Document ofThe World Bank

FOR OFFICIAL USE ONLY

Report No: 21931

IMPLEMENTATION COMPLETION REPORT(IDA-25280)

ON A CREDIT

IN THE AMOUNT OF SDR 60.0 MILLION (US$138.0 MILLION EQUIVALENT)

TO INDIA

FOR THE NATIONAL LEPROSY ELIMINATION PROJECT

04/26/2001

HEALTH, NUTRITION AND POPULATION SECTORSOUTH ASIA REGION

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

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CURRENCY EQUIVALENTS

(Exchange Rate Effective March 1, 2001)

Currency Unit = Rupee (Rs.)Rs. 46.62 = US$ 1.00

US$0.0215 = Rs. 1.00

FISCAL YEARApril 1 - March 31

ABBREVIATIONS AND ACRONYMS

Danida - Danish International Development AgencyGHS - General Health ServicesGOI - Government of IndiaIDA - International Development AssociationIEC - Information, Education and CommunicationMB - Multi-BacillaryMDT - Multidrug TherapyM. leprae - Mycobacterium lepraeMLEC - Modified Leprosy Elimination CampaignMMDT - Modified Multidrug TherapyMOHFW - Ministry of Health and Family WelfareMTR - Mid-term ReviewNGO - Non-Governmental OrganizationNLEP - National Leprosy Eradication ProgramPB - Pauci-BacillaryPHC - Primary Health CareSAPEL - Special Action Projects for Elimination of LeprosyUT - Union TerritoryWHO - World Health Organization

Vice President: Mieko NishimizuCountry Director: Edwin Lim

Sector Director: Richard SkolnikTeam Leader/Task Manager: Peter Heywood/Laura Kiang

FOR OFFICIAL USE ONLY

INDIANATIONAL LEPROSY ELIMINATION PROJECT

CONTENTS

Page No.1. Project Data 1

2. Principal Performance Ratings 1

3. Assessment of Development Objective and Design, and of Quality at Entry 2

4. Achievement of Objective and Outputs 4

5. Major Factors Affecting Implementation and Outcome 8

6. Sustainability 10

7. Bank and Borrower Performance 10

8. Lessons Learned 13

9. Partner Comments 14

10. Additional Information 18

Annex 1. Key Performance Indicators/Log Frame Matrix 19

Annex 2. Project Costs and Financing 22

Annex 3. Economic Costs and Benefits 24

Annex 4. Bank Inputs 25

Annex 5. Ratings for Achievement of Objectives/Outputs of Components 27

Annex 6. Ratings of Bank and Borrower Performance 28

Annex 7. List of Supporting Documents 29

This document has a restricted distribution and may be used by recipients only in theperformance of their official duties. Its contents may not be otherwise disclosed withoutWorld Bank authorization.

DEFINITIONS

Grade II Visible deformity or damage present on hands and feet. Severe visualimpairment (vision worse than 6/60; inability to count fingers at six meters),lagophthalmos, iridocyclitis and comeal opacities.

Leprosy Also called Hansen's disease (Hansen's bacillus was discovered by theNorwegian physician G. Armnauer Hansen in 1874). Chronic slow developingbacterial disease of man caused by Mycobactarium leprae affecting mainlyperipheral nerves and skin. The suffering of leprosy is caused by damage tothe peripheral nerves, which leads to sensory loss, paralysis and loss offunction of the hands, feet and eyes. It is feared because of its potential forcrippling and disfigurement. The resulting deformities are the main cause ofthe social stigma attached to the disease.

Multibacillary Leprosy case showing a high density of bacilli on slit-skin smear examination.Leprosy The result of this microscopic examination is recorded as the bacterial index.

Multibacillary leprosy is associated with the progressive and disseminatedform of disease called lepromatous leprosy.

Paucibacillary Leprosy case showing only a few or no bacilli on slit skin smear examination.Leprosy Paucibacillary leprosy is associated with tuberculoid leprosy, which is a

milder form of the disease.

Prevalence Rate Number of cases of a disease or condition at a given point in time as aproportion of the total population.

Project ID: P010424 Project Name: NATIONAL LEPROSYELIMINATION PROJECT

Team Leader: Peter F. Heywood TL Unit: SASHPICR Type: Core ICR Report Date: April 26, 2001

1. Project Data

Name: NATIONAL LEPROSY ELIMINATION PROJECT L/C/TF Number: IDA-25280Country/Department: INDIA Region: South Asia Regional

OfficeSector/subsector: HS - Specific Diseases, including Malaria, TB,

Others

KEY DATESOriginal Revised/Actual

PCD: 01/24/1992 Effective: 03/22/1994 03/22/1994Appraisal: 01/07/1993 MTR: 05/21/1997 05/21/1997Approval: 06/29/1993 Closing: 03/31/2000 09/30/2000

Borrower/lImplementing Agency: GOI/MOHFWOther Partners: DANIDA and WHO

STAFF Current At AppraisalVice President: Mieko Nishimizu Joseph D. WoodCountry Manager: Edwin Lim Heinz VerginSector Manager: Richard Lee Skolnik Richard Lee SkolnikTeam Leader at ICR: Peter F. Heywood Salim HabayebICR Primary Author: Laura M. Kiang

2. Principal Performance Ratings

(HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=HighlyUnlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible)

Outcome: S

* Sustainability: HL

Institutional Development Impact: SU

Bank Performance: S

Borrower Performance: S

QAG (if available) ICRQuality at Entry: S

Project at Risk at Any Time: Yes

3. Assessment of Development Objective and Design, and of Quality at Entry

3.1 Original Objective:

The main objective of the project was to eliminate leprosy as a public health problem in India bythe year 2000 by reducing the prevalence from 24 per 10,000 to I per 10,000 nationwide. Thiswould be accomplished by treating 2.2 million people with leprosy and 1.8 million new cases,reducing the leprosy prevalence to 100,000 cases nationwide. The second objective of the projectwas to reduce the impact of leprosy disability.

India is one of the few countries where leprosy is a major public health problem, accounting fortwo thirds of the global leprosy load. In the early 1990s, it was estimated that 2.2 million peoplehad leprosy in India, with 300,000 new cases arising annually, bringing the projected total diseaseburden to about 4 million people by the turn of the century. The elimination of leprosy was oneof several priority disease control interventions identified by the Government of India (GOI) in thehealth sector at that time.

The importance of helping India deal with leprosy was heightened by the fact that the diseasecaused deformities and by the extreme social stigma attached to affected people. Studies onleprosy showed that treating leprosy and related disabilities had a high social rate of return andshould be a high priority for investment in public health. Moreover, the Bank's publication, TheDisease Control Priorities in Developing Countries: An Overview, suggested that the costinvolved in intervention strategies for leprosy is very cost effective. IDA's assistance would allowGOI to accelerate the elimination of leprosy.

3.2 Revised Objective:

The mid-term review (MTR) concluded that the principal objective of the project to eliminateleprosy as a public health problem by the turn of the century remained valid and achievable.Based on a set of technical, operational and performance criteria, it was assessed that the projecthas made good progress at the mid-term. However, in light of results achieved to that time, itwas clear that the original target of reducing prevalence for the project life from 24 per 10,000 toI per 10,000 population was somewhat over-optimistic. Therefore, the objective of reducingprevalence was revised from 1 per 10,000 to 3-4 per 10,000. In addition, the secondary objectiveconcerning the impact of disability was dropped by the GOI because of the need to focus projectinputs on the elimination itself, and because of the comparative advantage of the voluntary andprivate sector in this field.

