World Bank Documentdocuments.worldbank.org/curated/en/... · 7/18/2016 · SHRDC State Health Data Resource Center SPU Strategic Planning Unit SPC Strategic Planning Cell TDP Tribal

Document of

the World Bank

Report No: ICR00003518

IMPLEMENTATION COMPLETION AND RESULTS REPORT

(IDA-40180 IDA-47560)

ON A

CREDIT

IN THE AMOUNT OF SDR 151.50 MILLION

(US$ 210.42 MILLION EQUIVALENT)

TO THE

REPUBLIC OF INDIA

FOR A

TAMIL NADU HEALTH SYSTEMS PROJECT

June 27, 2016

Health, Nutrition and Population Global Practice (GHNDR)

South Asia Region

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CURRENCY EQUIVALENTS

(Exchange Rate Effective May 31, 2016)

Currency Unit = Rupees (Rs)

Rs 67.29 = US$ 1.00

US$ 1.00 = SDR 0.71

FISCAL YEAR: April 1 – March 31

ABBREVIATIONS AND ACRONYMS AF Additional Financing

AIDS Acquired Immune Deficiency Syndrome

AMCs Annual Maintenance Contracts

ANMs Auxiliary Nurse Midwifes

BCC Behavior Change Communication

BMEs Biomedical Engineers

CAG Comptroller and Auditor General

CD Country Director

CEmONC Comprehensive Emergency Obstetric and Neonatal Care

CMS College Management System

C-section Caesarean Section

CTFs Common Treatment Facilities

CVD Cardio Vascular Disease

DCA Development Credit Agreement

DIR Detailed Implementation Review

DM&RHS Directorate of Medical & Rural Health Services

DMS Directorate of Medical Services

DO Development Objective

DoHFW Department of Health and Family Welfare

DPH Directorate of Public Health

EmONCs Emergency Obstetric and Neonatal Care

EMRI Emergency Management and Research Initiative

FM Financial Management

GAAP Governance and Accountability Action Plan

GoTN Government of Tamil Nadu

HCWM Health Care Waste Management

HMIS Health Management Information System

HMS Hospital Management System

IAS Indian Administrative Service

ICR Implementation Completion and Results Report

ICU Intensive Care Unit

ICDS Integrated Child Development Scheme

ICWM Infection Control and Waste Management

IDA International Development Association

IEC Information, Education and Communication

IMR Infant Mortality Rate

IO Intermediate Outcome

IP Implementation Progress

ISMR Institutional Services Monitoring Report

ii

ISRs Implementation Status and Results Reports

IT Information Technology

IUFRs Interim Unaudited Financial Reports

M&E Monitoring and Evaluation

MCH Maternal and Child Health

MIS Management Information System

MMR Maternal Mortality Ratio

MTR Mid-term Review

NABH National Accreditation Board for Hospitals

NCD Non-communicable Disease

NGOs Non-governmental Organizations

NHM National Health Mission

NIE National Institute of Epidemiology

OBGYN Obstetrician and Gynecologist

OPD Out-Patient Department

PAD Project Appraisal Document

PDO Project Development Indicators

PHCs Primary Health Centers

PINs Patient Identification Numbers

PMU Project Management Unit

PP Project Paper

PPPs Public Private Partnerships

PWD Public Works Department

QAG Quality Assurance Group

QCE Quality Circle of Excellence

RCH Reproductive and Child Health

RF Results Framework

SC/ST Scheduled Caste/Scheduled Tribe

SCA Sickle Cell Anemia

SHRDC State Health Data Resource Center

SPU Strategic Planning Unit

SPC Strategic Planning Cell

TDP Tribal Development Plan

TNCDW Tamil Nadu Corporation for Development of Women

TNHSP Tamil Nadu Health Systems Project

TNMSC Tamil Nadu Medical Services Corporation

TOR Terms of Reference

TPA Third Party Administrator

UAS University Automation System

Global Practice Director: Olusoji Adeyi

Country Director: Onno Ruhl

Practice Manager: Rekha Menon

Project Team Leader: Bushra Binte Alam

ICR Team Leader: Sangeeta C. Pinto

ICR Authors: Joy de Beyer/Surendra Agarwal/Owen Smith

iii

INDIA - TAMIL NADU HEALTH SYSTEMS PROJECT

Table of CONTENTS

A. Basic Information ....................................................................................................... v B. Key Dates ................................................................................................................... v C. Ratings Summary ....................................................................................................... v

D. Sector and Theme Codes .......................................................................................... vi E. Bank Staff .................................................................................................................. vi F. Results Framework Analysis .................................................................................... vii

G. Ratings of Project Performance in ISRs ............................................................... xxiii H. Restructuring (if any) ............................................................................................ xxiv

I. Disbursement Profile ............................................................................................. xxiv

1. Project Context, Development Objectives and Design ............................................... 1

1.1. Context at Appraisal ......................................................................................... 1

1.2. Original Project Development Objective (PDO) and Key Indicators (as

approved) .................................................................................................................... 3

1.3. Revised PDO (as approved by original approving authority) and Key

Indicators, and reasons/justification............................................................................ 3

1.4. Main Beneficiaries ............................................................................................ 5

1.5. Original Components (as approved) ................................................................ 5

1.7. Other significant changes ................................................................................. 9

2. Key Factors Affecting Implementation and Outcomes ......................................... 10 2.1. Project Preparation, Design and Quality at Entry........................................... 10

2.2. Implementation ............................................................................................... 13

2.3. Monitoring and Evaluation (M&E) Design, Implementation and Utilization 17

2.4. Safeguard and Fiduciary Compliance ............................................................. 21

2.5. Post-completion Operation/Next Phase .......................................................... 23

3. Assessment of Outcomes ....................................................................................... 24 3.1. Relevance of Objectives, Design and Implementation ................................... 24

iv

3.2. Achievement of Project Development Objectives (rating: Phase 1 –

Substantial; Phase 2 – High) ..................................................................................... 27

3.3. Efficiency (rating: Phase 1 – Substantial; Phase 2 - High) ............................. 36

3.4. Justification of Overall Outcome Rating ........................................................ 37

3.5. Overarching Themes, Other Outcomes and Impacts ...................................... 38

3.6. Summary of Findings of Beneficiary Survey and/or Stakeholders Workshops

40

4. Assessment of Risk to Development Outcome ...................................................... 40 5. Assessment of Bank and Borrower Performance .................................................. 41

5.1. Bank Performance .......................................................................................... 41

5.2. Borrower Performance ................................................................................... 42

6. Lessons Learned..................................................................................................... 43 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners........ 46

Annex 1. Project Costs and Financing .......................................................................... 47

Annex 2. Outputs by Component ................................................................................. 48

Annex 3. Economic and Financial Analysis ................................................................. 63 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 68 Annex 5. Beneficiary Survey Results ........................................................................... 70

Annex 6. Stakeholder Workshop Report and Results ................................................... 71 Annex 7. Summary of Borrower's ICR ......................................................................... 82

Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 85 Annex 9. Details on NSS 2004 and NSS 2014 Data on Access and utilization of health

services by poorest 40% and scheduled tribe (ST) populations in Tamil Nadu ........... 86

Annex 10. Tamil Nadu Key Indicators – National Family Health Surveys 2015 and

2005 .............................................................................................................................. 93

Annex 11. List of Supporting Documents .................................................................... 96

v

A. Basic Information

Country: India Project Name: India: Tamil Nadu

Health Systems Project

Project ID: P075058 L/C/TF Number(s): IDA-40180, IDA-

47560

ICR Date: ICR Type: Intensive Learning ICR

Lending Instrument: SIL Borrower: GOVERNMENT OF

INDIA

Original Total

Commitment: XDR 73.90M Disbursed Amount: XDR 137.75M

Revised Amount: XDR 151.5M

Environmental Category: B

Implementing Agencies:

Tamil Nadu Health Systems Project Project Management Unit (TNHSP PMU), Department of

Health and Family Welfare (DoHFW), Tamil Nadu Medical Services Corporation (TNMSC),

Public Works Department (PWD)

Cofinanciers and Other External Partners: n/a

B. Key Dates

Process Date Process Original Date Revised / Actual

Date(s)

Concept Review: 03/31/2003 Effectiveness: 01/27/2005 01/27/2005

Appraisal: 06/28/2004 Restructuring(s):

05/18/2007

02/19/2010

04/29/2010

06/28/2010

05/08/2013

08/07/2014

Approval: 12/16/2004 Mid-term Review: 11/26/2007 11/21/2007

Closing: 09/30/2010 09/15/2015

C. Ratings Summary

C.1. Performance Rating by ICR

Outcomes: Highly Satisfactory

Risk to Development Outcome: Negligible

Bank Performance: Highly Satisfactory

Borrower Performance: Highly Satisfactory

Note: The Outcome rating is S for the first phase, and HS for the second phase. Under the

methodology for weighting ratings, the overall outcome score is 5.57, which rounds up to 6, HS,

even though there were some small shortcomings in achievement of outcomes.

vi

C.2. Detailed Ratings of Bank and Borrower Performance (by ICR)

Bank Ratings Borrower Ratings

Quality at Entry: Satisfactory Government: Highly Satisfactory

Quality of Supervision: Highly Satisfactory Implementing

Agency/Agencies: Satisfactory

Overall Bank

Performance: Highly Satisfactory

Overall Borrower

Performance: Highly Satisfactory

C.3. Quality at Entry and Implementation Performance Indicators

Implementation

Performance Indicators

QAG Assessments

(if any) Rating

Potential Problem Project

at any time (Yes/No): No

Quality at Entry

(QEA): None

Problem Project at any

time (Yes/No): Yes

Quality of

Supervision (QSA):

QALP-1 rating 2 (Likely

to achieve DO)

DO rating before

Closing/Inactive status: Satisfactory

D. Sector and Theme Codes

Original Actual

Sector Code (as % of total Bank financing)

Health 80 80

Other social services 1 1

Sub-national government administration 19 19

Theme Code (as % of total Bank financing)

Child health 17 17

Health system performance 33 33

Indigenous peoples 16 16

Injuries and non-communicable diseases 17 17

Population and reproductive health 17 17

E. Bank Staff

Positions At ICR At Approval

Vice President: Annette Dixon

Praful Patel (Original

Credit)/Isabel M. Guerrero

(Additional Financing)

Country Director: Onno Ruhl Michael Carter/N Roberto Zagha

Practice Manager/

Manager: Rekha Menon

Anabel Abreu

AF: Julie McLaughlin

Project Team Leader: Bushra Binte Alam Preeti Kudesia

vii

ICR Team Leader: Sangeeta C. Pinto

ICR Primary Author: Joy de Beyer

ICR major contributors Surendra Agarwal, Owen Smith

F. Results Framework Analysis

Project Development Objectives (from Project Appraisal Document, PAD, p. 5): To significantly improve the effectiveness of the health system, both public and private,

in Tamil Nadu through: (i) increased access to and utilization of health services,

particularly by poor, disadvantaged and tribal groups; (ii) development and pilot testing

of effective interventions to address key health challenges specifically non-

communicable diseases; (iii) improved health outcomes, access and quality of service

delivery through strengthened oversight of the public sector health systems and greater

engagement of non-governmental sector; and (iv) increased effectiveness of public sector

hospital services, primarily at district and sub-district levels.

The PDO statement in the Development Credit Agreement (DCA, p. 17) is worded

slightly differently: “public and private” is omitted from the main clause of the objective

statement; item (ii) omits the reference to piloting interventions and (iv) omits “district

and sub-district levels”. The changes make the statement a little less precise.

Revised PDO July 2010 at Additional Financing (AF) (Project Paper PP, p. 6): 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 non-governmental sector; and (iv) increased

effectiveness of public sector hospital services, primarily at district and sub-district

levels.

Results Framework, baselines and Actual Values

In May 2007 (Management Letter and AM 5/18/2007), the Country Director (CD)

approved the revisions to the results framework and monitoring matrix to incorporate

recommendations of a Bank-wide review of results monitoring frameworks and outcome

indicators (completed in 2006). Minor deletions to the original PDO indicators are

indicated in [square brackets], baseline data were added, two Intermediate Outcome (IO)

Indicators were deleted (road traffic accident case fatality rate, and doctor absenteeism)

and a new IO Indicator was added “Evaluation of pilots being implemented to enhance

management of project facilities in terms of quality of care”.

The results framework documents three sets of changes to the PAD Results Framework:

Additional Financing (April 29 2010): Three PDO indicators were added to monitor

quality of inpatient care, supply and equipment management, and patient satisfaction; one

quality PDO indicator changed, and one PDO indicator change reflected the progression

viii

from NCD pilots to scaling up. Numerous changes in IO indicators were made to

measure specific outputs and activities, indicators were dropped that duplicated the PDO

indicators or were no longer relevant, and “Core Indicators” added as required by new

Bank-wide guidelines.

Restructuring: August 2014 restructuring paper lists 8 dropped, 2 new, 7 unchanged

PDO indicators, 37 dropped IOIs/parts of IOIs, 11 new IOIs and one revised IOI.

Please note: The order in which of some indicators are presented try make the table

easier to follow (e.g. AF indicator for NCD activities follows PAD original indicator 2

which also refers to NCDs) so some indicator numbers differ from their numbers in the

PAD. Indicators that were included in the original or revised project both as PDO and

IOIs are reported once.

(a) PDO Indicators

Indicator Baseline Value

Original Target

Values (from

approval

documents)

Formally

Revised

Target

Values

Actual Value Achieved

at Completion or

Target Years

Indicator 1: Original.

Dropped in 2014

Total in-patient utilization (considering both the public and private sector) by the

poorest 40% of the population increased (as measured by an asset mix)

Surgery with overnight

stay:

Other hospital stays:

Hospitalized cases per

1,000 persons in last

365 days by monthly

per capita consumption

expenditure pattern for

lower 40% MPCE

group

Proportion of (poorest

40%) population

reporting any ailment

in last 15 days, percent

of those who accessed

any form of care

2.45%

1.41%

(Source: Ferguson

Patient Satisfaction

Survey, March 2007).

32.1 cases per 1,000

(Source National Sample

Survey Organization –

NSSO 60th round (2004)

8.5% ailing (NSSO)

76%

10% increase by

2008

20% increase by

2010

14%

9%

(IPSOS Patient

Satisfaction Survey of

2015).

41.9 cases per 1,000

(National Sample Survey

Organization – NSSO

71st round (2014).

13.2% ailing (NSSO)

98%

Date 2004 and March 2007 9/30/2010 2014

Comments

SURPASSED. Increases in inpatient care were far above the 20% goal: 571% increase

in surgery with overnight stay, 638% increase in other hospital stays, and 31% increase

in hospitalization rate per 1,000 people in lowest 40% income group. Percent of those

who reported any ailment and accessed care increased by 29%, well above the original

20% target. NSSO 2014 excluded pre-existing disability from “any ailment”, 2004 had

included it so data are not strictly comparable, but unlikely to make much difference.

ix

Indicator 2: 2007, AF (Originally an IOI. Not

included in 2014.

Increased utilization of out-patient and in-patient services by Tribal Groups

Proportion of tribal

population reporting

ailment in last 15 days

of these, percentage

who accessed any form

of care

Hospitalized cases

8.5 per 1,000 (all TN)

0.8% (ST)

76% (all TN)

96.2% (ST)

13.1 per 1000

No target set for

increase

No target set

for increase

13.2 per 1,000 (all TN)

10.3% (ST)

97.5% (all TN)

93.3% (ST)

15.5/1000

Date 2004 (NSSO 60th round) 9/30/2013 8/30/2014 2014 (NSSO 71st round)

Comments

ACHIEVED. PAD suggested tentative target of 30% increase over baseline, to be

agreed after baseline value determined (not done). The 18% increase in ST

hospitalization is substantial, and 13 fold increase in ST reporting ailment shows

increased recognition of need for care, and makes the small fall in % of those reporting

an ailment who accessed care less worrying – it still indicates a very large increase in

utilization of services. The 2004 baseline data likely indicate very low recognition of

symptoms/need for care rather than very low illness incidence.

Indicator 3: Original,

modified in 2007

Completion of two rigorously evaluated pilots of clinic-based NCD prevention and

control, [careful monitoring of the effectiveness of other NCD prevention activities,]

and assessment of the impact of these pilots on the development of a state-wide policy

Pilots,

Evaluations,

Policy

NA (Not Applicable)

Pilots completed

and rigorously

evaluated.

Policy developed

In 2007,

dropped

“careful

monitoring of

effectiveness

of other NCD

prevention

activities”

Cervical cancer and

hypertension pilots

completed, monitored and

carefully analyzed.

Rigorous assessment by

NIE led to policy decision

to scale-up cervical cancer

and CVD interventions

state-wide.

Date achieved 2004 2008 2007 05/10/2010

Comments

ACHIEVED. Cervical cancer pilot in Theni and Thanjavar districts (Feb. 2007-Jan.

2010): 488,084 targeted women (30-60 years) screened (94.2% of women in the target

group in the two districts); those testing positive and confirmed were referred for

treatment. Hypertension pilot in Sivagangai and Virudhnagar districts (Oct 2007-

March 2010): 1.231 million adults in the target group were screened; 77,757 new cases

were diagnosed (suffering from hypertension) and provided treatment and followed up.

Analysis by TNHSP found substantial improvements in diastolic and systolic blood

pressures among clinic patients who were regularly followed up. Adults screened for

hypertension also received counseling on life-style modification.

In 2007, [careful monitoring of the effectiveness of other NCD prevention activities]

was dropped from the indicator, to align with the main focus of the project.

Indicator 4 – new at

AF (replaced OI 2)

Scale-up of cancer cervix screening and cardio-vascular disease prevention and control

based on a comprehensive assessments of the pilots

x

Programs scaled up

Cervical cancer screening

pilot operational in Theni

and Thanjavar districts,

and interventions for

cardiovascular disease

(CVD) prevention and

control pilot operational

in Sivagangai and

Virudhnagar districts.

No explicit target

set for number of

districts in which

to implement the

programs.

ISR #13 notes

that GoTN

added urban

areas to the

scale up plan.

End date

changed in

2014

Clinical screening and

follow-up treatment of

hypertension, diabetes,

cancers of cervix and

breast scaled up to all 32

districts in TN.

Date achieved April 2010 9/30/2013 9/15/2015 9/15/2015

Comments

ACHIEVED. In addition, (a) Preventive school based activities scaled up in 16,369

government and aided schools under the Sarva Shiksha Abhiyaan Program.

(b) Workplace interventions implemented in 400 worksites; and (c) Community based

interventions through TNCDW reached 250,476 (97%) TN women’s self-help groups.


modified in 2007

Improved quality of care (QOC) in public hospitals as measured by a series of

indicators [and implementation of a regulation/ accreditation system to improve quality

of care in private sector hospitals]

(i) Bed occupancy rate

(ii) Number of major

surgeries

(iii) Number of

diagnostic services

(iv) Number of night

time caesarians at

CEmONCs

80%

211,988

20,031,677

6,817

Maintain

No target

10% improvement

10% improvement

81%

125,537

25,842,226

11,406 (12 months)

Date achieved 2004 - 2005 9/30/2010 2009-2010

Comments

Baseline data for major surgeries (2004-2005) was an outlier -- annual data thereafter

were 60-80% of the baseline level. In any case, this and bed occupancy measure

hospital efficiency, not quality.

SURPASSED targets for quality indicators (ii) Number of diagnostic tests increased

by 29%, nearly 3 times the target; (iii) night time C-sections (indicating 24x7

functionality of CEmONCs) increased 167%, 16.7 times the 10% target.

Source: Institutional Services Monitoring Reports (ISMRs) prepared by hospitals.

[Regulation/accreditation system for private sector] dropped in 2007, GoTN had

intended to develop its own system, but decided instead to use the existing (fairly new)

system of the National Accreditation Board of Hospitals, and to focus on quality in

public hospitals, which are answerable to GoTN.

(See text for discussion of weaknesses in this and several other indicators.)

AF version of

indicator 5 (above).

Dropped in 2014

Improved quality of care as measured by (i) bed occupancy rate, (ii) number of

diagnostic services performed, and (iii) number of night time caesarians at CEmONCs.

(i) bed occupancy rate

(ii) number of

diagnostic services

performed

(iii) number of night

time caesarians at

CEmONCs

(i) 81%

(ii) 11.967 million

(iii) 4,656

Annual target: (i) maintain rate

(ii) maintain at

roughly 12 million

tests annually

(iii) maintain at

8,500 annually

Data for 6 months:

(i) 81%

(ii) 19.140 million

(iii) 10,551

xi

Date achieved April – Sept. 2009

(6 months) 9/30/2013

Oct 2013 – March. 2014

(6 months)

Comments SURPASSED (ii) by about 150% and (iii) by about 125%, (i) achieved. Also an IOI.

Indicator 6: Original.

Dropped in 2014

CEmONCs should handle more than 50% of complicated deliveries for women

belonging to SC/ST concurrently meeting the standards of quality of care. Modified in

2007 to: At least 23% of complicated maternal admissions at certified project

CEmONCs (state-wide) are for SC/ST patients.

Percent of all

complicated deliveries

at CEmONCs that are

SC/ST patients

23% (estimated)

Increase by 20%

of baseline

At least 23%

July 2010 - Sept. 2010:

36.5% for 48 Phase 1

CEmONCs, and 46.7%

for 31 Phase II

CEmONCs.

Oct. 2013 – March 2014:

34.5% for 55 CEmONCs,

and 51.9% for EmONCs.

Date achieved April 2004 2010 2014 2010 and 2013/2014

Comments

SURPASSED. A 20% increase on a baseline of 23% would be 27.6% Actual value at

end of project was 125-188% of this target increase, and 150-226% of the revised

target threshold of “at least 23%”.

Indicator 7: Added in

2014

Proportion of C-section deliveries amongst SC/ST mothers at secondary level

CEmONCs

% C-section deliveries

at secondary level

CEmONCs that are

SC/ST mothers/babes

28% 43% 40%

Date achieved 2007-2008 2014-2015 9/15/2015 (11.5 months)

Comments

PARTIAL ACHIEVEMENT (93% of the target level). SC/ST mothers accounted for

28% of C-section deliveries at secondary level CEmONCs in 2007/08, 43.3% in 2012-

2013 – reaching the target, but this fell slightly to 40% in 2014/15. Given the worrying

increase in C-sections over the period (less in public facilities than private), failing to

meet this target is not considered problematic.

Indicator 8: AF

“promoted” the

Original IOI to OI.

Dropped in 2014

Effective functioning of CEmONCs (state-wide) as measured by % of complicated

admissions and no increase in maternal and neonatal case fatality rates.

Risk adjusted maternal

mortality rate

Risk adjusted neonatal

case fatality rate

13.33

4.08

20% and 50%

reductions by

2008 and 2010

10% and 20%

reductions by

2008 and 2010

Maintain 2009

rates.

6.17%.

3.98%

Date achieved Nov. 2009 2008, 2010 9/30/2013 Oct 2013-Mar 2014

xii

Comments

No Appraisal baseline data available so not possible to assess performance at 2010.

SURPASSED for period 2010 to 2014. Risk adjusted maternal mortality fatality rate

fell to 46% of baseline, risk adjusted neonatal case fatality rate fell to 97.5% of

baseline. The rates are adjusted for percentage of all admission that are complicated,

which rose from 35% in 2009 to 71.9% of maternal and 47.8% of neonatal admissions

in 55 CEmONCs, and to 59% of maternal and 32.7% of neonatal admissions in 50

EmONCs in the reporting period Oct 2013-Nov 2014.

Indicator 9: Original

(also an IOI)

Increased patient satisfaction with care (perceived quality of care as measured by

patient satisfaction surveys) (Scores are on a Likert Score 1-5)

(i) overall satisfaction

score

(ii) overall in-patient

Score

(iii) overall out-patient

score

(iv) Satisfaction with

patient amenities

in-patients

out-patients

(v) Satisfaction with

cleanliness

in-patients

out-patients

(i) 3.96,

(ii) 3.99,

(iii) 3.95

(iv)

3.74 (in-patients),

3.72 (out-patients)

(v)

3.51 (in-patients)

3.7 (out-patients)

Maintain or

increase

Maintain or

increase

-79% of patients were

satisfied with the facility

(ii) 3.92

(iii) 3.87.

