MPHW system. A similar process of consolidation and analysis would take place at the divisional level. Those reports would go both to the Collector and the Senior Deputy Director of Health in Madras, where a monthly report along similar lines would be prepared for dissemination to those most directly concerned with the project. The Senior Deputy Director and his support staff would keep track of corrective actions planned or under way and would provide guidance to Divisional Health Officers or other levels of the system as necessary Coordination with Nutrition Delivery System - Although they work for different Government departments, MPHWs and CNWs and their supervisors would have to collaborate with one another effectively. CNWs would be expected to organize communities for clinics to be held by MPHWs. MPHWs would be expected promptly to examine, and, if necessary, refer for PHC scrutiny those children failing to gain weight during supplementation or otherwise exhibiting disease symptoms noted by the CNW. The MPHW would enroll eligible women for food supplementation to be provided through the CNC. In village visits and other work, the MPHW would be expected to reinforce nutrition education themes and encourage families to take part in the child-weighing program. Equally important, all family health records would be maintained at CNCs, thereby encouraging both MPHWs and their supervisors to spend more time in villages. The significance of these complementarities would be stressed during the initial training of nutrition and health workers and this would be reinforced by monthly inter-department meetings at the block level. Moreover, informal contact between health workers and their nutrition counterparts would be encouraged along with joint in-service training programs which either sponsoring department could propose. Nutrition and Health Communications 3.62 The central element of this component would be activities encouraging families to adopt a limited number of specific practices to improve nutrition conditions of young children. These would include timely introduction of semi-solid foods to supplement breast milk, feeding instead of withholding food from the sick child, increasing the home food ration for

34 children under three years of age and home rehydration of children with diarrhea. Such changes are considered feasible within existing family income and food availability constraints for most participating families since, according to TNNS findings, they could be accomplished by small shifts in current intrafamily food distribution patterns. The component's approach to nutrition education would differ from most previous efforts in Tamil Nadu by concentrating on a few practical and specific actions and practices likely to produce significant nutrition and health benefits for the target group. Additionally, the nutrition education program would stress worker use of emotional appeals and mobilization of group pressures for change rather than the more customary emphasis on scientific argument The component also would: (a) provide teaching materials for preservice and in-service training of project nutrition and health personnel; (b) prepare communities and their leaders for the introduction of project services through a combination of person-to-person contact and mass media campaigns; and (c) encourage local participation in project activities such as child weighing and supplementation, use of oral rehydration supplies, compliance with deworming procedures and regular use of iron and vitamin A supplements; and (d) motivate field staff through regular newsletters and public recognition of outstanding performance Through these combined activities, the component would: (a) improve the quality of training of CNWs and MPHWs and their supervisors; (b) prepare populations and community leaders for introduction of project activities; (c) help maintain high morale and motivation among health and nutrition field staff, thereby contributing to their improved performance; (d) increase the probable effectiveness of nutrition and health field worker performance by providing support media for their activities; (e) improve the pace of community response to project activities, and (f) speed up the likely rate of nutrition improvement by promoting self-help and at-home measures outside the direct control of project staff, thereby improving the chances that nutritional momentum generated by project activities will be maintained through the family's own efforts In support of training activities, the component would finance around 250 sets of film strips and 13,000 training manuals for use during pre-service and in-service sessions. CNW training would include practical communications training focusing mainly on developing expertise in using print media, such as flip books and charts to be financed under the component. Field staff also would learn how to develop self-made materials and during training would produce at least one set of flash cards, food charts or other similar materials. Each CNW would receive a project-financed field manual at the close of training for use during home and other visits The component would finance films for use by officials in preactivity visits to prepare area leaders and villagers for introduction of project nutrition services. The first visit to a project village would take place around three months before the nutrition delivery component went into local operation. Each supervisor would probably have to make an additional

35 two visits to each of the 15 villages for which she would be responsible. These meetings would involve leaders of village councils and other organizations such as womens' groups. One meeting would be for the entire population and would include a film show for selected project villages through projectors already available to the Collector's office augmented by six others, including generators, which the component would finance, to be used later for screenings of other nutrition messages. During this period, an average of women leaders would be identified in each project village. Every six months they would receive one day's orientation training from the CNW at the CNC. They would be expected to support her efforts by ensuring that children are brought for weighing regularly, that beneficiaries continue in the supplementation program and that other forms of desirable participation also take place. Efforts would be made for them to weigh children themselves or to supervise weight-taking by mothers or other responsible family members Printed materials, including posters and other visual aids, would be financed and disseminated to reinforce educational and motivational work by CNWs. Among the topics would be: (a) explaining the project's selective approach to food supplementation and entry and exit criteria; (b) encouraging regular participation in weighing; (c) promotion of management of child diarrhea through home-made oral rehydration therapy; (d) encouraging continuation of breast-feeding and increased home feeding of children receiving nutrition supplements, and (e) encouraging participation in vitamin A and iron supplementations and deworming activities The component would finance about three major campaigns annually to promote a few implementable nutrition and health practices affecting younger children. The principal audiences would be women, particularly mothers and their 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 last for about three months separated by a one-month interval for analysis of monitoring data and design modifications resulting from it. Campaigns would consist of 5-minute films to be shown in Tamil Nadu's extensive network of rural movie houses, averaging four per project block; short radio programs; newspaper and magazine advertisements; and on-the-ground efforts of nutrition and health workers, reinforced by flip-books, charts, posters and self-made materials. The component would finance the design, production and dissemination of all materials for these campaigns, including multiple copies of six different films, 3,200 radio spot advertisements, 10,000 wall paintings and 50,000 posters Each campaign would focus on one important idea or change and is expected to be repeated at least three times unless monitoring data suggest otherwise. Among the topics already identified for probable campaign focus are: (a) the introduction of low-cost, locally available semisolid 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 the young child;

