ICRR 11479 Report Number : ICRR11479 ICR Review Operations Evaluation Department 1. Project Data: Date Posted : 05/06/2003 PROJ ID : P010455 Appraisal Actual Project Name : Blindness Control Project Costs 135.7 US$M ) (US$M) Country : India Loan/ US$M ) 117.8 Loan /Credit (US$M) 107.7 Sector (s): Board: HE - Health (95%), Cofinancing 0 0 Central government US$M ) (US$M) administration (3%), Sub-national government administration (2%) L/C Number : C2611 Board Approval 94 FY ) (FY) Partners involved : None Closing Date 06/30/2001 06/30/2002 Prepared by : Reviewed by : Group Manager : Group : Ronald G. Ridker Madhur Gautam Alain A. Barbu OEDST 2. Project Objectives and Components a. Objectives Original objectives were to support India's efforts to (a) improve quality of cataract surgery, (b) expand coverage of its blindness control program into underprivileged areas with special attention to women, tribal and isolated areas, and (c) reduce the prevalence of cataract blindness by 50% and bilateral blindness by 30% in seven participating states (which accounted for over 70% of cataract blindness in India ). In addition, the backlog of cases in these states were to be eliminated by conducting more than 11 million surgeries. b. Components Original components included (1) enhancing quality of eye casre and expanding service delivery ($118.8 mill.), (2) developing human resources for eye care through opthalmological and related training ($5.0 mill), (3) promoting outreach activities and public awareness ($10.0 mill.), and building institutional capacity ($8.0 mill). c. Comments on Project Cost, Financing and Dates Savings were realized because of a fall in prices of equipment and devaluation of the rupee against the SDR . Much of these savings were reallocated to a new component to support the Gujarat Earthquake Rehabilitation Program . The closing date was extended by a year to compensate for slower than expected disbursement (see item 5 below). 3. Achievement of Relevant Objectives: Quality was improved by introducing new surgical techniques through training, providing specialized equipment for the new techniques, and improving quality control procedures . By the end of the project, the new techniques had become the dominant technique in most program states . Service deliver to underserved populations was expanded to the point where women and tribals comprised more than 50% of the number of operated cases . The backlog of cases, estimated to be 7 mill. in the project states in 1994, was dramatically reduced. A total of 15.35 mill. cataract operations were performed under the project, compared to a target of 11.03 mill. The prevalence of blindness was reduced from 1.49 (National Survey 1986-89) to 1.1% (National Survey 2001-02), a decline of 26% Human resources for eye care were expanded and upgrading through training . 100 faculty in opthalmic hospitals were trained as trainers and 842 surgeons were trained in IOL surgery, compared to a target of 817. Outreach and public awareness activities were promoted through Information, Education and Communication (IEC) programs established with the healp of a communications needs assessment and a beneficiary assessment survey . A Bank-funded evaluation of the effectiveness of these IEC programs suggests that their outcomes were satisfactory . Institutional capacity in program management was strengthened through training, the establishment of a National Blindness Control Board with its own Technical Advisory Board, the establishment of state and district program offices with authority to adapt the program to local conditions, the establishment of state and district blindness control societies to decentralize monitoring and ensure smooth flow of funds, and by expanding and improving monitoring and evaluation capacity, among other ways, through training and by establishing establishing 23 Sentinel Surveillance Cenbters applying Rapid Survey techniques . Throughout, substantial and effective efforts were made to involve NGOs and private practitioners . 4. Significant Outcomes/Impacts: The most significant outcomes/impacts were the introduction of new techniques which substantially increased the success rate of cataract operations, the dramatic increase in the number of operations and decline in backlog, and involvement of NGOs and private practitioners on a large scale, all with good prospects for sustainability . An important, unforseen, outcome has been the expansion of manufacturing capacity for high quality ophthalmic materials, which dramatically reduced costs and which are now being exported . 5. Significant Shortcomings (including non-compliance with safeguard policies): Management, staffing issues and frequent staff turnover have been continuous problems . Implementation of some civil works programs were inordinately delayed . Flow of funds problems impeded operations during early years but were considerably eased by the establishment of state level societies that directly received the funds from the center 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Highly Satisfactory Highly Satisfactory Institutional Dev .: Substantial Substantial Sustainability : Highly Likely Highly Likely Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Satisfactory NOTE ICR rating values flagged with ' * ' don't comply with OP/BP 13.55, but are listed for completeness. NOTE: 7. Lessons of Broad Applicability: Effective partnerships . Ways were found to effectively involve NGOs and private providers which could usefully be emulated elsewhere. These efforts were cost-effective, expanded the reach of the program into peripheral areas and contributed to long-term sustainability. Monitoring and evaluation mechanisms utilizing tools such as the Rapid Assessment Survey can help steamline the program, identify problem areas and organize effective responses . Defining indicators of success in terms of outcomes can have a significant impact on how a project is managed . Context -specific packages of services need to be planned for remote and rural areas . Lack of eye carea facilities, poor transport and inadequate communication in these areas require different service packages than those used in more built-up areas. The introduction of best technical practices . The Bank utilized its comparitive advange to the fullest in this project, by providing technical assistance to introduce state -of-the art technology that would have taken vastly longer to disseminate. Attention to stakeholder and beneficiary needs and concerns . Despite the introduction of superior technology, the project could have failed had needs and concerns of stakeholders and potential beneficiaries not been adequately taken into account. Particulary in remote areas, gender disparaity, low literacy, poverty, lack of motivation, taboos and suspicions could have resulted in low demand . The way the project overcame these problems, through a participatory preparatory process, well -designed beneficiary assessment and KAP studies, and targeted IEC and communication programs should be studies for possible use elsewhere . 8. Assessment Recommended? Yes No Why? A study focused on identifying the way in which the project accomplished various things could be very useful for project designers faced with similar problems . See lessons section for examples . Also see comment on quality of the ICR. 9. Comments on Quality of ICR: The ICR is of good quality. While it is not a responsibility of the ICR to do so, more information on how some aspects of the program were accomplished (for example, how effective partnerships were forged and how demand was generated, would have made the ICR more useful as a source of ideas for other projects .