Project Name                    China-Health Nine Project
Region                          East Asia and Pacific
Sector                          Basic Health
Project ID                      CNPE36953
Borrower                        Peoples' Republic of China
Implementation Agencies         Ministry of Health (MOH)Participating Provinces and Institutions
Contact Address:                
Foreign Loan Office, Ministry of Health
Beijing, China
Telephone:      (86-10) 6303-3033
Fax:            (86-10) 6303-0077

Project Appraisal Date          December 1998
Expected Board Date             April 1999
Available Project Documents

Background

1.      China has made remarkable achievements in improving the health status of its population since 1949. These achievements were made
much faster than the rate of economic growth and with far less resources than most countries.  However, there is good evidence that this progress has slowed since early 1980s, despite accelerating growth of the economy and personal income levels.  Furthermore, the discrepancy in health status between the richer coastal areas and the poorer inland provinces has become worse. At the same time, the
country is now facing newer health problems including those associated with economic growth and opening to outside world.

2.      The discrepancy in health status is even more pronounced in maternal and child health (MCH), which hurts the weakest members of
the society most.  Such discrepancy is not only limited between rich and poor provinces, this is also serious within the provinces. Furthermore, recent research and studies have indicated the rates of improvement in maternal and child health have not only slowed in China, they have leveled in some areas and even have reversed in some others.

3.      Perhaps no new health problem in China is more critical than the emergence of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) and the re-emergence of the sexually transmitted diseases STDs).  The first AIDS case in China was reported in 1985.  This was followed by increasing number of HIV cases among drug-users in Yunnan Province with the identification of 146 cases in 1989. By late 1997, over 8,000 HIV infections were officially reported, actual number is believed to be  much larger. STDs were believed to have been eradicated from China by the 1970s, but they have increased alarmingly since then.  In 1995, the reported STD cases numbered 362,000. Many believe that there are far more unreported cases.

Project Objectives

4.      The proposed project has two main objectives. First, it would reduce maternal and child morbidity and mortality in poor areas of China and would also introduce suitable programs for early child development. Second, the it would implement innovative programs, proven effective elsewhere, to prevent and control HIV/AIDS and STDs.

Project Description

5.      The proposed project would have two main components: maternal health and child development; and HIV/AIDS and STDs control.

I.  Maternal Health and Child Development will have the following sub-components:

(a) Basic MCH care in counties, townships and villages, including: (i) maternal care through systematic prenatal care, appropriate obstetric care and effective management of high-risk pregnancies; (ii) sick child management through effective management of childhood illness, malnutrition and newborn care; (iii)   well-child care and development, including nutrition interventions and prevention    and treatment of priority diseases; and (iv) promotion of information, education and communications.

(b) Improved access to essential care through effective financing mechanisms.

(c) Operational research on a number of innovative MCH interventions.

II. HIV/AIDS and STD Control will include the following sub-components:

(a) Policy and institutional development to raise awareness and commitment at     all levels, to strengthen multi-sectoral collaboration and to build capacity of public, private and non-government institutions.

(b) STD management, by: (i) improving STD protocols; (ii) strengthening   institutions; (iii) improving services; (iv) improving the contribution of private   sector; (v) and operational research.

(c) Program interventions to: (i) change behavior; (ii) demonstrate innovative  programs; (iii) condom social marketing; and (iv) HIV/AIDS patient support.

(d) Blood management and nosocomial infection control, through institutional and management improvements and the provision of equipment.

(e) Surveillance and monitoring programs, including: (i) epidemiological surveillance; (ii) behavioral surveillance; and (iii) specific research programs.

Project Cost and Financing

6.      The cost of the project is tentatively estimated at US$ 140 million, including the Bank Group financing of US$ 70 million consisting of  US$50 million from IDA Credit and US$20 million from IBRD Loan, as follows:

In Million US Dollars

Components	Government	IDA	IBRD	Total
Maternal Health and Child Development	25.0		35.0	60.0
STD/HIV/AIDS	35.0	15.0	20.0	70.0
TOTAL	60.0	50.0	20.0	130.0/td>

Project Implementation

7.      Overall coordination will be provided by a Project Leading Group headed by the Minister of Health with members representing a number of concerned multisectoral agencies.  Under the Leading Group, a Project Coordination Group will be established which will
coordinate regular project management and become responsible for the reporting requirements.  The  responsibility for technical coordination and direct supervision of implementation will lie with MOH departments, including the Maternal and Child Health Department,
the Disease Control Department and the Medical Administration Department. The direct responsibility for project implementation will lie with the project provinces.

Project Sustainability

8.      The project is considered sustainable because of  high commitment of the Government to the main objectives of the proposed project and considering the current policy to significantly increase emphases and resources for the preventive health investments. The budgetary impact of project is expected to be modest and manageable.

Lessons Learnt from Other Bank Projects

9.      While the Bank has supported some MCH services under several Bank projects in China, the ongoing Comprehensive MCH Project (Cr 2655-CHA) has provided important lessons that would be very relevant in the design of the MCH component of this project. Two essons from the on-going project stand out.  First, the poorest can not adequately benefit from the MCH services in the China's rural poor
areas unless arrangements are made to help finance the services.  Second,  for a successful MCH program,  a comprehensive population-
based approach is required instead of programs implemented narrowly within the institutional boundaries.

10.     The Bank's significant involvement in the AIDS/STD programs only started with the Disease Prevention Project (Cr 2794-CHA) which
was started in 1996.  While the lessons from that project are still limited, it is clear that, any significant success in the control of AIDS and STD will require: (a) a multi-sectoral approach, and (b) the implementation of a package of innovative policies and programs which have not been common to China.  The proposed project would attempt to initiate these measures in significant ways.

Environmental Aspect

11.     This project is not expected to create any adverse affect on environment.  However, special attentions will have to paid to ensure that medical wastes, especially needles and syringes, are handled properly.

Project Benefits

12.     The project would provide a number of  benefits.  The MCH component would help improve the services in the poorest areas of China and it would also include measures to improve access and service utilization.  By following new approaches, the project is expected to re-invigorate currently slow improvements in maternal and child mortality rates.  Furthermore,  it would also introduce early child development measures in a significant scale.  The AIDS/STD component is expected to establish effective measures to prevent and control these new diseases which have been increasing at alarming rates.

Risks

13.     There are two major risks in the project.  First, there is a possibility that the project will fail to receive adequate commitment necessary to design and implement the required bold policy measures and innovative interventions to prevent and control AIDS/STDs.  The seriousness of the present crisis is expected to help assure the necessary commitment. Second, there is a possibility that the MCH part of the project would fail to receive adequate counterpart financing.  This risk is expected to be reduced because of the recent decisions of the State Council to significantly raise investments on preventive health.

Contact Point:          
The World Bank InfoShop
1818 H Street, N.W.
Washington, D.C 20433
Telephone: (202) 458 5454
Fax: (202) 522-1500

Note: This is information on an evolving project. Certain activities and/or components may not necessarily be included in the final project.

Processed by the World Bank InfoShop week ending February 20, 1998.