36 (c) continued feeding rather than withholding food from children with diarrhea and the use of home-made oral rehydration mixes; and (d) improvement of environmental hygiene with emphasis on control of common disease vectors such as flies. Current plans call for a maximum of six campaign topics during the project Traditional folk theater as well as modern media would have a role in this component. In recent years, one such form popular in rural areas, Villu Pattu, has shifted from its original historic-heroic focus to more contemporary themes. It has been used successfully to convey development messages in such fields as agriculture and family planning. The project would finance the identification of around 20 Villu Pattu troupes; development of sample scripts for troupes to adapt; training to use these scripts, through apprenticeship to a master troupe, and the cost of around 20 educational performances monthly by each troupe in project villages which, because of poverty or isolation, have less access to films. On the basis of estimated costs per target person reached, the efficiency of traditional folk theater under these circumstances is comparable to that of rural cinema Managerial Arrangements - Because this component provides support to both the Social Welfare and Health Departments, it would be managed through the project coordination office. A Joint Coordinator for Communications (JCC) would direct the component. The staff of the communications unit would include an assistant communications officer, a news bulletin editor, an art director, a monitoring officer, a media officer, a production officer, a training officer, a photographer and support staff, most of whom would be recruited specifically for the project. The unit also would post one District Communication Officer (DCO) to each project district to coordinate field activities as they began to phase in. Incremental salary costs of these personnel would be financed by the component, along with around 10.5 personyears of local consultants to provide technical assistance in mass and interpersonal communication and other fields such as monitoring. Job descriptions for all communications staff and terms of reference for all technical assistance have been prepared for the component and are satisfactory to IDA The communications unit would set up a technical working group to provide ad hoc advice as needed on content or design or to solve special problems in specialized fields not covered by staff or technical assistance. It would consist of around six experts from both the public and private sectors including a nutritionist, a pediatrician, an anthropologist, a specialist in public health administration and the State Directors of Social Welfare and Rural Development or their nominees. The JCC would convene meetings and act as the Member-Secretary. Alternates also would be named for all members to ensure availability on short notice. The component would finance modest honoraria for remuneration of non-government members of the working group. Management, distribution and control systems to disseminate communications materials as well as contracting procedures for each of the media elements have been worked out.

37 Also financed by the component would be around one month of preservice communications training for the JCC; one staff car, a motorcycle and three bicycles for the communications unit; one motorcycle for use by each of the six DCOs; furniture and equipment for headquarters and district offices, and the costs of small background studies on socio-cultural constraints to changing food and health practices, media access and traditional media infrastructure, which are of direct use for finalizing decisions on communication strategy and message content Monitoring of the component by its management would focus on whether messages get out as planned, reach the right people, are understood and remembered by them and are found interesting and relevant. Regular feedback from field staff on how well nutrition education and other activities seem to be working, and how response develops to project activities would provide useful qualitative indications of how the component is progressing. Limited inquiries in regard to specific practices before and after each mass media campaign would reveal trends and problems in the communications interventions. Additionally, monthly health and nutrition reports consolidated at the district level would provide DCOs and component management with necessary information on the use of communications material disseminated under the component. Monitoring and Evaluation 3.75 This component would support the regular collection, interpretation and appropriate dissemination of analytic information required by project and component managers: (a) for timely and effective physical and financial implementation; and (b) to determine the extent, pace and cost of progress toward achieving project objectives 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

38 Monitoring and evaluation would measure concurrently, at varying levels of depth, the degree to which nutrition, health and communication services are producing desired results. If the delivery of inputs, messages and services are satisfactory and if they are relevant, acceptable and accessible to the target population (measured by monitoring), positive effects on the nutrition and health status of the beneficiaries should take place (measured by evaluation). This underscores the fundamental continuity between both kinds of activities Component monitoring would be undertaken by the executing agencies concerned. A list of what type of component data would be collected, at what intervals, by whom, and by what method would be worked out between the management of each component and the monitoring division of the project coordination office, which would have overall responsibility for project monitoring Project monitoring would draw upon data regularly generated by executing agencies. This flow of information would be supplemented by on-thespot field checks as well as a total of around 15 special monitoring surveys during the project. Those would include studies on drop-outs from the food supplement program, degree of supplement substitution for food consumed at home, changing patterns of intra-family food distribution, media penetration and the reliability of data generated by the nutrition and health delivery systems. Also included would be studies in the first, third and fifth project years of the efficacy of nutrition and health training, and costs per person reached and per service rendered. Annual surveys of leakages in the supplementary food distribution system also would take place through project monitoring Based on data from each component, the monitoring division would prepare consolidated monthly reports on project progress and would make these available to component and project management. These would include status reports on corrective measures previously undertaken or identified for each component. The monitoring group also would prepare quarterly and annual reports on project progress. Both would contain comparative information on progress to date against scheduled targets and progress during the reporting period. Using data generated by the monitoring division, the project communications unit would prepare summaries of these reports for distribution to project field personnel Additionally, during the first project year, a detailed monitoring study to refine the mix of project activities as necessary would be carried out in Kottampatti Block, where the project first would be implemented. The Kottampatti study would test: (a) the acceptability and shelf-life of the food supplement under field conditions and verify the number of feedingdays required to bring malnourished children back to normal growth; (b) the practicality and effectiveness of criteria and procedures for selection of children and pregnant and lactating women to be enrolled in the feeding program;

39 (c) the adequacy of the curricula proposed for various categories of nutrition and health trainees, and the feasibility and appropriateness of the staff workload, targets and schedules as presently conceived; (d) coordination arrangements proposed for the health and nutrition staff at various levels; (e) the proposed monitoring and supervision systems, confirm minimum information requirements, and identify priority areas for further in-depth studies; (f) the accessibility and acceptability of project facilities and services; measure the initial utilization and participation rates; determine who actually benefits from the services rendered and analyze determinants of relapse, dropping-out, absenteeism and non-participation; (g) teaching materials to be used in communication activities; (h) technical aspects of the program, including methods for providing oral rehydration therapy for diarrhea, maintenance of the cold chain for vaccines, use of the growth chart, suitability of scales, use of anemia recognition card; (i) logistical channels for the supply of inputs such as drugs and the most appropriate frequency and methods of re-supply; and (J) aspects of the proposed evaluation system, including training of field investigators, pre-testing of survey instruments, and communications survey methods. Evaluation staff would be posted in the field to facilitate collection and analysis of Kottampatti data The nutrition surveillance system would provide project management with 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 in feeding program participation of children with faltering growth. They would provide timely identification of villages, blocks, and districts which may require special attention because of continuing or emerging nutrition problems. Complementing this surveillance system would be another information-generating scheme operating in control districts outside the project. A sample of randomly selected children would be weighed each month using anthropometric criteria. Measurements would be done by specially recruited investigators who would report directly to project headquarters in Madras. This scheme

40 would provide sensitive early warning information on creeping and acute nutritional deterioration elsewhere in the state, and also would enable project authorities to isolate favorable effects attributable to project actions Evaluation of the impact of the project would concentrate on changes in levels of malnutrition, morbidity and mortality among target groups in project areas compared to changes elsewhere in Tamil Nadu. This will be accomplished principally through baseline and annual re-surveys in project districts and certain other areas which would serve as controls. Sampling would take place for a total of around 14,000 households during the project period. The initial baseline survey would get under way six months before the implementation of project activities in each district. Data collection and analysis would take about six months. Other evaluation topics would include efforts to determine changes in intra-family food distribution habits after the introduction of project nutrition activities and an assessment of the feasibility of making the food supplement available through fair-price shops and other commercial channels. Additional studies would seek to relate the costs and impact of project activities to other programs in Tamil Nadu aimed at similar target groups A major study of project achievements and their costs would take place in the year following the last year of project implementation. The study would include a sectoral review of Tamil Nadu's nutrition and rural health policies and programs, experience with the State's various modes of delivering nutrition and health services at the community level and their impact and managerial and budgetary implications; IDA would receive a copy of the report. Assurances were received during negotiations that terms of reference for this study would be satisfactory to IDA Evaluation would be carried out by a group under the overall supervision and technical guidance of the Director of Evaluation and Applied Research in the Finance Department. The Evaluation Division would be headed by a special officer with the rank of Joint Director. Three sections would report to him: evaluation and surveillance, special studies and administration The evaluation and surveillance section and the special studies section each would be staffed by a Deputy Director, one research officer and two research assistants. The special studies section also would recruit graduate students to be stationed for longer periods of time in selected villages as participant observers. A specialized staff consisting of a nutrition expert, a statistician, a social anthropologist, and a health specialist/epidemiologist would be available for consultation with both sections; they would work under the direct control of the head of special studies. In addition, a total of about 110 field investigator-years would be required to carry out the sample surveys as well as to contribute to data collection for the special studies. The administrative support section, which handles payments and logistical matters, would be headed by a research officer who would also undertake work in the evaluation and surveillance section. The

