Document of The World Bank FOR OFFICIAL USE ONLY Report No. 11404-CHA STAFF APPRAISAL REPORT CHINA RURAL HEALTH WORKERS DEVELOPMENT PROJECT JULY 12, 1993 Environment, Human Resources and Urban Development Operations Division Country Department II (China and Mongolia) East Asia and Pacific Regional Office 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. Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized
Transcript
Document of
The World Bank
FOR OFFICIAL USE ONLY
Report No. 11404-CHA
STAFF APPRAISAL REPORT
CHINA
RURAL HEALTH WORKERS DEVELOPMENT PROJECT
JULY 12, 1993
Environment, Human Resources andUrban Development Operations Division
Country Department II (China and Mongolia)East Asia and Pacific Regional Office
This document has a restricted distribution and may be used by recipients only in the performance oftheir official duties. Its contents may not otherwise be disclosed without World Bank authorization.
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CURRENCY EQUIVALENTS(as of February 28, 1993)
Currency Name - Renminbi (RMB)Currency Unit - Yuan (Y)US$1.00 - Y5.74SDR1.00 - US$1.38774
WEIGHTS AND MEASURES
1 square meter (m2
) - 1.2 square yards1 kilometer (km) - 0.62 miles
ABBREVIATIONS AND ACRONYMS
BOPH - Provincial Bureau of Public HealthCMT - Community-Based Medical TrainingCNTIC - China National Technical Import and Export CompanyDOE - Department of Education of the MOPHDOMA - Department of Medical Administration of the MOPHESC - Equipment Selection CommitteeFLO - Foreign Loan Office of the MOPHGIS - Government Insurance SystemHMP - Health Manpower PlanningICB - International Competitive BiddingIFB - Invitation for BidIPA - Inter-provincial ActivitiesITC - International Tendering CompanyLCB - Local Competitive BiddingLIS - Labor Insurance SystemMCH - Maternal and Child HealthMOF - Ministry of FinanceMOPH - Ministry of Public HealthPCR - Project Completion ReportPIO - Project Implementation OfficePMARs - Governments of Provinces, Municipalities and Autonomous
RegionsRHWD - Rural Health Workers Development ProjectRDA - Recommended Daily AllowanceSAA - State Audit AdministrationSEdC - State Education CommissionSPC - State Planning CommissionTCM - Traditional Chinese MedicineTFR - Total Fertility Rate
FISCAL YEAR
January 1 to December 31
FOR OMCIUL USE ONLY
CHIN
RURAL HEALTH WORKERS DEVELOPMENT PROJECT
CREDIT AND PROJECT SUMMARY
Borrower: People's Republic of China.
Beneficiaries: Six Provinces (Anhui, Fujian, Guizhou, Henan, Hebei,Shanxl) and the Ministry of Public Health
Credit Amount: SDR 79.3 million (US$110 million equivalent)
Terms of Credits Standard, with 35 years maturity
ProiectDescription: The goal of the project is to improve the quality of
rural health manpower, thereby contributing to betterquality health services and an improved health statusof the rural poor in the six provinces. The projecthas three province-specific components and one centralcomponent. The Health Workers Plannina component willstrengthen the planning capability at the national,provincial and local levels. This component willdefine the tasks to be done to solve health problemssnd will identify the demand, the requirements and theutilization for all health worker categories. TheHealth Workers Training component will retrain largenumbers of minimally trained rural health workers,train additional workers for underserved areas, andstrengthen the training capability at the provincial,prefectural and county levels. Technical assistancewould be provided for developing and implementingcommunity oriented curricula, new teaching andlearning methods, teacher training in pedagogy,integration of theory and practice, and evaluation ofchanges and innovations. The Rural Health ServicesManagement component will improve the workingconditions of rural health workers, developalternative means for mobilizing financial resourcesto support rural health care delivery, for organizingand managing rural health services, and forcompensating and stimulating rural health workers toemphasize preventive care; and provide support systemsfor supervising these workers effectively. A smallCentral Component will augment the institutionalcapacity of the Ministry of Public Health (MOPH) forcoordinating and supporting project implementationactivities. It will strengthen MOPH's capability tocarry out its national mandate in planning and policyformulation, provide technical assistance to theproject provinces, and evaluate project activities inorder to disseminate the experience gained to the restof the country.
I This document has a restricted distribution and may be used by recipients only in the performanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization.
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Proiect Benefits: At the end of project implementation, rural healthcare delivery in the project provinces will have beenstrengthened, end alternative means for mobilizinglocal financial resources and for compensating ruralhealth workers will have been developed. Villageclinics in the project area will be staffed by atrained village doctor and most villages will have twovillage doctors, one of whom will be female. Healthpersonnel at the township level will be able to solvea broader range of health problems. Health carefacilities at the township level will be repaired andequipped with appropriate medical technology. Countyand prefecture schools for training and retraininghealth workers will have been rehabilitated andexpanded, and will have adopted a practice-orientedcurriculum reflecting community health needs. Theproject's emphasis on the poor and its attention tomaternal and child health problems will have reducedmaternal mortality ratios in project areas. Projectoutcomes would also be relevant to the prefectures ofthe project provinces not included in the project andwould be disseminated to other provinces in thecountry.
Proiect Risks: The project would change the way rural health workersare trained. Reforming established training patternsinvolves important conceptual and attitudinal changeson the part of provincial authorities, schooladministrators, teachers and managers, which aredifficult to accomplish and difficult to measure.Training new students offers different incentives toschools than retraining existing personnel. Onlendingof credit proceeds by the Borrower to the beneficiaryprovinces at higher interest rates and a shortermaturity may selectively induce some provinces toinvest in counties that are more able to repay theloan thereby potentially decreasing the intended fullparticipation of the poorest counties. Implementingthe study results on alternative ways of mobilizinglocal funds and paying providers would need Governmentsupport for adoption on a large scale. However, theGovernment is keenly aware of the need for change inrural health care delivery and strongly supports theproject's goals and objectives. Careful projectplanning, supervision, and monitoring as well asgovernment assurances, would help alleviate theserisks.
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Eotimated C,ot: Local Foreign Total-------- (US$ Million) -------
The report is based on the findings of an appraisal mission which visited Chinain October 1992. Appraisal team members included Mr. W. Do Geyndt (Task Managerand Senior Public Health Specialist), Ms. Xiyan Zhao (Human Resourcos Economist),Mr. A. Andonyadis (Architect) and consultants W. Hsiao, J. Johnston., P. Mooreand S. Sung. Consultants K. Cox, T. Hall and V. Wong participated in earliermissions. Peer reviewers were Mmes. R. Martinez (Educator), M. Young (PublicHealth Physician) and D. Vaillancourt (PHN Specialist). The Division Chief isMr. Zafer Ecevit. The Department Director is Mr. Shahid Javed Burki.
Adult Literacy Rate The percentage of persons aged 15 and over who can readend write.
Crude Birth Rate Number of live births per year per 1,000 people.
Crude Death Rate Number of deaths per year per 1,000 people.
Dependency Ratio Population 14 years or under and 65 years or older as apercentage of the population aged 15 to 64 years.
Incidence Rate Number of persona contracting a disease as a proportionof the population at risk, per unit of time, usuallyexpressed per 1,000 or per 100,000 persons per year.
Infant Mortality Rate Annual deaths of infants less than 1 year old per 1,000live births during the same year.
Life Expectancy The number of years a new born child would live ifsubject to the age-specific mortality rates prevailingat time of birth.
Maternal Mortality Rate Number of maternal deaths per 1,000 births in a givenyear attributable to pregnancy, childbirth or puerperalcomplications.
Rate of Natural Difference between crude birth and crude death rates;Increase usually expressed as a percentage
Total Fertility Rate The average number of children a women will have if sheexperiences a given set (i.e., those then prevailingamong women of those agas) of age specific fertilityrates throughout her life time.
CHI
RURAL HEALTH WORKERS DEVELOPMENT PROJECT
STAFF APPRAISAL REPORT
I. SECTORAL CONTEXT
A. Population, Health and Nutrition Status
1.1 Demographic Status. According to the 1990 census, the population inChina is 1.13 billion, of which 74 percent are classified as rural. China'sdemographic transition reached a stable stage during the 19809. Crude birth anddeath rates remained at about 21 and 6 per thousand, respectively, throughout the1980s, stabilizing the annual rate of natural increase at about 1.5 percent.
1.2 In spite of the remarkable results from family planning programs,controlling population growth remains a major concern. Additional populationincrease is expected in the 1990. as a result of the large cohorts born in the1960s that are now entering their reproductive years. The total fertility rate(TFR) has been held to about 2.5 in the 1980s, but further sustained reductionin fertility will be very difficult without substantial progress in socioeconomicdevelopment and sustained success in the family planning programs.
1.3 The total dependency ratio will remain relatively stable at around 50percent into the early 21st century. Nonetheles, the age structure will changesignificantly. The proportion of the population over 65 will rise steadily, asa result of fertility and mortality declines. The total "medically vulnerable"population (those below age 5 and over age 50) will increase from 381 to 601 ofthe working age population by the year 2025. These structural changes will raisethe demand for medical care.
1.4 Health Sttu. Starting from a relatively low stage of economicdevelopment, China has successfully improved the health status of its peopleduring the past four decades. Infant mortality in China was over 200 deaths perthousand live births before 1949. The national average is now estimated at about30 deaths per thousand live births. Child mortality has been fallingconsistently since the mid-1970s. Childhood immunization, family planning,improved nutrition, better sanitation and housing, and accessible primary healthcare all contributed to these remarkable mortality reductions. Life expectancyof 70 years compares favorably with middle and high income developing countriesand with many developed countries.
1.5 The health transition (the change in disease pattern from primarilycommunicable and infectious diseases to a preponderance of chronic and non-communicable diseases) is clearly under way in China, partly because of the agingof the population. Heart disease, chronic obstructive lung disease, stroke,cancer, injuries and suicide were the leading causes of mortality in the 1980s,together accounting for 721 of all deaths. These chronic diseases also accountfor the majority of hospital admissions and health care expenditure. However,the health transition is uneven and varies by gender and residence. People inremote and poor regions are more likely to be affected by infectious diseasesthan urban people. The probability of rural men dying from infectious diseasseis double that of urban men; rural women are four times as likely to die from
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infectious diseases as urban women. Thus China has to face the challenge, ofdealing with the emerging prevalence of chronic noncommunicable diseases at thesame time as it continues to fight infectious and parasitic disaases. In theproces. it must also reduce geographic and gender inequalities.
1.6 Nutrition St-tus. Improved nutrition has been an importantcontributor to the gains in life expectancy and the decline in mortality.Average food consumption in China compares well with other developing countries.The results from the Nationwide Nutrition Survey in 1982 indicated that theaverage energy intake per capita vas 2085 calories (102S of the recommended dailyallowance or RDA) and 67 grams of protein (922 of RDA). Acute malnutrition hasbeen largely eliminated and the Chinese diet is on average not deficient.However, malnutrition still exists, particularly in poorer rural areas. About8-102 of the population have an energy intake lower than the RDA.
B. The Health Care System
1.7 Administrative Structure. China's health care system consists of anumber of subsectors, among which the subsector administered by the Ministry ofPublic Health (MOPH) is the largest. Other subsectors are the directresponsibility of their corresponding government units and provide healthservices to their constituencies (military, public security, industry,education). These subsectors are not included in this brief description.
1.8 China's national health care system is an integral part of thecountry's administrative structure. The State Council of the People's Republicof China is the apex of the executive arm of government and controls the centrallevel Ministries and the 30 governments of provinces, municipalities andautonomous regions (PMARs). Below the province are three levels of government,namely, the prefecture/city government, the county government and the townshipgovernment. Township governments were previously the administrative offices ofthe people's communes.
1.9 On average, there are 8 prefectures/cities in each province orautonomous region. The average population of a PHAR is 35 million people rangingfrom 1.9 million (Tibet) to 108 million (Sichuan). There are 2,137 counties inChina or an average of 71 for each PMAR and 10 for each prefecture/city, and eachcounty has about 25 townships. The average population per county is 0.4 million(ranging from 10,000 people to one million). A township averages 16,000 peopleand has an average of 14 villages. The villages are the primary units ofresidence under the township government and range in size from 100 to over 3,000people.
1.10 Before the administrative system reform in the early 1980s, thevillage was called a production brigade and consisted of several productionteams. Each production team served as an agricultural business accounting unit.After paying agricultural tax to the government, the production team retainedsome of its revenue in a Public Welfare Fund for education and health careexpenses and for old age support.
1.11 The health care system closely parallels China's administrativestructure. Except for township governments, each level of government has adepartment of public health vith a dual authority structure: for administrativematters it is responsible to the government at its own level and for technical
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matters it is responsible to the department of public health of the next higheradministrative level. Departments of public health at each level manage andsupervise hospitals, health centers and specialized health care institutions,following national guidelines and norms promulgated by the central level MOPH.
1.12 The Rural Health Care Slstem Before 1979. Before 1979, the primaryhealth care system in rural China was a "three-tier system" based on theproduction team, the brigade, and the commune. Health care was provided by: (i)part-time health workers at the production team level; (ii) the cooperativehealth station at the brigade level, consisting of 1 to 5 "barefoot doctors"(para 1.22) and serving on average 200-300 households; and (iii) the communeclinic/hospital, staffed by middle level practitioners providing a broader rangeof services based on Western and Chinese medicine. This health care system wasfinanced with contributions from the public welfare fund and from members of thecooperative health care system. The central government financed vaccines,contraceptives and the training of all health personnel.
1.13 The policy of "Put Priority of Health Care in Rural Areas" of the mid-1960s guided the rapid development in rural areas of the cooperative health caresystem with "barefoot doctors" and brigade health stations. In the 1970s thecooperative health care system covered 95 percent of all villages in China, andhelped provide primary health care to the rural population.
1.14 The Rural Health Care System After 1979. The implementation of thenew economic responsibility system in rural areas, initiated in 1979, shifted thecommunity-based production system back to a family-based one. The privatizationof the production and distribution systems stimulated productivity and totaloutput. However, the changes in the economy also affected the health sector asthe system of collectives collapsed and the financial viability of the publicwelfare fund was jeopardized. Other sources to pay for health care had to befound.
1.15 The health care system experienced a dramatic change in the aftermathof the economic reform. Responsibility for the commune clinic/hospital (nowcalled the township health center/hospital) shifted from the county departmentof public health to the township government. The township government is nowresponsible for the administration and the financial support of the townshiphealth centers/township hospitals. Another important change is the separationof preventive services from treatment services at the township level. Thetownship health centers used to provide both preventive services and curativeservices. After the reform, a large number of township health centers weredivided into curative township hospitals and preventive township health centers.
1.16 The most profound change in rural health service delivery systemoccurred at the village level. Before 1979, the village health stations were rununder a cooperative health care system. The barefoot doctors were paid by workpoints, which was a system of recording work contributions in the collectiveeconomy. The villagers who joined the cooperative health care system receivedfree medical care in the brigade-level health station and also could bereimbursed for a proportion of their medical expenses if they were referred toand treated at a higher level. The introduction of the new economic reformweakened the financial viability of the cooperative system. The brigade is nolonger a production or distribution unit. Funds previously available for socialwelfare, including old age support, schooling and medical care, have been sharplyreduced. The coverage by the cooperative health system declined substantially
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in most areas; in some places, it completely collapsed. Additionally, incre-aeain rural income and alternative job opportunities raiaed the opportunity coat forthe barefoot doctors and caused many to leave medical practice. The number ofbarefoot doctors decreased from 1.76 million in 1977 to about 1.2 million in1989.
1.17 Health services delivery at the village and township levels haaundergone a process of commercialization as the financial risk has shifted fromthe public payor to the private payor. Fee-for-service has become the dominantmethod of paying for health services. MOPH data for 1988 indicate that only 6percent of villages and 9 percent of the rural population are still covered undercooperative fund arrangements. Over 80 percent of villages operate on a fee-for-service payment basis. The doctor in about 45 percent of the villages is aprivate practitioner; 36 percent of the villages have a clinic run by the villagecommittee where the patients pay for services received. Only 10 percent of ruraldoctors received part of their medical income directly from the villages. Sixpercent of villages had no clinic and depended for health services on thetownship health centers.
C. Health Financing and Expenditure
1.18 The Bank's 1990 sector report "China: Long-Term Issues and Options inthe Health Transition' (No. 7965-CHA) reviewed China's health financing andhealth expenditures. Important trends identified in the 1980. were: (i) percapita health spending rose; (ii) the relative shares of public subsidies and ofhealth insurance payments declined; (iii) user fees increased in both absoluteand relative terms; (iv) total health expenditures grew rapidly, mainly as aresult of increases in hospital costs; and (v) drug consumption absorbed a highershare of total health expenditures. The impact of these changes on the qualityof, and the access to, health services and on the health status of the populationis not as yet clear.
1.19 The Health Financine System. The main sources of health financing inChina are government budgets, health insurance and user fees. The largest sourceis the health insurance system, covering about 12 percent of the total populationlargely concentrated in urban area. There are three types of health insurance:(i) the Government Insurance System (GIS) covers about 24 million civil servants(2S of total population); (ii) the Labor Insurance System (LIS) covers allworkers of state-owned enterprises (about 75 million people, or 7 percent of thetotal population) and in addition pays half of the medical expenses of theirdependents; and (iii) a variety of collectively-owned enterprises insure theiremployees, covering a maximum of about 35 million workers. Recently developedrural enterprises also provide certain health coverage to their employees. Table1.1 presents total estimated health expenditures by source for the period 1970-87. Noteworthy is the dramatic increase in the share of user fees and thecorresponding drop in the shares of government budget and health insurance.
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Table 1.1
Estimated Health Exnenditure Share BY Source
1970 1980 1985
Government Health Budget 28S 30% 27% 191
Health Insurance 53% 501 42S 411
User Fees 142 14% 26S 36%
Other sectors 51 6% 5S 4%
Total 100S 100% 100% 100%
Total Expenditure* 4,670 12,105 23,011 30,322
* Estimated expenditure based on 1980 constant prices, in million RMB
Source: 'China: Long-Term Issues and Options in the Health Transition", (ReportNo. 7965-CHA, 1990).
1.20 Rural-Urban Differentials. Significant rural-urban differentials inaccess to quality health care and in health status remain, notwithstanding thefact that priority of rural health care has been a long-standing health policyin China. The rural-urban gap has widened rather than narrowed during the pastten years. At the township level the number of hospital beds decreased by 6.8Zand the number of physicians by 10.8%. In contrast, the number of beds andphysicians in county hospitals and above increased by 29.6% and 49.0%,respectively. Also the share of public health expenditures on township hospitalsis declining, while the proportion of the government budget spent on higher levelhospitals is increasing. A dramatic difference between rural and urban areas isevidenced by the annual per capita health expenditure in the late 1980. ofgovernment employees (145 yuan) and of insured workers (151 yuan) while theaverage for rural people was only 34 yuan.
1.21 Health Financing in Rural China. In general, no government insuranceis available in rural China. Health services are mainly provided on a fee-for-service basis. According to a rural health services survey in 1985, the foe-for-service payment mode covered 81 percent of rural residents, collective healthcare sources accounted for 10 percent, labor insurance for 4 percent, publicwelfare funds for 3 percent and others about 3 percent. Access to primary healthcare has become an equity issue. Economically more advanced areas are able tofinance their local health services and more well-to-do farmers can "buy" bettermedical services. Poor villages, on the other hand, cannot support their clinicsand poor villagers have difficulty paying their medical expenses. Results froma rural health services survey (1985) indicated that, under the fee-for-servicesystem, about 20 percent of farmers could not obtain medical care when they weresick and the same percentage of patients who needed inpatient care could not beadmitted to a hospital for financial reasons. With the continuous increase inmedical care cost, illness has become one of the leading causes of poverty inrural areas.