3.3 Original Components:

Expansion of Multidrug Therapy (MDT) through a Vertical Structure (US$80.9 million) by:(a) targeting about 66 high endemic areas; (b) providing outreach services to the community andservice circuits designed with the participation of the beneficiary population; and (c) strengtheningcurrent control operations in 135 districts with high prevalence.

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Integration of Multidrug Therapy into the Primary Health Care System (US$22.3 million)by: (a) providing MDT through the existing primary health care system in about 77 moderatelyendemic districts and 20 pockets of infection; and (b) providing a limited amount of additionalstaff on a fixed-term basis for the duration of the project.

Disability Care and Prevention (US$7.9 million) by: (a) reducing the occurrence ofimpairments (first-level prevention); (b) limiting or reversing disability caused by impairmnents(second-level prevention); and (c) preventing disabilities from developing into handicaps(third-level prevention).

Promoting Public Awareness and Community Participation (US$12.4 million) by: (a)conducting information, education and communication (IEC) activities through village awarenesscamps, non-formal methods of education, and mass media; and (b) promoting communityparticipation which ultimately reduces the dependence on a limited number of outreach healthservice providers and enhances self-reliance and local responsibility.

Enhancing Skills and Institutional Development (US$12.6 million) by: (a) training of variouslevels of National Leprosy Eradication Program (NLEP) staff in highly endemic districts in thefirst two years of implementation, and short-termn training to 160,000 persons, and primary healthcare staff in intermediate-endemicity districts; (b) strengthening the Central Coordination Cell; and(c) supporting training and research institutes in Raipur, Chengalput, Agra, Aska and Gouripur.

3.4 Revised Components:

There was no change in the original components. However, on the basis of the global experiencefacilitated by WHO's Action Program for the Elimination of Leprosy, a plan of action on LeprosyElimination Campaigns in priority areas was developed in 1995. As a result of the mid-terrnreview, and within the broad original components, GOI requested that the Bank and WHO assistin expanding the implementation of these new enhanced interventions, which included (a)Campaign Approach for Leprosy Elimination; and (b) Special Action Projects for Elimination ofLeprosy (SAPEL).

At the MTR, the secondary objective concerning disability was dropped because of the need tofocus project inputs on the elimination itself and also because of the increasingly evidentcomparative advantage of the voluntary and private sectors in this field. However, for theremainder of the project GOI continued to support activities for prevention of disabilities throughNGOs.

Due to the availability of funds for drug procurement through the World Health Organization(WHO) for MDT, and at the Government's request, the original IDA credit was reduced fromSDR 60.0 million (US$85.0 million equivalent) to SDR 53.6 million (US$76.3 million equivalent).

3.5 Quality at Entry:

The project objectives were consistent with the Bank and IDA strategy at the time, which

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emphasized human resource development and reduction of poverty. Leprosy was a significanthealth problem in India and leprosy control showed significant direct and indirect social andeconomic returns. Involvement in leprosy elimination met the IDA strategic objective of assistingIndia in controlling major public health problems. The project design was built upon considerableinternational and local experience with leprosy at the time. The objectives were to be achievedthrough the combined efforts of the GOI, WHO, and other developments partners in leprosycontrol in India, especially Danida and SIDA, who were in general agreement with theGovernment's control strategy.

However, it was found to be that the prevalence of leprosy was greater than projected at the timeof project design. As a result, the elimination target was considered ambitious and could not beeasily met during the life of the project. At the MTR, the origional target of reducing prevalencefor the project life was revised from 1 per 10,000 population to 3-4 per 10,000.

4. Achievement of Objective and Outputs

4.1 Outcome/achievement of objective:

The overall achievement of the project objectives was satisfactory. The project, which supportedthe national program through a vertical structure in high endemic areas and an integrated structurein low endemic areas, has achieved substantial progress towards eliminating leprosy as a publichealth problem. The project made a number of contributions: (i) the aggregate nationalprevalence rate declined from 24 per 10,000 to a reported prevalence of 5 per 10,000; (ii) out of490 districts, 137 districts attained a prevalence rate of less then 1 per 10,000; (iii) 9 states/UnionTerritories (UTs) achieved elimination levels; (iv) none of the original 135 districts" remained

highly endemic; (v) Multi-drug Therapy (MDT) is widely available through government andNGO health centers and hospitals; (vi) over 99% of all new cases received MDT and about 4.4million patients were treated and cured; (vii) disability among new cases declined from 8 percentin 1993 to 3.12 percent in 2000; and (viii) the registered case load at the national level wasreduced from 1.2 million to 0.5 million cases.

The current prevalence rate at the state level ranges from 15 per 10,000 population in the state ofBihar to less than 1 per 10,000 population in nine states (Nagaland, Punjab, Haryana, HimachalPradesh, Mizoram, Meghalaya, Tripura, Sikkim and Jammu and Kashmir). The leprosy diseaseburden is concentrated mainly in five states (Bihar, Madhya Pradesh, Orissa, Uttar Pradesh, andWest Bengal), which represent 70% of registered cases and new cases detected in India.

11The original 135 districts became 152 districts due to the creation of new districts over the life of the project.

2IHigh endemic: Prevalence rate is above 50/10,000; Moderate endemic: Prevalence rated is 20-49/10,000; and

Low endemic prevalence rate is <20/10,000. This classification has now been replaced by eliminated (prevalencerate <1/10,000) or not eliminated (prevalence rate >1/10,000).

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4.2 Outputs by components:

4.2.1 Expansion of Multidrug Therapy (MDT) Through a Vertical Structure

Overall, this component contributed significantly to the achievement of project objectives. Afterinitial slow progress with the appointment of different categories of staff, over 3,062 contractedworkers were recruited and trained during project implementation. These included healthworkers, non-medical supervisors, laboratory technicians, physiotherapists, health educators andmedical officers. Guidelines for service delivery were updated and disseminated to all healthpersonnel. The MDT delivery has been enhanced through the vertical program and MDTcoverage of registered cases increased from 62% to almost universal availability. All new patientshave access to MDT through government and NGO health facilities in all states and UTs.

However, the supervision of the program activities was inadequate in some of the states,particularly in moderate and low endemic districts. In addition, the vertical structure used todeliver services was found to be of limited value in case detection; much of the additional casedetection during the project was due to the Modified Leprosy Elimination Campaigns (MLECs).Following the midterm review, special attention was given to MDT service delivery management.MDT became almost universally available, especially in the last year of the project. Themanagerial capabilities of middle-level managers responsible for motivating, supporting andmonitoring the leprosy program implementation staff at the district level were strengthenedthrough workshops using a module developed by WHO.

At the end of the project, and as stated above, none of the original 135 districts remained highlyendemic. Of these, 97.4% fall into low endemic category and 2.6% are in the moderately endemiccategory. However, elimination levels (<I per 10,000) could be attained in only four of 152highly endemic districts.