41 non-technical support staff would include one junior accounts officer, one superintendent, two assistants, two junior assistants, one record clerk and four steno-typists A field unit would be established in each project district as the main arm for data collection. Each unit would be headed by a research officer supported by junior research assistants and investigators, whose number would vary somewhat between districts depending upon the number of sample households to be covered. To ensure both objectivity and widest possible application of findings from the project, an Advisory Panel on Evaluation would be set up consisting of representatives of the State Government, the GOI and appropriate research institutions. The panel would be established by December 31, 1980 and would continue through the project period. The panel chairman would be the State Director of Evaluation. The head of the Project Evaluation Division would be its Member-Secretary. Assurances were received during negotiations that such a panel would be set up and would meet as necessary throughout the project period to review and comment on the evaluation of the project The component would finance the costs of monitoring and evaluation studies; furniture and equipment for the evaluation office and its field units; one four-wheel drive motor vehicle, one motorcycle and three bicycles for the evaluation office; one motorcycle and four bicycles for each of the seven field units, and incremental operating costs for the component including the salaries of agreed staff. Project Coordination Office 3.89 A small office to coordinate the project was set up in the State Secretariat prior to negotiations. Its professional staff already consists of a Project Coordinator and the Joint Coordinator for Communications; others to be assigned would include a monitoring officer, a senior accounts officer, an administrative officer, and two computer programmers. The Project Coordinator reports to the Secretary of the Social Welfare Department, who is the Chief Project Coordinator. However, the Project Coordinator also is a member and secretary of an interdepartmental project oversight committee, chaired by the Chief Secretary of Tamil Nadu, whose other members include the Secretaries of Social Welfare, Health, Agriculture, Rural Development and the heads of other interested government agencies The Project Coordination Office would review annual and quarterly budgets and work programs from each project district and executing agency to ensure their consistency with project schedules and operational criteria. It also would review proposed annual project budget submissions from these two sources, identify differences between such proposals and approved project implementation schedules and annual financing plans, seek to reconcile these with the agencies concerned and report on the outcome to the high-level committee. Remaining issues would be resolved there and the results communicated back to component managers through the coordination office. Final proposed annual budgets for each component would be forwarded to the Finance Department by the coordination office for inclusion in the annual state budget.

42 The coordination office would review monthly monitoring reports from each project district in respect to each component and prepare consolidated summaries. It also would keep track of corrective actions proposed or under way in each component and carry out extensive field observation of project activities to verify the accuracy of such reports. Additionally, the Project Coordinator would be in frequent contact with District Collectors in regard to the pace and quality of project implementation. To facilitate data management, interpretation and analysis, the project's evaluation unit would be located in the Project Coordination Office, although it would remain under the administrative control of the Finance Department The coordination office also would operate a US$500,000 equivalent management fund to support innovative activities relating to project objectives which implementing agencies would propose from time to time. Approval of the high-level project committee would be required for such expenditures; assurances were received during negotiations that advance IDA approval would be obtained for expenditures of US$50,000 or more from the project management fund For the coordination office the project would finance three vehicles; furniture and equipment, including a desk computer; staff salaries and other incremental 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 equivalent for five years of project operation and evaluation in the sixth year. Total project costs may be broken down into base costs of US$49.7 million equivalent and contingencies of US$16.7 million equivalent. The foreign exchange component is estimated at US$8.7 million, 13% of total project costs. Costs of civil 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 assistance and mass media contracts total US$2.4 million, 5% of base costs. Incremental operating costs total US$19.6 million, or 42% of base costs. Duties and taxes are estimated at US$1.9 million. All costs are based on calculations at the time of appraisal. Salary costs are based on standard Government pay and allowances scales in effect at that time. Local technical assistance cost estimates are based on prevailing rates for such services. Table 1 summarizes cost estimates by expenditure category. Table 2 provides cost estimates by component.

43 ndkia: TAM.rL NADU NUTRITION PROJECT - Table 1 Project rosc Estimates by Expenditure Category (In Rs 'eoo) (ln USS 't000) 2 I of Local Foreign Total Local Foreign Total FE Base Costs A. Civil Works 52,985 22,708 75,693 6,308 2,703 9, D. Vehicles, Equipment 39,959 14,462 54,421 4,757 1,722 6, and Furniture 1. Vehicles 8,665 2,888 11, , Equipment and 31, ,574 42,868 3,725 1,378 5, PUrniture C. Training 23,670-23,670 2, ,818-6 D. Contract Services 18,998-18,998 2,262-2, Coruunications 17,558-17,558 2, Ivaluation 1,440-1, r. Technical Assistance 1,522-1, P. Food Supplements 50,747-50,747 6,041-6, C. Project M.anagement Fund 4,200-4, IL Incremental Operating Costs 1. DJrugs and Supplies 33,977 11,326 45,303 4,045 1,348 5, Salaries and 96,386-96,386 11,475-11, Allovances 3. Veh. op. Costs 3,033 2,108 5, Other Op. Costs 17, ,1 -- 2,108 5 Subtotal 151, ,535 17, , " aase Costs 343,182 50, ,786 40,855 6,024 46, Contingencies Physical 23,828 2, Price L , Subtotal Con.inzencies 163,986 19,522 TOTAL 557,772 66,401 INDIA: TAMIL NADU NUTRITION PROJECT Table 2 Project Cost Estimates by Comoonent (in '000) Rutees us 'S5$ 5 Foreign 2 Base Local Foreign Total Lccal Foreign Total Excbanee C"st Yutrition Delivery Services 172,764 11, ,426 20,567 1,389 21, Rural Health Services 130,295 38, ,371 15,511 4,533 20, Nutrition Coamunicactins 23, ,275 2, , Monitoring and Evaluation 8, , t Iect Coordination 8, , base Costs 343,182 50, ,786 40,854 6,025 46, Physical Contingencies 19,267 4 L , SUB-TOTAL 362,449 55, ,614 43,149 6,567 49,716 Price Continsencies 122,17 17, ,135 16, TO'AL PROJECT COSTS 484,666 73, ,699 8,702 66,401