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D. Rural Health Maniower
1.22 The Transition from Barefoot Doctor to Village Doctor2. Rural healthmanpower expanded rapidly in the late 1960. with the introduction of the"barefoot doctor" program. Barefoot doctors (a term first used in 1968 anddiscontinued officially in 1985) were part-time health workers at the villagelevel responsible for: (i) the operation of the brigade health stations; (ii)treatment of coon diseases and injuries; (iii) promotion of health campaignsand health programs; (iv) disease surveillance and prevention, includingimmunization and health education; (v) provision of maternal and child healthcare (MCH) and family planning services; and (vi) cultivating, collecting andprocessing medical herbs. The barefoot doctors were an important force in ruralprimary health care. Their number increased to about 1.56 million in 1975 orabout 2.5 doctors per 1,000 rural residents. In the late 1970s, national healthpolicy emphasized improving the quality of health services and upgrading theclinical skills of lower-level health personnel. Barefoot doctors could becomevillage doctors by passing a basic examination. Those who did not pass wereclassified as village health aides. The total number of village doctors in 1988was about 731,700 or only 60X of the number of barefoot doctors in 1980. Somebarefoot doctors changed occupation and some practiced medicine at the townshiplevel. Overall, the number of rural health workers actually decreased during the1980s (Table 1.2).
1.23 Recruitment and Trainint of Rural Health ManDowor. The training ofassistant doctors and village doctors differs greatly from that of post-secondaryschool level medical doctors even though all carry the title "doctor'. Assistantdoctors, MCH doctors, midwives, nurses and public health workers are junior highschool graduates (nine years of general education) with satisfactory scores onprovincial level examinations. Villagers to be trained as village doctors wereselected by the villages. Often the retiring village doctor would pass his orher "business" on to a younger family member. Criteria for recruiting villagehealth workers were based on the community's judgment of the quality of theperson, which emphasized his/her performance, and potential as a responsiblemember of the community as well as political status. Usually, if there is onlyone village doctor, it is a male, but if there are two or more doctors, at leastone must be female in order to give more prominence to MCH services. The datafrom a national survey on village doctors in 1990 suggest that almost 80 percentof village doctors were male between the ages of 30 to 50. The majority of themhad only 6-9 years of general schooling. Younger village doctors tended to havehigher levels of education.
. See also the Bank's 1990 sector report "China: Long-term Issues andOptions in the Health Transition," Chapter 8: Health Manpower.
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Table 1.2
Village Health Workers 1970-86(in thousands)
1970 1975 1980 1986
No. of villages 651 675 703 738(formerly called 'brigades')
Villages with a health stationNumber 499 571 484 648Percent 76.6 84.6 68.8 87.8
Barefoot doctors 1,218 1,559 1,463 NA
Village doctors NA NA NA 695Village health aides NA NA NA 585
Brigade health aides 3,561 3,282 2,357 NA
Rural midwives NA 615 635 508
NA: Not ApplicableSource: Ministry of Public Health
1.24 Professional training in secondary medical schools is subject toprovincial and national norms. It is highly structured and the performance ofschools is judged by the ranking of scores obtained by their graduates onprovince-wide examinations. Pressure to perform well on these standardized testsinhibits innovation and diverts teaching from more meaningful educationalobjectives. Medical training for village doctors, on the other hand, is short,informal and by and large unstructured. The pre-service training that mostvillage doctors received is less than one year in duration. Initial trainingusually takes place in the central township hospital or township health centerwith a duration of 3 to 6 months. In 1974, a formal one-year course wasintroduced to train village doctors in an attempt to upgrade their clinicalskills, but it has not been widely adopted. Rural hoalth workers also receivecontinuing education, of which there are four typess In-service Training at thevillage health station through supervision from experienced health workers at thestation and/or periodic visits from township level professionals; Grou2 MeOtingsheld every month at the township hospital to discuss special issues and needs;Special Training Courses offered in the hospitals/health centers at township orcounty levels, or at county health schools, for specific local health needs;Retrainint Courses offered at the township or county levels mainly for skillsupgrading. The length of the total training varies depending on individualneeds, and on available financial support to pay for tuition and to replaceincome foregone during training. More than half of the village doctors havereceived less than one year of technical training (i. ., combining proservice andinservice training (Table 1.3)).
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Table 1. 3
Length of Training of a Sample of Village Doctors
Duration of Training Number of Percentage(in months) Village Doctors
Sources Do Ceyndt, Zhao and Liu, 1992. "From Barefoot Doctor to Village Doctorin Rural China", World Bank Technical Paper No. 187.
1.25 Training Institution. China train, health personnel at three levels.At the highest level are medical universities offering a 5-6 year program pluspostgraduate training. At the middle level (still post-secondary) are 3-yearmedical colleges training doctors in both western and Chinese medicine. At thelower level are secondary medical schools training assistant doctors, traditionalChinese medicine (TCH) doctors, midwives, MCH doctors, nurses and medicaltechnicians for the county and township levels, and county health schools mainlytraining doctors and labor attendants for the village level. Enrolment in post-secondary institutions has increased in recent years. At present, all graduatesfrom health training schools above the county level are employed by thegovernment except those who voluntarily leave for other jobs and sectors. Thispattern may change if economic reforms increase the demand by the private sectorfor graduates with medical training. Most schools have all or part of theirstudents as boarders, which allows students from more distant areas to attend andthus increases equity of access.
1.26 Most secondary medical schools offer three-year training programs andthe large majority of their students graduate as assistant doctors and nurses.In recent years fewer midwives have been trained but more MCH doctors. Secondarymedical schools are under the authority of provincial and prefecturalgovernments. To be admitted, students must have completed three years of lowersecondary school and must pass an entrance examination. Graduates must passprovincial qualifying xaminations and their diplomas are recognized nationally.Upon graduation they are assigned to a job by the prefectural public healthbureau. The bulk of the assistant doctors are assigned to township hospitals andhealth centers; nurses, midwives and public health workers predominantly go tocounty level facilities. Training is free for most students and the schoolreceives an annual per capita allocation of Y1,200 to Y1,400 from the prefecture.Knrollment is at times curtailed for budgetary reasons. Some paying students arealso accepted, providing an additional source of revenue to the school.
1.27 County health schools are under the supervision of the county healthbureau and train rural health workers for the villages. The length of trainingvaries widely among and within prefectures, ranging from one to three years.Schools are self-financed through student fees but may receive a small annualallocation from the county budget for capital expenses and teacher salaries.
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Students are primary school graduates from diverse backgrounds and some havehealth work experience. No entrance examination is required. Graduates are notguaranteed a job but those previously employed in the health field often returnto their post in the village. Upon graduation students receive a certificaterecognized in the county only. Length of training is often a function of theavailability of funds, i.e., students' willingness to pay tuition for more thanone year of training and to forego income and the county government'a willingnessand capability to subsidize the training process. The proposed project willstrengthen training at secondary medical schools and at county health schools.
1.28 Teachina Faculty. The academic background of the teaching faculty isvery diverse, with a few having been trained at a three-year medical college andmany at the secondary medical school level. Faculty at secondary edical schoolstend to have tertiary level training while faculty at county health schools aremore likely to be graduates from secondary medical schools. Doctors fromprefectural and county hospitals are part-time faculty and teach a course intheir specialty. Teachers are not trained to teach as such and their teachingmethods are typically lecture-style. Most of the full-time faculty have limitedclinical practice and many have not worked clinically at the township or villagelevels (this is more often the case for county school faculty than for secondarymedical school faculty). With a few exceptions, the faculty's knowledge andpersonal experience of community needs and priorities are limited. Teaching andpractice are not integrated, as schools have limited practice settings. The mostfrequently used practice settings are the county and prefectural/city hospitalswhere the clinical problems to be solved are not an accurate reflection of theprevalent pathology in townships and villages.
1.29 Retention of Rural Health ManDower. Assistant doctors at the townshiplevel are part of the civil servant stream and are paid a salary. A lightworkload and a generous assignment of staff at that level do not require full-time presence and most assistant doctors havo other occupations, usually farming,to supplement their low salaries. The commercialization of the sector during the1980. and the reduction in the percentage of the payroll paid by the countygovernment (typically now only 60 percent) have encouraged township levelproviders to generate more revenue from user fees for outpatient visits, dailyroom charges and diagnostic tests, but mainly from the sale of drugs. Revenueis used to offset the reduced salary subsidy and in some cases to pay anincentive bonus. Thus, staff are devising Ways to increase their income to acompetitive level. Another major cause of staff dissatisfaction (and a frequentreason for leaving the township and moving to county seats) is the lack ofsuitable housing and the poor professional working conditions (insufficientequipment, structurally deficient buildings).
1.30 Village doctors are not civil servants but are in effect privateentrepreneurs. Most of them work part-time on health care and about fortypercent of their income come from farming. Only 19 percent of village doctorsdevote full time to their medical practice. Health manpower at this level hasbeen quite stable until recently. Under the collective economy, village doctors(barefoot doctors at that time) were paid work points and their pay was equal toor better than other villagers. After the economic reform, however, the villagedoctor's pay is no longer guaranteed or competitive. The village doctors chargea smll fee for a visit but their earnings mainly depend on profit made fromselling the medicines they proscribe. The results of a national survey revealthat 77 percent of the village doctors' income from health care comes fromprovision of curative services and only 13 percent from the provision of
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preventive activities, with the remaining 10 percent coming from subsidies forperforming family planning services and immunizations. The sanctioning ofprivate practice has increased the mobility of the health labor force, andvillage doctors now also have alternative job opportunities and may leave thehealth sector. Rural areas with higher income earning potential in non-healthsectors have special difficulty retaining their health workers.
1.31 Performance of Rural Health ManDower. Health personnel at thetownship and village levels generally do not have post-secondary medicaltraining. The majority of township hospital doctors have graduated fromsecondary medical schools. Village doctors have usually received short trainingcourses from county health schools and very few have completed a three yeartraining program. On other hand, many village doctors have extensive practicalwork experience: more than 80 percent of village doctors have worked in thehealth field for over ten years and 40 percent for more than 20 years (the olderones started their careers as barefoot doctors).
1.32 Clinical training of rural health workers tends to be undulytheoretical, and not community-based or oriented towards problem-solving. Morethan half of village doctors have less than one year of formal training (Table1.3). Training curricula for rural health workers are simplified adaptations ofthe curriculum taught in tertiary level medical schools and therefore retain thestrong emphasis on curative medicine. About two thirds of courses taught arebasic sciences, TCM courses take about one quarter and non-medical courses makeup the balance. Deficiencies in clinical training are evident in clinicalpractice. Rural doctors are responsible for providing basic health care to themajority of the rural population, and curative services represent the bulk oftheir work. In poorer and more remote areas up to 90 percent of work done byvillage doctors is curative. Doctors have the authority to prescribe a varietyof drugs without the benefit of a proper clinical diagnosis. Some of the drugsare potent and outright dangerous when applied improperly. In general there aretoo many medically unnecessary intravenous infusions (e.g. amino acids, 10%glucose), too many injections (e.g. vitamins, fortifiers, antibiotics) andexcessive and inappropriate use of antibiotics. Health authorities are correctlyconcerned about antibiotic resistance in the rural population. These poorclinical practices are related to inadequate clinical training, absence ofclinical supervision and a perverse system of financial incentives.
E. Rural Health ManDower Development Issues
1.33 China is experiencing a rapid health transition concurrently with adramatic reform in its economic system. The existing health care system is notwell-equipped to cope with such rapid structural changes. Problems areexacerbated in rural areas. The increase in the prevalence of chronic diseasespartly due to an aging population and partly to a shift in epidemiological riskrequires the introduction and dissemination of new technologies and practices inhealth services delivery. Moreover, existing health service providers,particularly at the township and village levels, lack the necessary clinicalskills to cope with such changes. New technology requires upgrading personnelskills to improve quality and efficacy of health services. Key issues in thepresent rural health care system in China are: (i) how to upgrade clinical skillsto improve quality of services; and (ii) how to improve the working conditionsof rural health workers and provide them with adequate payment for servicesrendered, in order to stabilize health personnel and make them more productive.
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1.34 Quality of Health Services. As disposable income increases, peopleare willing to pay more for health care and vill no longer accept low qualityservices. The quality of health services provided by rural health workers hasbecome an important concern as the demand for medical care increases. Patientsare tending to bypass lower level health clinics and go directly to township orcounty hospitals. The income effect on the demand for health services requiresa parallel improvement in quality of health services at the township and villagelevels mainly by upgrading the clinical skills of rural health workers.
1.35 Quality of health care services is closely related to the quality oftraining and supervision of health personnel and the quality of teacher training,as well as the availability and appropriate pedagogic use of teaching methods andmaterials. Providing rural health workers with the needed clinical skills andsupervising their performance are essential for improving the quality of ruralhealth care.
1.36 Remuneration System. Appropriate financial incentives can help tobalance the geographic and skill distribution of the health labor force. Well-trained doctors often do not want to stay in rural areas, partly because of poorworking and living conditions, but also because of low payment. Thedisintegration of the rural cooperative health system and the implementation ofcost recovery schemes have made payment of village doctors unstable. Curativeservices are the main source of income for township hospitals and health centersand for village clinics. Selling drugs is the most effective way for healthproviders to generate revenue. The current system of health financing pushes therural health care providers to pursue income generating activities (i.e.,curative services) rather than preventive activities which are economically lessattractive. The excessive and often medically inappropriate prescription ofdrugs is now being observed in the practice of village doctors and townshiphospitals.
II_ GOVERNMENT POLICIES AND THE BANK'S ROLE IN RURAL HEALTH WORKERS DEVELOPMENT
A. Government Health Policies
2.1 The Eighth Five-year Health Plan for 1991-95 emphasizes reducing therural-urban gap in access to health care services. It argues that the provisionof quality rural health services is hampered by a lack of skilled health workers,a shortage of health manpower in the poorest areas and inadequate medicalsupplies, equipment and facilities. The Eighth Five-year Health Plan setsdevelopment strategies for the 1990s, among which, preventive care and ruralhealth care are the most important issues addressed. In order to reach the goalof "Health for All by the Year 2000", the Government intends to increaseinvestment in the health sector and strengthen primary health care in ruralareas. Concrete goals are to increase the number of health workers per thousandpopulation from 0.6 to 0.8 and the number of hospital beds per thousand from 1.6to 2. Priority in health manpower development is to train health professionalsfor rural health care. Village doctors are the primary health care providers andwould receive various kinds of formal training during the 1990s.
2.2 The negative impact of the new economic responsibility system on theprovision and financing of rural health services (paras 1.14-1.17, 1.21) was notoriginally anticipated. Government concern about the unintended consequences ofthe demise of the cooperative health care system and the rise of a private
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entrepreneurial fee-for-service system became evident during the mid-eighties.Towards the end of the decade several national and regional meetings and symposiaexamined and discussed the problems of organizing and financing rural healthservices. Research results from rural health evaluation studies vere alsodisseminated. As a result of this information flow and reflecting itstraditional comitment to the rural population, the Government has made ruralhealth a national priority. The Government's request for IDA assistance is anexpression of its concern. Central and provincial authorities have expressedtheir strong support for the proposed project.
B. Past Exierience with Previous Bank Group Operstions
2.3 The Bank's work with health sector authorities began when Chinaresumed its membership in 1980. The Bank's health sector dialogue with thegovernment has been pursued through health sector reports (1984, 1989) andthrough four projects financed by IDA. The Rural Health and Medical EducationProject (Credit 1472-CiA) started in 1984 and was completed at the end of 19911the Rural Health and Preventive Medicine Project (Credit 1713/Loan 2723-CiA)started in 1986 and is largely complete (except for a vaccine productioncomponent, which will run until 1995). The Integrated Regional HealthDevelopment Project (Credit 2009-CHA) initiated activities in early 1990 and isprogressing satisfactorily. A fourth project "Infectious and Endemic DiseaseControl" (Credit 2317-CHA) was signed in 1991 and implementation has startedsmoothly.
2.4 Credits 1472 and 1713 financed some rural manpower training, includingupgrading the plant and equipment of county health schools. Training was mainlyin-service and designed to improve management, introduce staff to the newlypurchased technology, and improve equipment maintenance.
2.5 The medical education component of Credit 1472 introduced a newemphasis in the core medical universities on continuing education for ruralmanpower in the areas of management, preventive medicine, and social medicine.Public Health Bureaus were encouraged to set up community bases for study andresearch.
2.6 Rural training centers were improved or constructed in all projectcounties in five provinces under Credit 1713. This approach was probablyappropriate at the time. Present thinking, however, is to consider largercatchment areas than a single county, with some division of responsibility fordifferent professional disciplines between county schools. Under the amecredit, provincial training schools were also upgraded and provided with modernequipment. The content of training courses was strengthened in primary care andclinical areas, and in equipment maintenance. However, the project's objectivesdid not include any fundamental review of health manpower planning or fundamentalchanges in curriculum development. These were left for subsequent projects.
2.7 The proposed project would continue the health sector dialogue, whilebuilding on many of the project activities and sector study findings of the lastten years. A number of lessons have been learned from the implementation of theprojects financed by IDA thus far. They include the need to: (i) provide thehealth sector better trained personnel; (ii) decentralize some operations suchas training down to the prefecture and county levels; (iii) strengthen thecapability at the central level to monitor and evaluate project performance; and
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(iv) ensure sustainability by carefully planning recurrent and other financialcosts. These lessons are of particular relevance because the proposed projectwould be implemented in six provinces that have not benefitted from previous BankGroup support for health improvement. Precautions have therefore been taken inthe design of the proposed project by: (i) using the prefecture and not thecounty as the planning unit for county schools, with sharing of training servicesamong counties; (ii) stressing inservice training over proservice training; (iii)incorporating a clearly defined central component to monitor and evaluate projectperformance, and to extract lessons for use in future programs; (iv) ensuringinclusion of technical assistance for key activities; and (v) carefully planningtho financing of recurrent costs.
C. The Bank's Role and Contribution
2.8 The Bank shares the Government's concern with, and its emphasis on,the organization, delivery and financing of rural health services, which servethree quartors of China's population. The availability of qualified manpower inadequate numbers is a necessary condition for the provision of affordable qualitycare. Project proparation has already allowed IDA to contribute substantiallyto identification and propagation of the main issues in rural health manpowertraining end gains have already been realized. Provincial Bureaus of PublicHealth and their respective preparation teams, as woll as the central level MOPHDepartment of Education, now fully embrace the need to change the manpowerplanning and training process. They are already promoting the conceptual modelof manpower planning based on community needs rather than on fixed ratios as inthe past, of training manpower using modern teaching methods integrating theoryand practice and distinguishing teaching from learning, and finally ofrecruiting, retaining and managing the planned and trained manpower. Theconcepts of task analysis and job descriptions have entered the lexicon of theGovernment's preparation teams, as well as competency-based assessment ofperformance and clinical supervision.
2.9 Rationale for IDA Involvement. The proposed project builds on theBank's earlier operations in the health sector. It meshes woll with both IDA'ssector study findings and the Government's health sector development strategies.The shortage of public funds for upgrading the quality of rural health personnelbecame more apparent in the process of decentralization, particularly in poorareas. Using its previous experienco with the health sector, the Bank is in aposition to holp the Government in its efforts to adjust its rural health system.The project design stresses community-based health care and emphasizes diseaseprevention in training programs partially basod on the Bank Group's experiencein other countries. The project would develop a methodology that could bereplicated in other counties within the project provinces and in other provincesin China.
2.10 As in previous health projects, there is a strong anti-poverty focusof the project which gives it priority for IDA's attention. Criteria forselecting prefecturos in participating provinces target those with infant andmaternal mortality rates and illiteracy rates above provincial averages and thosebelow the provincial average on per capita income. Project preparation hasprovided the Bank Group and the Government an opportunity to address some of theissues closely associated with poverty themes of the 1990 World DevelopmentReport and the Bank's recent report on poverty in China (China: Strategies forReducing Poverty in the 1990's, Report No. 11245, October 1992).
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III. THE PROJECT
A. Orliin of the Proiect
3.1 The Rural Health Workers Development Project (RHWD) identificationmission (June 1990) examined the rationale and feasibility of IDA's involvementin rural health manpower development and defined the context and scope of theproposed project. Preparation missions were preceded and accompanied by UNDP-financed Technical Assistance teams of foreign and local consultants inNovember/December 1990 and in June 1991, and worked closely with MOPH and theproject provinces in developing detailed project proposals. The project wasappraised in October 1992.