-86% of patients noted

continuous water

available at facilities

-98% said out-patients

dept and waiting area

were clean and hygienic,

-97% in-patients found

facilities such as labor and

ward rooms clean and

hygienic

Date achieved

2006

Fergusson Patient

Satisfaction Survey 2006

9/30/2013 9/15/2015

9/15/2015

(Survey Oct/Nov 2014,

IPSOS)

Comments

ACHIEVED. The differences in overall satisfaction scores reported are not

statistically significant, also, satisfaction is subjective and relative to expectations,

which rose over time as facilities were greatly improved by the project. Changes in

survey methodologies complicate make trend assessment. Objective measures such as

wait time show greatly improved patient experience: in 2014, 84% of patients were

satisfied with the wait period of 4 minutes to access outpatient care; 75% of in-patients

found the 10 minutes registration time acceptable and 88% of in-patients found 16

minutes for securing a bed acceptable. In so far as they are comparable, these are better

than results from the 2011 survey: 80% patients waited no more than 20 minutes to

access any services at OPD; 60% of inpatients perceived waiting times at emergency

registration and access to doctors in emergency as short, 89% outpatients and 91% in-

patients were satisfied with cleanliness of hospital, 81% out-patients and 88% in-

patients said running water in taps was available; 96% of in-patients were satisfied

with the admission process.

Indicator 10: New at

AF, dropped in 2014

Strengthened state-level capacity of pharmaceuticals and medical supplies

procurement, repair and maintenance of medical equipment

xiii

Capacity for:

procurement of

pharmaceuticals and

medical supplies,

repair and maintenance

of medical equipment

Baseline was 2010 status

quo.

A comprehensive

state-wide system

established for all

medical

equipment,

procurement,

maintenance and

repair

Well-functioning system

is in place. TNMSC now

handles procurement and

Annual Maintenance

Contracts for medical

equipment. 48 Bio-

medical engineers in post

to maintain medical

equipment of public

health facilities.

Date achieved April 2010 9/30/2013 9/15/2015

ACHIEVED. Established a system to track and improve utilization, repair and

maintenance of equipment in health care facilities: electronic inventory of about

100,000 equipment items in hospitals, and team of 48 engineers. TNMSC capacity for

managing pharmaceuticals and medical supplies procurement (using World Bank

procedures) enhanced.

Indicator 11: New in

2014

Number of public hospitals accredited by the National Accreditation Board for

Hospitals (NABH)

Public hospitals

accredited 0 12 12 fully accredited

Date achieved 2009-2010 2014-2015 9/15/2015

Comments

ACHIEVED – a major achievement; these were the first large public hospitals in India

to undergo the rigorous accreditation process. Based on the positive experience and

benefits for improving quality of service and health outcomes, GoTN is preparing

another 46 hospitals for accreditation of which 1 had entry level accreditation, and 3

had completed assessment and were awaiting results from the Quality Council of India

as of 5/23/16,

(b) Intermediate Outcome Indicator(s)

Indicator Baseline Value

Original Target

Values (from

approval

documents)

Formally

Revised

Target

Values

Actual Value Achieved

at Completion or Target

Years


Modified in 2007

Not included in AF

Dropped in 2014

Reduced case fatality-rate in SC/ST maternal admissions in CEmONC hospitals.

(i) No increase in case-fatality ratio for maternal admissions adjusted for the risk of

increased proportion of complicated maternal admissions in project CEmONCs..

(ii) No increase in case-fatality ratio for total neonatal admissions adjusted for the risk

of increased proportion of complicated maternal admissions in project CEmONCs.

(i) maternal

(ii) neonatal

MMR for complicated

maternal admissions

(i) 19.55

(ii) 5.24

114

50% reduction

20% reduction

from baseline

No increase

(i) 13.72

(ii) 4.04

80

Date 2006-2007 9/30/2010 2010 2009-2010

Comments

ACHIEVED. MMR in 2010 was 30% lower than baseline, IMR was 23% lower, so

partially achieved against PAD target. Results greatly surpassed all revised targets. In

2007 baseline was added, target modified to no increase, denominator changed to

complicated maternal admissions (not all admissions) as per Management Letter and

AM, 5/18/2007. The “no increase” target was inappropriate given expected (and

actual) improvements in quality of care.

xiv


Not in AF or 2014 Increased satisfaction and perceived quality of care in counseling centers (in hospitals)

% of patients satisfied

or highly satisfied with

-overall services

-counsellors’ behavior

% who would access

counselling services

on their next visit and

recommend them to

family and friends

N/A – centers began

operating in 2007

20% improvement

over mid-term

90%

92%

99%

End line study, ORGCSR,

The Nielsen Company

Date achieved 2004 9/30/2010 9/30/2015

Comments

ACHIEVED – based on high approval levels, since no mid-term level is available as

base-line. In addition to counselling centers in hospitals, counselling centers were also

set up in tribal areas; overall satisfaction with counselling services in tribal health

facilities increased from 85.6% in 2010 to 100% at end line in 2015.

Indicator3: New at

AF. Dropped in 2014

Health personnel receiving training (number): Doctors (OBGYN and pediatricians),

medical officers in 1st referral units and nurses.

Doctors trained

Nurses trained NA

1,068 doctors

1,334 nurses

1,419 doctors

3,342 nurses


Comments SURPASSED. Training completed as per plan, target numbers exceeded by 33% for

doctors, 250% nurses. Training focused on skills for operationalizing CEmONCs

Indicator 4: New at

AF. Dropped in 2014

Number of health facilities constructed, renovated and/or equipped. Maternity wings

constructed and equipped at selected medical college hospitals

Value (Quantitative or

Qualitative) 0 8 8


Comments ACHIEVED

Indicator 5: New at

AF. Dropped in 2014

Staffing of CEmONCs according to agreed norms (2 OBGYN, 2 pediatricians, 1

anesthetist) in 80 CEmONCs

% of CEmONCs with

staffing that is at least

85% of norm

Phase 1: 77%

Phase 2: 38%

Staffing at all 80

CEmONCs is at

least 85% of

agreed norms

75 CEmONCs with 4

OBGYN, 2 pediatricians

and 2 anesthetists.

50 EmONCs with 2

OBGYN, 2 pediatricians

and 1 anesthetist.

Date November 2009 9/30/2013 9/30/2013

Comments

SURPASSED All 80 CEmONCs staffed at 100% of norm or better in 2013. However,

the final AM notes that staffing has fallen below this level since due to rapidly

increased demand for these highly qualified doctors for expanded programs.

Indicator 6: New at

AF. Dropped in 2014 Increased provision of health services to the tribal population

xv

i) mobile outreach

services

(ii) NGO hospitals

providing bed grants,

(iii) NGO hospitals

providing testing,

counseling and

treatment services for

sickle cell anemia

(iv) patient counselors

at primary and

secondary health

facilities in tribal area

(i) 12

(ii) 2

(iii) 2

(iv) 32

(i) 20

(ii) 4

(iii) 3

(iv) 32

(i) 20

(ii) 4

(iii) 3

(iv) 42


Comments ACHIEVED for 3 of 4 items and exceeded by 31% for number of counselors (Item iv)

Indicator 7: new at

AF. Dropped in 2014

Increased emergency transport services (to facilitate use of hospitals by poor and

disadvantaged)

Vehicles providing

emergency transport

Also monitor:

# people transported

% pregnant women

% of road accidents

385

113,570

585

No targets set

730 (August 2015).

885,452, of which

26,915 from tribal areas

26% pregnant women.

20% road accident

victims

Date 2008-09 9/30/2013 April 2014-March 2015

Comments SURPASSED at 125% of target

Indicator 8: new at

AF. Dropped in 2014

Number of district hospitals with support services provided (laundry, cleaning, security

& food distribution)

Number of district

hospitals with services 0 at least 20 48

Date April 2010 9/30/2013 3/31/2014

Comments SURPASSED Actual value is 240% of target threshold. Resulted in improved services

– improved cleanliness etc, attested by patient satisfaction surveys and evaluations.

Indicator 9: new in

2014.

Total number of complicated SC/ST maternal admissions at certified CEmONCs (with

at least 2 OBGYNs, 2 pediatricians and 1 anesthetist)

Number 35,156 66,000 74,373

Date 2007-2008 2014-2015 Oct 2014 – Sept 15, 2015

Comments SURPASSED by 113% of target.

Indicator 10: new at

AF, Dropped in 2014 Number of tribal patients provided outpatient care through Mobile Outreach Vans

Number 137,543 200,000 244,003

Date 2007-2008 2014-2015 Oct 2014 – Sept 15, 2015

Comments SURPASSED by 122% of target


AF Dropped in 2014 Percentage of calls made by pregnant women, attended to by Emergency 108 services

Percent response 90.3% 96.8% 99.3%

Date 2009-2010 2014-2015 Oct 2014 – Sept 15, 2015


xvi


AF. Dropped in 2014

Percentage of calls made for Road Traffic Accident victims, attended by Emergency

108 services

Percent response 66% 79.4% 87%

Date 2009-2010 2014-2015 Oct 2014 – Sept 15, 2015



AF. Dropped in 2014

Number of performance based contracts delivering health care services in the project in

Tamil Nadu

Number 0 9 37

Date 2009-2010 2014-2015 9/15/2015

Comments SURPASSED by 411% of target. (5 contracts for Regional Diagnostic Labs, 2

Housekeeping services contracts and all 30 contracts for handling hospital waste)

Indicator 14:

Original, changed in

2007. Dropped at AF.

Decrease in smoking rates, particularly among the poor and young, in pilot

districts. Changed in 2007 to: Increase in awareness amongst 13-15 year olds of

the risk of tobacco use in two pilot districts

Original: % currently

smoke at least one

cigarette/day

Revised: Aware that

“smoking is injurious

to health”

No data for original

indicator

Awareness in pilot

districts before project

interventions: 63-67%

(Sivagangai) and 71-94%

(Virudhunagar) (page 29,

baseline survey)

5% decrease Increase in

awareness

79-80% (Sivagangai)

and

95-99 (Virudhunagar).

Date 2008 9/30/2010 9/30/2010 2010

Comments ACHIEVED. Weak indicator, awareness of harm does not correlate with use.

Indicator 15:

Original. Activity

Dropped at MTR/AF

Decreased road traffic accident case fatality rate.

Changed in 2007 to:

Increased use of helmets as measured by direct observation surveys.

Dropped

Date Nov/Dec 2007 (MTR)

Comments

NOT ACHIEVED. Activity excluded from the project at MTR. The project did

monthly helmet use surveys in 14 locations in 13 districts (April 2007-April 2009)

which showed mixed results across districts. An initial increase in use was followed by

falls after GoTN reduced enforcement in response to strong public resistance.


AF. Dropped in 2014 Health promotion for prevention of CVD among school children carried out

Number of schools

where promotion

activities are done

50 5,000 16,369 16,369

Date April 2010 9/30/2013 9/15/2015 9/15/2015

Comments ACHIEVED. Original target far surpassed, target revised at restructuring of 2014.

Activities done in collaboration with education department.

Indicator 17:

Original. Dropped in

2014

(i) Clinic based NCD control pilots implemented according to plan. (ii) Proportion of

hypertensives receiving effective treatment. (iii) Increased number of women being

screened for cervical cancer.

xvii

(i) Clinic based pilots

implemented per plan

(ii) Diagnosed cases of

hypertension receiving

treatment per

protocols.

(iii) Women screened

for cervical cancer

0

data not available

data not available

2 pilots completed

10% increase (tbc)

10% increase (tbc)

(i) 2 pilots completed,

evaluated, informed

design of full program.

(ii) 1.231 million

screened for hypertension

(iii) 488,034 women

(94% of targeted age

group) screened

Date 2004 9/30/2010 January 2010

Comments

ACHIEVED. Original placeholder targets of 10% increase over baseline in the PAD

RF were not revisited, baseline data were not collected as intended in a household

survey in the pilot areas. Screening and treatment rates were very low before the pilot,

so 10% increases are likely to have been exceeded by the large pilots. In 2007, (ii) and

(iii) were changed to: “Increasing percentage of hypertensive patients (measured

quarterly) correctly receiving treatment at facilities enrolled in the pilot”, and

“Increased coverage of women between 30-60 years of age screened for cervical

cancer in pilot districts.” These targets were achieved, and the pilots completed,

carefully evaluated and informed the design of the programs rolled out under the AF

Results: (ii) Of 1.231 million people screened for hypertension, 77,757 new cases were

diagnosed, about 68% followed up and 23% of those diagnosed were treated. (iii)

488,034 women (94% of the 518,000 women in the target age group) screened by Jan.

2010, only about 50% received further screening diagnostics, and the treatment rate

was only 23%. Detailed evaluation (by NIE) informed the roll-out, with improved

design to reduce loss-to-follow up and achieve higher treatment rates.


AF, wording changed

in 2014 to align with

indicator definition.

Dropped in 2014

AF: Cancer cervix screening and cardio-vascular disease (CVD) prevention and

control as measured by number screened and treated (equipment, training provided)

2014: (i) Percentage of eligible women in age group 30-60 years screened for cancer of

cervix and (ii) Percentage of eligible persons (both men and women) in age group >30

years screened for hypertension

(i) Percentage of

women age 30-60

years screened for

cancer of cervix

(ii) Percentage of

eligible persons (men

and women) age >30

years screened for

hypertension

(i) 488,084 (85% of

women aged 30-60)

screened for cervical

cancer in 2 pilot districts.

(ii) 1,231,259 (3.4% of

people aged 30+)


in 2 pilot districts.

(i) at least 50% in

districts where

program scaled-up

(ii) at least 50% of

people aged 30+

years where

program is

implemented

(i) 40% of

eligible

women.

(ii) no change

(i) 71% women 30-60

screened for cervical

cancer (10.3 million

during July 2012-

September 2015).

(ii) 77% of persons 30+


(29.03 million persons).

Date April 2010 9/30/13 9/15/2015 9/15/2015

Comments

SURPASSED. Cancer screening was 142% above the 50% target threshold and 178%

above revised target (revision was not warranted). Hypertension screening was 154%

above target threshold. The 2011 census was used for the denominator. The NCD

programs were scaled up to all 32 districts, in 1,710 facilities (PHCs, secondary and

tertiary). People screened as positive were referred for confirmation of diagnosis, and

then for treatment and/or life style counseling. TNHSP added screening and treatment

for diabetes and breast cancer. During July 2012-Sept 2015, 23 million people were

screened for diabetes, the 0.958 million detected positive were given treatment and

lifestyle counseling; 12.5 million women were screened for breast cancer, 153,330

women were referred for further diagnosis and treatment.

xviii


AF (Core Indicator).

Dropped in 2014

Number of Health facilities constructed, renovated and/or equipped

Number of facilities 0

2,176 facilities

(1,859 PHCs, 274

GHs and 43

Medical College

Hospitals)

2,228 facilities

(1889 PHCs,

274 GH, and

65 Medical

college

hospitals)

2,330 (1,889 PHCs, 274

GH, 100 medical

dispensaries and 67

medical college hospitals)

Date 2009-2010 9/30/2013 9/15/2015 9/15/2015

Comments SURPASSED at 107% of original target and 105% of target as revised at restructuring

in 2014

Indicator 20:New at

AF (Core Indicator)

Dropped in 2014

Number of health personnel receiving training

Number of persons

trained 0 105,000 398,285

Date April 2010 9/15/2015 6/30/2015

Comments SURPASSED at 379%

Indicator 21:

Original Operational HMIS being used for management decision making at project facilities

HMIS in all facilities Paper based HMIS

operational.

100%

computerized

reporting at

project facilities

Computerized reporting

in all Phase 1 facilities.

Roll-out to others begun

Date 2004 9/30/2010 9/30/2010

Comments ACHIEVED


AF

Operational HMS being used for decision making in 270 hospitals, and HMIS

operational across the state

Facilities reporting

through HMIS

- HMS in 38 hospitals

- HMS operational

in 270 hospitals

- Operational

HMIS across the

state

- HMS operational in 264

secondary and 45 tertiary

hospitals

- HMIS operational

across TN in 2,300 health

facilities: 1,889 PHCs,

274 GH, 70 municipal

dispensaries, 67 medical

college hospitals.

Date 2010 9/30/2013 9/15/2015

Comments

SURPASSED at 114% of target number of hospitals, and also rolled out CMS (college

management system) in 20 government medical colleges and Dr. MGR medical

university, and UAS (University Automation System) in Dr. MGR medical university.

HMS being used for decision making, especially to improve service quality.

Indicator 23: New in

2014 Number of health facilities where HMIS is used to submit monthly reports.

xix

Number of facilities 0

2,228

(GH -274, PHC –

1889, MC – 65)

2,300

1,889 PHCs, 274 GH, 70

municipal dispensaries,

67 medical college

hospitals.

Date 2009-2010 9/15/2015 9/15/2015

Comments SURPASSED at 103% of target

Indicator 24:

Original, modified in

2007. Part (ii) added

at AF, dropped in

2014

(i) Short and medium term measures for health care waste management (HCWM)

implemented at project facilities. (ii) Retraining of staff of health care facilities. (iii)

PPP with NGO/private partners for transportation and final waste disposal.

(i) Number of

facilities where

HCWM plan is

implemented

(ii) Number of

facility staff

retrained.

(iii) PPPs operating

and assessed.

0

0

0

(i) HCWM plan

implemented in all

project and non-

project public

facilities

(iii) Evaluation of

PPP pilots

(i) Plan

implemented

in 270 health

facilities (AF)

(ii) 44,000

staff in 449

facilities

trained/re-

trained (AF)

(iii) HCWM

plan

implemented

in 449 health

facilities –

Target for

9/15/15 (set in

2014)

HCWM plan

implemented in 449

public facilities.

49,500+ personnel from

over 449 facilities trained/

retrained in 9 regional

training centers in all

aspects of managing

health care waste.

PPPs piloted and

assessed, then PPPs set up

with 30 Common

Treatment Facilities

(CTFs) to collect,

disinfect and dispose of

waste. End-line

evaluation done.

Date 2004 9/30/2010 9/30/2013 8/5/2015

Comments

SURPASSED. The HCWM plan, which was broadened to an Infection Control and

Waste Management (ICWM) plan was implemented more broadly than originally

planned, and is one of the standout successes of the project. Original indicator (i) was

modified by replacing “short and medium term measures” by “HCWM plan” in 2007.

At Additional Financing, “Retraining of staff of health care facilities” was

added, and the target number of facilities specified. Implementation included an

intensive behavior change campaign. Effective coordination was established with the

State Pollution Control Board and municipal bodies, who do regular quality assurance

checks at all treatment facilities.


Rigorous evaluation of 12 PPPs completed in terms of measured gains in

access, quality and cost-effectiveness.

Evaluation 0

Independent

evaluation of PPPs

completed

Evaluations completed of

all PPPs which informed

scale-up decisions

Date 2004 9/30/2010 9/30/2010

xx

Comments

ACHIEVED. Evaluation studies of the PPPs included: 2 pilots for waste treatment, 2

PPPs for bed grant schemes (tribal areas), 2 PPPs for sickle cell anemia (tribal areas),

several PPPs for mobile van outreach programs (tribal areas), PPP for emergency

transport (ambulance), several PPPs for the provision of patient counsellors at

CEmONCs and non-CEmONCs facilities. Following evaluation studies, PPPs were

scaled up for implementation during Additional Financing. Nearly all PPPs (including

for housekeeping services and laboratories) have been absorbed by GoTN into its own

regular sector health sector budget.


AF. Dropped in 2014

Maintain hospital based Quality Circles of Excellence, as measured by submission of

monthly reports

Number of hospitals

reporting on 20

indicators monthly

80 CEmONCs reporting

on agreed quality of care

indicators

270 hospitals

reporting on

agreed quality of

care indicators

267 secondary care

hospitals have Quality

Circles of Excellence (3

converted into medical

college hospitals), and are

reporting online monthly

Date April 2010 9/30/2013 3/31/2014

Comments ACHIEVED


AF (Core Indicator).

Dropped in 2014

Number of health personnel of secondary hospitals trained to improve quality of care,

including hospital management, rational use of drugs and skills based training

Number of people

trained

355 staff trained in

hospital management

1,000 staff trained

in hospital

management and

900 staff trained in

rational use of

drugs

Additional 80 CMOs

trained in hospital

management and 739

staff trained in hospital

administration; 1,692 in

Quality Indicators, 1,915

in rational use of drugs;

37,468 doctors and nurses

trained in CEmONC

skills, medical equipment

use and NCDs.

Date April 2010 9/30/2013 2014

Comments SURPASSED at 213% of target for rational drug use training, and at 117% for

hospital management training (total number includes 355 trained before 2010)


AF (Core Indicator)

Dropped in 2014

Hospitals accredited including provision of civil works, equipment and training

Hospitals accredited 12 ongoing accreditations

Capacity for

strengthening

hospitals for the

process of

accreditation

established in

Department of

Health

12 hospitals upgraded and

successfully accredited.

In the process,

Department of Health’s

learned how to manage

the accreditation process.

Date April 2010 9/30/2013 9/15/2015

Comments ACHIEVED

xxi


AF. Dropped in 2014

Fully operational Project Management Unit (PMU) integrated into the Department of

Health

PMU operational

PMU integrated

into the

Department of

Health

PMU increasingly

integrated in Department

of Health. PMU’s work

absorbed by Department

of Health by project-end.

Date April 2010 9/30/2013 9/15/2015

Comments ACHIEVED


AF. Dropped in 2014

Mechanism established for planning and implementing IEC activities in the health

sector, and for monitoring of PPP activities

Mechanisms

established None

Support NRHM

for establishment

of a coordination

unit in Directorate

of Health for all

health

communication

activities in the

state

All IEC materials

developed during the

project and results of

monitoring of PPP

activities are stored on the

TNHSP website available

for use by National

Health Mission and

Directorate of Health.

Date April 2010 9/30/2013 9/30/2014

Comments

PARTIALLY ACHIEVED. The target statement omitted PPP coordination, which is

explicitly part of the Indicator, so is included in the ICR assessment for this indicator.

Mechanisms for monitoring PPPs have been established and institutionalized; the

move to performance-based contracts strengthens monitoring. Project PPP activities

have been handed over to NRHM and Government of Tamil Nadu for management and

financing. The PMU included an IEC coordinating unit, but a unit was not established

in Health Directorate for state-wide coordination.


AF. Dropped in 2014 Establish SHDRC (State Health Data Resource Center) in Tamil Nadu

None SHDRC

established

SHDRC established and

operational.

Date April 2010 9/30/2013 8/5/2015

Comments

ACHIEVED, The SHDRC collates, mines and runs higher order analytics on data

from over 20 Directorates of the Health Dept., to provide easy to use dashboards for

administrators and managers, and help drive continued improvement.

Indicator 32:Original

Dropped in 2014 Upgradation and repairs of project facilities completed according to plan.

Facility upgrading

completed per plan 0

Decision to take

up Phase III

districts based on

performance of

Phase II districts

in implementation

of software

activities

All civil works completed

as planned, in several

phases.

Date 2004 9/30/2010 9/30/2010

xxii

Comments

ACHIEVED. All planned civil works to provide need-based additional infrastructure

and enhance its quality completed and handed over – 35 Phase I works and 190

hospitals in Phase II. Planned “soft” activities including staff training undertaken and a

system to better utilize, repair and maintain equipment is in place. At Additional

Financing, a decision was taken to keep civil works to bare minimum – upgrade 8

CEmONCs and complete upgrades at 12 facilities needed for NABH accreditation.

Indicator 33:Original

Changed at AF.

Dropped in 2014.

(i) Increased number of laboratory tests, x-rays and other diagnostics at project

facilities. (ii) Reduction in equipment downtime. Added at AF: (iii) Equipment

provided to selected district hospitals in order to ensure the provision of a full range of

services, as per agreed norms

(i) Number diagnostics

(ii) equipment

downtime

Not available

(i) 20% increase

from baseline

(ii)Declining trend

in downtime

(i) covered in

OI

(ii) Dropped at

AF

(iii) no target

(i) Data reported in PDO

indicator 5 above

(ii) no data

(iii) Included in facility

upgrading indicator 32

Date 2004 9/30/2010 4/29/2010 9/15/2015

Comments

ACHIEVED. Diagnostics data captured in PDO indicator 5 above. System for

equipment maintenance and repair set up and working, as reported above. Regular

reporting by hospitals and availability of engineers has greatly improved notification of

problems, repair and maintenance of equipment.

Indicator 34:

Original. Item (ii)

dropped in 2007. (i)

dropped in 2014

(i) Availability of staff according to norms at project facilities, [(ii) reduction in doctor

absenteeism as recorded in supervisor’s logbook]

Number of project

facilities having staff in

position against

sanctioned posts: Doctors

- 116; Nurses – 150;

Technicians – 40; and for

all three categories: 22.