44 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 at 10% against estimated base costs of civil works, furniture and equipment. A similar allowance has been made for drugs and supplies, training, and food supplements because of possible variations in the numbers of beneficiaries involved. Price contingencies averaging 33.6% of base costs and physical contingencies were calculated on the basis of anticipated expenditure schedules and expected price increases from the end of appraisal currently estimated at 10% in 1981, 7% per year and 5% in 1984 and thereafter Recurring State expenditures for nutrition are about US$8.8 million , and for health, about US$82 million. These represent around 0.9% and 8% respectively, of the State's estimated revenues of US$1,011 million. By 1995, conservatively assuming continued 3% annual budget growth in real terms (although such State expenditures have been rising at around 4.3% yearly), State revenues would run around US$1,622 million. Using 1995 population projections, the state-wide recurring costs in real terms of the project's nutrition services for both rural and urban areas would be US$28 million at present malnourishment levels, which are, however, expected to fall significantly, and ignoring savings to the State budget as communities begin to absorb a share of CNC-CNW costs. Assuming that other nutrition programs remained constant, although it is expected that existing pre-school activities would be absorbed into the CNC-CNW system, total State spending on nutrition in 1995 would run around US$37 million in real terms, or around 2.3% of annual state revenues anticipated at that time. Incremental recurring costs of state-wide health coverage under the MPHW system would be around US$15.7 million in 1995 in real terms. State health expenditures in that year would rise to around US$127 million in real terms if other health costs kept pace with population growth and would account for around 8% of total state revenues projected for An IDA credit of US$32 million would finance 50% of total project costs net of duties and taxes. The GOTN would finance the balance. Retroactive financing of up to US$300,000 would be provided for expenditures from September 1, 1979, for baseline studies, development of nutrition and health workers' training curricula and training of communications and other personnel needed to get the project under way according to schedule. B. Procurement 4.05 Civil works contracts (US$9.0 million) would be small and dispersed both geographically and over time, which would not be suitable for international competitive bidding. They would be awarded on the basis of local competitive bidding through standard GOTN procedures, which are acceptable to IDA An estimated 102 sedans and station wagons, 9 buses and 212 motorcycles (US$1.1 million) would be procured under the project. They would be purchased mainly in small quantities over five years and dispersed principally

45 in rural areas. Maintenance facilities and ready availability of spare parts would be essential, requiring purchase of types of locally made vehicles already used by Government departments. Vehicle procurement thus would be by local competitive bidding under existing GOTN procedures which are satisfactory. Bicycles (US$0.3 million) would be purchased mainly by individual staff from loan funds provided by the GOTN; the purchase price would be recovered over 18 months from each buyer Orders for drugs, furniture, equipment and supplies (US$10.5 million) would be bulked whenever possible and purchased according to established local competitive bidding procedures, except where valued at less than US$50,000, when they would be procured through prudent local shopping. Drugs to be procured would include arrowroot powder and glucose-electrolytes (US$0.9 million), which would not attract foreign bidders. Other drugs and medications (aggregating US$3.3 million) would be of disparate types and procured over time due to limited shelf life of some items. They would represent an increment of less than 15% over drugs now procured by the State under established procedures which are satisfactory, ensure equitable, reasonable prices, and are provided through local manufacturers which include a number operating in collaboration with foreign companies from IDA countries. Contracts for media production, data processing of evaluation studies and technical assistance (US$2.4 million) also would be procured through prudent local shopping because the specialized nature of services to be provided makes competitive bidding unsuitable 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 be reviewed by IDA before bids are invited. All proposed contracts estimated to cost US$100,000 equivalent or more would be furnished for review by IDA before signing and, when based on local competitive bidding, would be accompanied by a copy of the relevant bid evaluation. Signed copies of other contracts also would 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 assistance, drugs, supplies and the project management fund Disbursements expenditures for civil works payments not exceeding Rs 300,000, for payments for vehicles, equipment, contract services, drugs and supplies not exceeding Rs 150,000 and for training would be made on the basis of certificates of expenditure. The State Government would retain relevant documentation for inspection in the course of project review missions. Disbursement against all other items would be made against evidence of receipt of and payment for civil works, goods and services.

46 D. Accounts and Audits 4.10 The Government would maintain separate accounts for expenditures made under the project. These would be audited annually for each fiscal year in accordance with sound auditing principles consistently applied. Such audit reports would be furnished to the Association within nine months after the close of a fiscal year. Certificates of expenditure would be audited internally at least once every six months and audit reports furnished to IDA. Those reports would show, inter alia, that the funds withdrawn were used for the purposes intended, the goods had been received, work performed and that payments had been made. V. PROJECT ORGANIZATION AND MANAGEMENT A. Overall Coordination 5.01 At the state level, an inter-departmental committee chaired by the Chief Secretary of the State, would meet quarterly to review project progress and decide on desirable budgetary and implementation adjustments. The Project Coordination Office, headed by the Project Coordinator, (paras ) would serve as Secretariat to the committee. Other members of that high-level committee would include the Secretaries of Finance, Social Welfare, Health, Rural Development, Agriculture and the managing directors of the Tamil Nadu Water Supply and Drainage Board (TWAD) and the Tamil Nadu Agro-Engineering Cooperative Federation. Wihile the latter agencies are not directly involved in project implementation, their participation in the committee is important because of recognized linkages between nutrition and their areas of responsibility. Moreover, the Government intends to provide improved water supplies on a priority basis to the estimated 30% of habitations in project areas where no public or protected source is available within one kilometer. Inclusion of a TWAD member on the high-level committee would help ensure coordination of that program with project activities Inter-agency coordination at other levels would take place through district and block project committees. The district committee would be chaired by the Collector. Its membership would include the District Assistant Director of Social Welfare, the District Health Officer and the District Assistant Director of Rural Development. District committees would meet monthly to monitor project progress and resolve difficulties arising at that level At the block level, the DDO would chair a monthly meeting of the nutrition instructresses, the MO, the BDO, the TNO and the concerned divisional health officer. These meetings would provide a forum for identification and resolution of local problems and for suggested improvements in the conduct and content of the program, which would be forwarded to the high-level committee and respective implementing agencies in Madras through the Collectors. Notices and minutes of meetings would be copied to Agriculture, Rural Development and TWAD staff and their presence requested when items of mutual interest

