PROJECT INFORMATION DOCUMENT (PID)



PROJECT INFORMATION DOCUMENT (PID)

APPRAISAL STAGE

Report No.: AB5658

|Project Name |Tamil Nadu Health Systems Project--Additional Financing |

|Region |SOUTH ASIA |

|Sector |Health (80%);Sub-national government administration (19%);Other social services (1%) |

|Project ID |P118830 |

|Borrower(s) |GOVERNMENT OF INDIA |

|Implementing Agency | |

| |Tamil Nadu Health Systems Project PMU |

| |7th Floor, DMS Buildings, DMS Campus |

| |Teynampet |

| |Chennai |

| |India |

| |600006 |

| |tnhsproject@ |

| |Public Works Department (PWD) |

| |Kamarajar Salai, |

| |Chepuk, |

| |Chennai |

| |Tamil Nadu |

| |India |

| |600005 |

| |TNHSP PMU |

| |7th Floor, DMS Buildings, DMS Campus, |

| |Teynampet |

| |Chennai |

| |India |

| |600006 |

| |tnhsproject@ |

|Environment Category |[ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) |

|Date PID Prepared |April 9, 2010 |

|Date of Appraisal Authorization |March 26, 2010 |

|Date of Board Approval |April 29, 2010 |

1. Country and Sector Background

Tamil Nadu ranks as one of the best performing states in India in terms of economic growth and development. It is the fifth largest contributor to India’s GDP. Its population is roughly 6 percent of India’s 1.15 billion people with the second lowest population growth in the country. It is the eleventh largest state in India in terms of the geographic area. Notably, Tamil Nadu is the most urbanized state in the country, with 44% of the state’s population living in urban areas. The state has 32 districts, 385 blocks and 16,317 villages.

Tamil Nadu has made significant strides in improving the health status and increasing access to health care services in the last decades. Importantly, the state has made major progress in improving the maternal and child health (MCH) outcomes. According to the most recent National Family Health Survey (NFHS-3) carried out in 2005-2006, substantial progress has been made since the previous survey in 1998-1999 (NFHS-2) prior to the preparation of the project. There has been a further 35% reduction in the Infant Mortality Rate (IMR) from 48/1,000 in 1999 to 31/1,000 in 2006 although additional efforts are needed to bring Tamil Nadu’s IMR closer to its better-performing neighbors, such as Sri Lanka (IMR 18.8/1,000) and the state of Kerala (IMR is 14/1,000). These improvements are in part due to a significant increase in overall vaccination coverage of children 12-23 months from 65%-81% between 1992-93 and 2005-06. Also, the overall nutrition status of children under age 3 has been improved, with a 30% reduction in underweight children. Improvements have also been made in maternal and neo-natal care, with a 25% increase in the number of institutional births (currently 98%) and births assisted by a doctor/nurse (currently 93%) and a 10% increase in the number of mothers who had at least three antenatal visits for their last birth (currently 96.5%). These improvements have led to decreased Maternal Mortality Ratio (MMR) from 195/100,000 in 1999 at 111/100,000 live births 2006. Indeed, Tamil Nadu has one of the lowest MMRs in India (estimated MMR for India is 254/100,000 live births in 2006). Notwithstanding this progress, the MMR continues to be 25 times higher than in developed countries and further improvements are needed in the overall quality of care through strengthening the provision of comprehensive emergency obstetric and neonatal care.

In addition to the challenges related to quality of care (for which the MMR is a good proxy), there are additional challenges in the health sector, including the need for more equitable access to care, a large and growing burden of non-communicable diseases (NCD), (with heart disease, diabetes and cancers being the leading causes of deaths), as well as prevailing low levels of public health financing (5% in 2009) which make it difficult to provide the necessary investments in public health infrastructure, equipment and materials and contribute to high out-of-pocket payments for health services. Indeed, even when substantial private sector expenditures are added to the public health financing, the per capita total health expenditures in Tamil Nadu are below all-India averages. Lastly, while a number of critical steps have been taken by the Government of Tamil Nadu (GOTN) to improve information collection and analysis of health data and to improve the strategic management of the sector, further work to consolidate these achievements is needed.

2. Objectives

The development objective of the proposed Additional Financing project would be to significantly improve the effectiveness of the health system in Tamil Nadu as measured by (i) increased access to and utilization of maternal and neo-natal care services, particularly by poor, disadvantaged and tribal groups; (ii) effective non-communicable disease interventions scaled-up throughout the state; (iii) improved health outcomes, access and quality of service delivery through strengthened oversight of the public sector health systems and greater engagement of the non-government sector; and (iv) increased effectiveness of public sector hospital services, primarily at district and sub-district levels.