(i) Manpower

according to

norms in all

(project) hospitals

(ii) Absenteeism

reduced by 50%

Support

additional

contractual

staff at 270

project

hospitals in

accordance

with agreed

norms

Of the 267 project

facilities, facilities with

staff per sanctioned posts

were: (i) Doctors - 241;

(ii) Nurses – 259; (iii)

Technicians – 258; and

(iv) all three categories:

211.

Date March 2005 9/30/2010 4/29/2010 9/30/2010

Comments

PARTIALLY ACHIEVED 79% of the 267 project hospitals had staff as per norms

by 2010. For each cadre, achievement was much closer to the very ambitious target:

90% for doctors, 97% for nurses and for technicians, the reason the ICR team

considers this partially achieved (rather than not met). Manpower norms were revised

and rationalized depending on hospital size, in the early years of the project. Part (ii)

on doctor absenteeism dropped in 2007.

Indicator 35: Added

in 2007. Dropped at

AF

Evaluation of pilots being implemented to enhance management of project

facilities facing difficulties.

NA Evaluation

Completed and system

implemented across all

public hospitals.

Date 2004 9/30/2010 9/30/2010

xxiii

Comments

ACHIEVED. The system to grade hospitals every month into A, B, C and D

categories on the basis of 20 performance indicators, with poor grades triggering action

plans, was evaluated and found useful for helping improve management and operations

in poorly performing project hospitals. PMU identified 65 poorly performing hospitals

agreed on action plans to improve performance, with continued monthly monitoring.

System was implemented across all hospitals.


AF. Dropped in 2014 TNMSC strengthened per agreed norms

None

TNMSC

strengthened per

agreed plan,

including

mainstreaming of

biomedical

engineers

Biomedical engineers

hired by the project.

TNMSC strengthening

was undertaken with state

government funds.

Date April 2010 9/30/2013 3/31/2014

Comments

ACHIEVED. See PDO Indicator 10. Biomedical engineers hired under the project

were absorbed as regular GoTN staff. This complemented TNMSC strengthening

undertaken with state government funds.

G. Ratings of Project Performance in ISRs

No. Date ISR

Archived DO IP

Actual

Disbursements

(USD millions)

1 05/07/2005 Satisfactory Satisfactory 7.50

2 11/04/2005 Satisfactory Moderately Satisfactory 7.52

3 05/10/2006 Moderately Satisfactory Moderately Unsatisfactory 7.52

4 11/07/2006 Moderately Satisfactory Moderately Unsatisfactory 7.71

5 05/03/2007 Moderately Satisfactory Moderately Satisfactory 11.89



















xxiv

H. Restructuring (if any)

I. Disbursement Profile

Restructuring

Date(s)

Board

Approved

PDO

Change

ISR Ratings at

Restructuring

Amount

Disbursed at

Restructuring in

USD millions

Reason for Restructuring & Key

Changes Made DO IP

05/18/2007 S S 11.89

Minor changes to Results Framework

approved by CD in response to

recommendations of a Bank-wide

review. Not processed as a

restructuring.

02/19/2010 S MS 87.08 Reallocation of proceeds among

categories.

04/29/2010 Yes S MS 88.59

Approval of Additional Financing,

changes in PDO, indicators and targets,

extension of Closing Date by 3 years to

9/30/2013.

06/28/2010 S MS 92.02

Reallocation of proceeds among

categories, to finance taxes and modify

definition of incremental operating

costs.

05/08/2013 S S 166.22 CD approved extension of Closing Date

by one year to 9/30/2014.

08/07/2014 S S 186.77

CD approved extension of Closing Date

by 11.5 months to 9/15/2015. Results

Framework was rationalized to be more

relevant and reduce number of

indicators.

1

1. Project Context, Development Objectives and Design

1.1. Context at Appraisal

Tamil Nadu was the 7th most populous Indian state (65 million in 2001), one of the five most

urbanized, and had the second lowest population growth rate (1.43%). Annual GDP growth was

averaging more than 6%. Good “social determinants” of health, and high coverage and

utilization of health services (e.g., 93% of children fully immunized, 89% of births in health

facilities) had contributed to steady improvement in infant- and under 5 mortality and other

health outcomes. The state’s human development and health indicators were among India’s best.

Health sector trends and challenges. Despite this significant progress in health and access to

services, Tamil Nadu’s infant mortality rate (IMR) of 52 per 1000 live births in 1999 was still

much higher than in Sri Lanka and Kerala (IMRs of 12 and 16 respectively), and maternal

mortality (MMR) had stagnated at 110 (2003).1 Audits of maternal deaths indicated that facilities

-- especially in disadvantages areas -- could not all provide comprehensive emergency obstetric

and neonatal care (CEmONC), and more needed to be done to improve and ensure quality of

care in all facilities in a systematic and well-organized way.

Tamil Nadu’s burden of disease from non-communicable diseases (NCDs) was large and

growing. Heart disease, diabetes, and cancers were already the leading cause of death, and traffic

deaths among the worst in India. NCDs and smoking (a key NCD risk factor) were especially

high among the poor, who were therefore most burdened by the economic effects of illness,

health care costs, lost productivity and premature death.

Although use of health services was far more equitable than in most states, hospitalization

among the poor was only 37% of the rate among the wealthy, and scheduled castes and

scheduled tribes (SC/ST) had very limited access to health services. Health outcomes were

relatively poor in districts and blocks within districts with pockets of SC/ST populations.

Total health spending in Tamil Nadu was low, and predominantly out-of-pocket. Public health

expenditure was less than US$3 per capita per year, and had fallen from 7.5% of the state budget

in the mid-1980s to 5.8% in 2001. Nearly 75% of the health budget went on salaries, leaving

very little for consumables, equipment, infrastructure and maintenance. Most central government

funding for health was for primary care, leaving secondary care chronically under-funded.

State Health Policy and Capacity Gaps. The Government of Tamil Nadu (GOTN) Health

Policy of 2003 laid out ambitious goals, including reducing IMR to 15 per 1000 and MMR to 50

per 100,000 live births by 2020, and doing more to address key non-communicable diseases and

injuries while sustaining vigorous efforts to control communicable diseases including HIVAIDS.

The strategy focus was on improving the health status of the general population, with special

emphasis on low-income communities and families. However, the state lacked experience in

strategic and financial planning for the health sector, and in quality improvement activities such

1 Tamil Nadu Health Indicators at a Glance, 2014-2015, Directorate of Family Welfare, Government of Tamil Nadu

(GoTN))

2

as setting technical standards, ensuring quick adoption of technological advances, oversight of

the private sector, accreditation of health facilities, efficient management of public sector

hospitals, and monitoring health policy impact on vulnerable populations.

Rationale for Bank involvement.

GoTN requested funding and technical advice to help implement its new Health Policy and

improve the quality of care across the state’s health system. In addition to substantial funding,

IDA provided experience in health system strengthening, and the ability to help GoTN build

capacity to develop, evaluate and implement quality assurance mechanisms, test innovative

interventions to reduce NCDs, rigorously evaluate innovations to decide which to scale-up, and

to collaborate better with the private sector to help achieve state health policy goals. Although

Tamil Nadu had not had a state-level health project before, as a progressive state with relatively

high capacity in the health sector, it was considered a good place to put into practice the shift in

state level health system projects recommended by a 2002 major review of all State Health

Systems projects in India.2 Additional Financing was approved in 2010 to continue successful

project activities, expand the scope of some, and roll-out the successful pilot of NCD activities

state-wide. The additional rationale for the AF was that the innovations in the project would be a

valuable model for other states in India and other countries.

The project was fully aligned with the core goals and strategic principles laid out in the World

Bank India Country Strategy for FY05-08 (CS), approved in 2004: to help improve the quality

of life especially for India’s poorest citizens and help India move closer to achieving the MDGs;

selectively expand lending in health (and other specific areas); and focus on outcomes to help

India achieve its development goals. Tamil Nadu was one of the 12 states where over 90 percent

of India’s poor lived, and the project explicitly aimed to expand health service access and

utilization by poor, disadvantaged and tribal groups. The CS noted that the project followed the

guidelines for Bank engagement in the health sector and would “break new ground in forging

public-private partnerships …strengthening oversight of private providers, increasing public

expenditure on health and reorienting health facilities to ensure service for the poor…”3 The

project also reflected “some of the most important elements of the fast reform scenario - most of

which are embodied in the Tenth Plan”: “Refocus health, education and social safety net

programs on outcomes. Improve the private market for health care through training, public

information and accreditation.” (CS p9). Rigorous assessment of the cost-effectiveness of private

provision of publicly financed services would generate information for the broader debate on

how to increase the effectiveness and efficiency of publicly financed services across India. This

would contribute to the third strategic principle of the CS: to expand the role of the Bank Group

as a politically realistic knowledge provider and generator.

The project would also help implement the Government’s core strategy for poverty reduction,

embodied in India’s Tenth Five-Year Plan for 2002/3 to 2006/7. The first two items in the

Plan’s core strategy were: (1) Improve governance and service delivery, placing greater reliance

2 India State Health Systems, Quality Enhancement Review, July 2002. The suggestions included putting more

emphasis on sectoral reforms, beginning to integrate disease programs into mainstream service delivery, giving

more attention to financing issues, and more engagement with the private sector. 3 CS p26 and Annex 5, which lays out the guidelines for Bank engagement in the health sector.

3

on the private sector and on public sector reforms to deliver accountability, reduce opportunities

for corruption and improve the speed and effectiveness of government at all levels. (2) Second,

reduce poverty, including by better access to health care. The project was designed to contribute

directly to higher-level MDG objectives to which India was fully committed: reducing

maternal, child and infant mortality and premature and preventable mortality among adults.

1.2. Original Project Development Objective (PDO) and Key Indicators (as approved)

Project Appraisal Document (p 5): The Project Development Objective was “to significantly

improve the effectiveness of the health system, both public and private, in Tamil Nadu through: (i) increased access to and utilization of health services, particularly by poor,

disadvantaged and tribal groups; (ii) development and pilot testing of effective interventions to

address key health challenges specifically non-communicable diseases; (iii) improved health

outcomes, access and quality of service delivery through strengthened oversight of the public

sector health systems and greater engagement of non-governmental sector; and (iv) increased

effectiveness of public sector hospital services, primarily at district and sub-district levels.”

The PDO statement in the Development Credit Agreement (DCA, p. 17) is worded slightly

differently: “public and private” is omitted from the main clause of the objective statement; item

(ii) omits the reference to piloting interventions and (iv) omits “district and sub-district levels”.

The differences make the PDO statement less precise.

The four key outcome indicators (PAD, p. 31-32) were:

(a) Total in-patient utilization (considering both the public and private sector) by the poorest

40% of the population increased (as measured by an asset mix),

(b) Completion of two rigorously evaluated pilots of clinic-based NCD prevention and control,

careful monitoring of the effectiveness of other NCD prevention activities, and assessment of

the impact of these pilots on the development of state-wide policy.

(c) Improved quality of care (QOC) in public hospitals as measured by a series of indicators

(including management of indicator conditions, patient outcomes, and quality control

mechanisms) and implementation of regulation accreditation system to improve quality of

care in private sector hospitals.

(d) An increase in the number of complicated deliveries by women in the Scheduled Caste/

Scheduled Tribe (SC/ST) population that are handled by CEmONCs that meet standards for

quality and neo-natal care. The PAD Results Framework in Annex 3 listed a slightly different

version: “CEmONCs should handle more than 50% of the complicated deliveries for women

belonging to the SC/ST concurrently meeting the standards of quality of care” (p.29); a few

pages later the table detailing the measurement strategy for the indicators gave a target of

20% improvement on the baseline which was still to be determined (p.32).

1.3. Revised PDO (as approved by original approving authority) and Key Indicators, and

reasons/justification

Additional Financing (AF) was approved on April 29, 2010 to enable successful NCD pilots to

be scaled up across the state; and to support the continuation of successful activities. The PDO

and key indicators were changed to reflect the focus of the activities that would continue to be

funded and the change from piloting NCD interventions to implementing them across the state.

4

Reference to the private sector part of the health system was dropped from the PDO, an

appropriate change since the project focus was mainly on the public sector, and because GoTN

has little direct influence or oversight of private sector health providers.

The revised PDO in the AF Project Paper was: “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 non-governmental sector; and (iv) increased

effectiveness of public sector hospital services, primarily at district and sub-district levels.” The

project objective in the AF Financing Agreement (page 5) was the same (except for trivial

differences in grammar).

The AF extended the project Closing Date and the end date for expected outcomes by three

years. The Results Framework was revised to reflect the new PDO focus on consolidating and

continuing the achievements made and to roll out NCD programs state-wide, with expected

outcomes defined as follows:

(i.) At least 23% of complicated maternal admissions at certified project CEmONCs (state-

wide) will be for SC/ST. patients.

(ii.) Effective functioning of CEmONCs (state-wide) as measured by % of complicated

admissions and no increase in maternal and neonatal case fatality rates.

(iii.) Scale-up of cancer cervix screening and cardio vascular disease prevention and control

based on a comprehensive assessments of the pilots.

(iv.) Improved access to health care as measured by in-patient utilization of services by the

poorest 40% of the population.

(v.) Improved quality of care as measured by (i) bed occupancy rate, (ii) number of diagnostic

services performed, and (iii) number of night time caesarians at CEmONCs.

(vi.) Patient satisfaction (perceived quality of care) as measured by patient satisfaction

surveys.

(vii.) Strengthened state-level capacity of pharmaceuticals and medical supplies procurement,

repair and maintenance of medical equipment.

This table explains continuities and changes in the outcome indicators:

Original

Indicator

AF

Indicator Comment on continuity and changes

(a) (iv) Same indicator, worded slightly differently

(b) (iii) Indicator for NCD pilots replaced by indicator for scaling up

programs across the state

(c) (v) The revised indicator on improved quality of hospital care dropped

reference to private hospitals, and specified 3 things to be measured

(d) (i), (ii) This revised indicator for ST/SC access to quality care for

complicated deliveries includes neonatal and maternal mortality

outcome measures, and includes baseline data for access to care.

(vi) New indicator

(vii) New indicator to explicitly measure aspects of quality

5

1.4. Main Beneficiaries

The primary target groups expected to benefit most from the project were “poor, disadvantaged,

and tribal groups” – people in scheduled castes and scheduled tribes, or living in tribal, hill,

remote and underserved areas, whose access to health care services would be increased. All

patients using Tamil Nadu’s secondary hospitals would benefit from improved services as a

result of hospital refurbishment and upgrading, equipment repairs and maintenance. The whole

population of Tamil Nadu would benefit from improved quality of health services, and women

and infants and their families would benefit from the expected improvement in maternal and

neonatal mortality. The AF would additionally benefit adults in the state through interventions to

reduce NCD risks, and screen and provide treatment for cervical and breast cancer and cardio-

vascular diseases.

Secondary beneficiaries: Health care providers and other staff working in health facilities were

also expected to benefit. Strengthening the Health Management System (HMIS) would benefit

the Department of Health and Family Welfare (DoHFW), hospital administrators, medical

professionals and other staff of hospitals and other health care facilities by digitizing health

records and reporting, enabling more efficient referral and management of patients, and

providing health facility information that could be used for better budgeting, planning and

accountability. DoHFW staff would benefit from training activities. Improved health care waste

management at health care facilities would enhance safety for patients and service providers.

Public-private partnerships (PPPs) with non-governmental organizations (NGOs) to provide

health services in tribal and remote areas would benefit patients, and develop the capacity of

NGO partners. Private sector service providers would benefit from government contracts for

house-keeping services and health care waste collection, transportation and disposal. The

provision of ambulances would benefit women in labor, victims of road traffic accidents and

others requiring emergency transport to a hospital. Strengthening the state health sector would

enable better implementation of ongoing and planned centrally sponsored health programs in the

state, including the Reproductive and Child Health Project, National AIDS Control Project, and

Revised National Tuberculosis Control Project that were funded by the WB. Finally, learning

from NCD pilots and innovations in HMIS would inform state policy and could be replicated in

other states of India.

1.5. Original Components (as approved)

Component 1: Increasing Access to and Utilization of Services (US$43.79 million). This

component would:

Reduce maternal and neonatal mortality by establishing at least 2 CEmONCs in each

district, first in disadvantaged districts, equipped with a trained complement of clinical

and paramedical staff and the equipment, supplies and drugs needed to provide treatment

for all types of obstetric and neonatal emergencies. Contracts would be signed with

NGOs to provide emergency transport services and facilitate referral.

Improve tribal health by strengthening existing primary and secondary health services in

tribal areas through PPPs with NGOs and contracting NGOs to provide mobile clinical

6

services in 12 identified districts; giving grants to NGO hospitals to provide in-patient

services; and training a cadre of village level tribal health volunteers.4

Facilitate use of hospitals by poor and disadvantaged people and stimulate demand for

services through: (i) community mobilization by NGOs and outreach workers, (ii)

behavior change strategies to promote health, (iii) counseling centers run by NGOs and

local self-help groups to guide patients seeking hospital services, and (iv) training health

personnel in inter-personal communication to improve provider behavior.

Component 2: Developing Effective Models to Combat Non-Communicable Diseases and

Accidents (US$5.65 million). The component aimed to develop effective ways to reduce NCDs

and road traffic accidents, undertake pilots and evaluate their impact so as to inform state policy

and future NCD programs. The activities supported under this component were:

Health promotion activities for preventing NCDs by reducing exposure to risk factors,

such as behavior change communication (BCC), interventions in communities, schools

and workplaces, and setting up life-style counseling centers.

Two NCD pilots, each in two districts: Pilot 1 screened for hypertension and provided

medications and advice on modifying risk factors such as diet, sedentary lifestyle, and

smoking in 2 districts. Pilot 2 assessed the costs and benefits of cervical cancer screening

and treatment. In each case, one of the pilot districts was relatively more industrialized,

so that the impact of urbanization on NCD risk factors could be analyzed. Rigorous

evaluation of the pilots provided information for decisions on whether and how to scale-

up across the state.

Traffic injury prevention and treatment interventions in coordination with relevant

Departments (e.g. Transport and Police).

Component 3: Building Capacity for Oversight and Management of the Health System

(US$25.61 million). The activities were designed to achieve four things:

Improve monitoring and evaluation by strengthening the health management information

system (HMIS) to report regularly on quality of care indicators, utilization rates at health

care facilities and hospital activity indicators. Establish a computerized system at all

levels to track patient, service and management information, network all hospitals to

track referred cases and monitor outcome of programs. Provide feedback to service

providers and program managers for follow up and continuity of care.

Improve Quality of Care by mainstreaming continuous quality improvement practices,

developing and implementing quality indicators, establishing Quality Improvement

Circles in health facilities, developing protocols for improved management of key health

conditions, and helping GoTN implement a stronger system for overseeing health

facilities.

Strengthen health care waste management through implementing guidelines on proper

segregation, color-coding, transportation, and disposal of hospital solid wastes; set up

4 Public-private partnerships (PPP) were a relatively novel approach, and included use of public funds to “purchase”

basic services for the poor from NGOs and private health providers, collaboration with the private sector for a range

of professional services by “contracting in” to government health facilities, and encouraging NGOs in remote tribal

districts to operate government facilities to ensure outreach of health services to disadvantaged populations.

7

PPPs with NGOs for waste transportation and treatment; develop training manuals, train

trainers, and monitor progress.

Build capacity for developing and implementing health strategies, by establishing a

Strategic Planning Unit to act as a think tank and conduct studies on important health

systems issues; setting up a PPP “wing” in the GoTN to manage and monitor PPP

contracts; conducting a health insurance pilot, and strengthening Project Management’s

capacity for monitoring and undertaking procurement.

Component 4: Improving the Effectiveness and Efficiency of the Public Sector to Deliver

Essential Services (US$50.90 million). The main activities were to:

Refurbish and upgrade secondary care facilities including assuring basic amenities such

as water and electricity.

Repair equipment and implement a good maintenance system through Tamil Nadu

Medical Services Corporation (TNSMC), equipment suppliers and hospital officials.

Establish and implement staffing norms and train government staff in human resource

planning and development; conduct activities to improve staff morale and courtesy to

patients; introduce accreditation of health facilities and performance appraisal to help

improve workforce efficiency.

Enhance management of public facilities by setting up twinning arrangements between

hospitals, giving recognition to high performing hospital administrators, and testing new

ways to enable hospitals to improve their performance.

1.6. Revised Components

AF of US$117 million was approved on April 29, 2010 to enable the GoTN to consolidate and

continue successful project activities, and scale up selected NCD programs state-wide, based on

the results of the NCD pilots. The AF continued to support three of the original four components,

but the activities under each were enhanced and expanded or fine-tuned (see detailed description

of components below). The second component changed from “Developing effective models to

combat NCDs and accidents” to “NCD prevention and Control”, supporting implementation of

NCD programs across Tamil Nadu, building on the successful pilots carried out under the

original project. The additional funding allocated to each component was as follows:

Component 1: Increasing Access to and Utilization of Service (AF of US$44.79 million,

totaling US$88.58 million allocation for this component).

Reducing Maternal/ Neonatal Mortality: support effective ongoing provision of obstetric

and neonatal services by the 80 CEmONCs established under the project, train doctors

and nurses, finance contractual staff salaries at CEmONCs for two years (subsequently to

be financed by GoTN), construct and equip higher maternity referral institutions at 8

medical colleges, design and provide Information, Education and Communication (IEC)

materials, and broadcast and disseminate information.

Improving Tribal Health: implement the Tribal Development Plan (TDP) in all identified

tribal areas (12 districts) to increase access to health care, and strengthen existing primary

and secondary services in tribal areas through PPPs. The AF supported (i) provision of

additional vehicles, equipment, operating costs, and TV/DVD sets for mobile out-reach

health services based on need; (ii) sickle cell anemia screening at three tribal hospitals;

8

(iii) tribal counseling services; (iv) a bed grant scheme for inpatient care for tribal

populations at selected hospitals; (v) performance-based payments, training and

incremental costs for village health volunteers implementing tribal activities; (vi) IEC

activities; and (vii) monitoring and evaluation of the TDP.

Facilitating use of hospitals by the poor and the disadvantaged: (i) retrain patient

counselors; (ii) provide patient counseling services; (iii) provide 200 additional

ambulances and mortuary vans; (iv) contract NGOs to provide mortuary van services; (v)

strengthen laboratories at selected hospitals; and (vi) finance and monitor housekeeping

services at selected hospitals.

Component 2: NCD Prevention and Control (AF of US$22.01 million, totaling US$27.66

million for this component). This component omitted the traffic injury prevention activities

planned under the original component, continued support for health promotion, and added

support to implement NCD screening and treatment programs across the state. The activities to

be funded were as follows:

Health promotion activities to prevent NCDs, training teachers and peer educators for

school-based activities (through the Education Department), interventions in workplaces

and community-based interventions through the Rural Development Department and by

NGOs.

NCD Interventions – on the basis of results of successful pilots, scale-up NCD

interventions state-wide: (i) provide necessary equipment at identified primary and

secondary level facilities, train doctors and nurses, fund honoraria for village link

volunteers/community resource persons supporting cervical cancer screening and breast-

cancer detection; (ii) provide necessary equipment and training for medical officers,

nurses, and laboratory technicians at identified primary and secondary level facilities for

cardio vascular disease (CVD) screening (including diabetes), and finance two years of

salaries for contractual nurses based on needs; (iii) IEC posters, stickers, flip charts,

information boards, broadcasting and dissemination for the scaled-up NCD interventions;

and (iv) monitoring and evaluation of NCD interventions.

Component 3: Building Capacity for Health System Oversight and Management (AF of

US$33.80 million, totaling US$59.41million). The new and revised activities funded under this

component were as follows:

Strengthen M&E Capacity in DoHFW – provide software, IT services and equipment to

roll out Phase II of the computerized Hospital Management System (HMS) in the

remaining 222 Project hospitals (total of 270 hospitals), selected Medical Colleges

(tertiary level hospitals) and attached hospitals.

Improve Quality of Care – support continuous monitoring of quality of care, provide

training in management and rational use of drugs for hospital and PHC staff, and enhance

capacity for the hospital accreditation process within DoHFW.

Strengthen Health Care Waste Management (HCWM) – expand training on infection

control and waste management to all health personnel at primary, secondary and tertiary

levels of healthcare, and carry out an impact evaluation of the implementation of the

Environment Management Plan.