47 - 41 are on the agenda. The Collector would meet regularly with these committees while on tour and at least twice yearly with DDOs for the express purpose of discussing progress and direction of the nutrition project. B. Programming and Budgeting 5.04 Block and district committees would collaborate on the formulation of quarterly project work programs under the currently approved budget and development of annual program proposals for the coming financial year. The project coordination office would review these proposals, reconcile them with annual project cost estimates and approved or requested departmental budgets and work programs and recommend suitable action by the high-level committee. The project coordinator would notify both district committees and executing agencies of decisions by the committee, and would forward approved proposals for the next fiscal year to the Finance Department for incorporation in the annual budget. After budget approval, the project coordinator would advise concerned departments and district collectors of details of programs and operations approved for the next fiscal year. Notification of approved work programs and budgets would be made at least 60 days before the start of the following quarter. The flow of funds would follow established Government procedures. C. Project Execution 5.05 Existing Government agencies would carry out project activities as indicated below: Agency Directorate of Public Health, Department of Health and Family Welfare Directorate of Social Welfare, Department of Social Welfare Bureau of Evaluation and Applied Research, Department of Finance Tamil Nadu Agro-Industries Corporation Highways and Rural Works Department Public Works Department Project Coordination Office, Department of Social Welfare Activity Health Services Operation, Management, Monitoring Nutrition Services Operation, Management, Monitoring Project Evaluation Food Supplement Production Civil Works Civil Works Project Coordination, Communications, Monitoring

48 Annex 5 provides an implementation schedule of key project activities. 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, which the project is expected to reach, would provide nutrition protection for an estimated 780,000 children under three years of age, including 470,000 currently deemed to be actively malnourished. It would also provide selective food supplementation for about 275,000 pregnant and lactating women. The health component, at 75% coverage of the project population, which is a realistic four-year goal, would improve the availability and quality of basic services to an estimated ten million persons, including an estimated 950,000 families and an estimated additional 1.25 million women and their children who are not now adequately served by the system. Although the project's specific objectives concern women and children, improved quality and reach of health services is likely also to improve overall health conditions of the labor force in project areas. Resulting morbidity reductions would increase the number of work days available per adult beneficiary, including during times of peak demand for agricultural labor. Through combined nutrition, health and communications interventions, the project would contribute to increased young child survival rates and would help such beneficiaries to reach full genetic potential, raising many to higher levels of educability and potential performance, enhancing the rate of return of Government investments in education, and providing a more favorable climate for acceptance of family planning These changes would help improve the quality of rural life; while nutrition is only one organizing principle for such efforts, the project offers an important opportunity to do so at district and local levels. Through its combined services, the project also would provide a focused and effective alternative to long-term feeding programs which now characterize the state's pre-school nutrition efforts and reach only a small proportion of those at greatest risk. Rationalizing the structure of direct nutrition intervention would help the state realign its other nutrition programs and improve their reach and effectiveness The program supported by the Project would require considerably less food supplement than the existing feeding programs. Under the Project, children 6 to 36 months would receive an average of about 110 days' supplementation, including allowance for relapse. Under existing programs, such children would receive supplementation for 300 days yearly for the full 2-1/2 years. Thus, considerably larger populations could be covered with a given volume of food supplement under the program supported by the Project.

49 The proposed project would reduce malnutrition through the stage of infant and young child development (where current evidence suggests that its effects are most harmful for human development) and would reduce perinatal, infant and child mortality. In quantitative terms, our expectation is that the program would: (a) reverse or avert around 570,000 cases of moderate to severe malnutrition among children under three years of age and (b) reduce the mortality rate among infants and pre-schoolers by some 25%, resulting in (short run) increases in five-year-olds entering the school-age cohort of about 37,000 per year. The per capita cost of achieving improved nutritional status through the nutrition delivery component, averaged over 570,000 direct child beneficiaries of the food supplement program (around 80% of those taking part), would be about Rs 220. These costs are incurred primarily in the pre-birth and infant stages when the mother and child feeding programs are utilized The potential economic benefits depend largely on the impact of improved nutritional and health status (as realized during this early childhood state) on productivity and earnings in adult life. In the present state of the art, estimates of such benefits are necessarily highly speculative. It is, of course, well known in a general sense that children whose early nutritional status is satisfactory tend to be substantially more productive and have higher earnings capacity in later life. What is difficult, however, is to separate out the specific "nutritional factor" associated with this difference from a host of other factors that tend to be highly correlated with nutrition status in early life--parental incomes, education, and position in society being some of the leading ones What can be demonstrated, however, is that the economic benefits, in terms of enhanced adult productivity and earnings, need not be very large to provide a healthy economic justification for the proposed nutrition delivery program. A conservative estimate for the present value of the prospective lifetime earnings of an Indian agricultural laborer, discounted at 10%, is some Rs 4,500. 1/ On the assumption that about 47% of the beneficiaries from the nutrition program would be full-time agricultural laborers at any one time during the forward period, 2/ the per capita present "value" of a 1% increase in productivity resulting from improved nutritional status during the formative childhood period would be some Rs 21. The present value of the estimated cost of nutrition services is Rs 187 per capita (the estimate of nutrition costs given above, after discounting). To earn 10% on the investment in improved nutrition status, therefore, requires an increase in adult productivity of less than 9% among fewer than half of those children who receive nutrition services through the project. 1/ The calculation is based on an annual earnings stream of Rs 1300 (260 working 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 realizing the earning span and that, on average, about 85% of the women are not employed as paid workers (versus about 10% of the men).

50 The required increase in productivity, while in itself reasonable, would be still less with: (a) a less restrictive assumption about prospective earnings, since the one above is equivalent to arguing for zero real increases in agricultural wages over the next 60 years and that all prospective workers become agricultural laborers, typically among the lowest earning groups in Indian society; and (b) the addition of a reasonable valuation of work done by those outside the formal employment sector, in particular the value of work done by women in the home, and an expectation that earnings prospects for women also will improve over the next 60 years The economic value of reduced child mortality would constitute an additional benefit from the project's nutrition and health services. Among other things the scale of this benefit would depend importantly on the ultimate impact on desired and achieved family size among the households affected by reduced child mortality. Thus, if reduced mortality brings forward in time attainment of desired family size--and there is some plausibility in this argument based on recent demographic studies--the impact is largely to advance the realization of the future income streams of the current generation of children who die in infancy and are replaced by others, but on average some four years later. In that case, the income stream of the survivor is realized rather than that of his/her "replacement," and is realized, on average, four years earlier. Using the agricultural laborer income stream as described above, such a four-year advancement would be "worth" Rs 1,400 in terms of present value. Assuming that 60% of the 37,000 whose deaths are averted by the project become full-time workers, this element alone would pay for more than half the recurring costs of the health components B. Risks 6.09 The project faces the fundamental risk that the determinants of malnutrition may be so complex that even effective implementation of the project as designed would not produce the anticipated results. However, the project has been designed on the basis of extensive research in Tamil Nadu and elsewhere, takes into account the most relevant experience available, and, if properly implemented, is expected to have pronounced effect. With respect to actual implementation, as opposed to design, the project faces five basic risks as outlined below The first is the usual risk of pioneering efforts associated with major training programs and the installation of new systems: possible problems with quality control and adherence to implementation schedules. A second risk is that CNWs may find it difficult to apply project criteria for the food supplement program. However, both of the above risks are reduced by the extensive performance monitoring built into the project, particularly through detailed reviews of the Kottampatti Block experience and again after another 69 blocks have become operational. The risk of distortion of the food program is further reduced because entry and exit are controlled by the supervisor.