B. Proiect Obiectives and Areas
3.2 Proiect Obiectives. The goal of the proposed project is to improvethe quality of rural health manpower, thereby contributing to better qualityhealth services and an improved health status of the rural population in theproject area. To achieve this goal the project vould: (i) strengthen manpowerplanning capability in six project provinces and at the national level; (ii)train and retrain better qualified medical teachers, rural health workers andmanagers by reorienting the training process through curriculum reform,introducing a wider variety of teaching and learning methods and more supervisedpracticums, and emphasizing training in the practical skills needed in ruralsettings; (iii) strengthen management and clinical supervision of health serviceinstitutions in rural areas; (iv) improve inter-institutional coordination anddevelop integrated provincial training networks with defined roles for each levelof training institutions; and (v) upgrade the physical conditions of traininginstitutions at the prefecture and county levels and of service deliveryinstitutions at the township and village levels.
Proiect Areas
3.3 Selection Criteria for Provinces. The MOPH and the Bank agreed on aset of criteria for selecting project provinces. They included: (i) evidence ofprovincial commitment to change policies, to organize interdepartmental projectleading groups, and to achieve project objectives; (ii) a per capita income levelbelow the national average; (iii) high prevalence of communicable and endemicdiseases, and a large number of counties in remote and medically underservedareas; (iv) evidence of having planned or initiated educational policy reform;and (v) ability and willingness to provide counterpart funds and willingness torepay the loan. Based on the above criteria, Anhui, Fujian, Guizhou, Hebei,Henan and Shanxi provinces were selected by the Chinese Government to participatein the project.
3.4 Selection Critsria for Prefectures. The criteria for selectingprefectures within tho six provinces participating in the project were:
(a) Health policy statements by the Prefecture Executive or by theprefectural assembly, expressing a commitment to solving the ruralhealth manpower problem;
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(b) Evidence of actions taken by the prefectural governments to improverural health services, such as rotation of urban medical staff torural areas, or assignment of medical school graduates to rural areas;
(c) Existence of an organizational framework and a managerial process topromote and improve rural health care services;
(d) At least two thirds of the prefectures selected in each provinceshould be in the lowest quartile of the province's per capita GNPrange and one third could be in the next higher quartile;
(e) Selected prefectures must have a secondary medical school capable ofreceiving assistance from higher level institutions and providingsupport to the lower level county health schools. In cases wherethere is more than one prefectural level school the best one shouldbe chosen. Likewise, not all county health schools within aprefecture should be selected but only the ones that have mostpotential for developing into quality teaching institutions;
(f) The infant and maternal mortality rates should be higher than theprovincial average; and
(g) The percentage of rural health manpower without formal training shouldbe higher than the provincial average.
3.5 Based on the above criteria, each project province selected five toseven prefectures to be included in the project. All counties in the selectedprefectures would be included in the project area and would benefit from theproject in one way or another, but only some of them would directly receivehardware investment funds. The project would invest in training schools inprefectures and counties and in service institutions in townships and villagesthat are clearly below acceptable provincial standards.
3.6 Basic Information on Proiect Provinces. The six selected provincesare relatively poor compared to the national average. Table 3.1 provides basicdemographic and socioeconomic information on the project provinces. There aresignificant variations in socioeconomic development among the six provinces.Guizhou stands out as the poorest with fewer natural resources and poorer healthconditions.
3.7 A total of 36 prefectures with 374 counties are included in theproject. There are 7,659 townships and 126,978 villages in the project countieswith 159 million people (about 55X of the total population of the six provinces).Table 3.2 shows the share of the population and the number of administrativeunits in each province that would be included in the project. Annex 1 providesadditional information by province on training facilities and health servicesdelivery units that are part of the project.
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Table 3.1 llic Iufori tiou on Project Proyiuce.*
Anhui** NJ Lan guishon 80bel Honan Shanxi CHINA
Main CharactoristLcs
Population (million) 57 29 32 59 86 29 1112
Total Area (1000 3(2) 137 121 176 188 166 156 9600
S Mountainous 55 75 87 35 27 80 42
Population Density (/3(2) 403 233 181 313 493 177 116
S Rural 86 61 83 83 66 78 s0
Socl economic Indicators
CUP per Capita (Yuan) 1,089 1,384 749 1,333 1,034 1,261 1,420
Health Up. as I of Cov. 4.0 3.7 4.6 4.3 4.1 3.9 2.5lip.
3.8 During project preparation, the six provinces have carefully plannedthe activities to be carried out during project implementation. Objective* andactivities were defined, responsibilities for execution assigned, end timing andresource allocation decided. Project management computer software (Time Line)was used by all project provinces to document specific project plans in terms ofwhat is to be done, when, how, by whom, and what resources are needed. Itdescribes the project in terms of activities, timing, resources and costs.Proposed project activities are presented in Gantt Charts (produced by TimeLine). Provinces will use the project management software to implement andmonitor project execution. The major proposed activities and resourceallocations are su-arized below for the three provincial components and thecentral component.
HEALTH MANPOWER PLANNING (Base Cost US$3.8 million)
3.9 Obiectives and Activities. The design of the health manpower planningcomponent was guided by a set of agreed on principles, objectives and activities(Annex 2). It would achieve six objectives, with each objective supported byspecific activities:
(a) Develop a health planning capacity in the Drovinces by organizing andstaffing health manpower planning units at provincial, prefectural andcounty levels and by establishing the necessary mechanisms forcoordinating planning and for common activities shared by all sixprovincesl
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(b) Train the Dlannina staff by: (i) organizing inter-provincial trainingworkshops for provincial and selected sub-provincial planners; (ii)holding training workshops in the provinces for provincial and sub-provincial planners; and (iii) training selected planners locally andsending some overseas for university-based academic degree programsor agency-based study tours;
(c) ImDrove the glannint data base by standardizing and upgrading thequality and relevance of the data collected;
(d) Im=lement he-lth maniower Dlannint by: (i) conducting or updating a'situation analysis" of health manpower and health system needs andpriorities; (ii) carrying out a small annual study or survey on apriority topic; (iii) updating and improving the accuracy ofprovincial demand estimates and supply projections; (iv) updatingmanpower staffing and productivity standards; and (v) carrying out aone year provincial manpower study and preparing a provincial manpowerplan;
(e) Establish a gualitative basis for manpower Dlanning by carrying outa job analysis study as a basis for writing job descriptions and byobtaining information and input from the local community; and
(f) Monitor and evaluate the manpower plannint function by holding annualmeetings to review planning priorities, problems, methods and toexchange results, and preparing an annual report on the healthmanpower situation and accomplishments.
Inputs
3.10 Trainina Health Manpower Planners. About 725 health manpower plannerswould be trained during the project period. Of these, about 8Z would receiveoverseas training (Annex 3). Annual working conferences would be organized forabout 85 participants (Annx 4). The total number of health manpower plannersto be trained is equivalent to an effort of 2,636 person/months of local trainingand 135 person/months of foreign training. Activities organized and implementedon an inter-provincial basis include seminars and workshops to improve data basesand projections, overseas study tours, and annual conferences for a total of 433person/months.
3.11 Office EauiDment for the provincial and prefectural planning officeswill be provided and shared with the project implementation offices at thoselevels.
3.12 Technical Assistance would be provided by local academic centers andby foreign experts: about 390 person/months of local and 45 person/months ofoverseas technical assistance for seminars and workshops. Annex 8 providesadditional detail on resources required for successful implementation of thiscomponent.
3.13 Research Studies supporting the health manpower planning componentare, inter jlia, a job analysis and workload study, improving the planning database and conducting a situation analysis, improving manpower staffing andproductivity standards, and annual surveys on priority topics to be selected.
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HEALTH MANPOWER TRAINING (Base Cost US$123.8 million)
3.14 Obiectives and Activities. Five objectives are underpinned by a metof agreed on guiding principles and by specific activities associated with eachobjective as detailed below and explained in greater detail in Annex 5
(a) Establish Provincial Trainina Networks and Plans. Within eachprovince, a provincial training network coordinating and linkingtraining institutions at the provincial, prefectural and county levelsand a provincial training plan for the project area would beestablished as the cornerstone of subsequent decisions on investmentin prefecture and county level schools and on the allocation ofresponsibilities and resources within the project's geographic area.The training network and the training plan would: (i) assess thecurrent strengths and limits of existing prefectural and countytraining institutions and document their resources and productivity;(ii) establish clinical practice sites as a training resource to beshared by several training institutions; (iii) articulate differentlevels of training programs to obtain cost savings and increasequalityl and (iv) establish a teacher development and evaluationcapability.
(b) Train Teachers and Administrators for Health Trainina Schools: (i) theskills of teachers in instructional design and educational measurementwould be enhanced in short-term workshops; (ii) national andinternational study tours would be organized for leaders of academictraining programs; (iii) each project province would establish acapability to conduct research on improved teacher performance,materials development, evaluation of teaching methods and studentperformance, end inservice training for the existing teachers; and(iv) teachers would receive training in new teaching methodscorresponding to the new curriculum.
(c) Improve the Skills of the Existing Health Workers: (i) an analysis ofcurrent duties and training needs of existing workers would beconducted in coordination with the job and task analysis describedunder the health manpower planning component; (ii) inservice training,correspondence instruction, and supervised clinical practice sessionswould be designed, conducted and evaluated to target specific skillsto be improved, and training modules would address the most severe andmost prevalent performance problemsl and (iii) educational performancestandards would be established analogous to job performance standardsto assess readiness for clinical practice.
(d) Revise Preservice Education and Train New Health Workers: (i) thecontent of the work that the future health workers will be expectedto do and the levels of proficiency they will be expected to havewould be identified as a basis for selecting the knowledge, skills andbehaviors to be included in the preservice course of instruction; (ii)existing curricula would be reviewed to determine needed revisions;(iii) new materials and approaches to instruction which emphasizeexpanded clinic-based training and learning-by-doing would bedeveloped; new health workers would be trained using the newcurricula, materials and instructional approaches.
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(e) Uvmrsde Infr-structure of Trgininx Institutions: The project wouldupgrade the physical infrastructure of secondary medical schools andof county health schools. Detoriorated, undersized and unsafebuildings for classrooms, laboratories, dining halls and studentdormitories would be repaired, or replaced if needed. Nowconstruction would meet the requirements of expanding enrollment, newteaching and learning approaches, and curriculum reform. Provincialtraining centers serving the project area would be repaired, secondarymedical schools and county health schools would be expanded orrehabilitated, and "practice bases" with classrooms andaccommodations for faculty and students at the county and centraltovnship levels would be established adjacent to or integrated withcounty and central township hospitals.
Inputs
3.15 Curriculum Development. The project would support the revision ofprimary health care education curricula. The current curriculum puts much moremphasis on theory than on clinical practice. Curriculum reform would be basedon the job descriptions and the knowledge and skills required by the village andtownship health staff. The new curriculum would emphasize comunity healthproblms, diagnosis and treatment of common diseases and preventive activities.The task of revising and adapting the curriculum to the epidemiology of thecommunity would be done more efficiently and at less cost on an inter-provincialbasis. Teaching materials and texts will require revision, pilot testing andevaluation.
3.16 Teaching Reform. The project would also support changes in teachingmethods. The aim is to increase teachers' teaching skills. Lecture styleteaching would shift to increasing group discussion, laboratory instruction anddemonstration, and practice-based learning. The current examination andcertification system would be evaluated and improved.
3.17 Trainina Teachers and School Administrators. The project wouldenhance the quality of existing faculty through in-service training for teachersof secondary medical schools and of county health schools. The project wouldprovide 44,613 person/months of inservice training for teachers of secondarymedical schools and county health schools. Training methodology would beexperience-based and use mainly workshops as a vehicle. A more detailed trainingplan is provided in Annex 4. About 90 school administrators of secondary medicalschools and of county health schools would receive ine-rvice training and alsoparticipate in national or international study tours (15 per province) to improvetheir management skills and increase the efficiency and effectiveness of theschools.
3.18 Training Health Workers is the central element of the trainingcomponent. It aims to improve the quality of rural health manpower throughinservice training and to increase the number of health workers throughincreasing enrollment. Of these two training modes, in-service training wouldreceive more mphasis.
3.19 Inservice trainina will include short-term (loes than three months),intermediate (from three to six months) and long-term (more than seven months)courses. The project would provide 1119570 person/months of short-term training,535,480 person/months of intermediate training, and 1,464,797 person/months of
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long-term inservice training. About 402 of township level health workero, 45Zof village doctors and 152 of other village health workers (village aid*e, birthattendants) would receive such training.
3.20 Preoservice trainina will include courseo of less than one year, oneto two years, or three years in duration. The project would provide about 73,190person/months of short-term preservice training to village doctors and othervillage health worker., about 279,178 person/months of one to two years trainingand about 594,892 person/months of three year training. Preservice training fortownship level health workers would be an additional 551,140 person/months (Anne4).
3.21 Cateaories of Health Workers. The following categories of townshiplevel health workers for the township level would receive training under theproject: assistant doctors, nurses, assistant pharmacists, public healthassistant doctors, laboratory assistants, HCH assistant doctors and midwives, andothers (Anne 4). About 360,000 workers would receive inservice training andabout 60,000 would have preoservice training over the life of the project.
3.22 At the villait lv2l, the project would train and retrain villagedoctors, village health aides and birth attendants. Training plans for eachcategory of health personnel would be made based on existing staff and theprojection of future needs. The content of training would be designed accordingto job descriptions and functional analyses of township and village health staff.
3.23 Civil Worko The project will finance the expansion of six provincialtraining centers/medical colleges, 36 secondary medical schools at the prefecturelevel, and 146 county health schools. The project will also finance theconstruction of training bases at about 500 county and township health facilitileto accommodate the trainees during their practical training. A total of about428,757 square meters of building area will be constructed at the 189 traininginstitutions either as extension of existing buildings or additional buildings.Also about 109,565 square meters of existing buildings will be rehabilitated.Depending on the functional requirements of the individual institutions, prioritywill be given to the construction of teaching facilities and of studentdormitories and related accommodations. The facilities to be constructed for thepractical training will consist mainly of teaching space and housing for studentsand faculty. It is eotimated that about 84,161 square meters of building willbe constructed for that purpose. Annex 6 presents details of civil worksrequirements by province, by type of investment and by level of traininginstitution.
3.24 juipment. The project would procure basic teaching and learningequipment and educational materials for secondary medical schools, for countyhealth schools and for provincial training centers. The suggested equipment hasbeen provisionally categorized into five areas (office and audio-visual, teachingaids, clinical, preclinical and special subjects). The final equipment listwould be based on the provincial training plan, the new curriculum to bedeveloped, the type and number of manpower to be trained, and the instructionalmethods to be adopted. It would be prepared during the first year of theproject. That list will then be submitted for approval to an Equipment SelectionCommittae (ESC). The KSC would therefore be organized at the and of the firstyear of project implementation and its composition, terms of reference, equipmentselection criteria and selection procedures are set forth in Anne 7. Duringnegotiations, agreement was reached with the Government on the composition and
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terms of reference of the Equipment Selection Committee to be established by June30, 1994, on the selection criteria and procedures to be used and applied.
3.25 Investment in equipment for training institutions would be aboutUS$13.2 million or 8.8% of total project investment cost.
3.26 Technical Assistance would be provided for the development of jobdescriptions, the establishment of the training networks, curriculum developmentand the provision of training. A total of 810 person/months of local and 80person/months of foreign technical assistance has been scheduled for this purpose(Anne 8).
MANAGING RURAL HEALTH SERVICES (Base Cost: US$24 million)
3.27 Oblectives and Activities: A set of guiding principles underlie thefour objectives, and the activities with their associated resource allocationshave been defined (Annex 9). A description of each objective and its supportingactivities follows.
(a) Develoo He-lth Services Management and Supervision Systems: Efficientand effective management of health services requires trainingmanagerial and supervisory staff and supporting them with information,tools and procedures which strongthen their knowledge of the workcontent and the standards of performance. Work procedures would bereevaluated and revised to support the work and the workers.Appraisal and feedback systems would be developed that concentrate onimproving the process and showing staff how to do their work moreaccurately and efficiently.
(b) Provide Retular On-the-Job Trainina: The project would develop asystm to monitor the standard of primary health care at the townshipand village levels. Regular auditing will be conducted to: (i)reinforce messages instilled through formal teaching sessions in orderto ascertain that clinical skills are maintained; (ii) assess theeffect of training on the standard of practice; and (iii) improve thequality of care through feedback from the auditing. The auditingsystem will also provide the framework for the supervision both oftrainees and of those receiving in-service training at theclinic/hospital level.
Standard protocols for managing major clinical conditions, standardapproaches to patient care procedures (e.g., aseptic techniques), andstandards for the physical environment and performance of the healthcare institutions will be developed for the different levels of careunder the guidance of the "clinical audit panall consisting ofteachers, clinicians and managers. "Rapid evaluation" manuals will beused at formal or unannounced supervisory visits. Clinical audit orpeer review meetings will be held regularly at township hospitals withinvolvement of staff from the village up to the county/prefecturelevel to discuss problems with logistics, diagnosis and treatmentwhich may have led to "avoidable" morbidities and mortalities.
(c) Develop Financina. Compensation and Incentive Systems: The projectwould design an experiment to study alternatives for: (i) mobilizing
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financial resources to support rural health care delivery; (ii)organizing and managing rural health services; and (iii) paying therural doctor. New approaches to organizing and financing rural healthservices and alternative payment and incentive schemes for ruralhealth yorkers would be developed. Baseline data would be collected,reviewing current sources of financing, expenditure patterns, abilityand willingness to pay, utilization rates, compensation and incentivesystems. The study would assess the strengths and weaknesses ofcurrent financing and payment methods. Based on this information,different organizing, financing and payment models would be designedand implemented to meet the needs of rural communities at differentlevels of socioeconomic development.
The project would select a number of townships as experimental sitesand an equal number as control sites in four project provinces andconduct the experiment for three years. (See Annex 10 for detailedstudy design.) Using these experiments that will be testedoperationally, the provinces will develop affordable models oforganizing and financing rural health care and of paying rural healthworkers. These models would be developed for townships with differentlevels of socioeconomic development. The results, including policyimplications, would be discussed with the Bank. An action programwould be developed and presented to provincial and national policymakers for possible adoption. The provinces would be assisted at thenational level by MOPH's Department of Medical Administration to carryout the experiments. Technical assistance would be provided by localacademic institutions and by overseas consultants for training instudy design, data collection, data analysis, and design ofsustainable models for national adoption.
(d) Uotrade Infrastructure of Health Services Facilities. The projectwould rehabilitate selected existing central township hospitals andtownship health centers. No new facilities would be constructed.About 1,302 townships would benefit (17S of the total number oftownships in the project area and 101 of the total number of townshipsin the project provinces) from rehabilitation of existingconstructions. The project would also improve the equipment of 460central township hospitals, 842 township health centers and 8,210village health stations.
Inputs
3.28 Trainina Health Service Managers gnd Supervisors. About 10,885person/months of inservice training will be provided to health service managersin basic management and personnel practices. About 1,285 person/months oftraining in methods of clinical supervision will be provided.
3.29 On-the-Job Trainina. The project would finance the development ofprotocols and manuals and the organization of workshops for teaching clinicalaudits. It would finance transportation costs for subsequent evaluationactivities but the township hospitals would be expectod to allocate funds tocover the continuation of such practice beyond the period of the project.
3.30 Financint. ComDensation and Incentive Systems. Staff inputs wouldinclude a director of the evaluative studies, technical staff (statisticians,
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economists), field survey supervisors at the prefectural, county and townshiplevels, computer programmers, data input staff and clerks. Other resourcesrequired are training vorkshops, equipment, materials, supplies, travel and studytours, and technical assistance.
3.31 Civil Wora. The project will finance upgrading and repairing about989 central township hospitals and township health centers or 17S of thoseestimated as needing repair in the project provinces and 28Z of those needingrepair and located in the project area. About 80,790 square meters of buildingarea will be rehabilitated. It is estimated that an additional 4,743 townshipfacilities in the six provinces require repair and these would be upgraded undera national program as part of the country's effort to reach the goals of "Healthfor All by the Year 2000".
