TEMPLATE FOR PROJECT CONCEPT NOTE (PCN) - World Bank
64544 v1Document ofThe World BankReport No: Restructuring PAPERON APROPOSED Project restructuring of India: CREDIT No. 3867-INMarch 11, 2004TO THEgovernment of IndiaSeptember 08, 2011ABBREVIATIONS AND ACRONYMSASHAAccredited Social Health ActivistBPLBelow Poverty LineDEADepartment of Economic AffairsICUIntensive Care UnitIECInformation, Education, CommunicationHMSHospital Management SystemHSITHospital System Improvement TeamsNRHMNational Rural Health MissionPDOProject Development ObjectiveRHSDPRajasthan Health Systems Development ProjectSIHFWState Institute of Health and Family WelfareRegional Vice President:Isabel M. GuerreroCountry Director:N. Roberto ZaghaSector Manager / Director:Julie McLaughlinTask Team Leader:Patrick M. MullenIndia Rajasthan Health Systems Development ProjectP050655ContentsPageA.SUMMARY4B.PROJECT STATUS4C.PROPOSED CHANGES6India: Rajasthan Health Systems Development ProjectRESTRUCTURING PAPERSUMMARYThe proposed changes will support cancellation of an amount of SDR 6.875 million (US$ 11 million equivalent) from the Rajasthan Health Systems Development Project (Credit No. 3867-IN).PROJECT STATUSAs of September 5, 2011, of the IDA Credit of SDR 61 million, approximately SDR 47.96 million (78.6%) has been disbursed. The key project data are as follows:Project DataCurrent Project Performance RatingsBoard Approval: 11/03/2004Effectiveness Date: 21/07/2004 Original Credit Closing Date: 30/09/2009Revised Credit Closing Date: 30/09/2011Credit Amount: SDR 61 millionAmount Disbursed: SDR 47.96 millionAchievement of Project Development Objectives SImplementation Progress: MSRisk Flags: nilThe Project Development Objectives (PDOs) of RHSDP are: (i) to increase access to health care of the Below Poverty Line (BPL) and underserved population by upgrading health care facilities in the remote areas, promoting public private partnership and improving health care seeking behavior through demand side interventions; and (ii) improve the effectiveness of health care through strengthened institutional framework for policy development, program implementation and management capacity, and increase in the quality of health care.Under Component 1: project management, policy development and capacity building, the project developed model contracts for engagement with the private sector; strengthened integrated management information systems at 238 project facilities; developed clinical, management and administrative training capacities for the health sector; undertook studies to inform policy decisions; completed evaluations of project initiatives; and disseminated best practices.As part of Component 2: development of primary and secondary health care services in public sector, 238 project facilities were strengthened through investment in infrastructure and equipment and supply of essential drugs and consumables; collection, treatment and disposal of health care waste management through a network of Common Treatment Facilities was funded; monitoring and evaluation systems were introduced for recording performance of facilities against key output indicators; and Health System Improvement Teams (HSITs) were established in the 238 facilities to sustain quality improvement processes.Under Component 3: health care innovations for the disadvantaged, the project used print, electronic and traditional media for information, education and communication (IEC) on health issues amongst target vulnerable groups, initiated facility-based counseling services, and held outreach camps in remote and inaccessible villages of nine priority districts. The camps included free-of-charge provision of maternal and child health services, necessary medicines, immunization, essential lab services, and health information. Significantly improved quality of services at project facilities and outreach camps and increased uptake by disadvantaged populations are demonstrated by hospital performance data and validated by independently-conducted patient satisfaction and utilization studies.Good planning and procurement practices resulted in substantial credit saving of around US$30 million at the original credit closing date of September 30, 2009. The credit was extended by two years with a category reallocation to continue the health system strengthening activities summarized above as well as pilot several innovations. Ongoing activities were maintained while several new initiatives were successfully implemented. Training on geriatric care, disaster management and skill upgrading for doctors was completed, as well as training on rational use of drugs, disability management and medical law. A web-based Health Management System (HMS) was operationalized in nine district hospitals. The project supported infrastructure development of the State Institute of Health and Family Welfare (SIHFW) and the state resource center, as well as trauma and rehabilitation centers, Intensive Care Units (ICUs) and burn wards. A consumer feedback and complaint redressal system was piloted in 23 facilities. Print and electronic IEC was created and disseminated through a contracted agency to encourage improved health behaviors. A pilot program supporting health communicators was rolled out in nine priority districts, leveraging the role of Accredited Social Health Activists (ASHAs) in the field.Frequent turnover of personnel in project management impeded implementation of some activities planned for the extension phase. Activities not completed included a number of training programs, accreditation of two district hospitals, a social accountability pilot, development of a medical equipment repair and maintenance system, establishment of a drug logistics and supply chain management system, institutionalization of a special purpose fund for major infrastructure maintenance and repair in the Health Sector for district level hospitals and below, and pilot private sector contracting for service delivery. The state government and the National Rural Health Mission (NRHM) have ensured support for a number of these planned activities, including initiating citizens’ report cards as a social accountability mechanism, supporting drug logistics and supply chain management, and establishing a medical equipment repair and maintenance system through the newly-established Rajasthan Medical Services Corporation Limited. Over the entire period of implementation, the project has achieved substantial progress towards its objectives. Access of BPL patients to both outpatient and inpatient secondary care has doubled: in 2006 8.1% of all outpatients were BPL, rising to 16.6% in 2011, while among inpatients in 2006, 8.3% were BPL, increasing to 16.9% in 2011. Similarly, access of patients from tribal communities to secondary level inpatient care has almost tripled; in 2006, 7.6% of all inpatients were from tribal communities, rising to 20.2% in 2011. Access to secondary health facilities providing obstetric services improved, demonstrated by a 35 percentage point increase in the number of facilities conducting more than 10 deliveries per month. The proportion of facilities maintaining a stock of 15 essential drugs rose from 69% in 2008 to 86% in 2011. 85% of project supported facilities participate in the monthly Hospital Systems Improvement review process. Over the life of the project, the availability of nurses has improved from 89.5% in 2006 to 116% in May 2011, although the availability of doctors and lab technicians continues to be a challenge.PROPOSED CHANGES FinancingDue to partial completion of the planned activities during the extension phase, a portion of the credit will not be spent during the remaining project implementation period. Consequently, IDA has received a request from the Government of Rajasthan through the Government of India, Ministry of Finance, Department of Economic Affairs (DEA) requesting cancellation of US$ 11 million. Accordingly, the revised allocation is given below. Category of ExpenditureAllocation in SDR equivalent% of FinancingCurrent?RevisedCurrent?RevisedCurrent?RevisedCivil WorksN/A24,000,00024,600,00085%N/AGoods, Materials and SuppliesN/A21,000,00017,300,000Foreign-100%Local-80%Local exfactory-100%N/AConsultancy ServicesN/A6,000,0002,400,00090%N/ATraining, Workshops & NGO service N/A4,500,0004,400,000100%N/AINC Operating costsN/A5,500,0005,425,000Declining80% through September 30, 2006;70% from October 1, 2006 through September 30, 2008; 40% thereafter.N/AUnallocatedN/A00Total61,000,00054,125,000 ................
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