3. Rationale for Bank Involvement

The GOTN originally expected (in 2007) to request the AF only to cover the activities that could not be carried out because of the reallocated Credit funds to the Post-Tsunami Reconstruction Project. However, given important achievements made under the project as part of its reform program, the GOTN, with the strong support from the GOI, decided to embark on a more ambitious undertaking and request AF to consolidate the achievements made and to expand key activities state-wide. As a result, in its formal request made to the Bank on October 14, 2009, the GOTN proposed that the AF would support (i) the continuation of ongoing successful activities under the project; and (ii) the scaling up of several activities state-wide. The total estimated cost of the proposed AF is US$130.78 of which Bank financing would be US$117.70 million and GoTN co-financing of AF would be US$13.08 million.

The rationale for GOTN in requesting the AF from the Bank is in large measure due to a successful collaboration with the Bank through this project which has introduced new approaches into the way the health sector functions, including promoting collaboration with the private sector, adopting quality assurance mechanisms, testing the cost-effectiveness of service provision, and close monitoring of the impact of these reforms. The proposed AF remains consistent with the original Country Strategy (CAS) objectives (2004) of improving governance, expanding access and upgrading effectiveness and quality of services, and enhancing community participation and empowerment. The AF is equally well aligned with the most recent 2009-2012 CAS, dated November 14, 2008 ,which aims to support improvements in the organization and delivery of publicly-financed services that would enhance the development effectiveness of public spending, including in the health sector, under its third pillar.

The proposed AF is the most appropriate instrument which would allow the GOTN to continue to support well-performing activities and to quickly scale up additional activities. The AF meets the criteria and conditions outlined in the Bank operational policy (OP/BP 13.20). Importantly, the GOI and GOTN are strongly committed to this project and its development objectives and are committed to complete the proposed additional activities within three years from the current project Closing Date. Notably, there are no outstanding or unresolved safeguard, environmental, social or fiduciary issues in the project, nor would the additional investments trigger any new safeguard policies.

4. Description

The project includes the following components:

Component 1: Increasing Access to and Utilization of Service (Total estimated cost US$44.79 million). This component would support (i) Reducing Maternal/neonatal Mortality by supporting the effective ongoing operations of 80 comprehensive emergency obstetrical and neonatal care centers (CEmONCs), the construction and equipment of higher maternity referral institutions at eight medical colleges, and the design and provision of various IEC materials; (ii) Improving Tribal Health through carrying out of the Tribal Development Plan in order to increase access to health care among tribal populations, and to strengthen existing primary and secondary services in tribal areas through public-private partnerships; and (iii) Facilitating use of hospitals by the poor and the disadvantaged through the provision of effective patient counseling services, the provision of ambulances and mortuary vans, strengthening of laboratories and financing housekeeping services at 32 hospitals.

Component 2: Non-Communicable Disease (NCD) Prevention and Control (Total estimated cost US$22.01 million). This component would support (i) Health Promotion activities for preventing non-communicable diseases through school-based, work place-based and community-based health promotion programs; and (ii) NCD Interventions throughout the state of Tamil Nadu in support of expanding the cervical cancer screening interventions, breast-cancer detection, and cardiovascular disease (CVD) screening interventions (including diabetes). In addition, the component would finance the salaries for contractual nurses at primary and secondary level facilities, IEC activities, and the monitoring and evaluation of NCD interventions.

Component 3: Building Capacity for Health System Oversight and Management (Total estimated cost US$33.80 million). This component would support (i) Strengthening M&E capacity of the Department of Health and Family Welfare of Tamil Nadu by establishing a computerized Hospital Management System (HMS) at all 270 secondary level hospitals as well as extending to 18 Medical Colleges (tertiary level hospitals); (ii) Improving Quality of Care through continuous monitoring of quality of care, the provision of management and rational use of drugs training for hospital and PHC staff; and enhancing the capacity for the hospital accreditation process within the Department of Health and Family Welfare of Tamil Nadu; (iii) Strengthening Health Care Waste Management through the expansion of training infection control and waste management to all health personnel at primary, secondary and tertiary levels of healthcare, and carrying out an impact evaluation of the implementation of the Environment Management Plan; (iv) Capacity building for Strategy Development and Implementation through training of doctors and TNHSP staff, supporting the TNHSP Society by financing its operating costs, and supporting the establishment of a data resource center.

Component 4: Improving Effectiveness and Efficiency of Public Sector to Deliver Essential Services (Total estimated cost US$30.18 million). This component would support (i) Equipment rationalization and strengthening of equipment and pharmaceuticals management through the procurement of essential equipment and strengthening pharmaceutical and equipment procurement, logistics, repair and maintenance system in the TNMSC; and (ii) Human Resource Planning and Development by financing additional contractual staff in 225 of the 270 project hospitals in order to improve overall efficiency and performance.