4.2.2 Integration of Multidrug Therapy into the Primary Health Care System

Whereas-achievements in delivery of MDT services have been impressive, the proportion of healthfacilities offering MDT services varied widely from one state to another. In many states, leprosyservices are already being accessed through general health services. An impact evaluation of theIntegration of Leprosy Services with Primary Health Services (The Tamil Nadu Case Study)suggested that voluntary reporting was significantly higher in the post-integration period (25% ofcases) as compared to the pre-integration period (14% of cases).

As a result of the midterm review, and as discussed in para. 3.4, case detection activities wereintensified. The GOI decided to undertake Modified Leprosy Elimination Campaigns (MLECs) inall the states after the successful pilot in the state of Tamil Nadu. The objectives were to: (i)create mass awareness about the facts of leprosy and availability of free MDT treatment; (ii) giveorientation training on leprosy to all the General Health Care staff, village level workers andvolunteers; and (iii) make use of awareness and training for detecting hidden or suspected caseswithin a short and specified period of six to seven days.

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The MLEC was aimed at peripheral capacity building and reaching hidden patients in the original22 states/UTs, geographically covering about 90% of the population of India during 1997 and1998. The strategy of the campaigns focused on promoting public awareness, involving thecommunity, the general health services and other sectors, including local bodies, panchayatleaders, school teachers, local volunteers, and workers of the Integrated Child DevelopmentsServices. The campaigns involved 860,000 personnel including doctors, general health workersand volunteers with the participation of various other related government departments and NGOs.State health authorities, in collaboration with other public sectors, were the prime movers incoordinating campaign activities, mobilizing people, organizing house-to-house diagnosticsearches, and supervising the campaigns which lasted a week, preceded by the orientation trainingof the health care staff and a systematic information drive and media blitz promotingself-reporting.

During project implementation, two rounds of MLECs were conducted in all states/UTs. Thefirst MLEC yielded about 2.9 million suspected cases of which 0.5 million were confirmed to beleprosy. The second round of MLEC saw 0.8 million suspected cases, of which 0.2 million wereconfirmed to be leprosy. The multibacillary proportion of the newly detected cases was 32percent.

Although the project envisaged full integration of the leprosy program activities into the generalhealth services in a phased manner in all the districts including those with high endemic, theimplementation of this component made only modest gains. Due to the lack of a strategicframework to deal with complex organizational issues related to integration of vertical programsinto the general health services, the integration of leprosy services with the primary health servicesremains challenging and will be addressed further by the second project.

4.2.3 Disability Care and Prevention

Activities under this component from the public sector were limited to prevention. Despite itsinclusion of disability care at the beginning of the project, the GOI did not formally pursue thedisability care through the public sector, but rather encouraged and supported NGOs to promoteactivities for the prevention of disabilities including reconstructive surgery because of thecomparative advantage of the NGOs in this field and because of the declining need for relatedinvestmnents. However, surgery camps were held in Orissa, West Bengal, Tamil Nadu andHimachal Pradesh during the MLECs. Disability care training and disability surgery camps wouldneed to be expanded in the future only in areas where needs are significant. Among new cases,severe grade II disabilities declined from 8 percent in year 1993 to 3 percent in 2000. Moreimportantly, various forms of disability were averted among millions of patients who were treatedwith MDT. Based on the natural history of the disease, it is estimated that at least 0.3 million'impairments and disability were prevented, or 7 percent of the total recorded patients cured on

3'WHO has suggested an even higher number exceeding one million individuals.

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MDT during the project period. Against the aggregate target of 200 reconstructive surgeryoperations in each high endemicity district during the project period, there were 3,200 majorremedial surgeries carried out annually in 50 centers, including NGO centers. Similarly, about31,000 minor surgeries were being done annually in various NGO facilities.

4.2.4 Promoting Publc Awareness and Community Participation

IEC activities have been successful in raising awareness regarding the cause and treatment ofleprosy. The Leprosy Elimination Campaigns and other LEC activities have intensified communityparticipation and increased mass awareness about facts of leprosy and availability of free MDTtreatment. Messages on the prevention and reduction of disability have been incorporated in allIEC activities through community awareness camps, mass media, and extension education toindividuals and small groups. However, without a specific media strategy for IEC, some IECactivities were undertaken using more traditional methods such as microphone announcements atfairs, meetings, posters, wall paintings, etc. In an effort to improve IEC effectiveness during thesecond round of MLEC in 2000, IEC was undertaken by the British Broadcasting Corporation(BBC) - World Service Trust with the help of DFID by using mass media approaches, which werefound to have high viewership and impact.

However, an evaluation of the IEC activity under the project concluded that IEC was limited topublicity for the MLEC campaigns, which were effective in reducing the social stigma associatedwith the disease. Other interventions envisaged under the project such as mass media initiatives,community awareness camps, and interpersonal education by health personnel were found to bead hoc in content and occurrence.

4.2.5 Enhancing Skills and Institutional Development

The project has significantly expanded training but the training quality was mixed. Various typesof short-term training were completed in all districts, including high, intermediate endemicdistricts, and in endemic pockets. A total of 49,000 doctors and 278,000 health staff have beenprovided orientation training which exceeded the original target. Specific learning materials weredeveloped in 14 regional languages for trainers, doctors, supervisory staff, paramedical staff,village level volunteers and general health staff. In addition, special Prevention of Disability(POD) training was conducted in 210 districts. During the MLECs held in 1998 and 2000,37,000 medical officers and a total of more than one half million village level workers were givenorientation training. However, there has been inadequate training of staff in support areas such ascounseling.

Extensive training was undertaken throughout the project period and has targeted variouscategories of health personnel, notably workers at the primary level. In addition, some supportwas provided by apex Leprosy Training Centers, both in capacity building and in contributing tothe supervision of MLEC campaigns.

4.3 Net Present Value/Economic rate ofreturn:

Not applicable.

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4.4 Financial rate of return:

Not applicable.

4.5 Institutional development impact:

The project, which supported the vertical program structure used by GOI, has developedinstitutional capacity through several interventions. It universalized MDT, instituted one shottreatment for single lesion cases, and achieved remarkable success in release of patients fromtreatment. The experience of the MLEC approach gained from Tamil Nadu was instituted afterthe midterm review to improve earlier low coverage and detection of new cases. This change to amix of campaign and routine case detection resulted in a remarkable fall in overall rates ofreported leprosy. Also, the MLEC created mass awareness about facts of leprosy and availabilityof free MDT treatment and the voluntary reporting of leprosy suspected patients in all theStates/UTs. In addition, in an effort to provide flexibility to meet local circumstances, the GOIalso began the institution of Special Action Projects for the Elimination of Leprosy (SAPELs).The SAPELs implemented during the latter part of project implementation were able to reachmarginalized population groups in difficult to access areas and also were able to successfullyinvolve community based organizations and NGOs. These efforts will be continued andintensified in the proposed second project.

5. Major Factors Affecting Implementation and Outcome

5.1 Factors outside the control of government or implementing agency:

The main factors outside the control of the implementing agency were:

v The changing unde.standing of the epidemiology of leprosy over the life of the project and theconsequent conclusion that the original targets were over-optimistic.

* Changing global knowledge on leprosy control, and particularly changes in the definition ofthe various forms of leprosy and resulting changes in prevalence estimates.

* Changing dynamics between the central and state governments which have resulted in aclimate more favorable to decentralization of central government activities and ownership tothe states.