Capacity Building for Strategy Development and Implementation – expand the

Directorate of Medical Services Annex building by adding two floors; train doctors and

9

Tamil Nadu Health Systems Project (TNHSP) staff, finance administrative costs and

additional staff for the TNHSP Society to enable it to scale up project activities, studies,

evaluations, monitoring, dissemination of project lessons learned and achievements,

convene an International Health Conference in 2010; and establish a data resource center.

The community based health insurance pilot was dropped because of its likely negligible

impact on the project objective, especially given the new TN Chief Minister’s Health

Insurance Scheme. Instead, the project provided complete administration and

management support to the health insurance scheme, rolled out with technical assistance

from the Bank in 2012.

Component 4: Improving Effectiveness and Efficiency of Public Sector to Deliver Essential

Services (AF of US$30.18 million, totaling US$81.08 million). This component supported new

and revised activities under two of the original four sub-components:

Equipment Rationalization and Strengthening of Equipment and Pharmaceuticals

Management – provide essential equipment (Intensive Care Unit (ICU), x-ray and poison

treatment centers); strengthen logistics and procurement of pharmaceuticals and

equipment; and strengthen repair and maintenance system in the TNMSC (including

financing salaries of biomedical engineers).

Human Resource Planning and Development -- finance additional contractual staff

(doctors, nurses, pharmacists, laboratory technicians, radiographers, auxiliary nurse

midwifes (ANMs), hospital workers, sanitary workers, dental surgeons and cooks) in

project hospitals for the first two years in accordance with established staffing norms in

order to improve overall efficiency and performance.

No civil works to rationalize secondary care facilities were included, as all priority works had

been completed.

1.7. Other significant changes

In January 2005, $20 million equivalent (at prevailing XDR exchange rate) from the

original Credit was cancelled for reallocation to the Emergency Tsunami Reconstruction

Project in response to severe damage caused by the tsunami of December 26, 2004. It

was understood that subject to satisfactory implementation of TNHSP, the Bank would

provide AF to fill the financing gap created by this cancellation.

Minor changes in the Results Framework (noted in data sheet section F) were agreed

with GoTN and approved by the Country Director (CD) on May 18, 2007 (Management

Letter and Aide Memoire, 5/18/2007). This was not processed as formal restructuring.

The changes reflected recommendations from a Bank-wide health portfolio review in

2005-2006, and added newly available baseline data. The details of the main indicators

were aligned better with core activities being supported by the project. Specifically,

“careful monitoring of the effectiveness of other NCD prevention activities” was dropped

from PDO indicator 2 to keep the focus on monitoring and evaluation of the NCD

intervention pilots; “implementation of a regulation/accreditation system to improve

quality of care in private sector hospitals” was dropped because accreditation was to

focus on public (not private) hospitals.

Traffic injury prevention was restricted to surveys of helmet and seatbelt use, instead of

the originally planned state-wide BCC activities, to avoid duplication of effort under a

Bank financed transport project. Although sales and use of helmets were rising, there was

10

strident public opposition to the new helmet use law. GoTN succumbed to public

pressure and backed away from stringently enforcing the law on an unwilling population.

As noted in section 1.6 above, this activity was dropped in the 2010 AF, and the project

focused on NCD activities where there was better traction.

The Community based health insurance pilot in the original project was dropped – an

AM in 2007 noted that it was likely to have only a marginal impact on the PDO,

especially in light of the state-wide Chief Minister’s Health Insurance Scheme that was

rolled-out with technical assistance from the Bank in 2008, and to which TNHSP

provided complete administration and management support.

Closing Date extensions: The Closing Date was extended by three years to September

30, 2013 as part of the AF. After the Bank removed the time limit of 3 years for AF, the

Closing Date was extended two more times – first by one year to September 30, 2014,

and then by 11.5 months to September 15, 2015. These extensions were needed to enable

full completion of innovative interventions that had taken longer than expected to start

up, some activities that had been delayed by back-to-back state and municipal elections in

2011 and national elections in 2014, periodic delays when the procurement workload was

especially heavy, and to ensure full scale up of the NCD interventions throughout the

state and of the HMS/College Management System (CMS) and University Automation

System (UAS) to tertiary level public health facilities. The second extension was also to

ensure that the TNHSP could consolidate the project gains and do a thorough handover

to DoHFW and the National Health Mission (NHM).

The Level 2 restructuring (approved August 7, 2014) streamlined the Results Framework

by selecting the most directly relevant outcome and intermediate results indicators (in

addition to the Closing Date extension noted above).

2. Key Factors Affecting Implementation and Outcomes

2.1. Project Preparation, Design and Quality at Entry

Background. The project was prepared in a little over two years (2002 to 2004)5, a reasonable

time for the India portfolio, especially given the scope, cutting edge reforms, innovative

approaches, and thoroughness of preparation. The GoTN’s Health Policy (2003) laid out a road

map for the next two decades toward reducing IMR to 15 per 1,000 and MMR to 50 per 100,000

live births, improving the health status of the general population and especially low-income

communities and families, starting to address key non-communicable diseases, while sustaining

vigorous efforts to control communicable diseases, and strengthening first referral hospital

services (district and sub-district hospitals) as a priority. The PDO and design of the four

components focused fully on these priorities. The project indicators were well aligned with the

objectives and design of the project components.

Project design was thoughtful, clear and straightforward. Although the project included a

large number of activities at all levels of the health system from communities to tertiary care

hospitals, the design was very “tidy” and coherent. Each of the four components included three

5 Project identification was in October 2002, Project Concept Review in March 2003, appraisal in June 2004,

negotiations on November 3, 2004, Board approval on December 16, 2004, and effectiveness on January 27, 2005.

11

or four mutually supporting sets of activities. Activities were clearly identified, with a tightly

linked results chain that gave the project strong clarity of purpose and design. Management and

institutional arrangements were well-specified, capacity gaps were identified by thorough

assessments documented in PAD annexes, and early activities included to address them. There

were no co-financiers, and only two safeguard policies were triggered and well addressed.

GoTN was fully committed and provided strong leadership throughout. GoTN established a

project preparation team led by a senior officer of the Indian Administrative Service (IAS) with

members from all levels of the health system, academics, and representatives from the DANIDA

funded primary healthcare project. GoTN organized workshops starting in early 2002 to discuss

possible project design, content and the results framework.

Extensive detailed analyses during preparation informed the project design. These included:

Burden of disease study on all causes of mortality and morbidity;

Analysis of regional imbalances and required interventions that identified districts in need of

certain interventions;

Criteria were established to identify four districts including two tribal districts for

investments in the first year, targeting tribal communities and disadvantaged groups with the

worst health indicators;

In addition to a social assessment study, several supplementary studies provided information

on ways to increase access to quality health care for SC/STs and other underserved groups;

District mapping of public and private hospitals;

An analysis of facility planning needs in pilot districts and a health facility survey identified

needs for strengthening facilities;

An environmental assessment included waste management practices and patterns in a sample

of health facilities to inform needed improvements;

Study on drug prescription and dispensing practices;

Service norms and associated staffing and equipment norms were developed for rationalizing

services;

Public and private service providers were mapped;

Private health care providers in 15 of the (then) 29 districts were enumerated, a qualitative

study done on the private sector including informal service providers, and a study on

practices and attitudes of informal rural medical practitioners in Tamil Nadu was completed;

An institutional assessment identified needs for strengthening capacity of GoTN for PPPs,

anticipated staff availability and skill mix issues that might arise in implementing the revised

service norms and planned how to resolve them, systems for personnel management were

developed, and a mechanism for stakeholder/community participation put in place to enable

feedback from communities on the quality of care;

A public-private partnership policy framework and terms of reference (TORs) for a proposed

PPP oversight unit were prepared;

An Environmental Action Plan; and

A Tribal Development Plan.

Preparation for the AF included development of a detailed Governance Accountability Action

Plan (GAAP), as required in the region and as part of the recommendations of the Detailed

Implementation Review (DIR).

12

Stakeholders6 were deeply engaged in project design and preparation, with extensive use of

participatory processes. Development partners provided input in their areas of expertise; for

example, DANIDA was consulted for technical input on the HMIS. Project preparation included

extensive consultation with NGOs providing health outreach services in tribal areas, and with

private providers on their experience of partnering with GoTN to provide services (such as

emergency transport and reproductive and child health (RCH) services). GoTN made special

efforts to increase participation and enhanced ownership of the Social Assessment by actively

engaging staff at all levels of the DoHFW, beneficiaries (individuals and communities), donor

agencies, NGOs, community organizations, local authorities, the private sector and academic

institutions in consultations. The PAD detailed the extensive use of participatory processes in

project preparation including for the Tribal Development Plan, researching how best to increase

demand for services and address the special health needs of the tribal population.

The project design reflects careful thought about behaviors, behavior change, and incentives.

In addition to activities to expand and improve supply of services, the project also included

efforts to increase demand for services, with activities to inform underserved groups and

encourage them to access services. Behavior change (BCC) interventions for providers aimed for

greater responsiveness to poor. Noting that complex “soft” investments may get less attention

from implementers, the project team used a phased approach which began with both

infrastructure and non-infrastructure (“soft”) inputs, but required the “soft” investments to be

completed before the next phase of infrastructure investment could begin.

QER and other project reviews: The Bank-wide Quality Assurance Group (QAG) did not

conduct an assessment. Project design benefitted from the recommendations of a quality

enhancement review (QER) arranged by the Health, Nutrition and Population anchor in 2002

shortly before appraisal. The QER panel were “impressed by the scope and range of preparation

work… and … many positive aspects of the project. The Panel is confident that, if the points

discussed are addressed, a project of good quality at entry will result.” The appraisal package

included the QER report, and the PAD shows how thoughtfully the recommendations were taken

on board.7 A Quality Assessment of the Lending Portfolio (QALP-1) in 2008 concluded that:

“the project was well designed. The design built on the state's successful track record in health as

well as the lessons learned from nine other Bank-financed state health system strengthening

projects in India. The panel was pleased to note the strong focus on the poor, the involvement of

NGOs, and the attention to the growing problem of NCDs through well-designed pilot programs.

The project rightly focuses on emergency maternal and neonatal care including the need for an

effective transportation system. While innovative, the panel did not consider the project to have

been over-ambitious.” (QALP-1, p4) The QALP judged the project’s FM design to be very good.

6 Stakeholders included members from all levels of the health system, academics, the public and private sectors,

civil society, NGOs, academics, and DANIDA. 7 In additional to suggestions on improving explanations in the PAD, the panel recommended: rethinking some of

the indicators; greater clarity about how activities in areas such as personnel, information and financing could help

integrate centrally funded programs and state health services; more attention to ensuring adequate levels of staffing

in facilities used predominantly by the poor; policy dialogue and attention to the state budget for health and

financing mechanisms to reduce out-of-pocket payment for health; considering simplifying the project

implementation arrangements, and stronger economic analysis.

13

The project design incorporated the lessons learned from a systematic review in 2002 of all

Health Systems Development Projects implemented in India since 1995 that considered

future directions for health projects in India. The TNHSP was the first State health system

project designed after this review, and deliberately and explicitly reflected its findings and

recommendations – facilitated by having the same Task Leader as the review. Six key

recommendations/lessons are clearly reflected in the project design: (i) project objectives should

focus on health outcomes among the poor, and special efforts are needed to reach the poorest:

several studies and participatory activities during preparation measured access to and utilization

of health services by the poor and sought their input on how to increase their access and use, the

project activities target least-served areas and populations with poor health; (ii) new ways to

enhance health outcomes need to be explored: the project included pilot testing of innovations in

NCD care on a reasonably large scale with rigorous evaluation to assess their effectiveness; (iii)

deepen public-private partnerships (PPP) by going beyond contracting out “hoteling” functions

which do not impact clinical care: the project contracted with private and NGO providers to

deliver clinical services particularly in underserved areas and enhanced GoTN capacity in PPP;

(iv) special attention should be paid to sector planning which was often weak at state level: the

project set up a strategic planning unit to function as a policy advisory body and think tank; and

to improving the management of public hospitals: the project included measures to enhance

public hospital management including twinning with well-performing private hospitals; (v)

implementation of non-infrastructure “soft” investments typically gets too little attention and is

often a weakness of project performance: the TNHSP team thought carefully about how to phase

implementation and incentivize completion of “soft” investments, as noted above; (vi) centrally

sponsored health schemes (CSSs) and programs and state-financed health services should be

integrated better: the project’s many activities to strengthen the state health system would enable

better CSSs service delivery by improving provider skills and availability, equipment and

supplies, the health information system, state level health planning, etc..

Risk and mitigation measures. Risks and mitigation measures were appropriately identified.

The risk of inadequate budgetary allocations was discussed early with GoTN, assurances were

received, and this was regularly monitored and did not become a problem. Capacity for

implementation was assessed and additional staffing, training and improved management

systems included in the project. New procedures were discussed in detail during preparation, and

groundwork completed during preparation. Detailed preparation for procurement was completed

well before project effectiveness (including all Terms of reference, bid documents, technical

specifications, Requests for Proposals and the procurement plan), to try to avoid early delays.

2.2. Implementation

Especially given the complexity, innovations and long time period, implementation was very

good. As rated in the Implementation Status and Results (ISRs) reports, implementation was

satisfactory or moderately satisfactory during the initial five years of the project (before AF)

except for two ISRs in 2006 that rated Implementation Progress (IP) moderately unsatisfactory.

After AF approval, project implementation was consistently satisfactory (5 years and 9 months).

Ratings for Development Objectives (DO) were satisfactory in 20 of 23 ISRs and moderately

satisfactory in the other three. Annex 2 lists the outputs achieved under each project component.

14

Factors contributing to consistently strong project implementation:

Consistently strong commitment of the Government of Tamil Nadu (GoTN), irrespective of

which of the two main political parties were in power. Successive governments in TN have

given consistent high priority to health (and other social sectors), and to implementing the

2003 health policy. Health has been “above politics” – shifts in political power have not

affected the emphasis on health or the continuity in policy and its implementation.

Successive governments have retained the 2013 health policy, and built on the actions of

previous governments, continuing to strengthen service delivery to improve health outcomes.

The GoTN assigned experienced, very high caliber senior officials to manage the project and

to staff the Project Management Unit and other key posts. The continuity and low turnover

among staff (from 2007) was especially important given the scope and complexity of the

project (and a sharp contrast, for example, to the 9 project directors in 2 years in a health

project in another state in India). GTN’s complete commitment to ensuring the success of the

project comes through clearly in ISRs and AMs, and is noted in the QALP-1.

Strong mutual respect and trust between the Bank team and GoTN. The AMs, numerous

other project documents, and information from people involved in the project attest to the

productive professional relationship between the Bank and GoTN. This enabled frank

discussion and constructive joint problem-solving when needed. It is noteworthy that this

relationship was not at all disturbed by tensions related to the Detailed Implementation

Review (DIR) of five health projects in India 2006-2007.

As a state-level project, it was not affected by the DIR tensions and tendency to centralize

and tightly control fiduciary functions that affected several national projects. The State’s

independent management enabled the project to continue its focus on strengthening the state

health system, including fiduciary aspects, without disruption (although the project was

required to comply with enhanced reporting requirements on procurement and financial

management for several years after the DIR).

The project was fully integrated within Government structures at all levels. Project activities

were an integral part of the DoHFW’s work and activities. This further strengthened project

ownership throughout the DoHFW, boosted commitment and implementation performance,

and enhanced the likelihood of sustainability after project completion. All project activities

were mainstreamed and their full financing absorbed into the state health budget or

nationally-funded health programs during the final years of the project.

Use of a phased approach for most project activities to learn and adapt before scaling up in

all districts in the state. Most activities followed this approach -- training, CEmONCs,

HMIS, NCD interventions, health care waste management, rationalization of health care

facilities, and improving equipment maintenance and repairs. The phased approach to

infrastructure improvements, whereby system reforms and “soft” investments had to be

completed before the second phase of infrastructure upgrading could begin, was an effective

incentive for successful and timely implementation of activities that often lag.

Well-functioning routine monitoring and information flows and feedback triggered clear

actions to continuously improve performance. (Details are provided below, in the section on

M&E utilization.)

15

Extensive independent assessment and validation as important input into decisions. The

project commissioned numerous independent assessments of activities by academics and

other experts, that provided data and unbiased views on strengths and weaknesses of

implementation processes and outcomes. The project team used the findings constructively to

make improvements and decisions on whether to scale up, drop, or change activities.

A strong focus on capacity building and skill enhancement through training and retraining.

The training covered activities essential for efficiently delivering health services across all

public facilities. It included specialized skills for doctors and staff nurses in CEmONCs;

hospital administration and management skills for administrators, senior medical officers and

nursing superintendents; a range of skill training for clinical, paramedical and laboratory

technicians needed for NCD screening and treatment; use of the HMS/HMIS; quality of care

and accreditation interventions; infection control and health care waste management; poison

treatment, and rational use of medicines for all relevant health professionals; and training in

proper equipment use (ventilator, dialysis, echocardiogram) as needed. Continuous quality

assessments helped identify training and retraining needs.

Continuity and a strong Bank team. There was one task team leader from project

identification (2002) to approval of the AF (2010), and two until project closing (2010-2015).

The Bank team was mostly based in the Delhi office, so all the necessary skills (operations.,

financial management, procurement, environment, social safeguards, information technology,

and health care expertise) were readily available during regular supervision missions, and to

respond quickly as needed in between missions. The Operations Officer who joined the team

in 2007 was exceptionally effective in providing continuous supportive supervision, and

ensuring continuity and “institutional memory” for the team including during changes in the

task team leader. The Bank’s Lead Health Specialist was also located in Delhi until the final

months of the project. The team had excellent working relationships with the PMU and

DoHFW. Supervision was systematic, detailed and regular, and the MTR was on schedule,

well-planned, intensive and detailed. There was strong follow-up between missions and

quick resolution of items identified for action. The QALP panel rated supervision inputs and

process as HS, and all other aspects S, noting that: “The Bank task team was proactive and

dealt in a timely and creative way with the hurdles encountered. The panel was especially

impressed with actions such as the team visit to Hyderabad to review a successful model of

emergency transportation that was subsequently adopted for this project.”

Candor in project assessment ratings. The project ratings were realistic throughout the

project, and the team did not hesitate to recognize potential or actual problems and forcefully

bring them to the PMU and DoHFW in a timely manner (the IP rating was downgraded to

moderately unsatisfactory in two ISRs in 2006). Early detection of potential problems and

candid discussions throughout the project contributed to keeping the project on track. The

QALP panel “began with the view that some of the ISR ratings were slightly optimistic…,

but concluded that the team, overall, was justified in its ratings”, rating PDO ratings as HS

and IP ratings as S, noting that the team’s ratings sometimes seemed premature to the sector

manager but were validated by subsequent implementation.

Provision of Additional Financing and recognition of good project performance. The

intention was always to process AF to replace the $20 million reallocated to an Emergency

Tsunami Reconstruction Project in 2005, if progress was satisfactory. The Bank agreed to a

16

much larger AF operation to continue successful activities and scale-up well-performing

ones, notably the piloted NCD screening, prevention and treatment; the HMIS; and maternal

and neonatal health services. Justifiable pride in the project’s accomplishments and

reputation as one of the best performing projects, and the associated “Hawthorne effect”

likely contributed to continued strong implementation performance.

Project extensions enabled the HMIS roll-out to be completed and even expanded beyond the

originally intended scope. This is especially impressive in the light of numerous failed HMIS

efforts elsewhere. Extensions also provided enough time for smooth institutionalization and

absorption of activities by the DoHFW, carefully and well-informed assessment and planning

for future financing by the government, and for all planned assessments to be completed.

Factors that were outside the control of the government and caused implementation

difficulties.

The massive tsunami that struck eleven coastal districts of Tamil Nadu two weeks after

project approval in December 2004 caused large scale destruction. Diversion of GoTN’s

attention, efforts, and resources to disaster relief, recovery and reconstruction activities

delayed project implementation at the start, which would have been an intense period of

activity. Government attention was diverted entirely to managing the damage caused by

tsunami for at least the first half of 2005.

Delays caused by the freeze on all procurement activity for the 45-60 days before all

national, state and municipal elections under the “Model Code of Conduct”. The Model

Code of Conduct caused procurement activities to be put on hold – sometimes for several

months, delaying project implementation. The project was very proactive in requesting

exemptions to the freeze, but these were not always granted, including in 2010 and 2014.

Factors that caused implementation difficulties included:

Turnover of Project Directors in 2005-2006. The turnover of Project Directors (senior

officers from the Indian Administrative Service) in the first two years of project

implementation slowed project progress. There was however stability thereafter.

Ineffective financial management for 15 months. The long-vacant position of Financial

Advisor and Chief Accounting Officer (FA&CAO) early in implementation resulted in

inadequate attention to financial management, notably a delay in submitting the 2006-07

audit report, delays and inadequate follow up in settling advances drawn for training etc., and

inadequate project financial oversight over NGOs. These problems were resolved after GoTN

posted a well-qualified professional to the project in early 2008.

Slow initial procurement affected disbursement. Delays in procurement actions in the first 18

months of the project (especially for civil works and baseline studies) slowed initial project

implementation and disbursements. This was exacerbated by the procurement freeze required

by the Model Code of Conduct before the elections in 2005 and early 2006. Procurement

issues were subsequently resolved as a result of proactive actions by the PMU. The delayed

start of the project in 2005 due to the tsunami, and the procurement issues noted above

slowed disbursements particularly during the first 2 years of the project (2005-2006). Weekly

audio follow-up meetings between the Bank team in Delhi and the PMU in Chennai starting

December 2006 led to an improved pace of procurement and disbursements.

17

Difficulties with contracts to NGOs for providing emergency medical transportation. The

MTR concluded that the NGO contracting and contract management process was not

working well, and needed more oversight and monitoring and action to ensure strong

performance and achievement of the intended results. It recommended that the PMU consider

hiring an external agency to take over this task, and use performance based funding with

clearly defined selection and monitoring criteria, and robust financial control systems. The

GoTN contracted Emergency Management and Research Initiative (EMRI) who were

operating very successfully in Andhra Pradesh, to provide these services, which proved

successful.

The complexity and time needed to design, test, trouble-shoot, implement and make good use

of a new HMIS were underestimated. Conceptualizing, designing, and back-end work to set

up an HMIS/HMS system – especially one that links hundreds of facilities across the state

and multiple levels of the health system, replaces many legacy systems, introduces new work

flow and technologies, and relies on adequate server capacity and extensive end-user

behavior change – was an enormous task. After a slow start and significant implementation

challenges, the MTR team worried that there might not be enough time to fully roll out the

system, and persuaded GoTN to pilot the system in five hospitals before proceeding.

Turn-over of specialist doctors at CEmONCs. Despite the proactive efforts by DoHFW, loss

of specialists – particularly anesthetists – has left some CEmONCs short of the agreed

staffing during some periods. The agreed process of regular recertification of CEmONCs

(every six months) kept a spotlight on staffing relative to norms. This will require constant

monitoring and proactive action by DoHFW.

2.3. Monitoring and Evaluation (M&E) Design, Implementation and Utilization

M&E design. Overall, the M&E design had many strengths, and reflected careful and logical

thought, consistent with “best practice thinking” about health systems. The “Flagship

Framework” on Health Systems Strengthening (developed by the Bank’s training institute with

Harvard University and other experts a few years before the project) defines three ultimate goals

of a health system: to improve the health of the population; to provide “financial protection”

(that is, to ensure that health care does not cause financial harm); and to provide patient

satisfaction. These three “ultimate outcomes” require a health system to provide good access,

quality, and efficiency, which the framework calls the “intermediate outcomes” by which to

judge a health system’s effectiveness. The project indicators cover all of these 6 outcomes.

Financial protection is measured less well than the other 5, in the numbers of people who

benefitted from the free ambulance and mortuary transport services, and the bed-grant scheme.8

The original project Results Framework (RF) in the PAD was comprehensive and logical,

developed in consultation with key stakeholders, and with input from the QER and other experts.

It reflected a clear results chain, with four appropriate outcome indicators to measure PDO

8 Financial protection was not a central explicit focus of the project -- activities to overcome financial barriers were

seen as increasing utilization/access. A community-based health insurance pilot added at the suggestion of the QER

panel was later dropped because it was judged likely to have little impact on achieving the PDO, especially in light

of the roll-out of the Special Minister’s health insurance scheme.

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progress – one for each component, and 22 fairly well-chosen intermediate outcome indicators

(IOIs) – one or two for each main activity. The PAD Annex 3 lists data sources, frequency, and

clear responsibility for data collection for all indicators.