51 A third such risk is that participation in the food supplement program would be less than expected because of the relatively modest size of the daily ration, its limited duration and difficulties in reaching the most disadvantaged. This risk is offset by the intensive surveillance, monitoring and nutrition education efforts designed to promote and sustain participation by eligible beneficiaries. Additionally, flexibility is built into the system in regard to both entry and discharge criteria and adjusting ration sizes as appropriate A further risk is that maintenance of separate administrative controls for nutrition and health delivery might hamper both project management and the emergence of an optimal package of village health and nutrition services. However, this risk is offset both by training and supervision arrangements which stress field coordination between the departments concerned and the willingness of the State to continue to address the organizational question through project reviews and evaluation Additionally, positive changes in intrafamily food distribution and family food habits may occur later or to a lesser extent than anticipated. In that case, more children would relapse than expected, the costs of food supplementation would rise and fewer beneficiaries would retain nutrition momentum during their later pre-school years. However, even in that event, the project would have made a significant contribution in helping the Government achieve its goal of substantially reducing mortality rates of younger pre-school children and in boosting their nutrition during the most critical years. VII. RECOMMENDATIONS 7.01 During negotiations, agreements were obtained from the State Government that: (a) reviews of project operations would take place after a year's operation in Kottampatti Block and after about 70 blocks had become operational but no later than the end of the third project year, under terms of reference satisfactory to IDA, and that the project design and implementation schedule would 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 current evaluation of mobile redical teams in Tamil Nadu carried out by the National Institute of Health and Family Welfare and (2) the results of other pilot projects and studies of ways to introduce community health and nutrition services in the State (para. 3.44);

52 (c) curricula for the training of staff under the project would be prepared and furnished to IDA for its comments and that such training would be carried out in accordance with these curricula, taking into account IDA comments; (d) criteria for entry into and discharge from the food supplement program for children and women would be satisfactory to IDA (para. 3.34); (e) should the State modify its health system in project areas during the project, after consultation with IDA, Tamil Nadu would take all necessary measures to maintain the efficiency, quality and level of nutrition and health services and ensure appropriate use of CNWs to avoid duplication of effort (para. 3.44); (f) a study to identify ways of improving procurement, delivery and choice of drugs and medicines to PHCs and HSCs would be carried out 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 in the Directorate of Public Health with special responsibility for assuring appropriateness and timeliness of project-financed trai.ing, and a buitable officer appointed thereto, by August 31, 1980 (para. 3.59); (h) an evaluation study of project achievements and their costs would be carried out in the year following the last year of project implementation, including a sectoral review of Tamil Nadu's nutrition and rural health policies and programs, experience with the State's various modes of delivering nutrition and health services at the community level, and their impact and managerial and budgetary implications, in accordance with terms of reference satisfactory to IDA (para. 3.84); (i) an Advisory Panel on Evaluation consisting of representatives of the State Government, the GOI and appropriate research institutions, would be set up by December 31, 1980 and meet as necessary throughout the project period to review and comment on evaluation of the project (para. 3.87); and (j) advance IDA approval would be obtained for any expenditures of US$50,000 or more from the project management fund (para. 3.92) Subject to the above assurances, the project is recommended for an IDA credit of US$32 million to the Government of India on standard terms.

53 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, ,693 B.. Vehicles, Equipment and Furniture 26,640 25, ,048 54, Vehicles 5,044 5, , Equipment and Furniture 21,596 19, ,868 C. Training 8,065 12,300 2, ,670 D. Contract Services ,558 1, ,998 E. Technical. Assistance , ,522 F. Food Supplements 50, ,747 G. Project Management Fund ,200 4,200 H. Incremental Operating Costs 1. Drugs and Supplies 4,782 39, , Salaries and Allowances 69,429 18,684 1,138 5,013 2,122 96, Vehicle Operation 4, , Other Operating Costs 15,033 1, ,705 Subtotal 93,609 60,009 2,340 5,441 3, ,535 TOTAL BASE COSTS 184, ,371 24,275 8,330 8, ,786 TOTAL BASE COSTS (US$ '000) (21,956) (20,044) (2,890) (991) (998) (46,879)

54 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 Furniture 1. Vehicles 3,298 2,148 2,193 2,758 1,156 11, Equipment and Furniture 9,976 8,107 9,030 10,984 4,771 42,868 Subtotal 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 Services 1. Communications 1,257 2,989 3,727 5,355 4,230 17, Evaluation Subtotal 1,397 3,189 3,977 5,555 4, E. Technical Assistance ,522 F. Food Supplements 122 4,173 8,699 15,091 22,662 50,747 C. Project Management Fund ,050 1,050 1,260 4, Incremental Operating Costs 1. Drugs & Supplies 1,705 5,233 8,333 12,557 17,475 45, Salaries & Allowances 2,847 9,646 17,286 26,944 39, , Vehicle Operating Costs ,442 2, , Other Operating Costs 420 1,736 3,290 5,034 7, ,705 Subtotal 5,112 17,125 29,885 45,977 65, ,535 TOTAL 45,424 52,253 71, , ,632 1, ,786

55 ANNEX 3 INDIA: TAMIL NADU NUTRITION PROJECT PROPOSED ALLOCATION OF CREDIT Percentage of Amount 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 % 5. Drugs and Supplies 6,300 80% 6. Unallocated 1,200 T 0 T A L 32,000

56 -50- ANNEX 4 INDIA: TAMIL NADU NUTRITION PROJECT ESTIMATED SCHEDULE OF DISBURSEMENTS Amount IDA Financing Cumulative FY 1981 September 30, December 31, ,200 March 31, ,000 June 30, ,900 FY 1982 September 30, ,800 December 31, ,750 March 31, ,725 June 30, ,075 6,800 FY 1983 September 30, ,100 7,900 December 31, ,250 9,150 Miarch 31, ,550 10,700 June 30, ,750 12,450 FY 1984 September 30, ,900 14,350 December 31, ,000 16,350 March 31, ,200 18,550 June 30, ,400 20,950 FY 1985 September 30, ,550 23,500 December 31, ,700 26,200 March 31, ,850 29,050 June 30, ,950 32,000