5.2 Factors generally subject to government control:

Although a major factor contributing to the success of the project was the strong commitment ofGOI to control communicable diseases, including the elimination of leprosy, there were severalfactors which affected implementation, such as:

* Absence of a strategic framework to deal with complex organizational issues related to theintegration of vertical programs into the general health services system.

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* Variable political commitment leading to inadequate management support, especially in thestates with high caseloads.

* Inadequate program monitoring and supervision, especially at the level of state leprosyofficers and District Leprosy Societies.

The government also used its control to take actions which improved project implementation.These included:

* While there were delays in the submission of SOE audit reports at the start of the project, theproject took action to improve the financial management systems, including computerizationand strengthening of internal control and capacity.

* Encouraging NGOs for delivery of disability services, including reconstructive surgery thusrecognizing the comparative advantage of NGOs.

a Collecting and processing financial information and the resulting good disbursement.

* Establishing standardized lists of goods for purchase by the districts.

5.3 Factors generally subject to implementing agency control:

A number of factors under the implementing agency control received insufficient attention withthe result that there were:

* Insufficient attention to training on interpresonal communication, especially in the preparationof general health staff and MLEC volunteers.

* Inadequate motivation of the general public to seek early treatment by creating bettercommunity awareness and dispelling fear of the disease.

* Inadequate technical supervision and monitoring particularly from peripheral units up to thecentral level.

However, the implementing agency also used its control to take the following actions whichimproved project effectiveness:

* Collection and analysis of data on leprosy.

* Shifted administrative control closer to the ground at MTR.

* Efficient procurement and distribution of MDT through WHO.

5.4 Costs andfinancing:

The total project cost of the enhanced national program over a six-year period was estimated at

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appraisal to be US$138.3 million, of which US$85.0 million (SDR60.0 million equivalent) were tobe financed by an IDA Credit and US$53.0 million by the Government of India. As noted inSection 3.4, the original IDA Credit was reduced from its original amnount of SDR 60.0 million(US$85.0 million equivalent) to SDR 53.6 million (US$76.3 million equivalent) because ofincreased WHO assistance in drug supplies. The final disbursement took place on January 31,2001 at which time the revised amount of the Credit, SDR 53.6 million (US$74.3 millionequivalent), was fully disbursed.

6. Sustainability

6.1 Rationale for sustainability rating.

The project's sustainability has been rated "highly likely".

The Government has continued a strong commitment to control communicable diseases such asleprosy, and has provided major support to the leprosy program for more than fifteen years.Significant training inputs have been made over the project period. Important lessons relating toIEC, detection and treatment of leprosy cases have been learned. Some progress in the integrationof vertical leprosy services with the general health services has been achieved. Although adequateGovermment resources have been earmarked for the continuing support of the program, thedisease burden has decreased and, hence, the resource requirements to deal with it will alsodecrease progressively. The needs for leprosy drugs and staff have already decreased, and it isclear that the steady reduction in the rates of leprosy will substantially reduce the need for futureinvestments in control and rehabilitation. In fact, the benefits achieved by the project generatedhigh positive extemalities and the dissipation of leprosy as a public health problem has pemlitted adecrease in annual expenditures as predicated at the appraisal.

6.2 Transition arrangement to regular operations:

The Govemment of India has asked the Bank to support the program for an additional three yearsin order to achieve and maintain elimination of leprosy from the country as a whole. Specifically,the proposed second project would consolidate the gains made in the first project, with theobjective of transforming the National Leprosy Elimination Program into an effective andsustainable program through a decentralized and integrated approach while supportinggovernment efforts to achieve and sustain lower levels of prevalence. Preparations for a secondproject have been completed. The project implementation plans, prepared by the Govermment,were appraised by the Bank in November 2000. The proposed second project was approved bythe Board in March 2001.

7. Bank and Borrower PerformanceBank7.1 Lending:

As noted in section 3.5, the project design was consistent with the Bank's strategy andgovernment policy, and was appropriate for achieving the stated objectives by treating more than4 million people with leprosy and reducing the leprosy prevalence rate. The project designincorporated lessons from international and local experience with leprosy. These included (i) the

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importance of using appropriate technology; (ii) having a vertical infrastructure for servicedelivery in high prevalence areas, and an integrated approach with the regular health care systemin moderate and low prevalence regions; (iii) providing disability care since deformity constitutesthe patient's single most important concern; (iv) not segregating patients or deterring patientsfrom seeking treatment; (v) the importance of inforning and convincing people that leprosy iscurable; (vi) raising awareness of the disease at the community level; and (vii) examination andfollow-up surveillance of contacts are more rewarding than mass surveys because of the clusteringtendency of leprosy. The experience of the project suggests that most of these remainedconstraints to implementation. In addition, the design lacked a strategic framework to deal withcomplex organizational issues related to integration of vertical programs into the general healthservices.

7.2 Supervision:

Supervision was planned for the period 1994-2000. .The project was thoroughly supervised."Formal" missions took place on average twice a year, but supervision was virtually "continuous".Technical skills were brought in over the project implementation period and issues were addressedin a timely manner. The implementation period benefited from continuity in responsibilities bothfrom the Bank and the Government. During the entire implementation period, there was only onechange of Bank task team leader and the same applied to the Govemrnment of India. These factorscontributed to a smooth supervision experience and improved follow up on implementation issues.The Bank and GOI also collaborated closely with external partners including Danida and WHO.The project was closely monitored through WHO resident technical assistance. Supervisionmissions were regular and thorough, and they consistently discussed and agreed on ways ofovercoming implementation problems. Contact between Bank staff and leprosy program staff wasmore frequent and issues were more easily resolved when project supervision responsibilities weremoved to the Bank's New Delhi Office.

The project was extended for six months. The main purpose of the extension was to provide abridging period to the follow-on project in order to enhance quality at entry and to continuestrengthening program and institutional capacity.

7.3 Overall Bankperformance:

The overall Bank performance is rated satisfactory. The Bank, WHO and the Government ofIndia identified a project that was a high priority at the time and assistance during preparation andappraisal was satisfactory. A very good working relationship was established and maintainedamong development partners and the health authorities. Supervision missions played a supportiverole in policy development and the advice and assistance provided contributed to the good projectimplementation.

Borrower7.4 Preparation:

The Govermnent of India took the leading role in project preparation. The team was led by theDeputy Director General for Leprosy, and assisted in preparation of project proposals by

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international and local WHO and Danida leprosy experts. A draft of the government's planningdocument, which was completed at appraisal, included training plans and curricula, selectioncriteria and time-tables for recruitment of health workers, additional beneficiary assessmentinformation, materials for patient health education, procurement plans, and agreementmechanisms between States and District Leprosy Societies. The Project Coordination Unit of theUnion Ministry of Health and Family Welfare was established prior to appraisal.

7.5 Government implementation performance:

Since the project is a centrally sponsored scheme, the Union Government has coordinated theproject, developed policy and technical guidelines, implemented public awareness activities andcarried out major procurement and logistics. Budgetary allocations and sanctioning of funds tothe districts by the Union Government also proceeded well throughout most of the projectimplementation. However, the implementation performance of the District Leprosy Societies wasmixed and slow in the early years. There was a short period of time during 1996 when theprogram implementation deteriorated due to abrupt managerial changes unrelated to the project,and seriously weakened the administrative and financial management performance at that time.During the latter part of project implementation, the project leadership was highly satisfactory.