The indicators for increased access and use of services, especially by the poorest and Tribal

groups, and for maternal and neo-natal mortality rates (adjusted for risk) were very important for

assessing the core impact of the project. Excellent systems were put in place as part of project

design for routinely collecting data on quality of care, utilization rates at health care facilities,

and hospital activities, and reviewing, analyzing, agreeing on actions and then continuously

following up. This enabled remarkable quality and impact improvements in a very short time.

The project design also included major investments to improve monitoring and evaluation

capacity through a new, integrated, system-wide HMIS to replace manual paper-based, time-

consuming reports that involved minimal feedback or basis for action. The new HMIS was

designed to track patient, service and management information, network all hospitals to track

referred cases, monitor changes in health outcomes, and provide feedback to service providers

and program managers for improved follow up and continuity of care. M&E design also included

an impressive number of independent evaluations of selected project activities that assessed the

impact of innovations – these included surveys and studies on NCDs, patient satisfaction, and

health services available to and used by tribal populations.

However, M&E design had some imperfections, despite the team following advice from the

QER. At appraisal, baseline data were available for only a few of the indicators, and most targets

were vague instead of SMART.9 Many targets were arbitrary placeholders (“10% increase”)

pending collection of baseline data, but relatively few were replaced later with carefully chosen

targets, as had been intended. As noted by the sector manager in ISR#6 (after baseline data had

been collected), targets that aimed only for an undefined increase or to maintain the baseline

value were disappointing in their lack of ambition. They probably reflect risk-aversion, and/or

inability to decide what might be feasible in the absence of evidence and experience on which to

draw. But this is a weakness in the project M&E design that was not well-addressed despite

creditable efforts by the team to improve the results framework during project implementation.

Despite the faults that can be found with the M&E design, it was stronger than in most projects,

especially considering how little experience in health system strengthening projects the team was

able to draw on a decade ago. The 2008 QALP noted that: “The task team, by its own admission,

struggled with getting the results framework right, not an easy task in a project of this type. To

its credit, the [Task Team] employed many experts and continue to revisit, refine and improve

the framework” – which was done in 2007, at AF, and again in 2014.

The 2007 RF revisions made well-considered improvements: over-broad and vague parts of two

of the IOs (e.g. “careful monitoring of the effectiveness of other NCD prevention activities”)

were dropped, base-line data were added, and indicator definitions refined. However, some

“Quality of Care” indicators measured efficiency and not quality (bed occupancy, number of

surgeries) or were ambiguous (night-time C-sections are only a valid quality indicator if they are

emergency and not elective procedures). Even the number of diagnostics tests in itself may not

9 Good practice requires targets that are Specific, Measureable, Agreed/Achievable/Assignable (clearly

defined responsibility), Relevant/Realistic, and Time-bound.

19

indicate quality. In its zeal to monitor all of the many project activities, and probably over-

compensating for slow implementation in the first 3 years, the AF added an excessive number of

indicators – for several years the PMU diligently reported on 72 items. (To their great credit, the

documents prepared for each mission were impressively complete and detailed, with thorough

attention paid by both Bank and project teams to each item.) The decision to drop 38 IOIs and

supplementary indicators as the project neared its end, to focus on core activities and impact

measures, was understandable. However, instead of formally dropping the indicators, the Bank

could have agreed with GoTN that reporting was no longer required on the activities already

completed, and retained September 2014 as the target date for activities on which no further

detailed reporting was warranted.

M&E implementation.

The planned M&E was fully and well implemented. Data reporting to supervision missions and

in ISRs was impressive: comprehensive project status reports including data for the RF and all

project activities were provided every six months throughout the project. The range of data

sources used to monitor and report regularly on progress and results included: routine health

system records, routine project data, on-line monthly reports from the hospitals on a set of 20

indicators (Institutional Services Monitoring Report or ISMR), facility surveys, baseline and

endline surveys, and many detailed studies of selected project activities. Data were used well to

monitor progress, check that activities were achieving their desired results, and decide where

corrective actions were needed (details below). The PMU took good advantage of expertise in

the state, for example, partnering with the Christian Medical College in Vellore, the Indian

Institute of Technology, and the National Institute of Epidemiology (NIE) in Chennai to evaluate

pilots and other activities.

Three weaknesses are noted: (i) delays in baseline surveys – 15 months for the NCD baseline

studies for the pilots and for patient satisfaction surveys, (ii) changes in methodology in repeat

surveys of patient satisfaction that make trends difficult to assess; and (iii) mistaken entry of data

on the poorest 40% in the results reporting for SC/ST. This latter was noted when preparing the

2014 restructuring; detailed scrutiny found mistakes in the analysis of NSSO data in a 2007

consultant report. The Bank commissioned a careful new analysis (see Annex 10) to correct the

data for the indicator on access and utilization of services by the poorest 40% and ST/SC groups.

An impressive aspect of M&E implementation was the successful comprehensive Health

Management Information System (HMIS), despite its challenging and increased scope during the

project. Rolled out in a phased manner from December 2008 onwards, the HMIS comprises (i) a

Hospital Management System (HMS) which automates reporting on clinical activities in public

health care facilities; (ii) a Management Information System (MIS) which is an online reporting

platform for clinical and ancillary support services, national health programs and administrative

information for all public health facilities; (iii) the College Management System (CMS) to

capture data from government medical colleges; (iv) the University Automation System (UAS)

for data from the Tamil Nadu Dr. MGR Medical University; and (v) customized web-sites for 20

government medical colleges. By July 2015, the HMIS was fully functional in 264 secondary

care hospitals and at an advanced stage of implementation in the state’s 50 tertiary care hospitals;

the MIS had integrated 1,889 primary health centers, 264 secondary care hospitals, and 50

20

tertiary care hospitals; and the CMS was operational in 20 government medical colleges. All

PHCs were reporting through the HMIS effectively, with all reports flowing to the Directorate of

Public Health (DPH), and all data from secondary care hospitals flowing to the Directorate of

Medical & Rural Health Services (DM&RHS). Over 165 million patient visits, 62.8 million

laboratory requests, 81.6 million pharmacy dispensations and 4.1 million in-patient visits had

been recorded in the system.

The new HMIS provides quick access to information of all important aspects of the health

system -- hospital activity and efficiency indicators (in-patient and out-patient data, referrals,

waste management, quality of care, morbidity/mortality), financial management information, and

human resources. In the final years of the project, project monitoring data were provided

exclusively from the HMIS. The HMIS system is a major project achievement, and has received

national and international awards.

A State Health Data Resource Center (SHDRC) was set up to collate, mine, and run higher order

analytics on data from over 20 Directorates of the Health Department. The SHDRC provides

easy to use dashboards for various levels of administrators and managers in the health

department. Its mandate is to drive and enable evidence-based planning, budgeting, management,

forecasting, monitoring and reviews by the DoHFW. The Center is managed by a consulting

firm, contracted (in 2015) to run the Center for two years, and then hand it over to the state, but

continue to maintain and support the activities of the Center until March 2021.

M&E utilization. The PMU was effective in using the data from all sources to make

improvements during project implementation. A few of many possible examples follow:

During the NCD pilots, an evaluation by the National Institute of Epidemiology (NIE) found

that patients were being lost in follow up for treatment, in response the PMU decided to issue

30 day supplies of medicines for hypertension and diabetes so that patients did not need to

visit health care facilities more frequently, and set up an online tracking system for patients

tested positive during screening. In response to the evaluation survey findings that (i)

shortages of staff nurses were affecting screening and treatment under the NCD programs,

and (ii) inadequate skills among health professionals for the NCD interventions, the PMU

sought approval from the State Empowered Committee to recruit nursing staff on contract,

and conducted periodic training programs to remedy specific gaps in knowledge and skills.

Assessments of IEC activities led to changes in the messages and methods used, and also

monitored the extent of changes in awareness and knowledge. The results of the pilot

evaluations were carefully incorporated into the design of the scaled up NCD programs.

Early in implementation, the PMU developed quality and utilization indicators to measure

hospital performance. All public hospitals reported these data monthly (Integrated Services

Monitoring Report). The project used the data to grade hospitals A to D every month;

hospitals with C and D grades were followed up to assess constraints and agree actions to

improve service delivery. Quality Circles of Excellence were set up in hospitals to track

progress, and develop and implement improvement actions. This proved be effective in

improving performance and quality of care at the hospitals.

The project and NHM and DoHFW instituted a practice of monthly reviews (by video/audio)

of every maternal death in which senior medical officials and relevant health facility staff

21

discuss the causes and actions to prevent future similar situations. This contributed to the

substantial fall in maternal deaths in the state.

The HMIS system assigns a unique patient identification number (PIN) to track all health

services provided to each patient, and make the patient medical record available at all points

of care. When the number of PINs began to exceed the estimated number of patients using

the public health system, it was realized that some patients were registering multiple times

(after losing their PIN). A concerted intensive state-wide campaign explained how the PIN

was used and the benefits of having a unique PIN, as a result of which patients made sure to

keep and use their PIN on each encounter (pasting them in notebooks, keeping them on a

small laminated card, etc.).

Despite the extensive use of data generated and reported for the project and by key project

activities, there is still unrealized potential to use the data to improve efficiency, quality, and

allocation of resources. For example, detailed data on the actual use of pharmaceuticals and

medical supplies could enable more accurate projections of need and trigger re-supply. The

established of the SHDRC is intended to realize this potential, which could make Tamil Nadu a

global leader in this area.

2.4. Safeguard and Fiduciary Compliance

The project was classified as a Category B and triggered two safeguard policies: OP/BP/GP 4.01

Environmental Assessment and OD 4.20 Indigenous Peoples. Both policies were handled well

and rated satisfactory in all ISRs. There was full compliance with all Bank requirements.

Environmental aspects. Improving management of health care waste and fully institutionalizing

the activities across all programs and facilities in the state under the project were exemplary. A

sound comprehensive Health Care Waste Management (HCWM) Plan was developed. It was

implemented in a phased manner -- first as a pilot in 2006, and based on satisfactory pilot

implementation, from 2008 it was scaled up steadily in 449 health facilities including secondary

care, tertiary care and ESI hospitals, and thirty-bedded PHCs. At AF, health waste management

was integrated with infection control, in line with emergent good practice, referred to as

Infection Control and Waste Management (ICWM). HCWM/ICWM activities were proactively

supervised by a Bank specialist. Implementation and adequacy were assessed at various stages

including near the end of the project (2014). Over 49,500 health personnel from 449 public

health institutions were trained and retrained in health care waste identification, collection,

segregation, disinfection, and disposal, through a network of 9 Regional Training Centers

established by TNHSP. Supervision missions found adequate availability of color coded bins and

bags, trolleys, needle destroyers, protective gear, consumables, handbooks on infection control

and biomedical waste management, IEC materials and training modules. PPPs were established

with 30 Common Treatment Facilities (CTFs) where waste was collected, disinfected and

disposed of. From 2013, the cost of implementation of the HCWM plan was financed through

the NHM, with the project financing training only.

Findings of a comprehensive end-line assessment in 2014 included the following: (i) all hospitals

were implementing Infection Control and Waste Management (ICWM) and had access to CTFs,

(ii) 95% of respondents had been trained in ICWM, 60% mentioned need for additional refresher

22

training and training for new recruits, 89% were fully satisfied with the quality, relevance and

method of training, (iii) best practice of labelling bins was observed in 60% of facilities, (iv)

92% facilities had storage room for biomedical waste, (v) sharps disposal “hub cutters” to

replace needle destroyers were available in 75% of hospitals,10 (vi) 78% of hospitals had an

infection control officer for monitoring ICWM processes, and 80% had infection control

committees. The assessment provided reassurance of well-implemented ICWM and offered

minor suggestions for improvements (e.g. on-line training, better reporting of needle-stick

injuries).

Indigenous peoples. Consistent with the project’s objective of improving health care outcomes

among vulnerable groups including women, ST/SC groups, the poor and populations in remote

areas, a Social Assessment was conducted with good participation of key stakeholders. This

informed preparation of a Tribal Development Plan (TDP) also done in a highly consultative

manner (October 2003) to develop appropriate and carefully chosen interventions to increase

access to health care in tribal areas.

There were some challenges in implementing the TDP. NGOs varied in their willingness to

partner with Government, which was eased by Project efforts to engage with NGOs regularly

through consultations and meetings in the field (facilitated by the Bank). Training/capacity

building of NGOs/field workers could have been improved. It took a long time for proper

guidelines to be finalized and then communicated to the NGOs and field staff. Turnover of field

staff of NGOs was a problem, and repeated capacity building was needed. The NGO consultants

who were supposed to do field supervision of the various NGO activities were never fully on

board, so adequate monitoring of various NGO activities remained a challenge. While the NHM

has taken over various programs for tribal populations, effective absorption of the activities will

require close collaboration between the DoHFW and the NHM.

Despite the challenges in implementation, a 2014 end-line assessment of four of the five

activities carried out under the project found strong results. A survey of the targeted population

found high levels of use and satisfaction with the services and their quality.

Financial management (FM). Overall, financial management was satisfactory. The financial

management arrangements for the project were completely mainstreamed within the regular

government funds flow and accounting systems and procedures. Twenty of the 23 ISRs rated FM

in the satisfactory range (S/MS). Three ISRs (May and October 2007 and April 2008) rated

financial management performance moderately unsatisfactory, largely due to slow

disbursements. Slow disbursements during the initial years were mainly due to delays: in

procurement actions, in releases from the Treasury, in the appointment of the Financial

Advisor/Chief Accounting Officer, and in the submission of monthly financial reports from the

TNMSC and PWD. These issues were satisfactorily addressed. The Bank agreed to the GoTN’s

proposal to change the funds flow mechanism by creating a Society at the state level (an

independent legal entity) for implementing all project activities other than civil works,

equipment and goods. Delays in settlement of advances drawn on training etc. were also

10 To prevent accidental needle sticks, used needles need to be safely disposed of, and re-use prevented. “Hub

cutter” needle-syringe disposal devices cut up the entire device, so the used needle does not have to be removed.

23

addressed. The PMU also took actions to strengthen control and monitoring of NGO contracts by

holding regular annual performance reviews before renewal of contracts, reviewing the cost

elements and building in an institutional fee to NGOs. All audit reports and IFRs were submitted

but in some cases with a small delay. The Comptroller and Auditor General (CAG) conducted

external audits per terms of reference agreed with the Bank, Department of Economic Affairs

and CAG. Very few financial statements of the PMU were qualitied and in one instance, because

of a special opinion, an accountability flag was triggered. All issues were addressed to the

satisfaction of the auditors and their observations were answered and resolved. There were no

unresolved audit objections. For the AF, a Governance and Accountability Action Plan (GAAP)

was prepared, and as part of the GAAP, Interim Unaudited Financial Reports (IUFRs) and

internal and external audit reports were hosted on the website of the project. For the AF, it was

agreed to shift to report-based disbursements.

Procurement. Procurement activities were under the overall direction of the Project Director.

The PMU was directly responsible for procuring consultancy services, and coordinated other

procurements. The GoTN Public Works Department (PWD) was the implementing agency for

civil works under the overall control of PMU. The Tamil Nadu Medical Services Corporation

(TNMSC), as the GoTN Procurement Agent, procured all equipment and goods. Capacity to

handle procurement was assessed as adequate and the procurement risk as average. A

procurement plan for the first 18 months was agreed prior to project approval. For the AF, the

Electronics Corporation of Tamil Nadu (ELCOT) was the procurement agent for information

technology (IT) hardware and associated supplies/services for HMIS. The AF assessed the

overall procurement risk as substantial.

As noted above, project implementation was slowed at the start by delays in procurement actions

by PWD and TNMSC, lack of interest by potential bidders in the first 18 months of the project

and in 2008, and slow decisions in processing two consulting services. The massive Tsunami that

struck Tamil Nadu a few days after project approval, causing huge destruction and diversion of

Government’s resources and attention to recovery efforts, greatly contributed to the initial

delays. Procurement issues were subsequently resolved. The triggering of the Model Code of

Conduct by the announcement of elections also put on hold decisions on procurement actions at

critical times of project implementation. Despite these issues, the PMU’s strong team, GoTN’s

commitment to the project’s success, and the Bank’s regular intensive implementation support

throughout the project ensured satisfactory completion of all procurement activities. The Bank

conducted regular ex-post procurement reviews and the PMU took actions as needed in a timely

manner to address issued raised. Overall procurement performance was moderately satisfactory.

2.5. Post-completion Operation/Next Phase

The GoTN is keen to continue its partnership with the World Bank, and is developing a proposal

for technical and financial assistance for a second Health Systems Development Project.

It is greatly to the credit of the GoTN that no immediate follow-up operation was needed to

sustain the project activities, which had all been fully mainstreamed. Transition planning was an

integral part of the project design, and GoTN ensured that programs continued without

interruption, and with adequate financing. Well before project closing, the GoTN started to

absorb project activities into the work and budget of the NHM and the DoHFW (e.g., mobile

24

outreach, counselling services, the bed grant scheme, heath waste management, emergency

transport, HMIS,) with only essential inputs (technical support and monitoring and evaluation)

continuing from the project. By the end of the project, all major activities funded by IDA under

the project had been taken on by the DoHFW Directorates for continued implementation as

regular departmental activities. All contract staff (female NCD staff nurses, bio-medical

engineers, IT coordinators) and other additional staff approved for the programs were retained

and transferred to the Directorates so that programs remained fully staffed. GoTN and NHM are

fully funding these activities. Project assets have been handed over to the Directorates. The few

project programs such as State Health Data Resource Centre, 108 Emergency Ambulance

Services, and Free Mortuary Van Services not integrated into regular DoHFW operations are

continuing, implemented by the TNHS Society, funded by the GoTN, and housed/located in the

Directorate of Medical Services (DMS) Annex. GoTN is continuing the innovations started and

supported under the project including ongoing public private partnership program contracts.

ICWM is a good example of the integrated mainstreaming of project activities. ICWM is now

implemented and monitored by the Directorates of Medical and Rural Health services, Public

Health and Preventive Medicine, and Medical education. To ensure sustainable capacity for

ICWM training, the project strengthened 9 Regional Training Centers. Institutionalization and

strengthening of HCWM in public health institutions under the project was exemplary, and

ICWM activities were integrated across all vertical programs in the state.

3. Assessment of Outcomes

Given the change in the PDO under the AF in 2010, two project phases are assessed, before and

after the AF: 2005 to April 2010, and May 2010 to closing in September 2015. The main

difference was the progression from piloting NCD interventions in the original project, to scaling

them across the state under the AF. The project performed well in all three outcome aspects—

relevance, meeting and exceeding objectives, and efficiency.

3.1. Relevance of Objectives, Design and Implementation

The project’s relevance is High in all aspects – objectives, design and implementation, for both

phases.

Relevance of Objectives – (rating: High)

The project objective of significantly improving the effectiveness of the health system in Tamil

Nadu responded fully to the state’s needs and policy priorities, and to the Bank’s assistance

strategy, both at appraisal and now. It was ahead of the strong global shift in emphasis to

strengthening health systems (HSS). HSS was advocated in the Bank’s Strategy for Health,

Nutrition and Population Results (2007) which also noted the importance of M&E systems (p. 6),

and concern that the increasing burden of NCDs would strain countries’ health systems. The

project focus on improving effective health services delivery, and access, utilization, and health

outcomes for all, especially marginalized groups, anticipated today’s global focus and

commitment to Universal Health Coverage.

25

The GoTN’s Health Policy (2003) identified strengthening hospital services and quality

(especially at district and sub-district levels) and preventive health as priorities, aimed for

ambitious reductions in IMR and MMR, to improve the health status of the general population

with an emphasis on poor and the disadvantaged, and to address non-communicable diseases.

The project fully reflects these, which remain current health policy. The GoTN DoHFW Policy

Note on Health 2015-16 provides a comprehensive update on health outcomes and services in the

state, including sections explicitly on the project, because the project is fully part of GoTN health

policy. The Policy as set out in 2003 remains in force.

The project objectives remained Highly relevant to successive Country Strategies for India

(2009-2012 and 2005-200811), and to the Bank’s current Country Partnership Strategy (CPS)

for India (2013-2017). The CPS focuses on using the Bank’s financing, knowledge, advisory

services and technical assistance in catalytic and transformative ways to strengthen health

delivery systems, improve access to services for excluded segments of the population, reduce

rates of maternal and infant mortality, address the growing burden of non-communicable

diseases, and improve delivery systems by strengthening accountability and M&E systems (p.

20-21, 27-28, CPS Summary). In lending to more advanced states, the CPS focus is on

innovative and transformative activities to test second generation approaches which can then be

applied to low-income states that often have limited capacity (p 30, 33). This was one of the

explicit justifications for the project’s AF.

Relevance of Design and implementation – (rating: High)

The design of the original project and AF was highly relevant and remained so throughout

implementation. The PDO clearly defined four sets of activities through which the overall goal

would be achieved, and one component was devoted to each of the four. Each component

included three or four intermediate results that were logically linked, with clearly defined

activities for each. The activities explicitly addressed constraints on access, utilization and

quality of health services in Tamil Nadu, with a dedicated set of activities to serve tribal groups.

The indicators kept the focus on the poorest 40% of the population (a key target group for the

Bank’s current “twin goals”). The PAD clearly explains how the project activities relate to the

identified constraints. For example, data on the main causes of most maternal and neo-natal

deaths informed the decision to provide free emergency transport and upgrade facilities to enable

them to provide 24 hour emergency obstetric and neo-natal care. Data and studies documented

Tamil Nadu’s growing burden of NCDs, so the project design included a dedicated component to

11 The project objectives were highly relevant to the third pillar of the Bank’s Country Strategy for India (2009-

2012, p. 2, 14, 16), consistent with the themes of India’s 11th plan (2007-2012). The first of 5 health targets in

India’s 11th five year plan was to reduce the IMR to 28 and MMR to 100. The vision of the 11th Plan was “to ….

ensure broad based improvement in the quality of life….especially of the poor, Scheduled Castes and Scheduled

Tribes, other Backward classes….create access to essential services in health…. especially for the poor… and good

governance.” The project objectives were also highly relevant to the Bank’s Country Strategy for India (2005-2008)

“…to reduce the health risks of the poor – by improving health outcomes including reductions in maternal and infant

mortality, by improving the overall health system of the states, by focusing on the access to and quality of health

services for the poor, by breaking new ground in forging public-private partnerships, and by reorienting health

facilities to ensure service for the poor, to reallocating public resources to priority areas for the poor, and to

improving governance and service delivery” (p. 31, 38-39, CAS).

26

improve NCD prevention and better enable the health system to detect and treat important

NCDs. Selection of activities was informed by current data on cost-effectiveness and “best buys”

in health.

The project design focus on partnering with the private/NGO sector through PPPs was well

aligned with the Government’s approach and Bank strategy. It was a sensible approach given the

limited capacity of the government’s own health service delivery network, and the very high use

of private sector health services by the population at all income levels. The services that were

delivered through PPPs with private/NGO providers were all things for which the public sector

did not have a comparative advantage (emergency transportation, service delivery to tribal

populations and in remote areas, disposal of health waste, counselling services, diagnostic

laboratory tests). One of many examples of good project design was that the project made the

capital investments (e.g. procured the ambulances) and then “contracted out” operation and

maintenance to NGO/private partners (many of which would not have been able to finance the

needed investments).

All project investments in infrastructure and equipment were informed by careful assessments of

existing situations and needs to achieve the desired reforms and improvements. Investments

included all necessary inputs for the expected output and outcome: equipment, drugs and

supplies, staff increases, training in skills and protocols, supportive supervision and quality

assurance, as well as demand-side activities. Moreover, these mutually reinforcing inputs appear

to have been well phased, sequenced and coordinated, which is an even greater design and

implementation accomplishment. Reforms and “soft” activities such as training, behavior

change, and new quality assurance mechanisms were thoughtfully timed relative to “hardware”

investments in buildings and equipment. The phased approach facilitated effective

implementation. Pilots and first phases were large enough in scale to test innovative and complex

interventions, learn from them, adjust design details, and then appropriately scale up.

Incorporating the new HMIS system as part of the project was important to being able to monitor

and evaluate the effectiveness of the health system, and hence a key part of the project design.

The phased approach to its development and implementation – and to other innovative or

complex activities – enabled design details to be refined and improved during implementation.