57 -51 AXNEX 5 F,~~~~~~cilit(uunievrySo ie stu lc office 'utritice * aet up taluk nutrition offices r * procure ar.d supply velhicles furnishings, supplies and equipment_k as 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 I Om - construct buildings -rouead irstall equipienen StaffLn, 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 and prepare training manuals for CN s, supervisurs and instructresses 5 develop in-service traini4g program for ThOs and cotduct training * select trainers of instrnictresses * organize and carryout trainers workshop and field trial teaching * carry our initial training of supervisors and 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 supplement in clinic and in field *to develop local financing arrangements for CNWs and CNCslm m, u Loni-torinj * * ~~ref ine key mnontoring indicators in consula.titon ~,:th orcject coordination offi.ce and Ev a.qaaicn ZivIiain and d;velor, monitoring pr ocedures * r,r nd dtssiaemonthlv, quarterly and annual imple~mentation reportsm 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

58 -52- ~Qv.k:torsAYN1EX,>.r,a:on 3b Activity. Year1 Year 2 Year 3 r4 4 Yeat Physical Facilities * construct dormitory and 1a~ classroom facilities in 0.1r ' existing female, K-0W schnools oven five new female bphw schools, one LWV school and one HFTC andi construct dormitories * improve one existing HFI7Cf * construact dormitory, classroom and tesidential facilities for field training of female ŽfPTWs * renovate and expand exist:ing micro- 1 T - procure fu-niture, equipment, vehicles and supplies for - State headquarters - Division Health Offices - PHCs - Health subcenters *site, construct, equip, furnish and operate new neal:h subcenters and upgrade existing ones- - - Staffing and Training * appoint State headquartera staff including senior deputy director and deputy director (training) recruit or post - Divisional Health O fficers - Puiblic Health Nurses - Female KHP1Ws - Female supervisors Im-- ' I I * complete develooment of curriculae and * organize and carry out preser-vice trainingj f of female ~{aand female, supervisors * retrain 1- - HNs -- Other Key, Act±on 7. *operate new training instit,tto,ns *operate health subcenters and MCH ' lv b.ealtn mcn.itor4ing unit and ~E~ *supervise ~P~fws m onitori'np and- Sz:dies establish revievw existing& monitoring tndlcato)rs and procedures in consultation with proiect communication o;ffice n vaut Division *conduct tests on var cus cnis aspects of health. D;-ogram *tes-t healt- delivery svste~, in Kottanpatt an eie agt drug * arry oult st'-dy Of wavs to ~prove p r ocz r enentan'd delry 5lystm I

59 -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 communication offices * procure vebicles, furnishings and equipment for NW - state headquarters - district communication offices I Staffing and Training * appoint headquarters staff * recruit local consultants * establish techniccl working group on communicatinns * recruit and post district communication officers Other Kev Actions * refine behavioral cbj:ctives for uutritioa and health communications * design, pretest and produce learnling materials 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 Li m - - * darry out mass media campaigns (radio _ and film) m _ m _ - r.n1 * utilize tradi,tional media (folk theatre) I I Iii * develop and implement procedures for Iii involving local formal and informal I IlI laaders in project implementation L Monitoring * establish communications monitoring unit an'i tefine mnitrcrn intdicators in consultation with, Project coordinati-on of officc and evaluation division uncdertake ad hoc monitoring surveys.. * U U* I * prepare and dissurainate ad hoc brochur.-:: and aress releares and periodic newsleltet mmm -~mn mmuuu * um

60 Su-asv of Key Lole entation Actions F.valuacion ANNEX 5 d 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 Staffinf - State headquarters i - Dlistrict field units ard Training * appoint component manager and state headquarters staff * establish evaluation technical advisory committee * organize in-service training for state and district level staff elect and train investigators 3 assist in development of curriculum7 for traininz of C3qWs, MPHWs and supervisory staff in monitoring and rinorting procedures F_valuation and Studies * design, procest and administer questionnaires for baseline and impact surveys 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 r I, I r * identify and set priorities fot in-depth studiesm m K L idencify research agencies for subconttraced selected special studies L 7 *review oeriodically overall project allocations and expenditures I I I I I I I I I I 1

61 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, supplies and vehicles Staffing and Training * recruit and appoint headquarters staff * organize management training course Other Key Actions * prepare detailed annual project implementation schedule * set up project accounting system * prepare annual budget * review periodically overall project budget allocations and expenditures * formalize coordination arrangements * fund innovations to be pilot tested _ - _ * insure proper maintenance of project equipment, buildings and vehicles Monitoring * establish project monitoring division * review and refine key monitoring indicators for use in coordinated health, nutrition and communications monitoring system in consultation with Evaluation Division and component management * develop proceduras for regular and timely receipts analysis and presentation of selected indicators of key project activities * arrange for speedy feedback and dissemination of implementation experience in Kottampatti * prepare quarterly reports for consideration in decision meetirgs of High Power Committee o H a I - _ -_ - _ I _ -

62 TAMIL NADU NUTRITION PROJECT NUTRITION DELIVERY SERVICES SIMPLIFIED ORGANIZATION CHART State Leve~l r Directorate of Social Welfare Joint Director of Social Welfare District Coletr I Madilrall ollectors ~~~Chenrgelpattu flanmanathaouram North Arcot Pudukottai Tirunelveli cr Assistat lt Assistant Assistant Assistant Assistant Assistant l)istl i evet it Durectoi Director Director Director Director, Oirector Taltikh Taluk Taluik Taluk Taluk Taluk Tahlik Nutrition Nuutiiion Nutrition Nutrition Nutrition Nutrition ilevel Offiicl-rs Offiicer s Officer-s Officers Officers Officers II- I 1I I - II i i g /12 TaluksJ (1 2 Talu.ks (12 Taluks) (13 Tulaks) 114 Taluks) 15 l-aluks) Block li"strilctress Istructress hsistructress lfistructress Instructress Instfructress Le-vel (33 Blocks) 1,27 Blocks) (22 Blocks) (36 8locks) 31 Blocks) j (10 Blocks) Is-evsti A Sipetvisors Supervisors Supervisors Supervisors Supervisors } Co lit&mity qe Coinmunitvep t Cora munittvua ComrunitV ArcComtunity rcomunitv Leel ) Nutrition Nutrition Nutrition Nutrition Nutrition Nutrition Ofrkers w Woriers Workers Workers Workers Workers World Bank

63 TAMIL NADU NUTRITION PROJECT RURAL HEALTH SERVICES COMPONENT SIMPLIFIED ORGANIZATION CHART State i evjel Directorate of Public Health Senior Deputy Director of Public Health 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 crs