Following the mid-term review, in addition to ongoing core operations, the Governmentconducted two rounds of MLEC in all the States/UTs of the country. As noted in section 4.2.2,the campaigns had an important impact on mobilizing political and administrative support, thecommunity and additional resources. Most importantly, the involvement of the general healthservices during these successful campaigns constituted an initial and important step towards thefuture integration of leprosy within the general health care system.

The GOI complied with all legal covenants in accordance with the Development CreditAgreement. Both funds flow and procurement were handled well. Leprosy drugs were procuredand provided by WHO free of charge. The project expenditures incurred by the Center and byeach participating State and Union Territory were audited by the normal GOI procedures. Therewere delays in submitting the audit at the early part of the project implementation. As a result,disbursements against SOEs were suspended twice, which negatively reflected on projectdisbursements and performance. The project financial management system is currently in theprocess of being computerized and would strengthen the financial control and managementcapacity in the follow on second project. At the end of the project, the audits were all current.The last fiscal year project and statement of expenditures audit are due on December 31, 2001.

7.6 Implementing Agency:

The performance of the implementing agencies varied across the States. The project was centrallysponsored and implemented directly through district leprosy societies, which limited the role ofthe state in leprosy elimination. The pace of implementation from the district leprosy societies wasslow in the early years. Poor functioning of many district leprosy societies and the lowrecruitment of personnel hampered the extension of service delivery. During the mid-term review,a number of issues and problems in implementation was identified. These issues were alleviatedsignificantly in the latter part of the project, especially when MLECs were conducted. The

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campaigns contributed considerably to improving project implementation, especially in thegenerations of public awareness, identification of hidden cases, and extending free MDT servicesto all states.

7.7 Overall Borrower performance.

The borrower's overall performance has been rated satisfactory, notably at the central level. Asnoted in section 7.5, the GOI coordinated the project, developed policy and technical guidelines,implemented public awareness activities, and carried out major procurement and logistics. TheGOI complied with all legal covenants in accordance with the Development Credit Agreement.All the 490 districts in 32 states and union territories (UTs) were involved in implementing theproject components. However, performnance among the states was mixed. The project wasoriginally designed for the five-year period 1994-2000, but due to slow implementation atstart-up, the project was extended by six months. During the extended period, the revised Creditwas fully disbursed.

8. Lessons Learned

Extensive reviews of the project experience, which began during the mid-term review, continuedin the preparation of the second project. The lessons learned from these reviews, which have alsobeen incorporated into the Second National Leprosy Elimination Project, are summarized asfollows:

Institutional

* When the disease burden is high, the centralized vertical organizational structure is useful.When the disease burden is reduced, an integrated approach is more efficient.

* The role of the states in project implementation needs to be strengthened.

: It is important to strengthen the capacity of the general health system to address long-termissues of diagnosis and treatment.

Technical and Social

* Effective program management requires high quality, up-to-date epidemiological andmanagement information. There is a need to develop simple computerized informationsystems to monitor and keep track of new case load cure rates and progress towardselimination.

* It is important to increasingly embed leprosy control activities in the General Health System.

* Effective targeted program require high levels of coverage and saturation, and theidentification, reach and coverage of hard-to-reach groups, particularly urban poor, womenand scheduled tribes/castes, remain challenging.

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* There is a need for a clear and well-coordinated strategy, which incorporates various IECinterventions to meet well-defined goals.

* It is important to be aware of epidemiological changes and to change project design andimplementation accordingly.

Operational

* Monitoring activities should be an integral part of the routine functions of the program andcannot be ad hoc activities linked solely to a Bank's supervision mission.

* NGOs played an important role and have a potential to increase their involvement in allaspects of the program. There is a need to identify capable NGOs and to build their capacityto effectively intervene in areas where the general health services are not functioningadequately or where they cannot function in a cost effective manner.

* It is important to monitor the quality of services, as well as their quantity.

* The involvement of the State playing a role between the Centre and the Districts (over 300 innumber) can improve the monitoring and control processes. This new structure is beingplanned for the Second Leprosy Elimination Project.

9. Partner Comments

(a) Borrower/implementing agency:

IMPLEMENTATION COMPLETION REPORTNATIONAL LEPROSY ERADICATION PROGRAMME IN INDIA

(CREDIT NO. 2528 IN)

BORROWER'S EVALUATION

In February 1994, the Government of India negotiated an IDA credit of US$85.0 million for aperiod of 6 years starting from April 1994 to March 2000 to support a National LeprosyElimination Project. In view of free availability of anti-leprosy drugs from WHO, an amount ofUS$9.0 million was surrendered subsequently. The project was completed on 31 March, 2000but was given an extension for 6 months with a revised date of 30 September 2000.

Obiectives of the Proiect

(1) To reduce the burden of leprosy as a public health problem by end of year 2000.(2) To decrease disability among new cases.(3) To reduce Multibacillary (MB) cases (with more than 10 lesions) to less than 200,000.

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The Proiect consisted of the followine component:

(1) Strengthening of on going MDT Services in 201 high endemic Districts.(2) Extension of MDT services to 289 uncovered moderate and low endemic Districts.(3) To promote public awareness of leprosy.(4) To provide disability/ulcer care services.(5) Capacity building of staff.

Target

Following quantitative targets were fixed:

(1) To detect 2 million new cases during the project period in addition to 1.17 million caseson record at start of project.

(2) Cure 3.17 million leprosy patients.

The National Leprosy Eradication Program was implemented in all the districts of the country forproviding free leprosy services through District Leprosy Societies, which were set up under theProject in the States/Union Territories (UTs). NGOs participation was encouraged by providingthem grant-in-aid for survey, education and treatment activities in an allotted population andNGOs were also involved in disability ulcer care services including Reconstructive Surgery.

Total expenditure under the Project until March 2000 was Rs. 507.39 crores. Reimbursementclaims sent to the World Bank as of 30 November 2000 are for Rs. 321.96 crores against whichreimbursement of Rs. 266.13 crores was received till 23 November 2000. Balance claims forexpenditure up to extended period are being sent. Credit has been fully utilized. Annexure I givescost details by components.

Achievement

The NLEP project has shown significant achievements as follows:

(a) The target of detecting 2 million new patients. 3.8 million new patients were detected.

(b) Against the target 3.17 million patients for cure, 4.4 million were cured.

(c) Disability among new cases are reduced to 3.12% by end of project from 8% in thebegmining.

(d) MDT coverage of registered cases increased from 62% to 99.6%.

(e) The total number of Multibacillary cases has reduced to 260,000 following the criteria ofmore than 10 lesion for describing MB patients, that was adopted at the time of startingthe project is applied the number of MB patients works out to 130,000 by end of the

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project.

(f) Prevalence rate was reduced from 24 per 10,000 to 5.2 per 10,000.

(g) Elimination level of leprosy considered as 1 per 10,000 population were reached in 9States/UTs namely Nagaland, Punjab, Haryana, Himachal Pradesh, Mizoram, Meghalaya,Tripura, Sikkim and Jammu & Kashmir. Another 7 States/UTs are very close to reachingelimination level. These are Kerala, Gujarat, Assam, Manipur, Rajasthan, ArunachalPradesh, and UT of Lakshadweep.