3.32 5juivmnt. The project would procure medical equipment to improveabout 460 central township hospitals, about 840 township health centers and about8,210 village health stations. Agreement has been reached on standard lists ofequipment for each of the first two types of institutions and these lists are inthe project file. Each township facility would select equipment from thestandard list that is appropriate for its situation and functional needs. Themaximum amount for any single township health center would be about US$8,800 andfor a central township hospital about US$20,000. For village health stations,equipment would be procured in standard packages costing about US$220 each.About 8,210 village health stations would receive the standard package (71 of thevillagea in the project ar-a). The total investment in equipment for healthservices facilities is US$14.1 million (9.41 of total project investment cost).
3.33 Technic-l Assistance would be provided to help redefine the system ofsupervision and to assist in finalizing the manuals for supervision and clinicalauditing. A total of 317 person/months of local and 70 person/months of foreigntechnical assistance is scheduled (Anne 8).
CENTRAL COMPONENT (Base Cost: US$0.9 million)
3.34 Obiectives and Activities. The central component would augment theinstitutional capacity of HOPH and especially of three MOPH departments: theDepartment of Education (DOE), the Department of Medical Administration (DONA)and the the Foreign Loan Office for coordinating and supporting projectimplementation activities and disseminating project results. HOPH, mainlythrough the DOE, would strengthen its capability to carry out its nationalmandate in manpower planning and manpower policy formulation. It would providetechnical assistance to the project provinces and evaluate the activities inorder to disseminate the experience gained to the rest of the country. MOPH,through the DOHA, would support, monitor and assist in the execution of thecomponent dealing with organizing and financing rural health services andcompensation systems for rural health workers. LO would coordinate alllogistical aspects of project implementation and assure liaison with theAssociation on general matters
3.35 The Deiartment of Education in MOPH would: (i) strengthen its capacityin health manpower planning (HMP) and in the use of community-based medicaleducation; (ii) develop a national capacity to conduct research and training inHMP through support and utilization of a center of excellence; (iii) coordinateand help with the organization of interprovincial activities in the aroas of jobdescription, curriculum design, development of educational materials, and
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evaluation methods and target.; (iv) determine national qualificationa incommunity-based medical education; (v) coordinate the development of appropriateteaching material. for rural health workers; and (vi) develop coordinatingmechanisms among the line departments in NOPH.
3.36 The DeDartment of Medical Administration in NOPH would receivetechnical assistance to enable it to lead and support the following projectactivities: (i) evaluate the current approaches in financing and organizing ruralhealth services and paying rural health workers; (ii) design the associatedexperiments, including selecting experimental and control sites; (iii) implementthe experiments; (iv) monitor and evaluate the experimentation; undertake thefinal assessment of the experiment; and (v) further develop models of financingand payment and assist in the general adoption of these models (see also A10).
3.37 The Foreign Loan Office in NOPH would monitor project implementationin order to make sure that: (i) the agreed on targets are not changed; (ii) theagreed on activities are efficiently and effectively implemented andmodifications are fully justified; (iii) the procurement of civil works andequipment and of services takes place according to agreed procedures and onschedule; and (iv) counterpart funds are timely available.
3 38 Inuts. The Devartment of Education of MOPH would need the followingresources to carry out its supportive and policy formulation roles: overseastraining and study tours (US$194,077) equipment (US$33, 101), national workshops,travel to project provinces, materials, supplies and publication expenses(US$178,014), local technical assistance (US$11,240) and foreign technicalassistance (US$105,000). Total expenditures would be about US$521,430.
3.39 The Department of Medical Administration in MOPH would requireequipment (US$10,450), local technical assistance (US$21,446), foreign technicalassistance (US$104,530), overseas training (US$24,007), research study (69,425)and a total budget of about US$229,858 (Aneg 11).
3.40 The Foreian Loan Office of MOPH would need local training (US$17,056)overseas training (US$9,826), local technical assistance (US$20,906) andequipment (US$5,226).
INTERPROVINCIAL ACTIVITIES (Costs included above)
3.41 Obiectives and Activities. Nineteen project activities are organizedon an interprovincial basis for the purposes of: (i) cost sharing; (ii)standardization; and (iii) efficiency and effectiveness. Activities whichrequire large amounts of technical assistance, training and study tours would beplanned in such a manner that all provinces can share costs. Comion approachesand materials would result in methods and techniques which can be easilyreplicated across the project provinces and ultimately to the rest of the nation.
3.42 Responsibility for each of the 19 interprovincial activitios (IPA) hasbeen assigned and accepted by a single province or an entity such as a medicaluniversity or MOPH. Each activity is shown in the overall plan as it is relatodto the components of the project, l.e., manpower planning, training or
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management. Details of each interprovincial activity are contained in theproject implementation schedules for each province (Annex 12). Two of thenineteen activities deal with project-related training for project managementstaff and with preparing the final project evaluation and the project completionreport.
3.43 Manvower Plannina IPAs. Four activities are planned. All activitiesinvolve training either in short-term (3-5 weeks) in-country workshops oroverseas training of one month duration. All are aimed at improving the capacityto undertake health manpower planning at the provincial level. Improving andstandardizing the data bases for planning are continuing collaborative activitieswhich will require coordination with MOPH.
3.44 Manpower Trainine IPAs. Nine activities are scheduled. The firstactivity involves a collaborative effort to develop job descriptions for healthworkers at the township and village levels. This activity has already startedafter project appraisal because it constrains many subsequent activities, e.g.development of provincial training plans, preparation for civil works design.Workshops on teaching reform, materials development, materialsevaluation/improvement, and training program evaluation would be spread acrossthe early phases of project implementation. The duration of each activity isusually 3-5 weeks.
3.45 Rural Health Services Management IPAs. Four activities are scheduled.Three management training activities involving 10,885 person/months are planned.Overseas visits of one month duration are planned for 48 health servicesmanagers. The annual meetings of provincial project staffs are included as anactivity within this component. These meetings would involve the leaders of eachcomponent for the purpose of exchanging experiences, coordinating collaborativeefforts and planning follow up activity.
3.46 Schedulina of Interirovincial Activities. Fourteen activities arescheduled for the first year. For example, the IPA to develop Job Descriptionswill begin with a workshop organized with overseas experts. The follow upactivity will be a two part interprovincial workshop scheduled for two weekseach. Each workshop would involve 10 persons from each province and at least twopersons from MOPH.
3.47 A workshop would be held at Shanghai Medical College on healthmanpower planning (8-10 participants from each province) for one month.Workshops on managerial training and materials development would also bescheduled for the first year. The focus of these Program Manager trainingworkshops would be on procedures required by the Government and IDA duringproject implementation, e.g., record keeping, financial accounting, managerialaccounting, reporting, inventory, procurement, etc. Hebei Province will host theseminar/workshop on training reform. It will involve 55 persons for one month.These IPAs will occur in the first half of the first year of projectimplementation and the remaining activities would be scheduled subsequently.
InDuts
3.48 Approximately 1,250 persons from the six provinces and 25 from thecentral government would participate in the interprovincial activities for atotal of 1,097 person/months of training and development activities. Thirty-six
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person/months of foreign end 180 of local technical assistance would be assignedand shared equally among the six provinces and the central component (Annex 12).Some 6,810 person/month. of overseas training and study tours are planned. Thecost of these inputs (US$4 million) is included in the respective projectcomponents.
PROJECT RELATED TRAINING
3.49 To ensure that appropriate management skills are developed in theprovincial Project Implementation Units, 63 person/months of training organizedby NOPH's Foreign Loan Office would be given during the first year of projectimplementation. There would be a series of three two-week training sessionsattended by seven people from each province. At the completion of each session,provincial representatives would conduct a two-week course for staff from projectoffices at the prefectural level or below and for other relevant officials,providing another 546 person/months of training. In addition, 84 months of long-term overseas training would be provided (Annex 13).
CHINA * 4 4*Rurai Heslth Workels 0ewlopsnt tr 0Su mry Accounts Cost Su awry*
4.2 Cost Estimates. Costs are based on October 1992 prices for similarprocurement in recent contracts. Civil works unit costs, based on recent similarcontracts, range from Y 265 per ma to Y 600 per m or about US$50 to US$110 perin,, depending on the locality. Unit costs for rehabilitating existing buildingsrange from Y 150 per m2 to Y 300 per m2, or US$30 to US$55 per nin, depending onthe extent of rehabilitation and locality. The cost of professional fees for thesurveys, designs and supervision of construction is estimated at ten percent ofthe cost of construction. Equipment costs are based on the unit costs of similaritme procured recently under competitivo bidding procedures. Local technicalassistance was estimated at Y 4,000 per person-month and foreign consultants atUS$10,000 per person-month including transportation cost, per diem andaccommodation expenditure. Training costs would range from Y 100 to Y 1,200 pertrainee-month for domestic training and US$2,045 to US$4,900 per trainee-monthoverseas depending on the length of training. Recurrent costs were based on pastprovincial budgetary estimates. Physical contingencies were estimated at 42 ofbase cost, while price contingencies, 16S of baso cost, were based on aninflation rate of 61 for local currency and 3.72 for foreign costs.
B. Financing
4.3 The proposed credit of US$110 million equivalent would finance about59S of the total project cost, including about US$30 million in foreign exchange.The local governments, mainly prefecture and county governments, would financeabout 411 of the total project cost. MOPE would finance a small part of thecentral component cost (about US$0.1 million). The Financing Plan is shown inTable 4.3.
4.4 The Government would on-lend the proposed credit in foreign and/orlocal currency to the project province, repayable over 15 years, including a sixyear grace period. Project provinces would have a choice whether to borrow fromthe Government in SDR or in RMB. The interest rate for onl-nding would be a dualratet 1.5 percent for foreign currency and 3 percent for local currency. Projectprovince, would bear the foreign exchange risk where applicable. Atnegotiations, assurances were obtained that the Borrower will make the proceed.of the Credit available to the project provinces on the above terms andconditions acceptable to the Association, and that the Borrower will ensure thatthe provinces make the credit proceeds available to prefectural and/or countygovernment, on terms and conditions acceptable to the Association which shall betho same terma and conditions as it receives or on more concessional terms ifwarranted by the poverty level of the county or prefecture concerned. Assuranceswere also obtained that the provinces will make credit proceeds available toproject townships and village, without obligation of repayment by such townshipsand villagos.
4.5 Recurrent Expenditures. The recurrent costs for maintenance of civilworks, equipment and vehicles and operation and maintenance (O&M) are estimatedat about Y30.5 million spread over six years until projcot completion.
4.6 Counterpart Funds. The proposed IDA Credit would financeapproximately 59 percent of total project cost. At negotiations, assurances wereobtained that the participating provinces would be able to acquire from theirrespective annual budgets, at least the relevant annual amount as shown in Annex15 as counterpart funds for the proposed project to carry out the project, andthat provinces would provide the counterpart funds for local governments in thepoorest areas in case the contributions of these less developed areas shouldprove insufficient. A Project Agreement, with terms and conditions satisfactoryto the Association, would be signed between the Association and the six provincesparticipating in the project.
4.7 Financing of Central Component. MOPH activities to be carried out byits Department of Education and its Department of Medical Administration wouldbe financed by MOF (about US$751,288). The credit share of this amount would bea grant by MOF to MOPH and the balance would be a supplemental budget allocation.
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V. PROJECT MANAGEMENT AND IMPLEMENTATION
A. Organization and Management
5.1 Organization and Management. Project management at the central levelwould be led by the Ministry of Public Health (MOPH). MOPH, through its ForeignLoan Office (FLO), has well-established systems for managing developmentprojects. The Department of Education (DOE) and the Department of MedicalAdministration (DOMA) are two line departments of MOPH that would be involved inproject management at the central level as defined in Annex 11. The managerialcapacity of these two departments would be strengthened under the project tocoordinate substantive and technical project activities and to supportdissemination and replication of project findings. During negotiations,assurances were obtained that these responsibilities would be assigned to a full-time project manager in DOE and a full-time coordinator in DOMA both employeduntil project completion. FLO would coordinate all logistical aspects of projectimplementation and assure liaison with the Association on general matters, whilethe participating provinces would communicate with the Association on detailedmatters. MOF would be responsible for managing the Special Account. The CivilWorks Design Experts Group of MOPH will review the conceptual design proposalsfor major civil works prior to preparation of preliminary working drawings andbid documents and will monitor the civil works program (Annex 16).
5.2 In each participating province, a leading group has been establishedfor supervising the management of the project. The leading group is headed bya provincial Vice-Governor, with the deputy provincial Secretary-General anddirector of the provincial Health Bureau as two deputy group leaders. The groupmembers include deputy chiefs of provincial Planning Commissions, provincialFinance Bureaus, and provincial Personnel or Labor Offices and the chief ofprovincial Education Commissions. The functions of the leading group are tocoordinate between government bodies and to decide on major project matters.
5.3 The project provinces have each established a Project ImplementationOffice (PIO) under the Bureau of Public Health at provincial level. Duringnegotiations, assurances were obtained that each project province would maintain,until project completion, its PIO with facilities, functions and staffingsatisfactory to the Association. The PIOs are in charge of routine managementof project implementation. The organization and staffing of the PIOs, as shownin Annex 17, is satisfactory. For civil works, the provincial Public HealthBureau is responsible for selecting the design unit to conduct surveys, designsand supervision of construction at the prefectural level and above. The countyPublic Health Office, under the guidance of the provincial Public Health Bureau,is responsible for organizing the design and supervision of civil works at thecounty level and below.
5.4 The Project Division in FLO and, more directly, the planners andeducators in the PIOs of the six participating provinces would be responsible forall project component activities including technical assistance, in conjunctionwith staff at prefecture, county, township and village levels.
5.5 Status of Prolect PreRaration. All existing training schools havebeen identified. The majority of the secondary medical schools at theprefectural level have been surveyed and conceptual designs of the facilities tobe constructed under the project have been prepared. Preliminary equipment listsincluding specifications for Phase I procurement have been prepared, reviewed and
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found to be satisfactory. Phase I procurement for about US$10 million couldtherefore be announced soon after Credit signing as the General ProcurementNotice would be announced after negotiations. Manpower planning, training andsupervision activities have also been listed in detail, including plans for theuse of consultants, local and foreign, and local and overseas fellowships. Earlystart-up activities would be initiated under retroactive financing (see para5.18). The proposed project is therefore ready to be implemented immediatelyupon Development Credit Agreement signing.
B. Procureent
5.6 Items to be procured and financed partly or wholly with creditproceeds include civil works, equipment, medical instruments, technicalassistance and training. Civil works includes new construction andrehabilitation. Most of the construction will be simple in style and in ruralsettings. Locations would be scattered in about 36 prefectures in six provinces.All civil works procurement at county level and below would follow the localprocedures of selection of the lowest evaluated bidder among the invited two tothree local contractors and community organized groups. Force account proceduresmay be used for the construction and repair of township level facilities forcontracts estimated to cost less than US$25,000 up to an aggregate amount notexceeding US$1.5 million. The average cost of civil works at a county school isabout US$100,000 and of a practice base is about US$20,000. The total estimatedcost of civil works at these levels represents about 60% of the total project'scivil works cost. All civil works procurement at prefectural level and abovewould follow local competitive bidding (LCB) procedures acceptable to theAssociation. IDA review prior to contract award and signing would be limitedonly to those contracts (about 42 institutions) estimated to cost more thanUS$300,000 each (about Y 1.6 million equivalent). The rest would be subject torandom sample review by supervision missions. Construction supervision will beorganized by the construction engineering units of the provincial Health Bureaus.Standard bid documents prepared for China will be used for LCB.
5.7 nuiRnj t financed from the IDA credit proceeds for this project wouldbe largely medical and teaching items, mostly of small unit costs but in largequantities. About 50 percent of teaching equipment and medical instruments,including computers for project management offices would be acquired throughinternational competitive bidding (ICB) following IDA's Procurement Guidelines.Contracts estimated to cost between US$25,000 and US$300,000 equivalent, inaggregate not exceeding US$11.7 million, may be procured through LCB proceduresacceptable to the Association. Goods estimated to cost less than US$25,000 percontract, and in aggregate not exceeding US$5.0 million, may be procured directlythrough local shopping procedures under contracts awarded on the basis ofcomparison of price quotations obtained from at least three eligible foreign orlocal suppliers. International suppliers may compete in these procedures.Contracts for proprietary items and items required for the purposes of achievingequipment standardization, subject to the approval of the association on a case-by-case basis, may be awarded after direct negotiations with suppliers, inaccordance with procedures acceptable to the Association. Under ICB, localmanufacturers would be eligible for a margin of preference in bid evaluation of15 percent or the prevailing rate of customs duty, whichever is lower.
5.8 Teaching equipment would be procured in three phases spread over fouryears. The first phase would cover about 25% of the teaching equipment to cover
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items unlikely to be modified due to curriculum improvments and changes intraining strategy. The second phase (602) would be for item identifisd duringproject preparation but reviewed during project implementation, whsn the trainingneeds have boen more clearly and more specifically defined. The final phase(152) would include unforeseen items end some for specific training purposes andwould be purchased around the fourth or fifth year of project implementation.Equipment for administrative purposes and equipment for health sorvicesfacilities would be includod in Phase I procurement.
5.9 Equipment lists have been prepared by the six participating provincesand reviewed by MOPB end the Association. Major items with high unit costs havebeen reviewed end are satisfactory in terms of items proposed and skeletonspecifications. Items with small unit costs and sometimes in large quantitiesare too numerous for detailed review. For Phase I procurement, both the itemproposed end the technical specifications have been reviewed end found to bosatisfactory. These are therefore ready to be included in the bidding documentfor the first Invitation For Bid (IPB) without prior IDA review. An EquipmentSelection Committee (ESC) would be established to review and approve equipmentproposed for procurement under the second end third phases. The proposed ESC issatisfactory from the points of view of: (i) organization; (ii) members in thereview com ittoes; (iii) qualifications of the members; end (iv) authority fordeleting, substituting, modifying suggested specifications and returning tooriginating unit for second thoughts end changes. During implementation, furtherESC end IDA review on items to be included would be needed for second end thirdphase procurement.
5.10 Equipment would be grouped, to the extent possible, to form packagesin excess of US$300,000 for each contract. Proposals from six provinces wouldbe forwarded to FLO for bulk purchase by the International Tendering Company(ITC) of China National Technical Import and Export Company (CUTIC) which hasexperience with ICB procedures using the Association's Procurement Guidelines.The provinces may each proceed with some procurement under LCB proceduresacceptable to IDA and use other procurement procedures including local shopping(para 5.7). For contracts exceeding US$300,000 each, prior IDA review of bidevaluation reports and no objection would be required before contracts could beawarded and signed. For other contracts, random sample review of bid evaluationreports and contracts would be carried out by supervision missions.
5.11 Consultant contracts estimated to cost l-es than US$100,000 equivalenteach may be procured - in accordance with principles and procedures satisfactoryto the Association on the basis of the Consultant Guidelines published by theBank in August 1981 - without prior review except for the terms of reference forsuch contracts, the employment of individuals and single source selection offirms. Contracts of US$100,000 equivalent or more will require priorAssociation review or approval of budgets, short lists, selection procedures,letters of invitation, proposals, evaluation reports and contracts.
TOTAL 15.5 29.3 127.1 13.6 136.0(12.6) (13.3) (34.1) (0.0) (110.0)
Note: Figures in parentheses arm the respectiv am_mts financed by InA.NIF: Not IDA financeda. other m_tbods include direct purchaes and local shopping.
5. 12 Prior IDA review of technical specification vould also be required
before inviting bids for equipment contracts estimated to cost in excess of
US$300,000.
5.13 On technical assistan£e, the procurement of foreign consultant
services would follov IDA Guidelines on the Use of Consultants. Employment oflocal consultants, to the extent possible, would be encouraged, as in many areasthere is such expertise in China. Training activities will be carried out underannual contracts with the training institutions on the basis of training programsacceptable to IDA.
