Project assistance completion report : child survival health support project (386-0504)

The project has been a success. The Universal Immunization Program (UIP), now one of the largest preventive health interventions in the world, has increased immunization coverage to 80% in all states; 98% of infants were immunized with DPT3 and Oral Polio Vaccine (OPV3), 97% with tuberculosis and 89% with measles vaccine, and 78% of pregnant women were immunized with tetanus toxoid. USAID's support of the UIP was channeled through UNICEF. Under the Government of India's (GOI) National Diarrheal Diseases Management Program, the Ministry of Health and Family Welfare (MOHFW) established an organizational unit and ORT surveillance centers, developed a new reporting format, and undertook a social marketing campaign. As a result of the program, almost half of rural and urban Indian households have knowledge of ORT, and there has been a 25% reduction in child death due to diarrheal disease. In addition, the project completed 19 small, innovative activities, studies, and seminars; it appears that about 25% of these will be continued by the GOI, State governments, or private agencies. Activities included production and distribution to state and district government offices of videotapes on maternal/child health (MCH). Both the UIP and ORT programs were strengthened through training, including U.S. training in MCH, financial management, and health administration for 34 central and state government officers; a basic epidemiology program at a local Indian institution for 15 District Immunization Officers; and the production of training films for health workers by the MOHFW. The following lessons were learned. (1) Previously, most health programs were defined at the Central and State levels. In this project, however, district-level planning and implementation strategies were an integral part of the UIP, which made the program more relevant to the district infrastructure, increasing the likelihood of sustainability. (2) The project included a very successful performance-based disbursement system, the first such attempt in USAID/I's Health, Population and Nutrition (HPN) portfolio. The performance-based system, which evaluates outputs rather than the line item value of inputs, allowed USAID/I and the GOI more flexibility in achieving objectives (e.g., the system can estimate the incremental return on policy changes and other inputs to which it is difficult to assign a value, thereby validating their pursuit). (3) This project was also the first in the HPN portfolio to obtain "extra budgetary status" for a component; with no activity in the first four years, the "extra budgetary status" allowed the innovative activities component to flourish; almost 19 activities were completed in just over 6 months. By bypassing the GOI's budgetary process, there was a reduction in the pipeline, and disbursement of funds was accelerated. (4) The UIP and ORT programs are still implemented in a vertical manner. This lack of integration not only wastes resources, it also leads to a focus on means, rather than objectives. Therefore, integration is probably preferable in terms of efficiency and impact.