(h) A package of services involving training, IEC and case detection drive was implemented inall the States for a short period as a campaign. This has been designated as "ModifiedLeprosy Elimination Campaign" (MLEC). Two rounds of MLEC were implemented inthe last two years detecting 0.46 and 0.21 million patients respectively. The training ofGeneral Health Care staff and intensive IEC activities were undertaken before and duringthe campaign in all districts of the country. The program received extensive coverage.Large number of panchayat members and volunteers were also sensitized to leprosy.

Sustainability

A major problem in leprosy has been either ignorance about the causes, signs, symptoms, and cureof the disease or not to report and seek proper treatment partly because of superstitious beliefs orstigma. Very substantial public awareness about leprosy has been generated by the MLECcampaign as well as large scale IEC activities done by BBC - MPM through DD/AIR, song anddrama division, field publicity units, DAVP in the five major endemic states. Side reach of leprosymessages has been reported. Awareness has also resulted in increased voluntary reporting toPHC's which have now been integrated with leprosy control efforts earlier in the program wasbeing run by vertical staff. During the Project a large number of general health care staff havebeen provided training and exposure in conducting leprosy field survey, specially during the laterhalf of the project as well as in identifying patients and providing treatment. The new casedetection activities have also improved consequently.

The above efforts created sufficient confidence that integration of leprosy with general health carecan be started in the 27 States/UTs and even in five Major Endemic States and greaterinvolvement of General Health Care is being planned in the future. Sustainability of the projecthas thereby been achieved to some extent but more needs to be done for complete and successfulintegration of leprosy services with general health care and for capacity building of State LeprosySocieties so that subsequent monitoring and surveillance activities are carried out effectively by allthe States and that disease resurgence does not take place.

Borrower's Performance

The Central Leprosy Division Directorate General of Health Services, Ministry of Healthstrengthened the country's capacity for management of leprosy, generation of public awareness,identification of hidden cases and extending free MDT services in all parts of the country. Apackage of Modified Leprosy Elimination Campaign has been developed which has been

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successfully implemented in all the States and the expertise of the States/UTs have beendeveloped for implementing such a campaign successfully in the future.

Constraints/Limitations

(1) Five major endemic state continue to contribute large number of patients. Availability ofGeneral Health Care staff and their preparedness to take up leprosy work is not adequatein these States. Coverage of the program in the difficult to access areas and slums are alsonot adequate due to inadequate infrastructure.

(2) In the 27 other States/UTs, there are still hidden cases, although comparatively less. Withreduction of patient load, work load for vertical staff has reduced in most of the areas.Therefore, the existing General Health Care infrastructure needs to be properly preparedfor taking up the responsibility of leprosy work under supervision and guidance of askeleton vertical staff from States and District nucleus.

(3) States need to take a more pro-active role in planning implementation and monitoring ofthe program.

Lessons Learned

Lessons learned during the first phase of the implementation have been reviewed and utilizedwhile preparing NLEP Second Project. Since the problem of leprosy has reduced, building ofownership and management capacity at States and Districts level through decentralized planningand implementation has become a priority to make the program sustainable in future. Specialactivities like SAPEL/LEC are being targeted for difficult and tribal areas and slums in the bigcities. The effective health management information system within the integrated set up will be anintegral part of NLEP Second Project. The administrative and technical support capacity arebeing built-up through strengthening of State Leprosy Societies and providing WHO Consultantsin the high endemic areas and by the involvement of ILEP support teams to improve programimplementation in problem districts.

Performance/Evaluation of the World Bank

Assistance extended by the World Bank contributed substantially in the management of leprosysituation in India by ensuring program to be extended to the entire country and generatingsubstantial public awareness. The Project was monitored closely by the Supervisory Missionvisits during the entire Project period. These visits had had a high levels of commitment andprovided useful guidelines to the borrowers which helped in the implementation of the project.All the aide-memories of the Bank were fully documented and contained the list of agreed actions.The borrower readily responded to the reviews of various missions by suitable action. Excellentcooperation existed between the Bank Staff and Implementing Agencies and this relationshipcontinues to grow. The World Bank has already appraised NLEP phase II.

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Conclusion

The first project has been very successful in achieving the targets set for case detection and cure.The reason for the success can be mainly attributed to the sincere efforts made by DirectorateGeneral of Health Services and Ministry of Health, Government of India and all the StateGovernments and the World Bank for making the project flexible and allowing a detailed specificaction plan at implementation stage.

Annexure I

Statement Indicating Componentwise Expenditure onPhase-I of NLEP

(1993-94 TO 30.9.2000)

(Rs. In crores)

S.No. Component IDA % GOI Total

1 Vertical Multi Drug 136.06 43.68 175.45 56.32 311.51,Therapy .

2 Integration of MDT 74.17 57.56 54.68 42.44 128.85through PHC . -

3 Disability Care and 18.91 95.20 0.95 4.80 19.86Prevention

4 Promoting Public 25.29 53.09 22.34 46.91 47.63Awareness

5 Enhancing Skill and 37.70 89.04 4.64 10.96 42.34Institutional Development

Total 292.13 53.10 258.06 46.90 550.19

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(b) Cofinanciers:

Not applicable.

(c) Other partners (NGOs/private sector):

Since the Danida and WHO have been extensively involved in leprosy control in India, the draftICR was provided to both agencies for commnents. The comments received were incorporated inthe final ICR.

10. Additional Information

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Annex 1. Key Performance Indicators/Log Frame Matrix

Outcome / Impact Indicators: ._

IndicatorlMattix Projected In last PSR Actual/atest EstimateTo eliminate leprosy as a public health Reduce the prevalence from 24/10,000 to Current national prevalence rate is 5/10,000,problem in India by year 2000, by reducing 3-4 per 10,000 nationwide. decreased from 24/10,000 when the projectthe prevalence from 24/10,000 to 1/10,000 was appraised.nationwide.

Treating 2.2 million people with leprosy and During the project, the registered case load1.8 million new cases. at the national level was reduced by 42.7%

(1.17 million cases in March 1993 and 0.51million in March 2000).4.4 million leprosy patents were treated andcured.

Out of 490 districts, 137 districts (24.6%)reached a prevalence rate of <1/10,000.

It is estmated that 10 states/UTs will achieveelimination levels by the end of year 2000.The remaining states would reach eliminationlevels after 2000.

Universal access to curative Multi-drugTherapy (MDT) achieved which hasexceeded the target of 90% of the Nation'spatients receiving MDT.

To reduce the impact of leprosy disability Earlier detection leading to a reducion in At the Ume of mid-term review of the projectnumber of persons newly diagnosed with in 1997, the GOI decided not to formallydisabilities (from 8 to 3%) pursue the secondary objecive relating to the

impact of disability, because of the need tofocus the project inputs specifically on theelimination of leprosy, which was theprincipal project objective.

GOI has encouraged and supported NGOsto strengthen activities for prevention ofdisabilities, including reconstructve surgery.

Disability among new cases is reduced from8% in the beginning of the project to 3% bythe end of project.