C. Disbursements
5.14 The proposed credit of SDR 79.3 million (US$110 million equivalent)
would be disbursed over a period of six and a half years according to the
following percentages and against the folloving categories of expenditures:
(a) 20% of the cost of civil works;
(b) 100% of the CIF costs of imported equipment,
100% of the ex-factory cost of locally manufactured equipment, and 75%
of local expenditures for other items procured locally;
(c) 100% of the cost of consultant services and overseas training; and 70%of local training.
5.15 Reimbursement against training and contracts for civil works and
equipment of less than US$300,000 each would be made on the basis of statements
of expenditure (SOEs). Documentation supporting the SOEs would be retained byFLO in MOPH and the PIOs in the provinces and made available for random sample
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review by IDA supervision misions. All other disbursements would be madeagainst full documentation.
5.16 The estimated forecast of disbursements closely follows thedisbursement profile for human resources projects in China (Annex 18).
5.17 Special Account. A Special Account with an authorized allocation ofUS$6.0 million, based on four months average expected expenditures, would beestablished in a bank acceptable to IDA. The account would be under the controlof the Ministry of Finance (MOF). Applications for replenishment of the SpecialAccount will be submitted monthly or whenever the Account has been drawn down byabout 50% of the initial deposit whichever occurs first.
5.18 Retroactive Financing. To ensure the timely implementation oftraining and technical assistance needed for a rapid start-up of the project,such as training of an initial core group of job analysts and manpower planners,preparing training plans, etc., eligible expenditures made after October 31, 1992and procured in accordance with IDA's Guidelines would be retroactively financedby the Association. Total retroactive financing would not exceed US$10 millionequivalent.
D. Accounts and Audits
5.19 Audits. Separate project accounts showing expenditures for projectactivities would be maintained by each province. A total project account wouldbe maintained by the FLO in two books, one by project component for each provinceand one by category of expenditures for the whole project. MOF would maintainthe Special Account and the SOEs in conjunction with FLO. Project accounts wouldbe audited by the State Audit Administration (SAA) and/or its local offices inaccordance with standard practices in China. During negotiations, assuranceswere obtained that within six months after the end of each Government fiscalyear, an annual audit report by independent auditors acceptable to theAssociation, including an audit of the Special Account and a separate opinion onthe SOEs, would be submitted to the Association.
E. Prolect Monitoring and Evaluation
5.20 Imolementation Schedule. The proposed project would be implementedover a six-year period, plus six months for the completion of payments and fullwithdrawal of credit proceeds. The project is expected to be completed by June30, 1999 and closed on December 31, 1999. A project completion report would besubmitted by PLO to IDA within six months of the closing date. PLO wouldcoordinate the preparation of semi-annual progress reports, with mainachievements and issues to be discussed with visiting IDA supervision missions.
5.21 Proiect Monitoring. FLO would coordinate project implementation andprovide support to provincial PIOs. Each PIO has used the same computer software(TIMELINE) to prepare project implementation plans, including Gantt Charts foreasy project monitoring. Progress reports can be generated easily at any time.Provincial PIOs and local governments would be responsible for necessarymodification and revision of original plans after reviewing progress ofimplementation and identifying needs and problems. A review meeting would be
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held annually and attended by all project provinces. Any major changes in plansare subject to review and approval by the Association and MOPH. IDA supervisionmissions would be able to track progress towards achieving objectives using thesame computer project management software.
5.22 Project Evaluation. Project provinces have agreed to a projectperformance plan to evaluate achievement of project objectives. Two sets oftarget indicators have been developed: one set for process indicators and one setfor outcome indicators. Process indicators are the same for all six provincesand would measure the development and use of plans and manuals, number of workerstrained, and civil works completed. Process targets are scheduled at threepoints in time and would ensure that milestones are reached and that achievementsare continued and institutionalized as appropriate. Outcome indicators areprovince-specific and would measure, inter alia, progress in staffing health carefacilities with qualified health workers, improving basic health services andemergency care at the village and township levels, and reducing maternalmortality rates. Values for outcome measures were estimated for the beginningof the project and targets were set to be reached by project completion. Theperformance plan is presented in Annex 19. During negotiations, assurances wereobtained that each province would carry out the project's objectives inaccordance with the performance plan consisting of performance indicatorsacceptable to the Association.
5.23 SuRervision Schedule. Project supervision would be a jointresponsibility of IDA and MOPH (Annex 20). Milestone events would be:
(a) Two supervision missions each fiscal year including visits to threeprovinces and an annual meeting for all six provinces to take stockof the progress in implementation and to determine the activities forthe coming year. A status report should be prepared for the use ofeach visiting mission;
(b) Financial Supervision: In May of each year, FLO and MOF will examinethe credit utilization and progress of payment, and help the provincesprepare the statement of accounts for the preceding year;
(c) Assurances were obtained that a mid-term review will be undertakenwith the cooperation of SPC and MOF no later than November 30, 1996;
(d) Final evaluation will be conducted at the beginning of the year 2000with inputs from the provincial PIOs, SPC and MOF and theparticipating MOPH departments.
F. Environmental Aspects
5.24 The project would have no significant impact on the environment. Itwould, however, train rural health workers to promote health education, toimprove sanitation and to protect the health of the villagers from theenvironmental effects and the occupational hazards of recently developed ruralindustries.
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G. ImDact on Women
5.25 Currently, about 80 percent of rural doctors are male. Thispercentage is expected to decrease as there is a trend towards admitting morefemale students to prefectural and county level health training institutions.This project will support this trend and accelerate it by requestingparticipating project provinces in the Project Agreement to agree to achievingtwo gender-specific project outcomes, viz, a substantial increase in the numberof villages with female doctors and also of villages with female doctors trainedand equipped to deliver family planning, MCH and obstetric care. The provincestherefore will train more female rural doctors who will also be better suited tohandle the MCH and family planning aspects of the rural doctor's practice.
VI. BENEFITS AND RISKS
A. enefits
6.1 At the end of project implementation, rural health care delivery inthe project provinces will have been strengthened, and alternative means formobilizing local financial resources and for compensating rural health workerswill have been developed. All village clinics in the project area will bestaffed by a village doctor with a "village doctor certificate" and most villageswill have two village doctors, one of whom is female. Health personnel at thetownship level will be better trained and able to solve a broader range of healthproblems. Health care facilities at the township level will be repaired andequipped with appropriate medical technology. County and prefecture schools fortraining and retraining health workers will have adopted a practice-orientedcurriculum reflecting community health needs, and their faculties will be ableto use new teaching methods. These schools will have been rehabilitated andexpanded, and more relevant teaching equipment will have been installed and used.The project's emphasis on the poor and its attention to maternal and child healthproblems will have reduced maternal mortality ratios in project areas. Projectoutcomes would also be relevant to the prefectures of the project provinces notincluded in the project and would be disseminated to other provinces in thecountry.
B. Risks
6.2 The project would change the way rural health workers are trained.Reforming established training patterns involves important conceptual andattitudinal changes on the part of provincial authorities, school administrators,teachers and managers, which are difficult to accomplish and difficult tomeasure. Not all teachers will be eager to change the way they teach in orderto improve learning achievements. Training new students offers differentincentives to schools than retraining existing personnel. Onlending of creditproceeds by the Borrower to the beneficiary provinces at higher interest ratesand a shorter maturity may selectively induce some provinces to invest incounties that are more able to repay the loan thereby potentially decreasing theintended full participation of the poorest counties.Implementing the studyresults on alternative ways of mobilizing local funds and paying providers wouldneed government support for adoption on a large scale. However, the Governmentis keenly aware of the need for change in rural health care delivery and stronglysupports the project's goals and objectives. Careful project planning,supervision, and monitoring as well as government assurances would alleviatethese risks.
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VII. AGREEMENTS REACHED AND RECOMMENDATION
7.1 At negotiations assurances were obtained that the Borrower will:
(a) establish an Equipment Selection Committee by June 30, 1994and agree on the composition and terms of reference of the Committeeand on equipment selection criteria and procedures to be used andapplied (para 3.24);
(b) make the proceeds of the Credit available to the project provinces at1.5 percent for foreign currency expenditures and 3 percent for localcurrency expenditures, repayable over 15 years, including a six yeargrace period, and that the provinces make the credit proceedsavailable to prefectural and/or county governments on terms andconditions which should be the same as it receives or on moreconcessional terms if warranted by the poverty level of the county orprefecture concerned (para 4.4);
(c) continue to employ until the completion of the project,a full-time project manager in MOPH's Department of Education and afull-time project coordinator in MOPH's Department of MedicalAdministration for the purposes of coordinating project activities andsupporting dissemination and replication of project findings (para5.1); and
(d) ensure that within six months after the end of each Government fiscalyear, an annual audit report by independent auditors acceptable to theAssociation, including an audit of the Special Account and a separateopinion on the SOEs, would be submitted to the Association (para5.19).
7.2 At negotiations, assurances were also obtained that the provinceswill:
(a) make the credit proceeds available to prefectural and/or countygovernments on terms and conditions acceptable to the Association, andmake the credit proceeds available to project townships and villageswithout obligation of repayment by such townships and villages (para4.4);
(b) provide amounts satisfactory to the Association from provincial annualbudgets as counterpart funds sufficient to carry out the project,provide the counterpart funds for local governments in the poorestareas in case the contributions of these less developed areas shouldprove insufficient, and sign a Project Agreement with the Associationwith terms and conditions acceptable to the Association (para 4.6);
(c) establish Project Implementation Offices and maintain them, untilproject completion, with facilities, functions and staffingsatisfactory to the Association (para 5.3);
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(d) audit project expenditures and, within six months after the end ofeach Government fiscal year, provide the Association with a report ofsuch audit (para 5.19);
(e) carry out the project's objectives in accordance with a performanceplan with performance indicators acceptable to the Association (para5.22); and
(f) participate in a mid-term review of the progress of projectimplementation by no later than November 30, 1996 (para 5.23).
7.3 Approval by the State Council of the Development Credit Agreementwould be a condition for credit effectiveness.
7.4 With the above assurances, the Rural Health Workers DevelopmentProject would be suitable for an IDA credit of SDR 79.3 million (US$110 millionequivalent) on standard IDA terms, with 35 years maturity, to the People'sRepublic of China.
VILLAGE HEALTH STATION 20835 1116 22852 1232 10576 220 47733 0 45009 3600 26560 0 184515 6210
0
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Annex 2Page 1 of 6
Rural Health Workers Develonment Prolect
Health ManRower Plannina ComuonenttGuiding Princiylos. Oblectives and Activities
1. Guiding Principles
Health MIn oHer and Health Plannin. Health manpower planning is anintegral part of health planning. Both must be strengthened together.They should be closely linked to the unit responsible for healthstatistics.
High prioritv for the Planning unit levels. The devolution ofresponsibility under decentralization requires a strong planningcapability at the provincial Bureau of Public Health (BOPE). The BOPHwill need to provide technical guidance to planners at prefectural andcounty levels. Strong linkages should be established among these planningunits and vith other governmental units concerned with planning, financeand policy.
Collaboration with other provinces. In order to reduce costs andaccelerate work, joint offorts in planning among provincial planning unitsshould be encouraged. This will enable useful products early and will bean effective means to pool the planning ezpertise and to exchangetechnology.
The i=mortance of training. Few people have training in health manpowerplanning. Resources for training, staff development, and informationexchange will be needod.
Emhasize treater numbers of planners at lesser levels of training. For agiven amount of resources a province can either train a few planners to ahigh level of espertise, or more planners to a lesser level. The latterstrategy coupled with a plan to increase the level of training ispreferred.
Short-term vorkshon training will be *ohasized. The preferred trainingstrategy for rapid development of the planning staff is based upon short(3-6 veeks) modular workshops rather than long academic programs. Theworkshops should emphasize the practical application of planningtechnology and should be followed by a period of application of the nevknowledge to produce useful products in the province. Performance inthese training vorkshops and on the job can becom the basis for selectionfor university training and overseas study.
Trainint targets ire for double the numb-r reauired. Approximately twiceas many planners should be trained as will be working in health planningat any one time. This higher training target is set to anticipate someexpected loss of trained planners to other sectors, i.e. education,
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Annex 2Page 2 of 6
planning commission, finance, and the lose of planners to managerial rolesin the BOPH. Planning skills and technology are part of the fundamentalpreparation of managers and executives.
2. Planning Objectives and Activities
OBJECTIVE #1: DEMVLOP A DEALT! PLANNING CAPACITY IN THE PROVINCE
Activity: Oraanize and staff health and heolth manoover Dlannina units atthe Drovincial and subDrovincial levels and establish necessary mechanismsfor coordination of plUnnina and for interorovincial ioint efforts.
Comments: The number of planners vill vary from province to province. Areasonable assumption about size would be from 4-6 trained planners at theBOP! provincial level and 40-60 persons with some planning training at theprefectural or county levels. Provincial planners are assumed to workfull time in planning while some sub provincial planners may combineplanning with other administrative, statistical or data supportactivities. Additional support (clerical and data) will be needed for theplanning activities. Rapid start up may be achieved through the loan ofexperienced personnel from other settings, e.g. planning bureaus,educational institutions, to provide leadership and help with the trainingof planning unit personnel.
Planner qualifications will need to be carefully considered. Skills thatare especially useful are public health planning end management,statistics, epidemiology and economics. Medical end other clinical skillsare useful, but not sufficient by themsolves. For the higher levelplanners at least three to five years experience is desirable. Theprovincial level planning director should be selected on the basis ofdemonstrated leadership ability. Planning unit effectiveness will dependupon the technical *nd the interpersonal skills of the leader.
The purpose of having planners is to provide senior health and educationalexecutives with better information and guidance on which to base theirdecisions. Every effort should be made to find persons with goodaptitudes and potential, to provide thm with some basic training and workexperience in planning and to provido them with opportunities foradvancement through career ladders.
OBJECTIVE t2: TRAIN ThE PLANING STAFF
Activity: Plan and hold inter-nrovincial trainihn workshols fororovincial and selected sub-provincial nlanners,
Coermnt: All provinces may join together to sponsor end contract for thedevelopment of short-term, intensive workshops designed for the leadershipof the planning units being established. Curriculum and study materialsdeveloped for these workshops may be useful in the subsequent inservicetraining for other planners in the province. Careful evaluation of these
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Annex 2Page 3 of 6
training sessions will inform the subsequent sessions about content andmethods which are most useful.
It will be desirable to develop a national resource, probably university-based, for the development of top level planners in the health field.This unit can have the additional responsibilities of conducting researchon planning methods and for the dissemination of new planning technologiesto the field of practice.
Activity: Hold training workshops in the orovince for Drovincial and sub-Prolincial planners.
Coment: Those workshops serve dual purposes. First, they are aneffective and necessary means to develop the planning skills andtechniques of the lower level planning staff. Second, they provide avenue for the coordination of planning activity within a province.Attention to building a team of planners should be equal to the objectiveof skills development. Local area statistics and studies will become thefoundation for provincial planning. Attention to the quality of the dataresources can be reinforced during these sessions.
Activitys Send selected planners for a university-based academic deareeoroaram or agency-based studt tour.
Coment: An academic degree at the masters level or a 1-3 month studytour to various locations that provide good examples of planning can be auseful activity to augment leadership development among the top levelplanning staff. Overseas training is very expensive, can be provided toonly a very few persons, and unless carefully planned, may not berelevant. The possibility of sending planners to Chinese universities andresearch institutes should be considered. Strengthening the acadmic basefor planning research and training is highly desirable.
Provinces may arrange for international training or assign theresponsibility to an inter-provincial conittec which would identify theoverseas academic progrms and study tours that best fit the needs of thoplanning units. Study tours involving persons from several provinces villstrengthen the planning skills and the inter-provincial collaborationactivity.
OBJICTIVE #3t IEPIOVE TEt PLAMING DATA IASE
Activity: Imurove and standardize the alanAina data base.
Coent: This activity will be very important to all the provinces and toall of China. It would be preferable to make this an inter-provincialcollaborative activity to assure standardization betwoen planning units.Leadership and resources from HOPS can be very useful to this activity.
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Annex 2Page 4 of 6
The major emphases of this effort should be toward improving the qualityand relevance (to decision making) of the data collected, and not onincreasing the quantity collected.
Efforts should be made to improve data standardization ao that numbers ineach province mean the same thing. Annual meetings to address mergingissues should be held to assure the continued high visibility andattention this activity deserves.
OBJECTIVZ #4: IHPLZHENT WALT! MANPOWER PLANNING
Activity: Conduct or undate a "situation analXsis" of health nimuower andh-alth system needs and priorities,
Coment: It is important to establish a good baseline analysis of thecurrent status of the health system and health manpower. The analysisshould identify the main problems, issues and priorities. It shouldpresent policy concerns and options to solve problems and it shoulddevelop a vork plan to carry out special studies on selected high prioritytopics in the near term. This activity is useful in the training ofbeginning planners. This work would familiarize them with the problcms ofthe health sector and give them practical experience in one of the tasksof planning.
Activity: Carry out an annual small study or surVey on a wouity topic.
Comment: This activity vill provide specific, timely and useful productsto the authorities to help them mike decisions, while at the same timeprovide practical planning experience to the new planning staffs. Thetopics should be well defined and should not require more that 10-12person/months of effort to complete. Complexity of topics can increase asthe planners become more experienced. Inter-provincial collaborativestudies may be an important variation if differences are thought to exist.Otherwise, the findings from one provincial special study may be usefulto the other provinces. Some interprovincial coordination of topicselection may be useful to avoid duplication of effort.
Activity: Ud ate *nd imrove the aulitv of oroXlacial supolvuroiction
Comment: This activity would use the emerging planning capability to beapplied to an important and timely problm. Som supply projections existin most provinces. The quality and currency is not known. By the end ofthis activity the supply data base should be much improved, thus reducingto a mLnmum the time necessary to update the projections in the future.In many ways supply data and projections are the easiest of the planningtasks. Success in this endeavor will build confidenco within the planningstaff and earn the respect of the decision makers.
Activity: Undto mnuower staffina and nroductivitv standrds.
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Annex2Page 5 of 6
Comment: This study is a major undertaking. Job analysis andperformance/productivity standards from the activities in Objective #5(Qualitative Data) will provide much needed information for revision ofstandards. The cost of this activity will be considerably reduced and theusefulness to China increased if the standards are developed through acoordinated, interprovincial effort. One province could revise townshiplevel standards, several others could work together on differentcategories of county level health facilities and others could work onprovincial level facility and staffing standards. All draft standardscould then be reviewed by all provinces and revisions adopted.
Activity: Carry out a one Tear urovincial meuower studv and arepare anrovincial usDovwer plan,
Comnent: This study resulting in a provincial health manpower plan bringstogether all the major findings of the previous efforts on such topics assupply, requirements, distribution, productivity, and costs.
The HOPE could find it useful to support and participate actively in thisone year study with two objectives in mind. First the HOPE plannors willgain experience in how to implement such a study--experience that could beshared vith other provinces. Second, they could work concurrently todevelop similar projections for the entire country. By using realprovincial data for many of the projection model inputs, valuable guidancecould be obtained for national decision making.
OJEICTIVE #5: ESTABLISh A QUALITATIVE BASIS FOR PLANNING
Activitv: Carrv out a iob analysis study.
Comnent: This is definitely a good ex=ple of an activity that can andshould be done with inter-provincial collaboration. Job analysis resultsin a good job description that vill help planners and policy makers decidehow many persons should have the required competencies. Likewise, it isuseful to educators in designing specific proservice and inservicetraining programs, and to managers as they supervise and evaluate theirstaff. Having data about job content helps planners decide how toredistribute work smong various staff and how to redistribute staff amongdifferent locations. The responsibility for defining the jobs (contentand competencies) lies principally with the BOPE, but the study shouldinclude educators as-part of the study teas to assure that the educatorswill use the final determination of duties and performance competencies intheir teaching.
Activity: Obtain infoTmation on the oninigns and attitudos of a broadarrga of exuerts. officials and citiznsg.
Coinent: One of the precepts of PRIOARY HEALTH CARE and one of thefundamental tenets of good planning is to involve all the stakeholders inthe process of planning, priority setting and program devolopment.Techniques such as the Primary Health Care Review, Delphi panels to
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Annex Page 6 of 6
identify priority problems and to render expert judgments about how beatto treat the problems, and other qualitative methods, e.g. focus groupsare useful means to acquire the input and the expertiso of the community.