64 TAMIL NADU NUTRITION PROJECT PROJECT COORDINATION AND COMMUNICATION ARRANGEMENTS High-Powered Comirittee Chief Secretary, Chairman Project Coordinator. Member- Secretary Secretaries of Fiiance. Social Welfare. Health, Agriculture, Rural Development; managinig directors of Tamil Nadoi Waler and Drainage Board andl Agro-engineering Services Cooperative Federation, Ltd. Chief Project Coordinator (Secretary, Social Welfare) J SCordinatoWlfr, CoPnctosAmnsration StatstidlnOficeon. Commupnications Oec ration Moritoring revalati I Joint Comunicationsand Coordnator, FinanceStiscaOfce Assistait Communications Otficer Administrative Officer 2 Computer Programrners I See separate char I Newslihloletin Editor Senior Accounts Officer 5 Statistical Assistants Ait Direciot Section Officer Mottitolifi) Offlicer Senior Assistai I Media Officer 4 Accounts Assistants Productioni Officer 2 Junior Assistants Trcamring Otflicer Pholoofar.pher,._L _~~ Technical Working G-rip World Bank 21070

65 TAMIL NADU NUTRITION PROJECT EVALUATION ACTIVITIES SIMPLIFIED ORGANIZATION CHART Directorate of Evaluation and Applied Research Exte inal Consultants jdept. of Finance) Technical Advisory Committee National Institute of Nutrition f Hyderabad Institute of Child Health, Madras Sri Avinashilingan College Coimbatore Joint Director Gandhigram Rural Institute Tamil Nadu Nutrition Study, Madras Erskine Hospital, Madurai ia Evaluationi and( Sui veillansce Section Specialist Staff Special Studies Section Administrative Stippiort Section ia Deputy Directolr 4 Nutritionist Deputy Ditector Research Officer - 1 Heseaicli Officer Health Expert Research Officer Jr. Accounts Oflicer 2 Research Assistarits Epirlemiologist 2 Research Assistants Office Superintendent Rural Sociologist 6 PhD Students 2 Assistants Anthropologist 2 Jr. Assistants Steno Statistician Computer Programmer Driver 6 District Field Units 20 Investigators Test & Pilot Block Record clerk Field Unit ilggs each stafted by Research Officer 3 Jr Research Assistatits 15 Investigators Research Officer 2 Jr. Research Assistants 10 Investigators 1] Also undertakes work in Evaluation & Surveillance Section World Bank

66 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, ,284,800 Vehicles, Equipment and Furniture 1. Vehicles 887,800 1,343,500 1,191,700 1,620, ,043, Equipment and Furniture 4,615,200 4,797,300 5,454,800 6,729, ,596,400 Subtotal 5,503,000 6,140,800 6,646,500 8,350, ,640,300 Training 1,597,636 1,750,919 2,008,312 2,431, ,365 8,065,183 s Technical Assistance 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 1,402,000 2,066,000 4,782, Salaries and Allowances 727,810 6,522,120 12,797,800 19,739,280 29,642,380 69,429, Vehicle Operating Costs 50, , ,000 1,250,000 1,840,000 4,365, Other Operating Costs 100,620 1,405,440 2,786, ,359,280 15,032,900 Subtotal 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, ,426,

67 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, , ,600 1,080,400 1,135,600 5,956, Equipment and Furniture 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, , ,150 1,145,650 4,783, Salaries and Allowances 1,025,394 1,605,186 2,616,015 5,291,083 8,146,137 18,689, Vehicle Operating Costs 29,400 49,000 88, , , , Other Operating Costs -- 5, , , ,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, ,371,396 ul

68 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, ,000 10,000 20, , Equipment and Furniture 386,756 19,800 35,800 30,800 40, ,156 Subtotal 478,056 19,800 55,800 40,800 60, ,456 Training 162, , , , ,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, , , , ,000 1,226,785 Incremental Operating Costs 1. Supplies 125,000 80,000 80,000 85, , , Salaries and Allowances 209, , , , ,798 1,138, Vehicle Operating Costs 13,400 13,400 15,800 17,000 19,400 79, Other Operating Costs 129, , , , , ,350 Subtotal 477, , , , ,868 2,340,684 TOTAL 3,022,369 4,096,419 4,923,748 6,468,897 5,764,540 24,275,973

69 Vehicles, Equipment and Furniture 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 1. Vehicles 141,000 46,000 23,000 46, , Equipment and Furniture 109,500 24,000 12,000 24, ,500 Subtotal 250,500 70,000 35,000 70, , Training and Conferences 78,200 78, , , ,800 56, ,800 Contract Services 60, , , , , ,000 1,440,000 Technical Assistance 38,000 38,000 38,000 38,000 38,000 25, ,000 Intremental Operating Costs 1. Supplies 36,000 37,000 42,000 42,000 42, , Salaries and Allowances 307, , ,427 1,136,765 1,270, ,000 5,012, Vehicle Operating Costs 8,300 11,100 11,300 11,300 11,300 5,500 58, Other Operating Costs 17, ,838 45,169 54,633 26, ,090 Subtotal 369, ,636 1,022,565 1,235,234 1,378, ,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

70 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, , Equipment and Furniture 892, _ 892,000 Subtotal 1,048, ,048,000 Project Management Fund , ,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, Salaries and Allowances 406, , , , ,724 2,122, Vehicle Operating Costs 37,500 37,500 37,500 37,500 37, , Other Operating Costs 155, , , , , ,000 Subtotal 608, , , , ,224 3,136,499 TOTAL 1,656,692 1,034,520 1,464,507 1,898,556 2,330,224 8,384,499

71 65 - ANNEX 8 Page 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 of Nutrition 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-Related Morbidity 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 Foundation Support," D.R. Gwatkin (1974). A.7 Food Habits Survey, Operations Research Group (Baroda) for Protein 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 Health and 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 ," Finance Department (1978).

72 ANNEX 8 Page 2 Section B B.1 "Tamil Nadu Integrated Nutrition Project," Department of Social Welfare (1979). B.2 "Tamil Nadu Integrated Nutrition Project," Department of Public Health and 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, and Monitoring and Evaluation. c.2 Working Paper on "The Number of Direct Beneficiaries of the Supplementary Feeding Program and Project Food Requirements." c.3 Working Paper on "Criteria for Enrolling Children in and Discharging Them from the Supplementary Feeding Program." c.4 Working Paper on "The Economics of Supplemental Feeding of Malnourished Children: A Case STudy of Leakages, Benefits and Costs."

73 A ~ ~ ~~~~~~~~~~~A P~~~~~~~~~~~RD INDIA TAMIL NADU NUTRITION PROJECT A NDHRA 'PR'A DFSH 2 PROJECT DISTRICTS ~ ~ 1,1. 11 ~ IT ~ -TI Ill ~ ~ ~ ~ ~ ~ ~ ~ N.VA AN N ATNH NAtN 'NOT, A R IA~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ (DH:AR/MA PC,URI KARNA)AKA NAN / R U HC AL I IONLICHkR -W - ~~~~~~~~~~~~~~~ 5 A PUDUKAADOR A- ADR A NNATA 'A 0~~~~~~~~~~ k LOME~~~~~~~~~~~NNI K NY K,RA I A~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ANI J ~~~~~~N( ~~~~~~~ ATI4NjAVUR-~- 'A-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-