Output Indicators:

Indicator/Matrix Projected In last PSR | Actual/Latest EstimateNo. of health personnel deployed in about 66 An average of 100 persons would be Completed appointment of vertical staffhigh endemic districts. required per district. involved in 52 districts. However,

appointment of contract staff has onlypartially completed the deployment of healthpersonnel in 13 districts, and one district inWest Bengal has not been created at all dueto a legal action.

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3,062 contracted workers have beenrecruited including health workers, non-medical supervisors, laboratory technicians,physiotherapists, health educators andmedical officers.

63 (96%) of the 66 high endemic areasreached low endemic level, and 3 (4%)reached the moderate category.

No. of Service Delivery Circuits established Ensure 90% of the nation's patients receive MDT coverage of registered cases increasedand patients received MDT MDT. from 62% to 99.6%. MDT is being provided

by primary health centers, community healthProviding MDT through the existing primary centers, and general health hospRtals in allcare system in about 77 the states except Andhra Pradesh.intermediate-endemicity districts and pocketsof infection within the remaining low The original 135 districts became 152endemicity regions of the country. districts due to bifurcation of the districts. At

the end of the project, none of 152 districtsremain highly endemic. Of these, 97.4% arelow endemic and 2.6% are in the moderatelyendemic category. However, eliminationcould be fully attained only in four of 152districts.

Partially integrated service deliveryapproaches were employed in moderate andlow endemic districts.

During the course of the project, about 4million of pabents have been cured ofleprosy, and about 4.5 million received MDTtreatment

All new patients have access to MDTthrough the govemment and NGO healthfacilities.

Prevent disabilities from developing into Reduction of burden of new disability "grade Among new cases, severe grade 11handicaps (3rd level prevention) by Il+W disabilities declined from 8 percent in yearre-constructive surgery in selected health 1993 to 3.12 percent in 2000.facilities.

Various forms of disability were avertedamong millions of patients who were treatedwith MDT. Based on the natural history ofthe disease, R is estmated that at least 0.3million impairments and disability wereprevented or 7 percent of the total recordedpabents cured on MDT during the projectperiod.

Provision for 200 operatons in the project Annually, 3,200 major remedial surgery wasarea per district. carried out in 50 centers, supported by GOI

and ILEP. Similariy, about 31,000 minorsurgeries were being done in various NGOfacilities. However, this activiy needs to beevaluated and capabilities to undertake itneed to be beKter defined.

GOI enacted legislation providing equalopportunity for the disabled, including thosedisabled by leprosy.

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Promoting public awareness and community Provide village awareness camps, non-formal Skin diagnostc camps have beenparticipabon methods of education, mass media and implemented in several states which helped

interpersonal education by heaflth personnel in creatng awareness of leprosy services.with an emphasis on the importance of eariy Overall, however, efforts in this area havetreatment and gender concems. been inadequate.

Interpersonal communication has beenhampered by insufficient attention to trainingespecially in the preparation of GHS staffand volunteers for the Modified LeprosyEliminaton Campaigns (MLEC).

The first MLEC was implemented in allStates/UTs, yielding 2.9 million suspectedcases, of which 460,000 were confirmed tobe leprosy.

The second round of MLEC (implemented inall States except Delhi, Andaman & NicobarIslands and D N Haveli), yielded 1.9 millionsuspected cases, of which 21 1,000 wereconfirmed.

During the MLEC in year 2000, IEC wasundertaken with the help of BBC-MPMparticipation using mass media approaches.

Some IEC has also taken place using themore traditionally employed methods such aspublicity at fairs and meetings, posters, wallpaintings, etc. These have not beenevaluated, but are generally assessed to beinadequate.

In all IEC activites, messages have beenincorporated on prevention and reducton ofdisability.

No. of National Leprosy Eliminaton Program Total of 160,160 NLEP staff received Short-term training of NLEP staff were(NLEP) staff trained training. completed in all districts, including high,

intermediate endemicity districts andendemic pockets. Specific leaming materialswere developed in 14 regional languages fortrainers, doctors, supervisory staff,paramedical staff, village level volunteers andall the health staff. In addition, special PODtraining was also conducted in 210 districts.A total of 49,000 doctors and 278,000 healthstaff have been provided orientaton trainingwhich exceeded the original target. Duringthe MLECs held in 1998/ 2000, a total286,000 village level workers were givensensitzation training. However, there hasbeen inadequate training of staff in areassuch as counseling, effectve use of localmedia, etc.

Developing training capabilities and providing Data not available Some support was provided by apexsupport to outreach patient care activites in Leprosy Training Centers, both in capacitythe main Leprosy Training and Research building and in contributing to the supervisionInstitutes in Raipur, Chengalput. Agra, Aska of MLEC campaigns.and Gouripur.

End of project

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Annex 2. Project Costs and Financing

Project Cost by Component (in US$ million equivalent)Appraisal ActuaULatest Percentage ofEstimate Estimate Appraisal

Project Cost By Component L US$ million US$ million

Vertical Multi-Drug Therapy 80.89 79.19 98Integration of Multi-Drug Therapy thru PHC 22.25 32.75 147Disability Care & prevention 7.95 5.05 64Promoting Public Awareness 12.45 12.11 97Enhancing Skills and Institutional Development 12.55 10.76 86

Total Baseline Cost 136.09 139.86Physical Contingencies 8.44Price Contingencies -6.26

Total Project Costs 138.27Total Financing Required 138.27 139.86

Source: Staff Appraisal Report (June 4, 1993); Directorate General of Health Services (Leprosy Division)

Project Costs by Procurement Arrangements (Appraisal Estimate) (US$ million equivalent)

Expeniditur?eCategoryr -CB KB M her .. F- ' To alCosto1. Equipment, Material, 13.77 2.00 28.14 - 43.91

Medicines, and Vehicles (12.39) (1.80) (21.03) (35.22)2. Consultants and Training - 8.17 - 8.17

(8.17) (8.17)3. Contractural Services - 37.97 - 37.97

(32.15) (32.15)4. Publicity Services - 6.18 - 6.18

(5.22) (5.22)5. Incremental Honoraria - 4.51 - 4.51

(2.25) (2.25)6. Incremental Operations and - 3.99 - 3.99

Maintenance Costs (2.00) (2.00)

7. Miscellaneous 3 - 33.54 33.54

Total 13.77 2.00 88.96 33.54 138.27(12.39) (1.80) (70.81) - (85.00)

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Project Costs by Procurement Arrangements (Actual/Latest Estimate) (US$ million e uivalent)

1. Equipment, Material, 9.05 0.51 37.25 46.81Medicines, and Vehicles (8.25) (0.41) (9.39) (18.05)

2. Consultants and Training 13.30 13.30(I 1.99) (I1.99

3. Contractural Services - 36.23 - 36.23(31.46) (31.46)

4. Publicity Services - 10.36 - 10.36(9.56) (9.56

5. Incremental Honoraria - 0.10 - 0.10(0.1I0) (0.1I0)

6. Incremental Operations and - 7.16 - 7.16Maintenance Costs (3.10) (3.10)

7. Miscellaneous 3 /- - - 25.90 25.90

Total 9.05 0.51 104.40 25.90 139.86(8.25) (0.41) (65.60) - (74.26)

1/ Figures in parenthesis are the amounts to be financed by IDA. All costs include contingencies.2/ Not Bank financed.