OBJECTIVE #6: MONITOR AND EVALUATE THE MANPOWER PLANNING FUNCTION
Activity: Prenare an annual report on the health mannower situation andacco.Dlishments.
Comments This report vill serve as a record of accomplishments, as a workplan for the next year and as one means of monitoring and *valuatingPlanning Unit effectiveness.
Activity: Sold &anual inter-,rovincial mootings to review 2nanningpriorities, ,robloo. methods and to exchsnae results,
Comment: A one week meeting to exchange experience, reviewaccomplishments, coordinate future inter-provincial activities, providesome training end to review future priorities will be useful to bothprovincial and national planning efforts. It also provides a venue forsenior health and education decision makers to attend and betterunderstand the needs of the other perspectives.
CHINARURAL HEALTH WORKERS DEVELOPMENT PROJECT
Overseas Training for Manpower Planners - by Year and Type of Training
PROVINCE Training 1 993 1 994 1 995 1 996 1 997 Total I
SUPPORT STAFF ANHUI FUJIAN GUIZHOU HEBEI HENAN SHANXI TOTALTRAINING
# of TeachersPerson/mos.Of:
Inservice 6120 3857 10694 4055 13736 6151 44,613
# of HealthServ. Mngrs.Person/mos.of:
Inservice 1690 864 3960 1587 1569 1215 10,885
* of ProjectManagersPerson/mos.of:
Inservice 120 137 231 275 137 265 1,165
# of PlanningstaffPerson/mos.of:
Inservice 330 182 273 767 247 837 2,636
TOT. SUP.STAFFTRAININGPerson/mos.of:
Inservice 8260 5040 15158 6684 15689 8468 59,299
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Annex 5Page 1 of 4
CHIA
Rural Health Workers Develoument Proiect
Health ManDower Trainina Comoonent:Guidina Principles, Obiectives. and Activities
1. Guiding Principles
Involve all stakeholders in decisions. Educational institutions facemajor internal changes if they are to be responsive to the shifting needsof the health sector coping with the health transition. Policy decisionsmust involve all those perepectives with a staka in the outcome and allthe tiers, .g. prefectural, county, township and village, affacted by thedecisions.
Eahasis on practical training. Training for improved quality primaryhealth care must be problem oriented, coununity based end its content mustbe derived from the health needs, condition. and goals of the community.
Perforance as the basis for reform. Job descriptions and performancestandards provide the tools for reforms in education and training.Training institutions may use them for instructional objectives andmeasurement of mastery while service institutions may use them forassigning duties end for appraising on the job performance.
Training content determinad from iob recuirements. The priority emphasismust be in practical training that includes only the skills and knowledgerequired by the tasks to be done. Tasks to be done are determined by jobanalysis techniques.
Teachers as full nartners in raform. Just as it is necessary to involveperspectives from outside education in the reform activity, it isessential to involve teachers in plsnning curriculum change. Teachersshould acquire ths skills of task analysis, job design, instructionaldesign end educational measurement.
Inservica training is a priority. Priority should be given to inservicetra-ining. First because it provides en imediate impact on the quality ofservices, snd second, because insarvice training can try out new teachingsad learning approaches (especially in clinical settings), evaluate themand decide if they are to be incorporated into preservice training.
Facilities snd eauiomnt serve rather than drive refor. Teaching reformsshould dictate the investment strategy in the educational institutions andnot vice versa. Major shifts toward use of clinical practice sites astraining sites are anticipated. This will require reformulating designsof space end equipment procurement.
Inter-provincial collaboration. Collaboration among the provincialtraining institutions is desirable from both the cost and the
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Annex 5Page 2 of 4
standardization points of view. Job descriptions, teacher training &curriculum modules are potential project activities.
2. Training Objectives and Activities
O&JMCTIVI #1: ESTABLISh A PROVINCIAL TRAINING NETWORK
Activity: Assess current strecuths and limits of existini traininainstitutions and docuoeat resources exd groductivity.
Comments Currently, there is little coordination or collaboration betweenand among the various training institutions vithin a province. Linkagesamong theso institutions will enable ome specialization for curriculavith limited demand, exhange of experience and teaching materials,standardization of content and methods and can aid in the diffusion of newmethods. Candid assessmnts of the strengths and the limits of eachtraining site can serve as the basis for institutional affiliationagreements which combine resources for a comon objective.
Activits: Establish clLnical siteg as trainia rources.
Cinment: A woll established clinical training facility can serve theneeds for practical training for a variety of health practitioners. Theseare ezpensive to establish and maintain and should be a shared resource tothe several training institutions.
Acti-its: Devolg0 a *rovincial train els ln.
Comment Agreement on overall goals, objectives, strategies, and actionplans can be an effective tool to obtain cost savings and to increasequality. Such a plan would allocate training progrms to the severalinstitutions in the network. Strategies for addressing the inservice andthe proservice priorities could be defined. Articulation between thedifferent levels of training programs can be defined to take advantage ofprior learning as a basis for entry into more advanced training.
Activitl: Establish a arovince-wide teacher develoont and evaluation
Comament Pooling the resourcoe of the several training institutions villenable a more coprehensive and thorough approach to teacher training andupgrading. Likewise, the potential for career ladders for teachers andpromotions vithin and between institutions can be defined and thestandards and qualifications agreed upon.
ONLCTSIVE 12 TUAI TACEAS AND ADUINISTRATO3S OF TRAINING INSTITUTIOS
Actkitly: Inhance the skills of teachers in Lnstructional desln. andeducational macuremnt.
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Page 3 of 4
Comment: Short-term. (3-6 week) workshops emphasizing the practicalcontent of these activities should be the basis for increasing theabilities of the teacher cadre. Selected teachers showing interest andpotential for further development can be identified and sent to moreadvanced training emphasizing the theoretical bases and the methodsunderlying the design of instruction and its assessment. Workshopsettings allow for exchange of idoas and positive peor influences onadoption of new methods and materials.
Activitv: Provide national and international study tours for leaders ofacademic trainin. prorams.
Coament: Teacher training and curriculum reform will not be sustainablewithout the understanding and full support of the administrators of thetraining institutions. These learning exporiences arranged for groupswill strengthen the personal and professional relations among the leadersof these units.
Activity: Establish an institut- with a mission of iunrovinm teachertrainina for the health crofessions.
Comment: Each province should develop a university-based institutecharged to conduct research on improved teacher performance, materialsdevolopment, evaluation of teaching methods, evaluation of studentperformance, inservice training for the existing teachers and the furtherprofessionalixation (cr-dentialing) of the teachers working in healthinstitutions.
OBJECTIVE #3 INCRLASE THZ SKILLS 0 THE EXISTING HALTT WORKE
Activity: Conduct an analysis of curront tob duties and traini=a needs.
Comment: The quality of the job performance of the existing workforce iswidely viewed as the most serious deficiency in the health manpower realm.Some documentation of this will be needed to guide the planning forimprovements. Coordination of this activity with the job and taskanalysis activity described above is strongly indicated. Defining thecurrent content of the jobs and defining the standards of performancerequires input from both the educational and managerial as well as theclinical perspectives.
Activitv: Desian. conduct and evaluate inservice tzaini. corrTeaoodenceinstruction, and sunervised clinical uractice sessio to trmet oecificskills develoment.
Coment: Based upon the job and performance analyses, training moduleswill be designed to address the most severe and most prevalentperformance problems. All possible means of instruction should beconsidered as the intent is to make a large and iie diate improv ement inthe quality of servico. The instruction must concentrate upon a narrowand spocific set of skills to be improved rather than a more global,
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Page 4 of 4
general upgrading of performance. Exporimentation and innovation areencouraged. Careful evaluation must be a part of the effort to judge theefficacy and the goneralizability to other setting.
Currently, many health workers (particularly village health workers) areunclear about their responsibilities, have few back up training materials,work with minimal resources and vork with minimal supervision of theirdaily tasks. Village doctors and midwives need inservice education tobring their performance up to acceptable levels, to keep them up to datewith new knowledge, technologies and changing responsibilities, and toprovide a pathway for upgrading their status.
Activity- Establish educational oerformace standards analoaous to iobperformance standards to assess readiness for clinical practice.
Coment: Educators must have standards of student performance whichsimulate the performance standards in the work setting. The mathods ofappraisal of student performance must concentrate upon the application ofthe practical knowledge and not just the theory. Continuing educationbased up the job description and the criteria of performance establishedby the BOPH is highly efficient in using the same basic materialsdeveloped for other levels. - The BOPE knows that the inputs it pays forare designed to achieve performance it has previously agreed to.
OBJECTIVE 14: REVISE PRESZRVICE EDUCATION TO EMPHASIZE PRACTICZ COMPETENCY
Activity: Identify the clinical. manacerial and educationalreasousibilities of the araduates of the varioue health professionsoccuDations.
Comentt As in the case of all training development it should begin witha thorough knowledge of the content of the work the graduates will beexpected to do and the levels of proficiency they will be expected to havethe first day on the job. This serves as the basis for faculty to choosethe knowledge, skills and behaviors to include in the course ofinstruction.
Activirt: Review existina curricula to determine noeded revisions.
Coment: The reworking of teaching inputs to focus on performance engagesall departments in rethinking what and haw they teach. This review shouldinclude the ascertaizment that each performance specified in the jobdescription is being addressed by some instructional setivity.
Activity: Develou new materials and onorosches to instruction whichemohasixo exoanded hosuital or clinic based training,
Coment: The current ratio of theory and classroom training to laboratoryand supervised clinical practice is nearly 3:1. A focus on performanceemphasizes learning by doing. lot only do the students learn more, butthe reorientation of the clinical site to its teaching responsibilitiesforces a rethinking of the justification for its current procedures.
TERMS OF REFERENCE FOR THE EOUIPMENT SELECTION CM4MIITTE (ESC)
1. PURPOSE - The ESC, established in the Ministry of Public Health (MOPH) vithTerms of Reference approved by the Vice Minister, vill select the equipment forprocurement from the schedule of requirements and technical specificationssubmitted by the provincial Bureau of Public Health (BOPL) and the qualifyingteaching institutions eligible for loan proceeds of the RHUD Project.
2. TASKS - The ESC will apply the agreed equipment selection criteria asspecified in Annex 1 to determine the recomended list for procuremsnt. It mayperform other related tasks as deemed necessary by the Chairman such as: (i)collecting and providing data on product quality and durability, (ii) providingrecommendations on the efficient use of the equipment, (iii) visiting thephysical sites vhere equipments are to be installed and determining theirsuitability.
3. STRUCTURE - The ESC consists of 13 members as follows:
* The Director of the Department of Education (DOE), MOPE or hisrepresentative as Chairman
* The Program Officer for the RMD Project, LO, MOPH as secretary
* One reprosentative from the State Planning Comission (SPC).
* One representative of each of the six project provinces
* Four specialists from outside the project provinces in each of thefollowing fieldst (i) rural primary health caret (ii) occupational or jobanalysial (iii) pedagogy of clinical training at the prefecture and countylevels; and (iv) in-service traiLing and distance learning for ruralhealth vorkers.
The ESC, vhenever necessary, may co-opt, for the discharge of its tasks,not more than 5 additional members who are technical specialists because of theirad-hoc expertise needed for a specific purposo.
4. MEETING LOGISTICS AND DECISIONS
4.1 The ESC will meet three months prior to the announcement of the bidinvitations in the second and fourth year of project implementation.
4,2 At least three months before the scheduled meetings, the provincial BOPEvill submit the equipment list with specificaticon to the LO.
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Annex 7Page 2 of 3
4.3 The secretary will check to ensure all necessary data are submitted,consult the chairman regarding the need for co-opting technicalspecialists, collate the lists from all 6 provinces, collect furthertechnical data as deemed necessary and send the total package to membersof the ESC at least 2 weeke before the scheduled meeting date.
4.4 Before the meeting, ESC members will review the submitted information and,vherever necessary, request additional information, from the secretary orthe provincial BOPH through the secretary.
4.5 At the meeting, the presence of 8 members (excluding the co-optedmembers), will constitute a quorum. Each member (excluding the co-optedmembers) has one vote and the chairman has a casting vote. A motion iscarried vith a simple majority.
4.6 The ESC will use the selection criteria to review the items on thesubmitted lists and determine those that are:
* approved;
* approved with revision of specifications and advice on effective andefficient usage and maintenance;
* rejected giving reasons for rejection as taken from the selectioncriteria.
4.7 The Secretary of the ESC will keep minutes of the meetings and record ofdecisions made by circulation and submit it before an affixed deadline tomembers of the ESC.
5. EXPENSES
Expenses for travel and communication will be covered by the centralcomponent.
6. ANIUDHENTS
The terms of reference of the ESC may, from time to ties, whenevernecessary, be smended by MOPH/FLO and IOPH/DOE after consultation with all otherESC members and the details will be added after approval by the Vice Minister.
7. TERMINATION
The ESC may be terminated by the Vice Minister but not before the closingof the RED project.
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Annex 7Page 3 of 3
CRITERIA FOR SELECTING TRAINING EOUIPMENT
A. EFFECTIVENESS IN ACHIEVING THE OBJECTIVES OF THE PROJECT
1. The equipment is to be used to suDport student learning and teaching in theprovincial training center, the secondary medical schools, the county healthschools and the practical training bases
2, The equipment must be used effectively in the revised curriculum inconjunction with new teaching methods that are developed as a result of thedevelopment of complete job descriptions based upon task analyses in the firstyear of the project.
3. The degree of technological sophistication of the equipment should beappropriate for the level of teachine under modern scientific conditions.Obsolete models should not be selected but new technological advances should bescreened carefully.
4. The equipment is going to be used regularly and frequentlv . If it is notfrequently required for teaching or learning purposes, the possibility of usingsimilar equipment available from other departments in the same school orneighbouring health or teaching institutions should be considered.
5. The equipment must be ipproDriate to the doveloDment of the skills whichthe trainee will perform in the health services delivery institution. Much ofthe learning will occur in practice settings (not in classrooms) and in self-study programs. The equipment should be easily available to support student useand should not be limited to use by teachors.
B. UTILIZATION AND MAINTENANCE
6. The recurrent cost in terms of consumables, supplies and spare parts shouldnot be hieh.
7. The consumables and spare parts are easily available locally.
8. The county has the caDabilitv to maintain the equipment as evidenced byqualified maintenance staff or agreement to signed service contracts.
9. The purchasing institution has trained Dersonnel to use the equipment.
10. There is budaetarv Rrovision for the recurrent cost.
11. Notwithstanding regulations governing bidding procedures, the cualitv anddurabilitv of the product as judged by past experience of members of the ESCshould be taken into consideration.
CHINARURAL HEALTH WORKERS DEVELOPMENT PROJECT
Swmy of Foreign and Local TA ReqP ,nws by Province aid Year
Pemon lmon FdRign Tecslic AssatmProiSc Prvnce Total
Manazina Health Services:Guiding Principles. Obiectives and Activities
1. Guiding Principles
Supervision is essential to assure auslity. Supervision is also trainingand staff development. Regular and-competent supervision based upon welldefined job descriptions and performance standards providce feedback onperformance, detects needs for additional training, and offersencouragement and recognition necessary to maintain morale.
Adeau&to and stable compensation systems are essential. Recruitment andretention of competent staff depend in large measure on the adequacy andthe stability of the workers compensation package. This goes beyondsalary to include paid training opportunities, planned and systematicupgrading of pay and benefits through promotion or job enrichment, fringebenefits, etc.
Workine conditions and the work desian must suooort the worker. Adequateperformance depends upon the appropriate tools, aide, supplies, materials,equipment and yell designed procedures. Frequently, poor workerperformance is due to deficiency of the working environment or poorlydesigned work procedures.
Incentive systems must unooort health toals. Adequate incentives forconduct of prevention and primary care activities must be provided tobalance the current structure which gives the greatest financial rewardsfor more complex treatment oothods.
Career laddars lead to efficient use of mannover. The ability to retainexperienced workers protects the investment in their training, providesstability to the organization, and demonstrates comitment and loyaltyfrom the organization enhancing morale. It is good policy to promotethese experienced and competent workers into leadership positions, or toenrich their current positions in recognition of worker growth.
Eliminate numerical oals or auotas and eliminate annual nerformanceratint of individuals. It is impossible to separata an individualsperformance from that of the systm. Meeting short taro objectives statedin terms of quotas places the emphasis on quantity rather than quality.
2. Management Objectives and Activities
OBJECTIVZ #Is PROVIDE FOR DEVELOPHINT O KAN&GERS AID SUPERVISORS
Activity: Train sataters and supervisors for their roles and sunnort thmwith techoolpo dcc whch stroeathen their knowledts of the work content anthe standards of gerformancc
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Annex 9Page 2 of 4
Comment: Perhaps the most critical factor affecting the success of healthservices delivery in a decentralized system is the knowledge andinterpersonal skills of the managerial and supervisory staff. Developingmanagement/supervisory talent is more than providing training in humanrelations, motivation, leadership, etc. It requires an informationsystem that informs both workers and supervisors about the content of thework to be performed and the standards of performance that are required.It requires that tools and procedures for job design, recruitment,selection, orientation, on the job training, staff development, andperformance appraisal be based upon this data base and that all theseprocedures are based upon a common description of the job.
OBJECTIVE t2: IMPROVE WORKING CONDITIONS
Activity: Analyze for and remove barriers that rob workerc of pride intheir verformance.
Coment: Management must discover what hinders peoples work. That meansasking several questions: Do employees understand what their jobs are? Dothey know what level of work is acceptable? Have they boen adequatelytrained? Is the equipment they use in good condition? Are they getting theassistance they need from the supervisory structure? Is there an effectiveway for them to report problems or suggestions? Is prompt action taken toresolve problems?
Activity: Constantly improve the work irocodurs.,
Comment: Standardization can lead to rigidity and the perpetuation ofinefficient or ineffective procedures. Management must be willing toreevaluate its procedures and to revise them to support the work and theworkers. A work climate free from fear: to ask questions, to ask forfurther instructions, to express ideas for change, to express issues aboutworking conditions is necessary to obtain the participation and wisdom ofthe workers who know exactly what the barriers are.
OBJECTIVE 13: IMPROVE PZRIORMANCZ STANDARD SETTING AND APPRAISAL
Activityt Eliminate work standards that ursccrLbe numerical auotas--substitute leadershin and gualitv upervisiLon
Comment: The problm with quotas and standards is that they are basedupon averages, which means that half of the workers may fail to reach thestandard. Shoddy performance and poor workmanship are allowed to slip bybecause of urgent nood to produce. The key to productivity and quality isto look for differenco in performance and to croate an atmosphere ofreceptivity to new ideas. Discovering how and why tho highly productiveworkers achieve provides clues to systom improvement.
Activitv: D*volov aouraisal and feedback systme that do not rely oninsvectlons of the final Product, i.e. rocords audit.
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Ane 9Page 3 of 4
Cooents Concentrate on improving the proc.s. and showing poople how todo their work more accurately and officiently. Change the role of thesupervisor from quality police to quality coach. This will require changein the organization throughout all its tier. All appraisal is aimed atimproving performance and must necessarily take the conditions of workinto account.
OECTIVE #43 PROVIDZ REGULAR ON-TUE-JOB TRAIlING
Activity: Ascss. trainina needs. n-rovid on site f-odback. identifyperformance oroblem that have training solutious. and provide on sitctraining
Coment: Too often workers learn their jobs from workors who are poorlytrained, inadequately supervised or from inadoquate written doscriptionsof job duties and performance standards. Many workars do not kno whatconstitutes a good or a bad job. Training in this case is not a fringebenefit for employees, it is a specific prescription for improving anaspect of performance that is deficient due to incomplete knowledge,inadequate practice, or incorrect tochnique.
ActivitY: Identity nerformace vroblm that are due to enviromntal orattitudinal caus-e wad nrovido a response,
Coent: Frequently, the underlying cause of performance discrepancy isnot lack of skills, knowledge or practice, but rather som constraint inthe work environmont or in the incentive structure that affects vorkermotivation. While a formal "training' intervention is not appropriate, itis important to discover more about the factors inhibiting performance.Group feedback sessions designed to diagnose the nature of the problem andsuggest solutions can have very positive effects on morale andparticipation. Do not leave these matters unattended.