This approach, as well as the quality of the project design, and its forward-looking focus on

strengthening the health system to be able to cope with emerging as well as current health care

needs, resulted in very little need for changes in the project scope or design, despite its long

implementation period of more than 10 years. The MTR in 2007, the QALP in 2008, and the AF

processing in 2010 all gave the objectives, design and implementation thorough scrutiny, and all

concluded that the relevance was strong. The change at AF from piloting NCD programs to

scaling up state-wide was a natural progression. The few (minor) activities that were dropped

were in response to changed circumstances, to avoid duplication of effort, and a clear-eyed

judgement on their likely contribution to the PDO.

Institutional and implementation arrangements were based on two sound principles: (1) placing

project management responsibility within the DoHFW, given its responsibility for the state’s

health sector, and (2) the full use of the different health system actors for project implementation.

PMU staff were deputed from different health Directorates, and consultants were recruited only

27

when necessary because the DoHFW or other state agency did not have the specialized skills

needed, or capacity to take on additional tasks. Project extensions were fully justified and

provided sufficient time for critical institutional capacity building and mainstreaming of project

activities, helping ensure a high likelihood of sustainability of the Bank’s investments.

3.2. Achievement of Project Development Objectives (rating: Phase 1 – Substantial;

Phase 2 – High)

As noted in the section on M&E design, the project indicators enable a fairly complete

assessment of changes in the effectiveness of the health system. The impact of the project on the

well-being of Tamil Nadu’s population is assessed through the three “ultimate outcomes” by

which to measure health system performance – health outcomes, financial protection, and

patient satisfaction. The indicators include patient satisfaction; for health outcomes the

important indicators for maternal and infant mortality; and some (although inadequate) measure

of the extent to which the project improved financial protection, through numbers who benefitted

from various free services. The indicators also include various measures of the three intermediate

outcomes by which to measure health system performance – access, quality and efficiency.

Summary of Project Achievements against Results Indicator Targets

Phase 1: 2005 - March 2010 Phase 2: April 2010 - 2015

PDO Intermediate PDO Intermediate

Surpassed 2 1 4 16

Achieved 3 10 5 14

Partially Achieved 0 0 112 113

Not Met 0 114 0 114

Data not available 3 3 0 0

Total indicators 8 15 10 32

% surpassed and/or achieved

(indicators with available data) 100% 92% 90% 94%

Phase 1: effectiveness on December 16, 2004 through AF approval in March 2010

Phase 2: AF (when the PDO was revised) to project closing.

Most project indicator targets were met and many surpassed (summarized in the table above and

detailed in Data Sheet Table F). The only PDO indicator not fully met was the percentage of

caesarean sections (C-sections) that were among ST/SC women. Given the large increase in C-

sections from 15% to 26% of all deliveries in public facilities, the shortfall from this target is not

considered a problem.15 The indicator on use of helmets is relevant for traffic accident fatalities

12 93% of target for “C-section deliveries among SC/ST mothers at secondary level CEmONCs”. 13 “Availability of staff according to norms at all project facilities” was met for 79% of project health facilities (211

out of 267) - an excellent improvement on 8% (22 facilities) in 2005. An IEC unit to coordinate all activities across

the state was not set up in DoHFW. 14 Improved helmet use was not achieved (dropped at AF). 15 An independently conducted study (financed by the project) confirmed that C-sections done at CEmONCs were

medically indicated in response to complications. Women with pregnancy complications were increasingly referred

to CEmONCs – as intended. Treatment for pregnancy complications in Government facilities increased from 46% in

DLHS3 to 64% in DLHS4, and treatment for post-delivery complication rose from 48% to 59%. Thus the

CEmONCs were dealing with more complicated cases, and their rate of C-sections was within internationally

accepted norms for both SC/ST women and other women.

28

but is not a measure of the effectiveness of the health system but of police enforcement of traffic

safety regulations and related state policy.

Assessed using the project indicators only, the project’s achievement of its objectives was much

better than satisfactory. An assessment of whether the project made Tamil Nadu’s health system

more effective follows, drawing on other data in addition to project indicators to assess each of

the six aspects of health system performance.

The original PDO in the PAD explicitly included “both private and public” parts of the health

system. Most project activities were in the public sector, and project indicators measure impact

on public sector effectiveness, as well as that of the NGOs and other private sector service

providers contracted under the PPPs and informal health care providers (including traditional

medicine practitioners) trained under the project. However, this excludes many private facilities

and health care providers. The GoTN (like the rest of India) has almost no oversight over private

sector health care providers. Changing this would have required a difficult, major policy shift

and new enforcement capacity, and was not the intention of the project. The project could have

had an indirect impact on the effectiveness of the private health sector if, by improving the

quality and availability of services provided by the public sector, private providers improved

their own effectiveness in order to compete. There could be a direct impact through a

demonstration effect if private providers adopted treatment protocols or other good practices

developed under the project, and also as a result of providers moving from the public sector into

the private sector after their skills and capacity had been improved by project activities. No

measures are available of the effectiveness of only the private sector, but all data from the NSSO

and other household surveys (for example on health outcomes) reflect the effectiveness of the

whole health system, both private and public.

Ultimate Performance Measure 1 - Health Outcomes. Rating: High (both phases)

The state NFHS surveys 3 and 4 (2005-06 and 2015-16) and the 2010 Census show marked

improvement in TN’s infant mortality per 1,000 live births from 30 in 2005 to 24 in 2010 and 21

in 2015 (nearly half the India national rate of 40 in 2015), and in under-five mortality which fell

from 35 in 2005 to 27 in 2010, with no additional decrease in 2015. Tamil Nadu had by far the

largest decline in IMR of all states in India in the decade before 2010: 46%, a full ten percentage

points more than the states with the next-largest falls in IMR (IMR fell 29% nationally). Tamil

Nadu also has one of the smallest disparities between male and female under-five and infant

mortality in India. There were also improvements in all measures of child nutrition status (see

Annex 10). The maternal mortality ratio (MMR) fell steadily from 134 in 2003, to 97 in 2009-11,

79 in 2012-14, and 68 in 2015, less than half of the all-India rate of 167 per 100,000 births.

Although population-wide data are not available for trends in NCD outcomes, the available data

on risk factors and from evaluations commissioned by the project suggest that a positive impact

is likely to have been achieved. Between 2005 and 2015, there was a notable decline in the

percent of adult men using tobacco from 40% to 32%, and from 2.8% to 2.2% among women,

and high percentages (40% of women and 23% of men) who used tobacco at the time of the 2015

NFHS reported having tried to stop during the past 12 months. Data on other NCD risk factors

were collected for the first time in the 2015 NFHS, so no trend data are available.

29

The NCD screening and treatment programs achieved extensive state-wide population coverage:

77% of people over 30 years of age were screened for hypertension. Evaluations commissioned

by the project found substantial improvements in diastolic and systolic blood pressure among

patients who were regularly followed up. Diabetes screening covered 61% of the population over

30 years of age. Of women aged 30-60 years, 71% were screened for cervical cancer and 86%

for breast cancer. This resulted in a dramatic increase in case detection and – despite some loss to

follow-up – in treatment for these diseases. Although no data are available on treatment

outcomes, it is safe to assume a significant gain in disability-adjusted life-years (DALYs - a

combined measure of prevented deaths and illness). Tamil Nadu has one of the highest burdens

of road-traffic fatalities and injuries in India; the large increase in the percentage of calls for

ambulances after road traffic accidents that were served from 66% in 2009-2010 to 87% in

2014/2015 (exceeding the project target of 79.4%), as well as the investments in hospital

capacity to provide emergency care, are very likely to have improved outcomes for traffic

accident victims.

There certainly are other factors that would have contributed to improved health outcomes

in the absence of the project. During the project period, fertility levels continued to decline,

literacy among women and men to improve, electricity reached most of the 11% of households in

the state who had not had it in 2005, households using clean energy for cooking rose from 31%

to 73% (removing a major risk factor for NCDs), and households using improved sanitation rose

from only 22% to 52%. Much more sophisticated analytic work would be needed than is possible

for this report to try to disentangle the impact of these and other relevant factors from the impact

of the project activities on the improvements in health outcomes in Tamil Nadu over the course

of the project. But the project’s contribution was clearly substantial, given the strong declines in

the rates of neonatal and maternal mortality in project facilities, and the fact that by 2015, 67%

of all institutional deliveries took place in public facilities (see next paragraph).

Ultimate Performance Measure 2 - Patient Satisfaction. Rating: High (both phases)

An important measure of the improved effectiveness of the public health system is the extent to

which people seek care in public facilities, rather than from private sector providers. The

NFHS-4 shows a large shift from 2005 to 2015 in the percent of institutional deliveries that took

place in public rather than private facilities, from 48% to 67%, and an increase from 75% to 86%

in children aged 12-23 months who received most of their vaccinations in public rather than

private facilities. The NSSO records a small increase in the percent of hospitalizations that were

in public hospitals among patients in the lowest two income quintiles, from 51% in 2004 to 54%

in 2014, but a fall from 40% to 35% for all hospitalizations in the state – all accounted for by a

fall in urban areas from 37% to 29%.

Patient satisfaction surveys were done in 2006, 2010 and 2014. The project team thinks that the

fairly high satisfaction scores at baseline (2006) reflect low expectations: Likert Scores on a 1-5

scale were: (a) overall satisfaction: 3.99 (in-patients), 3.95 (out-patients), (b) satisfaction with

patient amenities: 3.74 (in-patients), and 3.72 (out-patients), and (c) satisfaction with cleanliness:

3.51 (in-patients), and 3.7 (out-patients).

30

The 2010 survey used a different methodology, complicating comparisons, but satisfaction was

higher. It found: (a) 91% of out-patients and 92% of in-patients were satisfied with the facility,

(b) 89% of out-patients and 91% of in-patients satisfied with cleanliness, (c) 96% of in-patients

satisfied with the admission process, (d) 79% of out-patients and 70% of in-patients likely to

return to the same hospital, 76% of out-patients and 82% of in-patients would recommend the

facility to a friend or family. Waiting times were short: 80% of patients waited no more than 20

minutes to access any services at OPD; 60% of in-patients perceived waiting time at emergency

registration and access to doctors in emergency as short; 71% of in-patients were assigned a bed

immediately. Indicators for the quality of care were good: 82% of out-patients and 71% of in-

patients said that doctors asked questions to understand their history, 85% of out-patients and

92% of in-patients said they had adequate time with the doctor, and 70%/85% were satisfied with

their discharge summary and explanations.

By the 2014 survey, when patient expectations were considerably higher, overall satisfaction

scores were 3.92 (in-patient) and 3.87 (out-patient), 98% reported that the out-patient department

and waiting area were clean and hygienic; 97% of in-patients said facilities such as labor and

ward rooms were clean and hygienic; and 79% of patients were satisfied with the facility.

Waiting times set high standards: 84% of patients were satisfied with the 4 minute wait for out-

patient care and 75% of in-patients found 10 minutes of registration time acceptable.

Satisfaction scores improved for infrastructure, communication and behavior of hospital staff,

quality of treatment, cleanliness, crowding, the discharge process and outcome of treatment, and

also for outpatient registration. The improved satisfaction with treatment quality and staff

interactions are critical aspects that encourage patients to return to a facility.

An end-line study among tribal groups who had been hospitalized under the bed-grant scheme

found that almost all were satisfied with the facilities, 93% received medicines, 88% considered

services to be of good quality.

The project clearly made considerable and successful efforts to provide health care services that

met the needs of the populations, with high standards for access (services within 30 minutes of

everyone, free emergency transport, 24/7 availability of many services, ensuring that drugs and

other medical supplies were always available), mobile services for tribal and remote populations

that brought a doctor, nurse and medical technician and vehicle equipped with basic laboratory

services to their doorsteps regularly every 7-14 days, and training providers in respectful care.

Ultimate Performance Measure 3 - Financial Protection. Rating: Substantial (both phases)

A key measure of health system performance is that care does not cause financial hardship. This

is part of the definition of Universal Health Coverage, a goal fully embraced by the global health

community and India (and most other nations). At the start of the project, Tamil Nadu, like other

Indian states, had very high out-of-pocket (OOP) spending on health care, and a low share of all

health expenditure financed by the government. Public expenditure on health in Tamil Nadu was

less than US$3 per capita per year in 2005; health’s share of the state budget had fallen from

7.5% in the mid-1980s to only 4.6% in 2005. During the first three years of the project, per

capita spending on health more than doubled from Rs. 227 to Rs. 472 (Figure 2 below, from AM

08/2015), all of which came from the state budget (central transfers for health were fairly

31

constant from 2006-07 to 2009-10, as indicated in the upper (blue) section in Figure 2). The

GoTN absorbed all the recurrent costs by the end of the project, notably by regularizing nearly

3,000 staff nurses hired for the NCD programs and CEmONC units. The state budget share for

health did not rise during the project, but robust economic growth increased the health budget

substantially by an average of nearly 8% annually.

Source: NIPFP, 2012.

In 2005, only 4% of households in Tamil Nadu had any member covered by health insurance or a

health scheme; in 2015 this was over 64%. Although not funded by the project, the PMU was

responsible for administering the state insurance scheme that achieved this. The project directly

reduced OOP by providing free emergency transport services and free mortuary transport to over

a million people. The bed-grant scheme provided free in-patient care for nearly 12,000 tribal

patients between 2007/08 and 2013/14.

Data are not fully comparable, but the average patient spending per hospitalization in public

sector facilities across India of 6120 rupees (NSSO 2014) was many multiples of the amounts

reported in the Tamil Nadu 2014 patient satisfaction survey: patients interviewed after receiving

care at facilities reported having spent just under 200 rupees on average, and respondents to a

household survey reported having spent less than 100 rupees for care (IPSOS, End-line

evaluation - Patient Satisfaction Survey, March 2015).

While scanty, the available data suggest a considerable improvement in financial protection in

Tamil Nadu, which, combined with increased access to care especially among the poorest 40%

and the tribal populations, and greatly improved quality of care, indicates substantially improved

well-being for Tamil Nadu’s population as a result of the project.

Having assessed the 3 “ultimate outcome” indicators of the performance of the Tamil Nadu heath

system, we now look at the 3 “intermediate outcome” indicators: access, quality and efficiency.

Intermediate Performance Measure 1 - Access and Utilization. Rating: Phase 1 –

Substantial, Phase 2 - High

Access to health care – especially the project focus of maternal and infant care services, was

greatly improved, particularly among the poorest 40% of the population and tribal groups. Most

Per capita Total Public

Expenditure on Health

Per capita State Expenditure

on Health

32

respondents to an end-line study among tribal groups said that the bed-grant scheme motivated

more tribal community mothers to deliver in facilities, and reduced self-medication/visits to a

traditional healer. Regular visits by well-equipped, well-staffed mobile vans provided door-step

access to doctors and nurses.

The project paid attention both to supply (which enables access) and to demand (which results in

utilization). The first project phase provided emergency obstetric and neonatal care services

within no more than an hour of travel time for every woman in the state; the second phase

improved the access standard to no more than 30 minutes. Combined with IEC/BCC

interventions to encourage appropriate care-seeking, and counsellors to guide and advise patients

in using of services, the project impact on service utilization was high. The graph below shows

increases in numbers of maternal admissions, complicated maternal and neonatal admissions,

and deliveries, from 2006 to 2015. The fall in neonatal admissions is a highly desirable outcome,

likely a result of improved quality of care at delivery and improved follow-up.

The percent of births in facilities rose from 88% to 99%, with almost all births (99.3%) assisted

by a trained attendant by the end of the project. There were surprising decreases in utilization of

individual antenatal services (Annex 10 indicators 32-35) and immunization of children under 2

(indicators 50-55). The low incidence of vaccine-preventable illnesses in the state during the

decade resulting from the earlier impressively complete coverage may have made immunization

seem less important, and this also likely reflects some shift in emphasis in service provision. The

percent of children who were taken to a health facility if they had diarrhea rose from 62% to

73%, and from 76% to 82% for children with symptoms of acute respiratory infection (NFHS).

The roll-out state-wide of breast and cervical cancer, hypertension and diabetes screening and

referral for treatment reached more than 65% of the targeted age-groups, and identified 3.65

million positive cases, most of which are unlikely to have been detected without the project.

Overall, utilization of care increased markedly in TN. The NSSOs in 2004 and 2014 show an

increase among people who reported any ailment in the past 15 days and received any medical

care from 81% to 97%, and especially large increases for rural residents from 78% to 97%, and

33

for the lowest 40% from 76% to 98%. The increase for urban residents was from 87% to 98%,

and for the upper 60% income groups from 84 to 97%. The negligible differentials between the

lowers and highest income groups, and rural/urban residents are very unusual, and show the

impressive success of the project in achieving its aim of improving services “particularly for

poor, disadvantaged and tribal groups”. Although the percent of ST who received any medical

care fell slightly from 96% to 93%, the percent who reported any ailment rose from only 0.8% to

above 10%, much closer to the general population norm, indicating a dramatic change in

recognition of need for care, and an overall very substantial increase in use of care. The SC

population treatment rate rose from 71% in 2004 (well below other groups) to 97% in 2014,

completely closing the gap in treatment utilization. Hospitalization rates were 34% higher in

2014 than in 2004; the 27% increase among the poorest 40% compared to a 14% increase among

the richest 60% narrowed but did not eliminate the disparity that existed before the project (see

Annex 9, table 4).

Intermediate Performance Measure 2 - Quality. Rating: High (both phases)

Most available indicators show large improvements in the quality of care. The percentage of

mothers who had full antenatal care (at least four visits, took folic acid for at least 100 days

while pregnant, and received a tetanus shot) rose from 27% to 45% for their most recent

pregnancy. Another strong improvement in quality of care at the primary care level is that the

percentage of children with diarrhea who received oral rehydration salts almost doubled from

32% to 62% between 2005 and 2015 (NFHS).

The risk-adjusted maternal case fatality rate at CEmONCs fell from 19.6 in 2006-07 to 4.6 in

2014-15, and risk-adjusted neonatal mortality fell from 5.24 to 3.98, indicating greatly improved

case management and outcomes despite the much higher proportion of high-risk maternal clients.

Referral of mothers from CEmONC centers decreased from 15% of total maternal admissions in

2004-05 to 4% in 2014-15, indicating better case management and availability of comprehensive

care.

The increase in caesarian sections (C-sections) from 15% to 26% in public facilities, although

well below the increase in private facilities from 33% to 51% (2005 to 2015, NFHS-4 and

NFHS-3) was worrying. Experts consider a population rate above 10% unlikely to improve

maternal or infant mortality; rates above 15% often indicate medically unnecessary C-sections

and are not recommended.16 The project commissioned an independent review that found that the

increase was a result of the increase in complicated pregnancies (from 46% to 64% between the

DLHS3 and 4) and post-delivery complications (from 48% to 59%) being treated at Government

health facilities, especially CEmONCs, and not the result of medically unnecessary elective C-

sections. The increase in use of government facilities for complications of pregnancy and

childbirth suggests increased confidence in their ability to provide this care, an indirect indicator

of improved quality.

The project provided vital inputs for achieving higher quality care: renovations at 2,330

facilities, ensuring availability of running water, electricity, sanitation and proper health waste

16 WHO Statement on caesarian section rates, April 2015.

34

disposal and infection control, additional staff, extensive training for staff, protocols, equipment,

improved maintenance and repair of equipment, and supplies of drugs and other consumables.

The project put in place rigorous quality assurance and quality improvement mechanisms:

monthly reporting on 80 indicators by all EmONCs and on 20 indicators by all public hospitals

used to assign quality grades that triggered immediate remedial action to address substandard

grades, in concert with Quality Circles of Excellence in 267 secondary hospitals. The

accreditation of 12 public hospitals by the National Accreditation Board for Hospitals, with

another 46 preparing for accreditation, is a major and path-breaking project achievement – these

were the first public hospitals in the country to undergo the rigorous process.

Extensive independent evaluations of all pilots and many project activities by universities and

the National Institute of Epidemiology to identify ways to improve programs were an integral

part of the project’s commitment to continuous improvements in the quality and effectiveness of

the health system. The summary of the stakeholders meeting held at the end of the project (see

Annex 7) contains recommendations for improvements, showing that this mindset persisted.

Intermediate Performance Measure 3 - Efficiency of the health system. Rating: High (both

phases)

There are two aspects to efficiency: allocative efficiency, or spending money on the “right”

things, and technical efficiency, the rate at which inputs are transformed into outputs or

outcomes, or “doing things the right way”. The project explicitly aimed to improve allocative

efficiency in the health system by strengthening services at the primary and secondary levels.

Over the life of the project, Tamil Nadu’s overall health budget became more cost-effective by

focusing more on primary care, increasing its budget share relative to secondary and tertiary care

by more than 15 percentage points, while the tertiary share fell by more than 10 percentage

points. The project funded services to prevent and treat conditions that account for well over half

the disease burden in Tamil Nadu, another indicator of the project’s likely positive impact on

allocative efficiency of the health system.

The available global literature on cost-effectiveness, summarized in the definitive Disease

Control Priorities17 project (DCP), suggests that the innovative state-wide programs to screen for

four major NCDs/risk factors and provide treatment and life-style advice to reduce NCD disease

risk, are likely to be cost-effective. For example, cardiovascular disease management (e.g.,

screening and treatment for ischemic heart disease) is among the more cost-effective

interventions available, costing approximately $1000 per disability-adjusted life year (DALY)

averted. Drug treatments for acute episodes such as heart attack and congestive heart failure are

even more cost-effective. Treatment costs for the more treatable cancers covered by the project

(breast and cervical cancer) have ratios of $1,300-$6,200 per year of life saved, compared to

$53,000 - $163,000 for less treatable cancers. Thus, the project appropriately targeted the more

cost-effective cancers and other NCD interventions. In addition, “improved quality of

comprehensive emergency obstetric care” and “neonatal packages” are both identified as

17 Laxminarayan, R., et al. (2006). “Advancement of global health: Key messages from the Disease Control

Priorities project”. Lancet 367: 1193-1208.

35

neglected low-cost opportunities in the Disease Control Priorities project, with very favorable

costs per DALY averted.

The quality improvements and increased utilization of the health system that the project helped

to achieve would have increased the technical efficiency of the system. The better the quality of

health care, the greater the impact on health outcomes, the lower the cost per unit of health

gained, and the greater the system “outputs” (of health, patient satisfaction and financial

protection) for a given level of inputs. The total project cost was small compared to the total

budget of the health system in TN, rising from 2.6% in the first year to a maximum of 7.6% in

2010, and steadily decreasing to only 0.1% in the final year. This is a modest cost for the

measured improvements in quality, access and utilization. Total health spending in Tamil Nadu

in 2015 was about US$17 per person, with relatively good health outcomes compared to other

states and countries with similar levels of spending.

The HMIS system also improved the health system’s efficiency by saving time for patients and

providers at each visit, and enabling better continuity and quality of care by making patients’

health records available to providers at every point of contact, and by automatically prompting

providers with relevant clinical protocols and treatment options. The immediate availability of

system-wide data, presented in dashboards that are designed to support quality improvements

and data-supported decisions offer potential for continued improvements in care and system

efficiency well beyond the project life.

Can the outcomes and impact be attributed to the activities supported by the project, or might

other factors be responsible?

An assessment of what might have happened without the project is difficult. The GoTN was

strongly committed to improving the health system and health outcomes, and it seems likely that

some actions would have been taken without the project. However, it is clear that the Bank’s

strong technical advice throughout the project, and the accountability that a Bank-funded project

brings – especially one that is supervised with such regularity, energy, proximity and attention to

detail, provided important support for the project’s accomplishments. In fact, the project was

developed at a time when the tensions around the DIR deterred many states from wanting to

work with the Bank, but the GoTN was clear that they wanted and needed the expertise and

advice of the Bank in seeking to strengthen their health system.

A possible counterfactual might be the extent to which Tamil Nadu’s health system improved

compared to health systems in other states or countries, looking at “difference in differences”

over the project time period. But there are (at least) two major difficulties: the choice of

appropriate comparator states is not obvious, and it would be extremely challenging to control

sufficiently for confounding factors to be able to draw useful conclusions.

There are other factors that likely contributed to the observed improvements in health outcomes

and utilization of health care: gains in literacy and per capita incomes, and a (small) rise in the

age of marriage and child-bearing and continued drop in fertility (see Annex 10), anti-tobacco

activities in response to the FCTC, the activities of the Transport Project to make roads safer and

reduce road traffic accidents. However, none of these external factors would have improved the

other measures of the effectiveness of the health system discussed above. The well-chosen and

36

focused investments by the project clearly resulted in increased quality, access and efficiency of

TN’s health care system.

There is compelling evidence that the project’s achievement of its development objective

was at least Substantial for the first phase, and High overall and for the second phase,

looking both at key project indicators and other data.