3/ Includes civil works, furniture, NGO services, office operation & maintenance, patient ex-gratia, hospital services, salaries andconsumable materials.

Project Financing by Component (in US$ million equivalent)Percntage of Appraisal

Component Appraisal Estimate Actual/Latest EstimateFDA Govt. CoF. IDA GovL Cop. IDA Govt. CoF.

Vertical Multi-Drug 43.67 38.48 34.59 44.60 79.2 115.9TherapyIntegration of Multi-Drug 14.49 6.76 18.85 13.90 130.1 205.6Therapy thru PHCDisability Care and 8.43 0.42 4.80 0.24 56.9 57.1preventionPromoting Public 6.99 6.17 6.44 5.68 92.1 92.1AwarenessEnhancing Skills and 11.46 1.40 9.58 1.18 83.6Institutional DevelopmentTOTAL 85.04 53.23 74.26 65.60 87.3 123.2

Source: Staff Appraisal Report (June 4, 1993); Directorate General of Health Services (Leprosy Division)

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Annex 3: Economic Costs and Benefits

No economic costs and benefits analysis was carried out at the time of project appraisal or for the ICR.

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Annex 4. Bank Inputs

(a) Missions:Stage of ProjectCycle : No. of Persons.and Specialty -PerformanceRating&

(eGg.2 Econo,Mistsi*IFMS, otoi) D J "mentatio_ion .DoveoprmcntMonth/Year Count Specialt Progress: :Objective

Identification/PreparationIdentification 5 Mission Leader, Economist, S S01/28/1992 - Financial Specialist, Sr.02/11/1992 Anthropologist, Health

Education and CommunicationConsultant

Preparation S S05/11/1992 - 6 Mission Leader, Economist, Sr.05/26/1992 Anthropologist, Public Health

Specialist, HRD and TrainingConsultant, Health Educationand Communication Consultant

Pre-Appraisal S S10/04/1992 - 8 Mission Leader, Economist, Sr.10/23/1992 Anthropologist, WID Specialist,

Sr. Architect/ImplementationSpecialist, Operations Officer(Financial Analyst), HRD andTraining Consultant, HealthEducation and CommunicationConsultant

Appraisal/Negotiation01/24/1993 - 9 Mission Leader and Sr. S S02/07/1993 Public Health Physician, Sr.

Anthropologist, Economist,Sr. Architect/Implementation Specialist,Operations Officer, Sr.Operations Officer,Procurement Specialist,Financial Analyst(Disbursement andAuditing), HRD andTraining Consultant

Supervision05/01/1994 - 2 Mission Leader, Public S S05/15/1994 Health Specialist11/06/1994 - 2 Mission Leader, Public Health S S11/27/1994 Specialist

10/24/1995 - 3 Mission Leader/Public Health S HS11/27/1995 Specialist, Health Education,

Service Organization

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05/29/1996 1 Public Health Specialist S HS04/11/1996 - 3 Mission Leader/Public Health U HS27/11/1996 Specialist, Health Education,

Service Organization04/05/1997 - 3 Mission Leader, Financial S S05/25/1997 Management Specialist, Training

Specialist (IDA) & 7 teamsincluding Public, Academic,Bilateral, Mulitlateral and NGO

01/19/1998 - 2 Mission Leader/Principal Public S S01/23/1998 Health Specialist, Public Health

Specialist08/31/1998 - 2 Mission Leader/Principal Public HS S09/30/1998 Health Specialist, Public Health

Specialist04/22/1999 - 3 Mission Leader/Principal Public HS S04/23/1999 Health Specialist, Public Health05/10/1999 - Specialist, Finance Specialist05/12/1999

11/22/1999 - 9 Mission Leader, IEC/NGO/ S S12/08/1999 Training, Surveillance/

Epidemiologist, ProcurementSpecialist, Leprologist,Information System, DrugLogistics, Leprologist/Institution,Surveillance/Training

05/28/2000- 1 Public Health specialist S S06/03/2000

ICR08/25/2000 - S Mission Leader, Principal S S09/03/2000 Public Health Specialist!

Team Leader, Public HealthSpecialist, ProcurementSpecialist, FinanceManagement Specialist

(b) Staff:

Stage of Project Cycle Actual/Latest EstimateNo. Staff weeks US$ ('000)

Identification/Preparation 24.0 84.0Appraisal/Negotiation 36.7 128.4Supervision 96.0 335.9ICR 18.7 65.4Total 175.4 613.7

Source: Project details at a glance as of 12/20/00.

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Annex 5. Ratings for Achievement of Objectives/Outputs of Components

(H=High, SU=Substantial, M=Modest, N=Negligible, NA=Not Applicable)Rating

Macro policies O H O SU OM O N * NAZ Sector Policies O H OSU*M O N O NAN Physical OH OSUOM ON ONAN Financial O H OSU*M O N O NA• Institutional Development 0 H * SU O M 0 N 0 NA• Environmental O H OSUOM * N O NA

SocialZ Poverty Reduction OH *SUOM O N O NAN Gender OH OSUOM ON ONAM Other (Please specify) OH *SUOM O N O NAStakeholder Participation

E Private sector development 0 H 0 SU * M 0 N 0 NAZ Public sector management 0 H O SU * M Q N 0 NAM Other (Please specify) OH OSU*M O N O NAInvolvement of NGOs

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Annex 6. Ratings of Bank and Borrower Performance

(HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HU=Highly Unsatisfactory)

6.1 Bank performance Rating

I Lending OHS*S OU OHU• Supervision OHS OS OU OHUM Overall OHS *S O U O HU

6.2 Borrowerperformance Rating

N Preparation OHS OS O U O HUZ Government implementation performance O HS O S 0 U 0 HUN Implementation agency performance O HS OS 0 U 0 HUE Overall OHS Os 0 U O HU

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Annex 7. List of Supporting Documents

Report of the Mid-term Appraisal of World Bank NLEP Supported project (7-9 April, 1997). TheMinistry of Health and Family Welfare, Government of India, April 1997.

Report on the Modified Leprosy Elimination Campaign, under National Leprosy EradicationProgramme. Directorate General of Health Services (Leprosy Division), the Ministry of Healthand Family Welfare, Government of India, March 1999 and January 2001.

Various Project Progress Reports. The Ministry of Health and Family Welfare, Government ofIndia. 1994-2000.

Report on Independent Evaluation of National Leprosy Eradication Programme. NationalInstitute of Epidemiology (Indian Council of Medical Research), June 2000 and January 2001.

Report on Data Validation under NLEP. Organized by Central Leprosy Teaching and ResearchInstitute, Chengalpattu, Directorate General of Heal Services (Leprosy Division), the Ministry ofHealth and Family Welfare, Government of India, June 1999.

Staff Appraisal Report (SAR), India National Leprosy Elimination Project. World Bank. June 4,1993.

Development Credit Agreement, Credit Number 2528-IN. World Bank. February 4, 1994.

Project Agreement, Credit Number 2528-IN. World Bank. June, 1994.

Mid-Term Review/Supervision Mission Aide-Memoire. World Bank. May, 1994.

Project Status Reports of various supervision missions. World Bank. 1994 - 2000.

Aide Memorire, Implementation Completion Mission Report. World Bank. August 25 -September 3, 2000.

Weekly Epidemiological Record, No. 28. World Health Organization. July 2000.

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