OBJECTIVE #5: UPGRADE FACILITIZS AND LQUIPIENT.
Actvlitv: Provide remalar insuctions and preventivo aintenance activityor all facilities and eauigUMnt * R ir or roulace as needed, Procureauality uroducts which meet the standards of use,
Cosents It is the job of management to provido the means of productionand to maintain the workplace and the tools, aids, materials, supplios inufficient amounts and in good working order. The practice of awardingcontracts to the lowest bidder may not support performance. Manag e ntmust understand how and where these materials will be used and createspecifications to match the conditions of performance.
OJEZCTIVE #6s INSTALL ADEQUATZ, AND STABLE COKPNESATION AND INCENTIVE SYSTESWHICH SUPPORT PROGRAM GCOAL
Activity: Develop new a*uroaches to finance rural hoelth services nd
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Annex 9Page 4 of 4
alternativo incentive schmes to pay the rural health workers,
Conment: Unless rural health workers are paid adequately they may notstay on their jobs and their trained skills and knowlodge would becomeunavailable to the health sector. Moreover, appropriate incentives mustbe given to implement the national policy of "Prevention First" and togive priority to primary health care. This will also require thatrasponsibilities and functions of county, township and village personnelwill be coordinated and managed to achieve greater quality of sorvices ataffordable cost.
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Annex 10Page I of 7
CHINA
Rural Health Workers Development Proiect
Financing and Payment of Rural Health Services - Study Design
Problem statement
China had an organized system of community financing of preventive andprimary care services for the rural popu-lation. Health workers were organizedand paid by the agricultural collectives. Since the agricultural reform of early1980'., the community financing and organization of primary care services havecollapsed in most of the poor rural areas which created the following problems:
(a) Many trained health workers for the village and township levels cannotbe sustained due to the lack of financial support. Trained health workers soughtother gainful employment or moved. Many villages have no village doctors (V.D.)For example , 602 of the villages in the province of Guizhou have no V.D.Prevention is neglected and people lack access to primary care services.
(b) The current payment system creates perverse economic incentives. Mostof the V.D. practice on a fee-for-service basis. Since visit fees are set by thegovernment at a very low level, the V.D. generate their income by prescribing anddispensing drugs, and giving injections.
(c) The V.D. and the township health centers are not organized together andtheir respective services are not adequately delineatod, coordinated and managed.Consequently, a majority of the township health vorkers are under-utilized dueto the duplication and competition between V.D. and township health centers. Theaverage health worker at the township health center is only productive half ofthe time. On the other hand, the V.D. are spending as much as 752 of their timeon non-health related activities such as farming. Moreover, the quality ofprimary care services is not being managed and monitored.
Obiective of the Financing and Payment Studies
Develop suitable approaches to finance the village and township healthworkers so they can be sustained and perform their vork in an efficient and andeffective manner to improve the health status of the rural population.
Strategies to Achieve the Obiective
1. The rural communities would be stratified into five or six levelsaccording to their socioeconomic development. For each level, develop one or twomodels of financing and organization of preventive and primary care healthservices that can be put into practice by most of the towns and villages in thatlevel of socioeconomic development.
2. These models would be developed with rigorous scientific methods sothere will be strong confidence in their vorkability, validity and credibility.These models would be derived through quantitative evaluation of current
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Annex 10Page 2 of 7
approaches, and experimenting with different prepayment schemes of financing,with alternative methods of paying V.D., and various ways of organizing andmanaging the V.D. and township health centers.
3. The models will be developed according to a orderly process. First, thecost per capita for preventive and primary care services in a comunity will bedetermined through needs assessment and demand analysis. Second, the economiccapacity to pay and willingness to pay by the farmers, rural collectiveenterprises, and local government would be evaluated. Prepayment schemes wouldbe designed and experimented after these evaluations.
Alternative methods of paying the V.D. would be designed and experimentedafter assessing attitudes of V.D. and their behavioral responses to economicincentives and administrative measures.
Alternative ways of organizing and managing V.D. and township healthcenterra will be tried after evaluating the functions and responsibilities ofrespective health workers, the organizational and economic dynamice among thepersonnel, the relationship between the villago comittees, Parmers' CooperativeFund, township government and the health centers.
Activities and Steov to be Carried out
Tho proposed scope of activities are planned in light of the followingsituations:
The four project provinces participating in this study cover 100 millionpoople, located in 242 counties, 3,775 towns and 79,859 villages. Currently, thefive provinces have at least six approaches in financing and more than sevenapproaches in paying the V.D.
There are approximately five levels of socioeconomic development coveredby the project. At each level of development, it is desirable to experiment withat least two ways of mobilizing financial resources to support preventive andprimary health services, three different methods of paying V.D., and twoapproaches in organizing and managing township hospitals and village clinics.There should be three sites for each category of experiment. With thesevariables in mind, there should be about 200 experimental township sites.However, due to budgetary considerations, the studies propose a total of 100sites in the five provinces. The folloving activities are planned with thisnumber of sites in mind.
Pro-oroiect Activities:
Each province will conduct a baseline study of the goneral conditions onrural health care financing and payment at the county, township and villagelevels. Data will be collected from evory county and then data will be collectedfrom three randomly selected towns of each county and throe randomly selectedvillages of the surveyed towns. Surveys of village leaders and V.D. will beconducted to assess their attitudes toward financing and payment of the V.D.
Annes 1 0Page 3 of 7
This study will be completed by April 1, 1993. The survey instruments are shownas Exhibits 1,2,3,4,5.
Proiect Activities:
Activity 11: Evaluation of the current approaches in financing andorganization of rural health services.
Step 1: Household survey and evaluation. Collect household data toevaluate people's health status, needs, demand, utilization rates, current totaland out-of-pocket health expenditures, economic capacity and villingness to pay,satisfaction vith the current system and opinions about alternative methods offinancing and organization of rural health services. Each province would conducta household survey in 50 towns, sampling 400 households in each town. Thissurvey will be completed by the end of the first year of project implementation.A preliminary design of survey instrument is shown as Exhibit 6. The sample sizerepresents approximately 2.81 of the households. Surveys should be completod bythe end of project year I end evaluations vill be completed 18 months after theproject began.
Stop 2. Data collection and evaluation of village health stations. Eachprovince vould collect data from a sample of IS0 village health stations toassess the preventive, maternal and child health, family planning and publichealth vork being performed, illnesses being treated, patient referral totownship and county hospitals, drug prescribing and dispensing, and quality ofservices being offered. The sample sizs represents about 1.1 of the villagehealth stations. The data collection would be completed before the end of yearI and the evaluativions vould be completed 18 months after the project bogan.
Step 3: Data collection and evaluation of selected township hospitals.Each province vould collect data from a sample of 50 township hospitals to assesstheir functions, productivity, quality of sorvices, relationship vith the V.D.,sources of revenue, expenditures and management. The sample sixz representsabout 3.5S of the towncship hospitals. The data collection would be completedbefore the end of year I and evaluation would be completed 18 months after theproject began.
Step 4: Evaluation of comaunity organizations. Each province would selecta sample of 200 townships to evaluate their coesunity organizations. The studywould assess the functions and interrelationship among the various organizations,their ablity to represent the interest of the farme and the popular confidenceenjoyed by the organization. This part of the study would ascertain vhichorganization can most effectively mobilize financial resources from the farmersfor health services and provide the external supervision of the health servicedelivery unit. This study is to be completed by the end of year 1.
Step 5: Survey the attitudes of health cadres. Conduct a survey of healthcadres to ascertain their judgements on the financing, organization andmanagement of rural health services and administrative feasibility of various
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Annex lOPage 4 of 7
approaches. This survey is to be completed nine months after the project hasbegan. The preliminary survey instrument is shown as Exhibit 5.
Activity #2: Scientific Experimentation
Step 1: Select experimental and control sites. All five provinces woulduniformly stratify their townships and villages into different levels ofsocioeconomic development. Each province would select 20 experimental townshipsand another comparable 20 townships as control sites. This task should becompleted at the end of year l.
Step 2: Design the experimentation on the financing and payment of V.D. andobtain agreement from the 20 townships to carry out these evaluative studies. Thedesign would focus on the three variables: different methods of mobilizing localfunds to support the rural health services, alternative methods of paying theV.D., and various ways to organize and manage the village clinics and townshiphospitals. The design work relies on what is learned from the assessments of thecurrent approaches and the evaluative studies outlined in Activity #1. This taskshould be completed 15 months after the project has began.
Step 3: Implement the experiments. This part includes the training ofpersonnel at the prefectural, county, township and village level to carry outthese studies. The experiments should be implemented 18 months after the projacthas began.
Step 4s Monitor and evaluate the eperimentation. The study vill becarried on for 3 to 4 years. Each year, data will be collected to analyze thesuccesses, failures, problems, health status of the population, preventive andpublic health conditions, patients' satisfaction, public support, stability andproductivity of the health workers, stability of financing, behavioral responsesof V.D. to different payment methods, organizational behaviors under differentmanagement approaches, efficiency and effectiveness of health care delivery,quality of health services and drug usage. The annual data collection includeshousehold surveys, examination of a sample of patients' records at the townshiphospitals and village health stations, and financial analysis. Data would becollected from both the experimental and control sites.
Step 5: Final asoesement of the experimnt. Comprehensive data vould becollected to answer the following questions: (i) under what circumstances thefarmers, rural collective enterprises, and local goveruents are capable andwilling to jointly prepay the rural health servies;l (11) how much money couldbe mobilized from these sources when towns and villages are at different levelsof socioeconomic development; (iii) vhat is the cost per capita for thepreventive and primary care services and for hospital in-patient services; (iv)which financing methods are most stable and sustainablel (v) how do V.D. reactto economic incentives (e.g. various payment methods) and management measures;(vi) what payment levels, payment approach, and working conditions vould retainthe V.D. and health workers in their health jobs and perform the appropriateservices; (vii) how to organize and manage the township hospitals and V.D. toobtain the most cost-offective preventive and primary care services; (viii) which
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Annex l0Page 5 of 7
financing and organizational arrangements give the most satisfaction to thepeople and deliver the best quality of services. The scope of data collectionand analysis for the final assessment are comparable to the initial assessmentdone in the first and second year as described in Activity #1. This task shouldbe largely complete.. by the end of year 5.
Activity #3: Develop models of financing and payment and assist in thegeneral adoption of these models.
Step 1: Design the models of financing and payment for each level ofsocioeconomic development, based on the quantitative analysis and other findingsfrom the evaluation of the current approaches and the experimentation results.Organize focus groups composed of farmers, V.D., other health workers, villageand township leaders, and health cadres to help design the models. Organizeseminars to obtain comments to refine the models. This task should be completedat the beginning of year 6.
Stop 2: Develop training manuals on how to adopt the models, theimplementation steps, methods of community assessment, the actuarial andaccounting methods, job descriptions of the health workers, the administrativeprocedures and management techniques.
Step 3: Educate the public and local officials on the findings of theseevaluative studies and the resulting models developed from them, and obtain theiracceptance to adopt these models.
Step 4: Provide training and technical assistance to the towns that adoptthe models.
Activity #4: Organization and Administration of the Evaluative Studies.
Step 1: Organization and staffing. Staff requirement would be:
Provincial level:Director of the evaluative studies: I FTE personTechnical staff (a statistician and an economist): 2Field supervisor: 1 personComputer programs r: 1 personKeypuncher for data entry: 2 personsClerk: I person
Prefectural levelsField supervisor: 2 persons (assuming the studies
will be done at two prefectures in each province)County level:
Field supervisor: 4 persons (assuming the studies will bemainly done at four counties)
Township level:Supervisor: 20 half-time persona one at each site
Step 2: Staffing for the data collection and tabulation of data may becontracted to a provincial institution. The design of surveys and complex
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analysis of data will be done mainly through domestic and foreign technicalassistance.
Stop 3: Training of the staff. The staff has to be trained on theobjective and methods of these studies, the substantive issues to be answered bythe studies,and certain basic knowledge and methods such as statistical methods,computer progrtming, economics, behavorial sciences, research design, sampling,management sciences, health care financing and payment, field interviewing, dataverification.
Training conducted at the inter-provincial level: aninitial 8 week session on the purposes of the studies, basic knowledge andmethods. The staff will return to the provinces and actually carry out some ofthe work then return for another 6 week training session. Also the computerprogrammers, statisticians and economists will be trained at the inter-provinciallevel in specializad short tarm courses.
Training conducted at each provincial level: these sessions are for thelocal field supervisors who will implement the studies.
Study missions and training overseas: a study mission composed of 4-5people from each province will undertake a one month study tour overseas. Eachprovince will also s*nd one or two persons for a one year ovarseas training.
Activity #5s Technical Assistance
Tachnical assistances is nooded in seven major activities described below.Technical assistance would be provided by domestic and foreign experts throughlong term institutional arrangements. It has been estimated that, in terms ofman-months, the ratio of domestic technical assistance would be three timea thatof foreign technical assistance.
Step 1: Training. First year training involves a general training thattakas an eight-week session with a six-week follow-up session. There would beseveral specialized training courses for subjects such as computer programming,statistical analysis and sampling methods.
Second year training involves a course on the design of the experiments andtheir implementation. This course may take eight weeks. In addition, there willbe specialized courses.
Third year and fourth year training involves a 4-week course on the*valuation of the progress and implementation of the studies. There will alsobe several specialized courses.
Fifth year training involves a 8-week training course on the evaluation ofthe results from the experiments and on the design of the models of financing andpayment.
Stop 2: Analyze the current conditions in each province and the data thatalready existed bofore the project begins.
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Step 3: Field work and investigations in each province to understand thereal practices and conditions in the rural sector.
Stop 4: Design the data collection instruments, pilot testing, training thefield staff, design the sampling framework, supervise and monitor the datacollection process.
Stop 5: Establish and test hypotheses, perform the more complicatedquantitative analysis, derive conclusions based on scientific principles.
Step 6: Select the variables that will be tested by the field experiments,design the experiments and the data to be collected to assess the effects of thevariables, establish the method to compare experiences of the control sites viththe experimental sites.
Stop 7: Design the models of financing and payment of rural health servicesby different levels of socioeconomic development.
Activity t6s Reporting Findings.
Preparation of progress reports and final report according to the followingschedule and under the responsibility of the indicated organizational unit:
Progress Reports: Annual progress reports must be submitted by eachexperimental township to the provincial office. The provincial office villcompile the vhole progress report and include a section on its own progress andactivities. The progress report should include the income nd wxpenes of thestudy for the fiscal year and cumulative since the beginning of the project. Theprovincial reports would be sent to MOPH/DOGA which is responsible fortransmitting the reports to the World Bank.
Final Report:
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Page L of 8
CHINARural Health Workers DeveloDment Proiect
Central ComDonent
The central component would augment the institutional capacity of threoMOPH departments for coordinating and supporting project implementationactivities. The Department of Education (DOE) would strengthen its capabilityto carry out its national mandate in manpower planning and manpower policyformulation. It would provide technical assistance to the project provinces andevaluate project activities in order to disseminate the experience gained to therest of the country. The Department of Medical Administration (DOI&) vould lead,monitor and assist in the execution of the activity dealing with financing ofrural health services and the payment of rural health workers. The Foreign LoanOffice (FLO) would monitor overall project execution against targets and payspecial attention to procurement and disbursement issues.
A. MOPH/Deivrtment of Education
I. BackgroundThe Rural Health Workers Development Project is the first large scale
project in rural health manpower development since the introduction of economicreforms in the late 1970s. Until now DOE has focused its attention on trainingmedical doctors at the lev-l of three-year medical colleges and of medicaluniversities.
The Department of Education (DOE) in MOPE will provide assistance andguidance in coordinating, monitoring and evaluating the activities in the projectprovinces and disseminate the experience thus gained to the rest of the country.In the execution of its duties, DOE would strengthen its capability in healthmanpower planning and policy formulation; new educational theories and teachingmethodologies; and the ability to coordinate its activities with other linedepartments in MOPh.
II. Objectives of the Central Component
* strengthen the national capability in health manpower planning (MIP)and cocmunity-based medical education (CHT) and develop a systm ofcoordination among the line departments in MOPE concerned with IMP -Activities 1, 2 & 6
* guide, coordinate and monitor the implementation of the project -Activities 3 & 5
* assimilate the experience gained in the project areas, disseminatethe information to the rest of the country in order to improve thestandard of community-based medical training (CMT) in non-projectprovinces - Activities 4 & 5
* develop MIP and CMT policies, logistics and methodology appropriatefor modern China - Activities L & 4
Annex 1 1Page 2 of 8
III. Activities
1. Strengthen the capacity of MOPH in health manpower planning and developcoordinating mechanism among the line departments in MOPH.
1.1 Form a leading group among the line departments with the objective ofdeveloping a national strategy in HMP. Regular consultation with expertsin the field will be conducted to find solutions to prevailing problems.Technical Assistance will be provided to help organize two meetings inBeijing for the leading group (1993-96).
1.2 Collect information on current capacity for HMP in the country.Information will be collected by the use of a questionnaire to allprovincial BOPH with follow-up site visits by a researcher. The leadinggroup will meet in Beijing with experts to discuss the findings of thestudy in order to formulate a strategy for action (1993-96).
1.3 Evaluate and disseminate the experience gained from the REWD project.Visits to project provinces will take place in 1995 and 1996 to collectinformation. As a result of such consultation, a nationwide conference onRHWD will be conducted.
1.4 Improve the knowledge and skills in HMP and develop awareness of the needfor HMP through overseas training for representatives from different linedepartments and overseas study tours for representatives from relatedministries.
1.5 Improve the operational efficiency of the DOE team through improved officeequipment.
2. Strengthen the national capacity to conduct research and training in HMPthrough support and utilization of a center of excellence at ShanghaiMedical University Department of Social Medicine.
2.1 Improve the capacity of SMU to train staff from MOPh and provincial BOPHthrough overseas training in 1993 and the acquisition of audiovisualequipment.
2.2 Disseminate information on EMP to medical administrators and planners atcentral and provincial levels by publishing a newsletter on EMP twiceyearly, editing and translating HMP educational material for use inworkshops and teaching sessions, and conducting EMP workshops for plannersand administrators at provincial and central levels, 1993-96.
2.3 Conduct EMP research int
* planning methodology* evaluation of health manpower utilization* evaluation of health manpower management (1992-96).
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Annex 11Page 3 of 8
2.4 Use existing HMP data base to analyze trends in the requirements fortraining different categories of health care workers in the country inorder to help MOPH develop HMP strategies and policies, and organize HMPpolicy development workshops for MOPH.
3. Coordinate and assist in organizing interprovincial project activitiest* job analysis, workload standards, develop planning data bases* job description and training objectives* design and develop curriculum* develop educational material -
* develop evaluation methods* upgrade management and supervision capacity
3.1 Conduct interprovincial workshops planning content and agenda,coordinate invitation of participants and evaluate outcome:
* develop workshop content and background material* attend interprovincial planning workshop* evaluate report of outcome of workshop as prepared by hosting province
3.2 Organize overseas training : coordinate and evaluate overseas training
* prepare the terms of reference for the training or study tours(objectives, subject matter, destination and host, duration, traineeselection criteria)* help provinces select candidates and prepare them for the overseas trip* evaluate the outcome of the training based on reports from the traineeand the overseas trainer* where applicable, hold debriefing meetings to relevant personnel fromproject provinces.
4. Determine national policy and development of community-based medicaleducation
4.1 Evaluate project activities with regard to the following: trainingobjectives, curriculum, teaching material and methods, standards forteachers, schools and examinations.
4.2 Determine national requirements for the award of certificates forgraduates of CMT programs (1994).
4.3 Formulate national policy for developing community-based medical educationincluding formulating evaluation indicators (1995).
4.4 Disseminate recormendations to the rest of the country through nationalmeeting and regional meetings (1996).
5. Coordinate the development of appropriate teaching materials for ruralhealth workers
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Annex 11Page 4 of 8
5.1 Based on the result of the interprovincial activities, determine theoverall strategy in developing teaching materials - the topics, the media,the key editor and producer, the quantity, the quality, the projectednumber, the cost, the financial support and the ownership of the copyright(1993).