3.3. Efficiency (rating: Phase 1 – Substantial; Phase 2 - High)

The comments above on the project’s impact on the efficiency of the health system in TN and

the discussion of the relevance of the project’s objectives and design have already made the case

for the project’s allocative efficiency (spending on the right things). The project was exemplary

in deciding what to fund. The choices made in designing the project were informed by rigorous

data gathering and problem analysis for every component and sub-component. The best available

technical advice was solicited – including from intended beneficiaries. For example, the QALP

team noted that: “The Tribal Plan was developed based on consultations with various NGOs

working on tribal health issues, tribals and their ‘sangams’, and field visits to tribal areas, and

also various government departments including the Health, Tribal Welfare and Forest

Departments. Both primary and secondary data were collected and analyzed to provide the basis

for the chosen interventions. The TDP includes a broad range of interventions to address the

issues identified and provide quality health care to tribal populations in Tamil Nadu. The TDP

emphasizes the integration and strengthening of existing health interventions like the RCH

project, the RNTCP, the NLEP and other on-going government welfare schemes.”

Well-justified decisions were taken to drop activities that duplicated other efforts (e.g. the road

safety component), were judged unlikely to contribute to achieving the project objectives (the

proposed pilot community insurance scheme), or for which the policy environment and low

enforcement capacity made successful implementation unlikely (regulation of the private sector).

The project was an “early adopter” – even a trail-blazer – in its decision to pilot and roll-out

state-wide NCD interventions. The estimated costs of treatment and lost productivity caused by

cancers, heart disease and other NCDs suggests high rates of return on well-chosen NCD

program investments.18 The screening and treatment protocols, technical decisions and reporting

formats developed under the project have had a very strong influence on national policies and in

other states in India. In addition to being strongly justified by allocative efficiency, the costs

relative to outputs and outcomes indicate that the NCD interventions have strong technical

efficiency as well. For a total project cost of just US$19m, the NCD program provided

hypertension screening for 29 million people, diabetes screening for 23 million people, breast

cancer screening for over 12 million women, and cervical cancer screening for 10 million

women. This detected approximately 3 million new hypertension cases, 1 million people with

diabetes, 350,000 cervical cancer and 153,000 breast cancer cases. It would require only a very

18 Bloom et al, 2014, “Economics of NCDs in India: The costs and returns on investment of interventions

to promote healthy living and prevent, treat and manage NCDs”, (World Economic Forum, Harvard

School of Public Health), estimates that between 2012 and 2030, India will incur very high costs of $2.17

trillion from cardio-vascular disease, $0.25 trillion from cancers, and $0.15 trillion from diabetes.

37

tiny fraction of these 78.5 million people to gain even one additional year of life as a result of

screening and treatment for the benefits to far exceed the costs (see Annex 3 Economic and

Financial Analysis for a more detailed estimate). The study by Bloom et al cited in footnote 18

estimated the return on investment of the project NCD program at well above 15%. An economic

analysis of the NCD pilots provided important justification for the decision to scale the programs

up and expand their coverage by adding screening for diabetes and hypertension, and low-cost

cervical cancer screening in addition to breast cancer screening.

The ISRs and Aide-Memoires show close attention to efficiency, discussing ways to reduce costs

and improve efficiency and effectiveness. Monitoring data and rigorous evaluations were used to

make improvements. For example, at the suggestion of the WB, the project analyzed and

compared the costs per patient of the three NGOs contracted to provide care under the Bed Grant

scheme. Significant variation was found across the three service providers, which triggered

negotiations to rationalize the reimbursed costs and align them with the reimbursement rates

used by the new state-wide health insurance scheme. The project monitored the number of

patients served by each of the Tribal patient counsellors, assessed who was using the services

(mostly poor and often illiterate people) and that satisfaction with the services was high, to

ensure that the costs were well-justified. Improvements were constantly made – for example, a

high risk antenatal screening program was tested in two districts in 2014, and scaled up to 20

more districts when good outcomes were achieved. In one year (June 2014- June 2015), 89,000

pregnant women were screened in 1674 “camps”, 45,000 (about half) were identified as at risk

for complications, and 21,700 were referred early to CEmONCs for better management of

possible complications. There were 25 fewer maternal deaths over the year compared to the

previous year, a very substantial reduction. Changes in the way the emergency transport services

were managed and IEC to increase their use reduced the average operating costs per trip from Rs

2,551 to Rs 1,096 from 2008/09 to 2014/15.

The project also increased implementation efficiency by working through government partners

(departments of education and labor), schools and workplaces, and NGOs including the TN

Women’s Development Corporation and Gandhigram Rural Institute. Disappointing initial

results from contracting NGOs to operate emergency ambulance services led the project to seek

and adopt the much more efficient arrangement with the EMRI.

The investment in the new HMIS was specifically justified by its potential to enable more

efficient services, and will pay for itself many times over if it is instrumental in achieving even

small (e.g., 1%) system efficiencies. The project extensions provided the time needed to fully

complete (and expand the intended scope) of the HMIS development. Although disbursements

were much slower than expected for most of the first phase of the project, disbursements

accelerated from 2009, and from 2010 they tracked the revised expected disbursement profile

closely (see data sheet section I).

Project efficiency is rated Substantial for the first phase and High for the second phase.

3.4. Justification of Overall Outcome Rating

A summary table of the ratings for each phase of the project (before and after the 2010 AF) is

provided below. Consistent with the rating guidelines, the overall outcome of phase one is

38

satisfactory (high relevance, and substantial achievement of PDO and efficiency). The overall

outcome for the second phase is highly satisfactory, given high ratings for relevance, efficiency

and achievement of objectives. The project disbursed US$88.59 million – 42.65% of the total

$210.05 million prior to the Additional Financing, and $121.5 million – 57.35% in the second

phase. The weighted overall outcome rating is assessed as Highly Satisfactory, since the

weighted rating score is 5.57, and should be rounded up rather than down (see second table)

Phase 1 (2004-2010) Phase 2 (2010-2015)

Relevance High High

Objective H H

Design H H

Implementation S H

PDO Achievement (Efficacy) Substantial High

Efficiency Substantial High

Overall Outcome Satisfactory (5) Highly Satisfactory (6)

Phase 1 Phase 2 Overall

1 Rating S HS

2 Rating value 5 6

3 Total disbursed (US$ million) 88.59 121.50

4 (% = total disbursed/final disbursed amount) 42.65% 57.35%

5 Weigh value (2 x 4) =5x42.65 =6x57.35

6 Final Outcome Rating 2.13 3.44 5.57=HS

Note: HU (1); U (2); MU (3); MS (4); S (5); HS (6)

3.5. Overarching Themes, Other Outcomes and Impacts

(a) Poverty, Gender Aspects, and Social Development The project central focus on poverty and vulnerability in improving access to, utilization of, and

improved quality and efficacy of public health services particularly by poor, disadvantaged and

tribal groups has been well covered already. Loss of productivity and health care costs are a key

cause of poverty and worsened impoverishment – the improved effectiveness of the health

system and better access to free care would have reduced both. The Tribal Development Plan and

interventions targeted to tribal groups were a core part of the project. In addition to specific

interventions to strengthen service delivery (ensuring adequate medical staff in PHCs, Health

Service Centers and government hospitals in tribal areas, IEC activities and counsellors in PHCs

and general hospitals in tribal areas to encourage use of health services, increased services access

through PPPs with NGOs to provide regular mobile outreach services, the bed grant scheme to

provide free hospitalization in selected private hospitals – as well as free care provided in TN’s

public hospitals), the project also addressed a specific health need of the tribal population –

sickle cell anemia, and arranged for pregnant tribal women to stay at PHCs prior to delivery to

encourage institutional deliveries. The project also gave priority to the poorest regions and

communities with the worst health outcomes in selecting facilities to be the first to get EmONCs.

Criteria for selecting secondary hospitals for upgrading included health indicators (IMR and

MMR), and those that served populations below the poverty line, and in tribal areas.

39

The benefits to the poorest 40% population and ST/SC groups surpassed project targets, with

1.84 million tribal people living in remote rural areas treated through mobile outreach health

services, 11,889 people receiving free hospitalization under the bed grant scheme, and 1.936

million patients using counseling services in tribal PHCs and hospitals. The 30 four-wheel drive

vehicles to transport patients over difficult terrain increased uptake of services by tribal groups

from 16,000 in 2013-2014 to nearly 27,000 in 2014-2015. IEC activities included use of

traditional media such as street plays that brought messages into poor communities, in addition

to use of mass media and print materials that have much lower penetration in poor communities.

Interventions to reduce maternal mortality, cervical and breast cancer obviously benefit women

primarily, and women also benefitted from all other project interventions. In addition, project

preparation included development of a Gender Plan to ensure that all components were sensitive

to the specific needs, constraints, and situation of women.

(b) Institutional Change/Strengthening The project emphasis on institutional development in all activities has been noted above –

notably extensive training of health care staff at all levels in clinical, managerial and process

skills; and setting up the new SHDRC, Strategic Planning Cell, PPP Unit, and system for

inventory control, maintenance and repair of all medical equipment. The project was

instrumental in overcoming GoTN wariness of working with the private sector, demonstrating

the benefits and efficiencies that could be gained through careful contracting. As experience and

skill were gained in contracting, the project began to move from fixed-cost to performance-based

contracts to ensure better value for money and incentivize contracted partners.

The staff and functions of the various cells in the PMU have been absorbed into the relevant

Directorates of the DoHFW without any loss of the expertise and capacity developed under the

project, and project activities smoothly transferred. The additional nurses contracted under the

project have also been added to the state regular payroll. Accreditation of 12 hospitals helped

build hands-on capacity in the Directorates of DoHFW on all quality dimensions of health

service delivery, and has enabled the state to begin the process towards accreditation of another

46 hospitals.

(c) Other Unintended Outcomes and Impacts (positive or negative) Although the demonstration effect of the project was intended, the extent of its influence went

beyond expectations. In addition to the other state governments, the project has also been visited

by USAID, JICA and the Bill and Melinda Gates Foundation (among others), and has had a very

strong influence on national level policies. The extent to which the processes and evaluations

have been documented and disseminated has also been beyond expectations, covering policy,

administration, financial, operational and management aspects. Another unplanned benefit was

the introduction of a unique patient identification number (PIN) that is able to be integrated with

the identifier provided by the Gol Aadhaar program, and also the extension of the HMIS to

include medical colleges and the Tamil Nadu Dr MGR Medical University. Third, the project

provided complete administration and management support for rolling out the state-wide Chief

Minister’s Health Insurance Scheme after 2008. This scheme had not been envisaged when the

project was being developed.

40

3.6. Summary of Findings of Beneficiary Survey and/or Stakeholders Workshops

The GoTN held a workshop of stakeholders in Chennai on August 28 and 29, 2015 to solicit

stakeholders’ views on the project’s performance, capture and disseminate experiences, discuss

innovative interventions under the project, discuss challenges and recommend actions to help

address them. Stakeholders included officials from the GoI, GoTN, Governments of Kerela and

Uttar Pradesh, former and current Project Directors, NIE, Indian Council of Medical Research,

academic institutes, Institute of Public Health, officials of various DoHFW Directorates, project

hospitals, Medical Colleges, consultants, NGOs, PPP providers, civil society, and project staff,

as well as eight WB staff. Topics covered project interventions and support to maternal and child

health, HMIS, health care quality, health care waste management, surveys and studies, PPPs, the

Tamil Nadu Chief Minister’s Comprehensive Health Insurance Scheme, tribal health, and NCDs.

Findings are presented in Annex 6. In summary, there was consensus on the strong achievements

made under the project in reducing maternal and infant mortality, improving tribal health,

implementing NCD interventions, strengthening monitoring and evaluation including the HMIS,

improving quality of care and HCWM, and strengthening secondary care hospitals, and making

progress on adequate staffing of public health facilities across the state. There was a shared

conviction that the project has helped improve the functioning of Tamil Nadu’s health system,

and brought together and helped develop a talented group of officials who are now working in

the DoHFW, and will be able to sustain and continue the project impact. A continuing theme

throughout the workshop was the commitment to continue all activities implemented under the

project. Appreciation was expressed for the World Bank’s expertise and rigorous implementation

support throughout the project, complementing Bank financing to help put in place a robust

health sector system and to scale successful ideas.

4. Assessment of Risk to Development Outcome

Rating: Negligible risk that the PDO will not be maintained, given strong commitment at all

levels in Tamil Nadu to build on the successes and lessons learned under the project, the strong

M&E system, and the availability of financing from the NHM and state budget to continue

activities.

The justifications for the negligible risk assessment are as follows: (i) continued strong

commitment of the GoTN to and its full ownership of the project development objective and

activities including public-private partnership programs, outsourcing contracts and other

innovations started under the project. (ii) Project activities are fully mainstreamed and integrated

into the work programs and budget of Tamil Nadu’s DoHFW. All programs and activities have

been handed over to the Directorates of DOHFW for continued implementation as regular

departmental activities. All contract staff and other new staff sanctioned under the project have

been transferred to the Directorates along with the programs. GoTN and NHM are fully funding

these activities. The State Health Data Resource Centre, 108 Emergency Ambulance Services,

and Free Mortuary Van Services have been retained and funded by GoTN through the TNHS

Society. The GoTN is acting fully on its commitment to provide state budgetary funding for any

activities not financed by the NHM. (iii) The project administrative structure, formalized as the

TNHS Society, together with the DoHFW, has built a strong consistent track record in

implementation performance. (iv) There has been consistent demonstrated strong capacity in

41

monitoring and evaluating project programs, and a culture of evidence-based decision making.

Data are being collected routinely and scrutinized to continue this. (v) TN is justly proud of

being the first state or among the first in India to start and implement innovative activities such

as the HMIS, a large scale NCD program, tapping into the resources of the private sector and

NGOs to help deliver carefully chosen priority health services through PPPs and out-sourcing,

focusing on quality of services simultaneously with infrastructure investments, and developing

and applying more realistic staffing needed to deliver defined services to clear standards, starting

with the CEmONCs. The strong sense of achievement and commitment bode well for the future

sustainability of the programs put in place under the project.

It should however be noted that full success of (i) the NCD interventions will depend heavily on

adequate follow up for confirmatory diagnosis and appropriate treatment of patients who test

positive during screening, and (ii) the CEmONCs in delivering effective 24x7 maternal and neo-

natal health services will depend on continued adequate staffing of specialists and staff nurses.

5. Assessment of Bank and Borrower Performance

5.1. Bank Performance

(a) Bank Performance in Ensuring Quality at Entry

Rating: Satisfactory. As discussed earlier (Sections 2.1 and 3.1), project objectives and design

were strongly relevant and remained relevant, and were fully aligned with government and Bank

priorities. The project benefitted from extensive analytic work including an organizational

review of Tamil Nadu’s DoHFW and a quality enhance review in 2002 of the Bank’s experience

in India since 1995 with health systems development projects to inform future directions, and

from workshops in India to disseminate and discuss the review findings. Lessons were

incorporated, as noted in the PAD, p.8-9, for example on the need for special efforts to reach the

poorest and to measure their access to and utilization of health services; to proactively explore

possibilities for experimenting with news ways to improve the public health sector, including

opportunities to partner with private sector providers in underserved areas; and to pay attention

to strategic planning and management in order to strengthen hospital management. The Bank

team engaged fully with important relevant stakeholders in developing the project.

Implementation arrangements were appropriate, and, apart from some baseline surveys, the

project was fully ready for implementation by effectiveness, including a detailed procurement

plan for the first 18 months of planned activities. Risks were sensibly identified and well

mitigated through project design and preparation. Some of the delays in awarding contracts in

the first year of the project indicate that procurement processing capacity of the state’s PWD for

civil works and of TNMSC for goods was overestimated; but this was appropriately and quickly

addressed. Although there were some weaknesses in selection of indicators, other aspects of

M&E design were clear and comprehensive, notably the development of a computerized HMIS

system to replace manual reporting and make real-time rich data available for decision-making,

and independent evaluations of numerous project activities. Environmental and social safeguards

aspects were adequately covered including a sound HCWM plan, a Tribal Development Plan and

a social assessment, which were fully implemented.

(b) Quality of Supervision

42

Rating: Highly Satisfactory

The project was supervised by a strong team with one task team leader from the start of project

preparation in 2002 until after approval of the AF in 2010, and two task leaders in the remaining

five years of the project. After the DIR, project supervision budgets were supposed to increase.

The project did not in fact receive the 30% increase it was supposed to get, but still managed to

provide highly satisfactory supervision. An important factor was that the project team was

mostly based in Delhi, comprising all necessary skills including an IT specialist (for the HMIS

component). The relationship with the PMU and DoHFW was professional and strong.

Supervision was systematic, detailed, and every six months, including a carefully prepared and

rigorous MTR; field visits to hospitals were frequent. Aide Memoires were comprehensive,

detailed, issue- and action oriented; they included the status of results achievements, and

benchmarks. Project ratings were realistic. Potential and emerging problems were recognized

early, discussed candidly, and forcefully brought to the PMU or higher state authority’s attention

as needed. The Bank team in Delhi held weekly audio meetings with Chennai to follow-up issues

and support the PMU in resolving bottlenecks, and was diligent in monitoring fiduciary and

safeguard aspects including implementation of the Tribal Development Plan and the Health Care

Waste Management Plan. The Bank team and PMU jointly paid close attention to the project’s

development effectiveness, and the Bank offered technical advice as needed. The Sector

Manager and Country Management Unit paid close attention to the project.

Satisfactory project implementation (and highly satisfactory for several project activities)

particularly since 2007 justified Bank approval of AF in 2010 to replace the $20 million that had

been released for dealing with the Tsunami aftermath, plus almost $100 million in new financing

to implement the NCD activities across the state and extend well-performing components. The

extensions of the closing date were well justified, and enabled full disbursement and completion

and expansion of planned activities.

(c) Justification of Rating for Overall Bank Performance Rating: Highly Satisfactory. With a rating of satisfactory for preparation and highly

satisfactory for supervision, overall Bank performance is rated as highly satisfactory in line with

the overall outcome rating of Highly Satisfactory.

5.2. Borrower Performance

(a) Government Performance Rating: Highly Satisfactory. GOI supported the Government of Tamil Nadu at all stages of the

project preparation and implementation including its endorsement of GoTN’s request for the AF.

GoTN’s ownership and commitment to the overall project objective was consistently strong,

reflected in its decisions to establish CEmONCs able to provide 24x7 maternal and neonatal

health services, try using PPPs to deliver health services to low-income communities including

SC/ST populations in remote and tribal areas, to pilot test innovative approaches to NCDs on a

reasonably large scale and subject them to rigorous evaluation before scaling up, and establish

the first fully computerized HMIS in India. The project was fully integrated into Government

structures at all levels. To ensure sustainability, the GoTN began absorbing project activities

(well before project closing) into the work and budget of the NHM and the DoHFW (e.g., mobile

outreach, counselling services, sickle cell anemia, bed grant scheme, heath waste management,

HMIS, emergency ambulance transport), with only essential inputs (technical support and

43

monitoring and evaluation) continuing to be funded by the project. As needed, the government

approved recruitment of doctors and staff nurses on contract for CEmONCs and NCD

interventions to ensure adequate staffing to deliver services, and subsequently absorbed them

into the civil service cadre. The Government is continuing all project activities with financing

from the NHM and state budget. The GoTN showed unwavering strong support and commitment

to the project during thirteen years of preparation, implementation and transition, and managed

to push the project to do much more than originally envisaged and complete all activities.

(b) Implementing Agency or Agencies Performance Rating: Satisfactory.

The PMU had overall responsibility for managing the project with support from PWD for civil

works and TNMSC for procurement of equipment and maintenance. GoTN appointed a Senior

Officer from the IAS as Project Director of TNHSP. The PMU team was highly experienced and

successfully managed implementation of the many project activities in different technical areas

including new areas of NCD interventions and HMIS -- large undertakings in any context. It

maintained a strong focus on capacity building and skill enhancement and built strong

professional training capacity for the public health sector. The PMU worked diligently with the

Bank, PWD and TNMSC staff to resolve the issues that delayed procurement and

implementation during the first 18 months of the project. It proactively adjusted interventions

during implementation to address bottlenecks or improve efficiency or impact.

The PMU took a strong lead on actions to improve quality of care in hospitals, championed the

system of grading, and regularly followed up agreed actions with hospitals graded C and D. It

was proactive in preparing proposals for the State Empowered Committee chaired by the Chief

Secretary to obtain Government Orders to proceed with project activities when necessary (such

as requests for exemptions to procurement freezes prior to elections). The PMU consulted fully

and regularly with key stakeholders and worked closely with the DoHFW Directorates. On

financial management, audit reports and IUFRs were submitted regularly but with some small

delays. Disbursements were slow in 2005-2006, but picked up pace from later in 2006; one

important action was establishing a TNHSP society to ensure a smooth flow of funds for all

activities except civil works and major equipment and goods procurements. Minor shortcomings

(slow disbursements in the first two years), delayed procurement actions in PWD and TNHSP

and small delays in the submission of audit reports and IUFRs) did not impact the timely and

smooth implementation of the project activities.

(c) Justification of Rating for Overall Borrower Performance Rating: Highly Satisfactory, combining the ratings of highly satisfactory for government

performance and satisfactory rating for implementing agency performance given the overall

outcome rating of highly satisfactory.

6. Lessons Learned

Key Lessons

Careful strategies, including skillful sequencing, can help deal with the complexities of

health system strengthening. Strengthening a health system is a complex undertaking, and

requires appropriate balancing between physical investments and reforms, careful phasing

44

and sequencing, ensuring well-trained personnel, supplies, governance, and a long-term

horizon for institutional capacity building. A health system is as strong as its weakest link, so

there is need to consider the whole chain of care, and identify bottlenecks on which to focus.

For example, the potential health gain of an excellent fast-responding emergency transport

service is lost if the quality and capacity for care upon arrival at the hospitals is not at least as

good (and hopefully better) than the care that the ambulance and its crew are equipped to

provide. If patients are being successfully stabilized in the ambulance, but then die waiting

for care or for want of capacity to provide appropriate care at the hospital, then the

investment in the ambulance service is wasted (at last for that patient). However, the

temptation to try and implement everything at once should be resisted. Phasing enables data

to be analyzed and to inform decisions, and time to learn from and incorporate lessons from

pilots and their evaluations. Skillful sequencing of physical upgrades that are relatively easy

to implement (civil works to ensure running water and good sanitation, and fully equipping

facilities) with the incentive of further upgrades if “soft” investments19 are successfully

implemented, can add strong motivation for reforms that require behavior change. A highly

supportive environment, incentives, and shared belief in their purpose are also needed.

Thoughtful, nimble adjustments are needed throughout implementation, learning along

the way and resolving issues as they arise. It is not possible to anticipate all details when

designing new programs, and very important to put in place good mechanisms and shared

commitment at all levels for making continuous improvements. Regularly measuring and

monitoring performance of CEmONCs and of tribal health interventions including PPPs and

then actively using the information to make adjustments in the interventions and PPP

contracts during implementation were essential to the project’s success in reducing maternal

and neonatal mortality, improving tribal health, and facilitating the use of hospitals by the

poor and disadvantaged groups. The experience of designing and implementing the HMIS

pilot is another good example. The complexity and time required were underestimated, and

the work would not have been able to be completed within only five years. Working

productively with the technical agency hired to design and help implement the system

required intensive and frequent interactions with the government and users, and a significant

amount of “hand holding” and mutual trouble-shooting. It took time to establish good

reporting formats that would be easy to use. Careful behavior change support was needed for

hospital staff at all levels to transition to the new ways of reporting, including to allay the

perceived threats and insecurity, and to overcome the belief that both paper and electronic

reporting were needed, by demonstrating the reliability and robustness of the electronic

system before gradually phasing out paper reporting.

The design of the NCD component offers lessons in successful use of well-evaluated

pilots to make difficult choices and set priorities. The GoTN initially wanted to address all

NCDs and provide a wide range of curative services. Careful and evidence-based discussions

on what was technically possible, especially within the staff and other constraints of the

system, as well as what was most cost-effective, helped reach agreement on a limited initial

scope for TN’s NCD program. The Bank brought in international expertise from CDC and

India’s leading national expert (Dr Srinath Reddy) who is also a highly respected global

19 “Soft” investments refer to new procedures and processes, and other reforms that require behavioral

change, as opposed to “hardware” investments in infrastructure and equipment.