5. Financing

|Source: |($m.) |

|BORROWER/RECIPIENT |13.08 |

|International Development Association (IDA) |117.7 |

| Total |130.78 |

6. Implementation

The implementation arrangements would remain as they are under the leadership of an effective Project Director and competent staff in the Department of Health and Family Welfare, the central Project Management Unit (PMU) within the Department, and the District Project Management Units. However, given the large scope of the proposed AF and the limited three year period, it has been agreed that the capacity at the central PMU would be increased further to be able to manage the implementation of the scaled-up project. This will involve the hiring of additional staff, with specific skills, as required. In addition, third parties would be brought in to assist in the management of the project, including for the monitoring of PPPs, the implementation of IEC activities, as well as for project monitoring and evaluation. Notably, during the 3-year AF period, a phased plan to institutionalize successful project interventions as well as the work of the Project Management Unit (PMU) into the DMS (Directorate of Medical Services) and DPH (Directorate of Public Health) would be undertaken with staff and programs gradually transferred under their responsibility. This would ensure the sustainability of the programs launched and supported under this project. Budget provisions for these programs would be reflected starting in the state budget 2012/2013.

7. Sustainability

The proposed Additional Financing would support the continuation of successful activities which have been carried out under the project in areas of maternal and child health, improving access and utilization of health services by the poor, remote and tribal populations in Tamil Nadu, improving quality of health care provision, and improving human resource planning and capacity.

In addition, AF would scale-up well-performing activities supported under the original project, including (i) the state-wide expansion of the non-communicable disease (NCD) prevention and control activities which have been supported in two districts in the state of Tamil Nadu (TN); (ii) the state-wide implementation of the hospital and health management information systems, including to tertiary healthcare facilities; and (iii) the expansion of maternal and neonatal health services to the tertiary level.

The proposed interventions would further enhance the overall development impact and effectiveness of the project and are expected to serve as examples for other states in India as they attempt similar reforms.

8. Lessons Learned from Past Operations in the Country/Sector

Lessons have been learnt from completed and on-going state health systems projects in other states, which have been shared at several dissemination workshops during the preparation of the original project. A quality enhancement review (QER) provided the following recommendations which were incorporated into the original project design and which remain relevant under this Additional Financing.

(i) Project objectives should specifically focus on health outcomes for the poor;

(ii) The need to pilot-test new approaches to NCD prevention;

(iii) Deepen opportunities for public-private partnerships;

(iv) State capacity for health sector planning and management requires strengthening; and

(v) The need to focus project investments on non-infrastructure interventions- “software” interventions rather than on traditional infrastructure investments. This means more emphasis on improved service delivery at hospital-level and broader system strengthening, including in areas such as health care waste management, HMIS, quality of care, and monitoring and evaluation.

9. Safeguard Policies (including public consultation)

The proposed AF would not trigger any additional safeguard policies.

Environment: The environmental rating would remain B and the Environment Management Plan disclosed at project appraisal of the original project would remain valid for the duration of the AF and would apply to the proposed additional civil works (maternity wings).

Social: The detailed Tribal Development Plan (TDP) disclosed at project appraisal remains valid for the AF. The plan has been refined based on implementation experience during the original project and additional stakeholder consultations, and will form the basis for extending support for tribal activities implemented under the AF.

|Safeguard Policies Triggered by the Project |Yes |No |

|Environmental Assessment (OP/BP 4.01) |[x] |[ ] |

|Natural Habitats (OP/BP 4.04) |[ ] |[ ] |

|Pest Management (OP 4.09) |[ ] |[ ] |

|Physical Cultural Resources (OP/BP 4.11) |[ ] |[ ] |

|Involuntary Resettlement (OP/BP 4.12) |[ ] |[ ] |

|Indigenous Peoples (OP/BP 4.10) |[x] |[ ] |

|Forests (OP/BP 4.36) |[ ] |[ ] |

|Safety of Dams (OP/BP 4.37) |[ ] |[ ] |

|Projects in Disputed Areas (OP/BP 7.60)* |[ ] |[ ] |

|Projects on International Waterways (OP/BP 7.50) |[ ] |[ ] |

10. List of Factual Technical Documents

Project Paper & Datasheet

11. Contact point

Contact: Preeti Kudesia

Title: Sr Public Health Spec.

Tel: 5785+101

Fax: 91-11-24619393

Email: Pkudesia@

Location: New Delhi, India (IBRD)

12. For more information contact:

The InfoShop

The World Bank

1818 H Street, NW

Washington, D.C. 20433

Telephone: (202) 458-4500

Fax: (202) 522-1500

Email: pic@

Web:

* By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download