5.2 Design the action plan, organize the bidding for the production of theteaching material (1994) and supervise the production and distribution(1995-96).
5.3 Coordinate the evaluation of the material by teachers and students inorder to effect improvements in future editions.
5.4 Production of videos for inservice training of village health workers.The MOPH has a leading group for the production of medical educationmaterial with terms of reference in planning, organizing, and distributingaudiovisual teaching material. Its past experience give- MOPH acomparative advantage in the production of high quality and low costmaterial. This would be more cost-effective than production by eachprovince (1994-96).
6. Strengthen the capability of the MOPH/DOE to provide guidance in thedelivery of community-based medical education
6.1 Provide overseas training in the following areaas* teaching methods and material (1994-95)* curriculum design (1994)* research & evaluation of medical education (1995, 1996)* distance loarning (1994)
6.2 Organize overseas study tours in the areas oft* comunity medical education (1994)
* continued medical education (1995)* education manag eme nt (1996)
6.3 Procure additional office equipment for the efficient execution of theabove activities.
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Page 5 of 8
IV. Estimated Cost
Expenditure Total Cost(1,000 Yuan)
Equipment 190.0
Study & Research 1021.8
Technical AssistanceLocal 64.5Foreign 602.7
TrainingLocal 0Foreign 1114.0
Total 2993.0
B. MOPH/Delartment of Medical Administration
I. Problem Statement for Financing and Payment Studies
China had an organized system of coemunity financing of preventive andprimary care services for the rural population. Health workers were organizedand paid by the. gricultural collectives. Since the agricultural reform of theearly 1980' , the coununity financing and organization of primary care serviceshave collapsed in most of the poor rural areas which created the followingproblems: (i) many trained health workers at the village and township levelscannot be sustained due to the lack of financial support, and trained healthworkers sought other gainful employment or moved; (ii) the current payment systemcreates perverse economic incentives forcing village doctors to generate incomeby prescribing and dispensing drugs, and giving injections; and (iii) servicesof the village health clinics and the township hospitals are not adequatelydefined, coordinated and managed.
II. Objectives
The Rural Health Workers Development Project would develop suitableapproaches to finance health workers in the village clinics and townshiphospitals so they can be financially sustained and perform their work in anefficient and an effective manner to improve the health status of the ruralpopulation. It would, inter alia, investigate the sources and method offinancing, the willingness and ability to payl investigate the workingrelationships and division of labor between the health care workers at thetownship and the village levols; and investigate the method and level ofpayment, the incentives and disincentives. (See also Annex 11).
The Department of Medical Administration (DONA) of HOPH wouldt (i) provideleadership to the implementation of the Financing and Payment Studies, contralizeplanning, coordinate provincial activities and supervise project execution; (ii)organize and coordinate local and foreign consultants to discuss projectplanning, coordinate local and foreign technical assistance and interprovincis1
Annex I11Page 6 of 8
training activitiesl and (iii) coordinate the different departments within HOPEand the different ministries within the contral goveranent in order to assuresupport for theme studies from the policy perspective.
III. Activities
1. Situation analysis and design of experiment - January to December 1993
1.1 organize expert panel and working group from MOPE
1.2 analyze factors related to economy, geography, population, cultureand health status to determine the study areas and control areas
1.3 design plan of study
2. implementation and montoring of study - January 1994 to Dcoember 1996
2.1 participate in the study by providing leadership and centralguidance
2.2 develop and utilize the data base system
2.2 supervise and monitor progress of study
2.4 conduct a mid-term review
3. evaluate implementation and draw policy conclusions - January 1997 toDecember 1998
3.1 evaluate the financing sources and methods, and the methods andlevels of payment
3.2 evaluate the organization and the quality of rural health careservices
3.3 draw final conclusions and make policy reco onedat-ions
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Annex 11Page 7 of 8
IV. Estimated Cost (in 1,000 Yuan)
Expenditure Total Cost (1,000 Yuan)
Technical AssistanceLocal 123.1Foreign - 600.0
TrainingForeign 137.8
Study and Research 398 5Equipment 60 0
TOTAL 1319.4
C. MOPH/ Foreian Loan Office
I. Problem Statement for Project Implementation Supervision
DOE and DOHA in HOPd ar- line departments and are responsible for thetechnical supervision of the project. The Foreign Loan Office (nLO) is a staffdepartment in HOPE and vill supervise the non-technical aspects to ensure thatproject impl eme ntation proceeds according to plans especially as it relates toproject financing, disbursement and procurement matters. Its role becomes moreimportant in this project as this is the first time that the six selectedprovinces participate in a World Bank project and therefore lack experience andrequire assistance in supervision and monitoring.
II. Objectives
nLO would monitor project implementation plans in order to make sure thatt
* the agreed on targets are not changed;
* the agreed on activities are efficiently and effectively implemented andmodifications are fully justified;
* the procurement of civil works and equipment and of serviess takes placeaccording to agreed procedures and on schedule;
* counterpart funds are timely available
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An 11Page 8 of 8
III. Activities
1. Project Supervision vlll take place every November of tho six years ofproject implementation. It vill include visits to three provinces and anannual meating for all six provinces to take stock of implementationprogress and to determine the activities for the coming year.
2. Financial Suporvisiont In May of every project year, no and HOF vllexamine the credit utilization and disbursement progress and help theprovinces prepare the stat ement of accounts for the preceding year.
3. Civil Works and Equipment Procurement Supervision: In January of everyproject year, there vill be an xamzination of the quality, design andbidding procedures of all civil vorks, including those in progress andthose completed. The installation and operation of equipment purchasedand the procedure for LCB viii be exmined. The plans for civil vorksand equipment procurement for the same year vill be determined.
4. Kid-term evaluation vlll be undertaken vith SPC and HOF at the beginningof 1995.
5. Final evaluation vill be conducted at the beginning of 1999 vith SPC andHOF and vith the participating MOPH departments.
IV. Estimated Cost (in 1,000 Yuan)
Expenditure Total Cost (1,000 Yuan)
Technical AssistanceLocal 120.0
TrainingLocal 97.9Foreign 56 4
Equipment 30 0
Operational Cost 500.0
TOTAL 804.3
Rural Health Workers Develop-ent Prolect
Interprovincial Activities
IPA OJUCTIw 3 a On Ilux STAT no DATE TOTAL_ff_ /I lT DATE (in 51000)
"ownh! 1IAMIN3 Istabllehimg & lprowlag the planning 4 230etwork and ope ration mecbhaoli
1. St Ltat M. Plan 4-Jan-93 2-Sep-98 2,143
Traliln Pleannre to learn plaoulg policy and methods NDH 3-Feb-93 4-Apr-98 1217Moitoring L Etvalusting to &soess the proc-es and the lpact 3-Jan-94 2-Sep-96 I9S
2. Planning Iesercb to Identify planming L training *eeds 18-Jan-93 19-Sep-97 2,050
Job Analysjo to :Liv task descriptions for bheltb staff 16-Jan-93 16-Aug-93 220Iqirovlg Data Bass to Irov data maoagm_nt 4-Feb-94 20-Nov-9S 366Sitatioo StudiLes to assess an evaluate the performance 6-Jun-94 19-Sep-97 524 X
TR-AIMIG HCALTJ WOKES Eatablishing Training network, developing l-Jan-93 4-Nov-98 139,613curriculim and conducting training at thevarious lovell
1. D-vejoO Job Descrtriot to provide coms language for planning, Shanrl 16-Jan-93 16-Jul-93 230trainiog * d auprvoion
2. Curralmcl Develosment to litroduce teaching m_tbods an m_terials obel/ 16-Aug-93 31-Dec-97 ,S51m_tching witb the noeds Guiubou
Study Tours to for teacbers to learn training progrem DMW 16-Aug-93 1S-Sep-93 132design, _moitorlng and evaluation
Teachilg lofom Worksbop to initiate teaching refom with teachers ebbl IS-Dec-93 19-Dec-94 643involvesent
Materials Dove. Workshop to introduce the mthodology of toacblhg Cuisbou 14-Feb-94 21-Oct-96 903m_terial dvelo_pm*t
Materials limproewmeet to transfor technology to improv m_terials Anhui 27-Feb-95 5-May-97 422
Trainlig Prog. Evoluatilo to strengthn evaluative capaclty to easure Boman 6-Jul-94 20-Jul-94 141the success of training refon
Teacileg lvaluat. Systm to ostabliab a scientific and effective Hebei 3-Aug-94 24-Sep-97 36 u :Jevalution system wbicb can prowide valid ga and reliable feeback on training effects UQ n
1-~
3. Final Tra l welsocie to e mmise all the doeei. dewelopent, NDM 23 Sep-98 4-Ue0v93 17testitg a*d 1lmm_ttaz m ct twitle wilcbave occurred
Rare= I t^FWSEStW le m irow t netitutional m*a _eat capacity I-Jan-93 24-Sep-98 17.172
1. 04d Mt C . 17-Feb-93 26-bec-96 1,138
Hacg. systo _Drelopn_t to t row the mmea emat of *ealth Mare rm 17-feb-93 14-Feb-9S 381
- Job Aielyis Mancers t idetstity the reepseibllity of mcager. 17-Feb-93 17-Jun-93 104
- Owerse-e Utudy to Iea verie appro ache to * perWIcle 19-Jel-93 14-Feb-95 201
Tralning JNagerc to l-rn m _ yc of menag_mat 0eSm c 17-Mar-95 26-Dec-98 271
HOPE Administrative Procedures Raiardina Civil Works
1. Plannn. Tho civil works plan of each province's project institutions(including location, area, purpose of CW and cost estimate) - approved by theState Planning Coiission and confirmed during Project Appraisal - would becomethe basis for the CW component of the Project. Each province will submit toMOPK/FLO a sumary sheet of the functional space for each project institutionidentifying in square meters the areas of the existing facilities to be utilizedand the proposed CW to be carried out under the project. The summary sheet willstate the current enrollment capacity of each institution and will indicate thecapacity that the institution will reach upon completion of the CW program. TheCW design ezperts group of MOPE vill visit selected sites of major CW to inspectexisting conditions and to advise the local project office on technical mattersto be taken into consideration during the design of the CW.
2. Dosi . The provincial Public Health Bureau is responsible for theselection of the appropriate architectural design unit to conduct the design work(including site survey, conceptual design for site developmont and buildinglayout, preliminary drawings, working dravings and the periodic supervisionduring construction) for civil vorks at prefectural level and above. For eachconstruction estimated during the design stage to cost over US$300,000, theconceptual design should be approved first by the CW design experts group of MOPHbefore developing preliminary drawings and working dravings. County PublicHealth Offices under the guidance of tho provincial Public Health Bureau willorganize the design work for the CW at county level and below. The county PublicHealth Offices vill give assurances to the provincial Public Health Bureau thatthe design of the civil works comply with the sumary shoot of functional areasapproved by MOPI/FLO.
3. Bid Invitaton. The Provincial Public Health Bureau selects the buildingcontractor for CW at prefectural level and above in accordance vith LocalCompetitivo Bidding (LCB) procedures. For contracts in excess of US$300,000, thebid evaluation report should firat be submitted to the Foreign Loan Office (FLO)of HOPE for concurrence before the bid award. For CW at county level and bolow,the appropriate contractor vill bo selected under the guidance of the ProvincialPublic Health bureau following local procedures of selection of the lowestevaluated bidder among the invited local contractors and community groups.
4. Construction Supervision. For civil works at profectureal level and above,the Provincial Public Health Bureau approvoe the torms of referonce (TOR) forconstruction supervision and appoints the site supervisor. For each constructionproject estimated to cost over US$300,000, the terms of references forconstruction supervisor and the C.V. of the selected site supervisor should besubmitted to FLO of MOP for record and reference. For CW at county level andbelow, the county Public Health office selects and appoints the site supervisorunder the guidance of the Provincial Public Health Bureau.
5. Miscellaneous. MOPS sends its civil vorks experts to provinces to assis:
Aanne 16Page 2 of 2
ln site surveys before the co_encoemnt of design work. The TOX of the MOPIDesign ExpArt Group have been rcileowd by the World Dank Appraisal Mission andthere vas no objection. Did invitation for civil vorks estimated to cost overUS$300,000 vould follow LCD procedures acceptable to the association and voulduse the standardized bidding document agreed between the Ministry of Finance andthe World Bank.
Rural secitb vorkARa aM.eJ.o.set Prolect
Project Organiaation Chart
|?reriDcid Project looting Group I......................................................
Provisnil DOM . ; .
be@, v , iU iL m >le rvie 0 DartPre] ct Pl_iw Uf *ir srci | | inictratioI i
a~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~;t a
* a
* P
a a a~~~~~~~~~~~~~~~~~~~a~~ ~ ~~~~~~~~~~~~~~~~~~~~~ a
- 96 -Annex 17Page 2 of 2
Rural Health Worker. DeveloDment Proiect
Proiect Imolementation Office
A Sample of a Project Implementation Office
|Project Impl ems ntation OfficeI ~Direcltor
aon Equipx nt
Group on Civil Works
Task Mn-ager Accountent Procurement Building Computer TranolatorSpecialist Specialist Statistician
Total Full-Time Staff 1
Director 1Task Manager 1Account ant 1Procuremnt Specialist 1Building Specialist Computer Statistician 1Translator 1
-97 -
Anne 18
CHIRural Health Workers Devolooment Pro1ect
Schodule of Diaburoments
AMOUNT (USS million) Disburs emnt Profile (S)
Year Semester Absolute Cumulativo Project China'
1994 1 12.0 12.0 11 3
2 4.2 16.2 15 14
1995 1 7.6 23.8 22 38
2 14.5 38.3 35 50
1996 1 15.6 53.9 49 66
2 12.5 66.4 60 70
iJ97 1 12.5 78.9 72 78
2 9.0 87.9 80 86
2I9 1 7.8 95.7 87 86
2 6.5 102.2 93 94
99l~j 1 3.5 105.7 96 94
2 2.2 107.9 98 96
2000 1 2.1 110.0 100 98
2 100Note:a. Standard Disbursement Profile for human resources sector projoct in China.b. Initial Deposit in Special Account and Retroactive Financing.
- 98 -
Annex 19Page 1 of 3
CILMkRural Health Worker. DeveloDment Proiect
Performanc Plan - Outcome Measures
1. Indicators for Vllmas Health Staff -
1 .1 Percentage of villages vith a village doctor and a health station
1.2 Percentage of villages vith two village doctors, one of whom isfemale
1.3 Percentage of villages with at least one female village doctortrained and equipped to deliver basic family planning. MCH andobstetric care
1.4 Village doctors vith training reaching the standard of countryhealth schools and are eligible for a "village doctor" certificate
1.5 Villages with the ability to organize basic on-site first-aidactivities
2.1 Indicators for TOuns h ablth Staff and Facilities
2.1.1 Health care personnel/1.000 total population ratio
2.1.2 In-service training for townchip and village health care staff
2.1.3 Assistant doctors, public health doctors, MCH doctors andmidwives,after graduation from secondary medical schools, returningto work in township health facilities
2.1.4 Township health facilities staffed with secondary medical schoolgraduates or above
2.1.5 Township hospitals with the capability to conduct the three coonlaboratory examinations (routine blood, urine and stool tests)
2.2 Indicators for CetaLZT ,jis He-lth Staff and Facilities
2.2.1 Central township hospitals staffed by laboratory tochnicians.pharmacists, radiographers. and dentists who have received formalprofessional training
2.2.2 Central township hospitals with the capability to performlaparotomy
2.2.3 Central township hospitals vith the capability to manage acuteemergencies including cross-matching blood for transfusion
- 99 -
Ame 19Page 2 of 3
3. Indicators for Health Status and Preventive Car-
3.1 "New method delivery" at village level
3.2 Systematic maternity care
3.3 "Pour basic immunizations" rate (at county level at the beginningof the projoct and at township level at the *nd)
3.4 "Childhood preventive health care" coverage rate
3.5 Township and village secondary school children with healtheducation conducted by health care personnel
3.6 "No smoking" in all health care facilities
4. Indicators for mortality and morbidity
4.1 Maternal mortality ratio per 100,000 live births
* bhgianig of the project, Ms end of the project, T.D.: village doctor
0 -D
RURAI. IHIEATII WVRKERS DEVE1b,A 4ENT P1'11 UIW SUPERVISION PLAN
I mif... d.
Wbere Superioa Would No sat No salS?llLikely Take Place: Approximala Dome laecvl (b4osha) Nusbeer of Perom_ Wece
Aclivisa lo be Superviaed Headquae (H) Field (F) of 1i Miami -kneen Miasioe Meamoc Skill Rcqired Required Required
Cijvi Woik
Review ot "mph ak Flaw fom all types of civil woeks F aWl H Ha Nafled as rquied as rquaed AttAihect I I
Review of co_atu p_c to coauc awards (Ace H Idi quair 1994 as eqsied *a squid Arebilct 1 2exceedag $300.000 only)
Inapcum ocfworeklsducou _nwouaadpo oi-award m-1994 12 3 Arciulect I 6review of coUlt (samim) Subil 9
Review Of eququWAd s aidW aecieCados P awl H Has" Naed a rquird 3 (for 3 phaes) Techai&al Sjeciaist 1 3
Prior view of idWdi D Dowadaboek. amucmcm of F and H Ha aled as required s required Technical Specialisi I I3IFB (dhs excediag 530.001 voly)
Pfior award revie of bid evaudic epma r_ he aca H Euly 1994 as required mAreq Tehical SieciaIh 1 2zceerdi 5300.000 cub oily S-dtl I
Tecbhical Asiawce
Review of TORm. qualVecadam eaquWd ai oidisoc of H or F HU Saed ma reuired ma reqird T.A. cpenicace I 68*MlYIMe; maW aavm review. feaw ia andly eawl woikakmpa
Capaiv of "oigs. nab. ma by poliyra&em. F mid-1994 12 3 Mtaspaawer Piame I
. Policy Aualyd
Trsaisa Co.wumm of Pwieta
lolaamayuadeaciplunmeacher raining. clinical keaciag; F mid-1994 2I I jid AnalyS 2 ueeaeovuecwia dima minwl evausagius -b lAWlsim5a Uicaigamer
* a..5.aa. .as~ .aa.I * aU..~a: .1. l as lan.... usr r'>
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Peiwhw .6 d aiw" . H_i f. N a" F * _mu saw l}
_bc. .__ w;m mu _a __1 _i .awlw6*c"Goig_m O SO E_ a
bdsA*avwdi _<aamcaedpia. SEE H U 34WX_ aF _ s 13 AI ae _ E _ I 2
e _odwift 6mg Sa_Wmna n ma.- um maPb-paleaa F aTsci SISpN& "fenpaim I
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- 103 - Annex 21
Rural Health Workers Devoloi Mnt Protect
Selected Doceunts Available in the Prolict File
A. Proiet Pronosals
A-1. Anhui Project ProposalA-2. Fujtan Project ProposalA-3. Guizhou Projoct ProposalA-4. HRbot Project ProposalA-5. Resan Project ProposalA-6. S 1azi Project ProposalA-7. Proposal for Central Component
S. Proiect Costa
3-1. Total Project Cost tables3-2. Detailed Cost Tablos for *iz provinces (Anhui, Fujian, Guizhou,
Hebei, Hanan, and Shazi)
C. Proiect T.Ilmentation Plans
C-l. Tmelineo Reports for AnhuiC-2. Timline Reports for FujtanC-3. Timeline Reports for GuixhouC-4. Timline Reports for HebetC-5. Timeline Reports for honanC-6. Timeline Reports for Sheai
D. Selected PFsors and Resorts Ralated to the Prolect
D-l. Chinese Health Statistical Digoet, 1990.D-2. The Syposius of the First Rural Doctor gducation of China, 1990.
RUSS ANRUSSIAN FEDERATION FEDERATION
KAZAKHSTAN
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UZB KISTAN S.o JAPAN
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RURAL HEALTH WORKERS DEVELOPMENT PROJECT ' PACIf*C
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S PROVANCE CAPITALS
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PROIANCE BOUNDARIESINTERNATIONAL BOUNDARIES
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