45

expert, to work with the TN team. The result was well-focused pilots to test the feasibility

and impact of screening and interventions to manage hypertension and detect and treat

cervical cancer, with a strong focus on prevention, early detection and disease management.

The pilot protocols were developed through extensive consensus discussions with national

experts. A rigorous evaluation was built into the pilot design, with input from international

and national experts. The data collected throughout the pilot, and impact and process

evaluations were all carefully scrutinized before deciding whether, how, and how fast to

proceed with scaling up. Valuable lessons were learned from the pilots and incorporated into

the scale-up design. One of the most difficult challenges was effective follow up of people

who tested positive in screening to ensure they receive appropriate treatment and education

in life-style changes to help manage and prevent further complications. Careful additional

assessment was needed to understand the systemic and behavioral reasons for high loss-to-

follow up, and how best to address them. This is absolutely central to the success of a

screening program.

Additional Lessons

Well-designed partnerships with the private sector/NGOs through PPPs for delivering

health care services and outsourcing carefully selected services such a diagnostic tests,

cleaning and laundry, can improve efficiency and services, and make health care more

accessible for hard-to-reach populations. There is usually more than one way to deliver

services, and new potential partners can be attracted to service areas where they have not

operated before. When initial contracts with local NGOs to operate emergency medical

transport did not yield the desired results, the GoTN found a very different approach in

partnering with the EMRI that was operating a successful ambulance service in another state.

EMRI proved willing to partner with the project and expand its operations into TN. Careful

monitoring and willingness to acknowledge that the initial arrangement (with NGOs) was not

working well, and to try a different solution, were important. Another lesson is that contract

terms and approaches may usefully be changed over time, as the contractual parties become

more familiar with each other, and with the contractual process, and the activities. For

example, the initial contract with EMRI (and other partners) were lump-sum contracts, but

the project is slowly embracing performance-based contracts that increase the incentive of

the contracted partner to improve efficiency and utilization.

Infection control and health waste management are better addressed in a systematic,

sector-wide, state-wide way rather than a smaller-scale project-specific approach. The

approach adopted under the project was efficient, and enabled the Ministry to rely on the

municipal authorities for regular quality assurance of the private sector disposal facilities. It

ensured that the whole health sector in Tamil Nadu would benefit.

IEC and BCC activities were a well-integrated part of the design of programs and

components, and carefully considered both supply of services, and demand. The project

made skillful use of Information, Education and Communication (IEC) and Behavior Change

Communication (BCC) activities, especially to boost demand and use of services that were

being set up and expanded, and to encourage and enable expanded use of services by SC/TC

members. Counselling sought to reduce loss to follow-up in NCD screening and treatment

programs. The project made thoughtful and strategic use of IEC and BCC.

46

Resistance to being evaluated can be overcome by demonstrated usefulness of good

evaluations. There are many reasons why implementers may not welcome evaluations.

Delay in selecting and contracting the consultants for the NCD evaluation was partly the

result of resistance from a skeptical key official. It took patience and persistence to get the

evaluation underway. During project implementation, the usefulness and value of

independent evaluations was clearly demonstrated, and came to be highly valued for being

able to answer important questions about the impact of programs and activities, and as the

basis for well-informed decisions. The project funded numerous evaluations of specific

programs and activities (for example, to discover whether the increased rate of C-sections

was medically warranted or not).

A “perfect storm” of mutually reinforcing factors all contributed to the project’s

outstanding success. The project was very well designed, implementation was flexible and

evidence-driven, both client and Bank teams had continuity, and high sustained commitment

and competence. The project also had a strong champion in the Department of Health with a

deep commitment to its goals. In addition to health being treated as “above politics” and

being given consistent priority by successive ruling parties, Tamil Nadu’s civil service has a

reputation for seriousness of purpose and “getting the job done well”. Close, collegial,

supportive supervision helped identify early problems and bottlenecks, and to work out

solutions. In the initial period when the project was not doing well, weekly phone-calls

between the Bank and TN team helped resolve issues. The close supervision also enabled the

Bank team to effectively and diplomatically be a “broker” when needed between the TN

team and consultants or external evaluators. The stability in the Bank team was also a clear

signal that the Bank was fully committed to the best interests of the state. Frequent changes

in Bank teams give a negative signal to the client, undermine trust that is achieved over time,

and can generate resistance.

7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners

(a) Borrower/implementing agencies

(b) Cofinanciers

(c) Other partners and stakeholders (e.g. NGOs/private sector/civil society)

47

Annex 1. Project Costs and Financing (a.) Project Cost by Component (in USD Million equivalent)

Components

Appraisal Estimate

– Original

(USD millions)

(a)

Total Final

Estimate20

(USD millions)

(b)

Actual

(USD

millions)

(c)

Actual as

Percentage of

Appraised

(c/b) x100

Increasing Access to and

Utilization of Services

43.79 81.60 82.97 101.68%

Developing Effective Models to

Combat Non-Communicable

Diseases and Accidents (Revised

to “NCD Prevention and Control”

at Additional Financing)

5.65 26.72 26.68 99.85%

Building Capacity for Oversight

and Management of Health

System

25.61 55.41 60.86 109.84%

Maximizing Efficiency of the

Public Sector to Deliver Essential

Services

50.90 73.00 73.28 100.38%

Total Baseline Cost 125.95 236.73 243.79

Contingencies 5.64 5.64

Total Project Cost 131.59 242.37 243.79 102.98%

Total Financing Required 131.59 242.37 243.79

(b.) Financing

Source of Funds

Original

Appraisal

Estimate

(USD millions)

(a)

Appraisal Estimate

minus $21 cancelled

due to Tsunami plus

Additional Financing

(USD millions)

(b)

Actual

(USD millions)

(c)

Actual as

Percentage of

Appraised

(c/b) x100

Borrower 20.76 33.84 33.70 99.58%

International Development

Association (IDA) 110.83 208.53 210.09 100.75%

Total Financing 131.59 242.37 243.79 102.98%

Disbursements:

(i) Up to April 29, 2010 (date of Approval of Additional Financing) = US$ 88.59 million (42.17% of the total

disbursed)

(ii) From April 30, 2010 to August 7, 2014 (From AFs approval to the date of change in the Results Framework/

Restructuring): US$ 98.18 million (46.73%)

(iii) From August 8, 2014 to final disbursements: US$ 23.32 million (11.1%)

20 To simplify presentation, this column shows the final estimated cost: the appraisal estimate, less the $21 million

($20 million at 2005 exchange rate) cancelled on June 30, 2005 to use to help finance the Emergency Tsunami

Reconstruction Project in 2005, plus the Additional Financing approved on April 29, 2010

48

Annex 2. Outputs by Component

TNHSP completed almost all planned activities and exceeded targets for many. This Annex

summarizes the main outputs delivered, compared to what was planned under each component.

(Final actual disbursements for each component are noted in the component heading.)

Component 1: Increasing Access to and Utilization of Services (USD 82.97 millions)

Planned Accomplished

Sub-component 1: Reducing Maternal and Neonatal Mortality.

Establish at least two

CEmONCs in each of

the 32 districts, able to

treat obstetric and

neonatal emergencies,

including C sections.

First ones to be in

disadvantaged districts.

Established and strengthened 75 CEmONCs (including 20

CEmONCs in Medical Colleges) and 50 EmONCs in the state to

provide definitive treatment and improved quality of care, 24x7

for all obstetric and neonatal emergencies. In addition,

strengthened 8 identified medical college CEmONCs with

extensive civil works and inputs.

Instituted a mechanism for regular recertification of

CEmONCs using established criteria to ensure adequacy of

resources at the facility and quality of care for provision of 24

hour emergency obstetric and new born care services. Four

rounds of re-certification of CEmONCs were taken.

Equip CEmONCs with

treatment protocols,

trained staff,

equipment, supplies

and drugs needed.

Steadily staffed CEmONCs with doctors and specialists per

norms (2 OBGYN, 2 pediatricians, 1 anesthetist)-75 CEmONCs

had 4 OBGYN, 2 pediatricians and 2 anesthetists, and 50

EmONCs had 2 OBGYN, 2 pediatricians and 1 anesthetist

(9/30/2013) against the target of 80 CEmONCs.

562 staff nurses were recruited for CEmONCs and their

salaries paid through project for the first two years, thereafter,

the GoTN absorbed the staff nurses into existing cadres and

financed their salaries from budget.

1,419 doctors and 3,342 nursing staff were trained in skills for

operationalization of CEmONCs during Oct 2010 – March 2014

(target was 1,068 doctors and 1,334 nurses by 9/30/2013).

(from 2010: 37,468 doctors and nurses trained in CEmONC

skills, medical equipment use and NCDs)

Prepared and disseminated several guidelines such as for “Blood

transfusion to obstetric cases” to the obstetricians, blood bank

medical officers of the CEmONC hospitals; guidelines and

protocols for high risk pregnancies to all secondary care

hospitals in the state.

Provided several rounds of technical training (labor skills, new

born resuscitation techniques, ultra-sonogram) to specialists and

nurses (skilled birth attendants), for managing maternal and

neonatal emergencies at CEmONCs.

49

Provide emergency

transport services to

reduce delayed referral.

Provided free emergency transportation for mothers to

CEmONCs, and to inter-facility transfers if mothers had to be

referred to tertiary care centers for complications.

Train personnel who

attend deliveries in

homes and primary

care facilities to

recognize obstetric

emergencies, also acute

respiratory infections,

and to identify and

track high-risk infants.

Established a high risk antenatal screening program in two

districts of the state in July 2014, later scaled-up to 20 districts

based on the appreciable outcomes achieved. The program

involved screening of all ante-natal mothers (mobilized by

village health nurses) by a team led by obstetrician and medical

officers of the PHCs in a camp mode. Identified high risk

mothers were referred to CEmONCs in advance of their delivery

date for better management of complications and to reduce

maternal deaths. Program included extensive training of all

relevant providers.

Print, outdoor and electronic IEC materials were developed and

successfully deployed to improve uptake of services at

CEmONCs. IEC materials are stored on TNHSP website and

available for future use by the NHM and DoHFW

Improve quality of care

to prevent maternal

deaths (sub-component

2(ii) is also relevant)

Established a process to analyze every maternal death in

secondary care and tertiary institutions once a month, by a team

of OG specialists led by the concerned Nodal Officer, NHM and

an expert at the NHM, through video conferencing, and used

findings to improve the quality of care in hospitals.

Project convened regular reviews of progress of delivering

maternal and neonatal health services -- monthly performance

reviews through ISMRs and CEMONC Center reports, monthly

review of services by Joint Director of Health Services,

Quarterly reviews by DM&RHS, and state level review by

Secretary Health.

Carried out baseline and end-line assessment of CEmONCs.

Sub-Component 2: Improving Tribal Health.

Strengthen existing

primary & secondary

services in tribal

areas through PPPs

with experienced

NGOs (e.g., to provide

key staff for vacancies

in selected PHC/HSCs,

reimburse in-patient

services provided by

NGOs, train village

level tribal health

workers, provide

Trained/retrained NGO partners on delivery of quality health

care services to tribal groups.

Introduced mobile outreach services in partnership with 12

NGOs (PPO model) in 13 districts to enhance service

accessibility (outpatient, maternal and child health (MCH) and

laboratory services) for tribal groups, typically living in remote

rural areas. Twenty vehicles, equipped with basic laboratory

services and necessary medicines, were staffed by a medical

doctor, staff nurse and a lab technician visited difficult to access

areas once in 7-14 days per a fixed schedule. 2007-14, 1.84

million tribal patients were treated. Availability of services at

door step was main factor that motivated assessment survey

respondents to use mobile outreach van services.

50

mobile clinical services

in 12 identified areas).

(Note: very detailed

plans were developed

and summarized in the

PAD, Annex 10)

Supplied 30 four-wheel drive vehicles for emergency

ambulance service for difficult terrain to increase uptake of

services by tribal groups.

Established a Sickle Cell Anemia (SCA) screening and

treatment program (a genetic disease specific among tribal

population in Nilgiris district) in three NGO run hospitals in

Nilgiris and Coimbatore districts. A standard management

protocol for diagnosis and treatment of SCA was followed. From

2008/09-2013/14, 21,900 persons were screened; 5,158 people

given secondary confirmation tests; 252 persons with confirmed

SCA enrolled in a treatment program. All patients received

genetic counselling, more than 90% received services (blood

test, body check-up etc). Genetic, premarital, and antenatal

counselling was provided to those in SCA endemic areas to

ensure long-lasting health-seeking behavior. Impact: About

63% of the respondents (end line study) reported reduced

instances of critical illness because of this intervention.

Instituted a bed grant scheme to provide free in-patient care for

tribal patients (3 NGO hospitals provide a range of services

including complicated deliveries including C sections and

pediatric services). Between 2007/08 and 2013/14, 11,889 in-

patients received care. An analysis of per patient cost of the

scheme was carried out in order to rationalize the charges in line

with the reimbursements authorized under the statewide

insurance program. An end-line study found that almost all

patients were satisfied with the facilities, many had used the

scheme for delivery related services or general ailments, 93%

received medicines, 88% considered services to be good quality,

most agreed that the program motivated more mothers from

tribal community to deliver in health facilities, and that the

scheme reduced self-medication/visit to traditional healer.

Launched a program in 4 PHCs to enable pregnant tribal women

to stay at PHCs for up to a week prior to their expected date of

delivery to encourage institutional deliveries. The program was

handed over to the National Health Mission in 2010, which

scaled up to over 20 PHCs in remote villages.

IEC strategies will be

directed at behavior

change so (i) those who

are underserved

demand better services

and are better able to

manage their own

health care; and (ii)

more responsive

Print, outdoor and electronic IEC materials were developed and

deployed on preventive and promotive health behaviors for tribal

populations.

A campaign using traditional modes of communication was

deployed to inform tribal and disadvantaged populations and

encourage use of public health services.

Trained/retrained NGO partners for delivery of quality health

care services to tribal groups.

51

behavior by service

providers. Established Tribal Patient Counselling facilities (32 in 2008-

2009 and 42 in 2013-2014) at 42 district, taluk and non-taluk

hospitals as well as in selected PHCs in partnership with local

NGOs, to improve health seeking behaviors of tribal

communities in Government hospitals, assist tribal patients to

navigate through health facilities, better understand doctors’

advice and prescriptions and for preventive and promotive health

care. Between 2008/09 and 2013/14, about 1.936 million

patients availed the services of these counsellors. Feedback: 2/3

satisfied and 1/3 highly satisfied with counsellor’s service.

Comments: all fully achieved.

Carried out mid- and end-line assessments of all four above schemes through PPPs to

draw lessons for further improvement.

Uptake of services by tribal groups increased from 16,379 tribal beneficiaries in 2013-14

to 26,915 in 2014-15.

Handed over these initiatives to the NHM and GoTN for sustainability.

Sub-component 3: Facilitating Use of Hospitals by the Poor and Disadvantaged

(i) community

mobilization by NGOs

and outreach workers;

(ii) well-designed

behavior change strategies for health

promotion;

(iii) counseling centers

run by NGOs and local

self-help groups to

provide information

patient rights,

availability of services,

and legitimate charges

for services.

(iv) interpersonal

communication training

for health personnel to

improve provider

behavior.

Added 108 Emergency ambulances (currently 730 ambulances

in operation). Since 2008-09, use of 108 ambulances for

maternity cases increased from 20.2% to 26.3% and for

cardiovascular cases from 5.4% to 6.1%). Added 30 four-wheel

drive vehicles for difficult terrain (June 2014) (target was 200

more ambulances)

Print, outdoor and electronic IEC materials were developed

and successfully deployed to encourage uptake of emergency

transportation services. A campaign using traditional modes of

communication was deployed to inform tribal and

disadvantaged populations and encourage use of public health

services. (noted above also)

Provided 63 mortuary vans to provide a Free Hearse Service

(FHS), operated through a PPP with the Indian Red Cross

Society, supporting poor families in their time of need (in three

months (April – June 2015), 21,505 deceased were transported

by the FHS.

Established 185 Patient counseling centers through NGOs in

all CEmONCs and selected non-CEmONC hospitals to

facilitate access to information by the poor and disadvantaged

patients. This activity was discontinued in the Additional

Financing phase.

52

Component 2: Developing Effective Models to Combat Non-Communicable Diseases and

Accidents (USD 26.68 million)

Sub-component 1 : Supporting Health Promotion

Help develop the evidence-

base to advocate policy

change (tax reform, policies,

enforcement) by analyzing

available data, and

commissioning special studies

(Dropped in 2010)

Project used data on smoking, NCDs, TN’s very high rate

of traffic accidents to advocate for policy change.

GoTN adopted several policies on tobacco including

restriction on sales to youth, advertising and smoking

restrictions near schools.

Mass media BCC on

smoking cessation, healthy

diets and exercise,

(Mass media dropped 2010)

Community-based

interventions for enabling

environments and targeting

specific groups such as

women

Designed and carried out a community-based BCC for

CVD prevention.

Carried out community based interventions, leveraging

women’s Self Help Groups (SHGs) on preventing,

screening and treatment select NCDs. Over 250,476 (97%

of the target) women’s self-help groups through Tamil

Nadu Corporation for Development for Women

(TNCDW) oriented in risk factors for CVDs and

encouraged to avail screening and comply with treatment

if screened positive for risk factors or disease conditions.

School-based health

promotion

Workplace-based health

promotion

Carried out health promotion activities in 16,369

government and aided schools in the state with the Sarva

Shiksha Abhiyan (Department of Education). (establish

health-related school policies, provide safe water and

sanitation, skills-based approach to health, hygiene and

nutrition, and healthier school meals

From 2010, expanded health promotion activities for

prevention of CVD in schools in collaboration with

education department, completed IEC prevention

activities in worksites

Workplace based health promotion activities conducted

at 400 worksites with the Department of Labor. (smoke-

free workplaces, programs to help employees quit

smoking, workplace exercise and healthier food available

in the cafeteria etc.)

life-style counseling centers

to help control cardio-

vascular risk factors in district

hospitals through PPPs with

experienced NGOs to provide

advice, particularly to poor

and disadvantaged patients,

on risk factor management

adults screened for hypertension were counseled for life-

style modification

(Dropped in 2010)

53

Sub-component 2: Pilot Testing Clinic-Based NCD Control

Pilot 1: screening and

treatment of hypertension

using anti-hypertensive

medications.

Pilot 2: assess costs and

benefits of universal cervical

cancer screening and

treatment.

NGO partners will provide

agreed services such as

community-based

mobilization, health

promotion and follow-up of

registered patients.

Implementation will involve

training staff and private

providers, hiring additional

staff, providing extra

medications as per “stepped-

up care” protocol), etc.

Carried out two NCD pilots on cervical cancer and

cardiovascular diseases (CVD) in two districts each – cancer

cervix February 2007-September 2010, and hypertension July

2007 -- September 2010 -- to serve as examples for state-wide

roll-out after evaluations of the pilots.

The NCD pilots were the first of their kind in the region.

Health professionals were trained in the skills they needed to

carry out the pilot interventions

Cervical cancer pilot: implemented a sensitization and

mobilization program, among 30-60 year old women,

established functional screening center at PHCs and general

hospitals in the pilot districts, women tested positive during

cervical cancer screening were referred for treatment

Hypertension pilot: patients diagnosed with hypertension

were provided treatment and followed-up, adults screened for

hypertension were counseled for life-style modification

Operational research – collect

and analyze data on cost, field

effectiveness of risk factor

management; operational

issues such as adherence, and

challenges of implementing

the intervention in different

settings (more/less

industrialized)

The National Institute of Epidemiology, Chennai, evaluated

the pilots for hypertension and cervix screening during 2008-

10, and concurrent evaluation of the clinic based

screening/treatment program of four diseases (cancer of

cervix, breast cancer, hypertension, and diabetes) in all

districts since 2011, as well as end line evaluation of school

and community based interventions. Lessons learned from the

pilots informed design of program for scaling up NCD

interventions state-wide.

AF: Scale up NCD Programs throughout Tamil Nadu in two phases (16 districts each).

AF: Scale up throughout the

state screening and treatment

of specific NCDs (based on

the pilots)

Scaled up hypertension and cervical cancer pilot, added

diabetes and breast cancer - provided functional screening

services for screening of cancer of cervix, breast cancer,

hypertension, and diabetes free of cost at 1,753 PHCs, 270

GHs, 23 Government medical college hospitals, ESI

dispensaries and hospitals, and 100 selected municipal

health facilities in the state.

Provided reagents, consumables, drugs, and necessary

equipment for implementing the NCD program.

Recruited 2,344 NCD staff nurses in health centers to

facilitate the NCD screening program. Trained them to

counsel patients on accessing screening, complying with

advice and medication and ensuring follow-up care. The

54

salaries of the staff nurses were reimbursed by the project.

The GoTN has absorbed the NCD staff nurses in regular

cadres and their salaries are now being paid through

domestic budget and NHM funding.

Provided skills training to 1,155 clinical staff comprising

female medical officers and staff nurses of private

empaneled hospitals for clinic based interventions

(October, 2014 – March 2015); and trained 190,567

persons affiliated to SHGs, statisticians affiliated to the

Integrated Disease Surveillance Program (IDSP) and staff

nurses in NCD online screen use.

Based on the lessons from the CVD pilot, made

improvements in health care delivery such as in

dispensing medication supplies for longer durations.

Several print, outdoor and electronic IEC materials were

developed and successfully deployed on preventive and

promotive health behaviors with respect to NCDs. The

mass media campaigns were very well received as

indicated in concurrent evaluations conducted by NIE.

Screened 77.4% of over 30 years of age persons in Tamil

Nadu for hypertension, and 71.3% of the women in the

age group of 30-60 years for cancer cervix. During July

2012 and September 2015: (i) screened over 29.03 million

individuals for hypertension, 2.972 million were positive

and put on treatment (a positivity rate of 9.62%); (ii)

screened 23 million individuals for Diabetes Mellitus,

0.958 million positive were put on treatment (a positivity

rate of 4.17%); (iii) screened 10.3 million women for

cancer cervix, 0.353 million positive and availed higher

level diagnostics and treatment (a positivity rate of

3.45%); and (iv) screened 12.50 million women for breast

cancer, 153,330 women positive, availed higher

diagnostics and treatment (a positivity rate of 1.23%).

Provided life style counseling to all individuals screened

Higher order diagnostic, medical, pharmaceutical and

surgical interventions required for breast cancer and

cervix cancer services linked with the package of services

available under the Chief Ministers Comprehensive

Health Insurance Scheme for individuals with a certified

annual family income of less than INR 72,000. (FP)

Monitor and evaluate the

NCD interventions An external quality assurance program was established for

all laboratories of health facilities running the NCD

screening program with Christian Medical College,

Vellore to ensure high quality of diagnostics. Contract is

55

performance-based, with service norms for quality and

turn-around time.

Evaluations of the clinic based screening/treatment

program of four diseases (cancer of cervix, breast cancer,

hypertension, and diabetes) done in all districts since

2011, also an end line evaluation of school and

community based interventions.

Sub-component 3: Traffic Injury Prevention and Treatment

Additional support for health

promotion to encourage

helmet use, obey traffic rules,

not drink and drive.

Project advocated with state to pass new laws on helmet and

seat-belt use, with police on enforcement, and with on-going

WB-financed Transport Project to visibly mark all spots

where traffic accident fatalities occur.

Strengthen emergency

transport through

partnerships with NGOs to

place fully equipped

ambulances at accident-prone

spots on identified highways.

More than 200 additional ambulances brought into operation,

and response time for ambulances fell well below the

standard of under 30 minutes. Ambulances stationed at police

stations, all health facilities, and other strategic places near

accident “black spots”.

Provide training and

equipment for paramedics in

accident relief for better

immediate care (“golden

hour”)

Develop standard treatment

protocols for trauma care,

emergency and poison

management, to improve

trauma management in public

and private facilities in

accident-prone areas.

Extensive training program established and all cadres

trained, with continuous training as needed, including in

immediate care protocols, trauma care, etc.

Emergency services in TN are operated by a private agency -

The Emergency Management and Research Initiative

(EMRI), which had started in AP. Its demonstrated and

documented impact in TN enabled it to expand to 15 other

states in India. Initially, EMRI bore 5% of the costs of the

services provided, now it has a lump-sum contract that covers

full costs.

Poison centers set up in all 32 districts, protocols developed,

training done.

The Strategic Planning Unit

will analyze and use data for

advocacy for policy changes

and better enforcement of

traffic rules and regulations.

Monthly helmet-use data collected and analyzed, but not used

to advocate for enforcement. The state backed away from

enforcing the helmet law in the face of strident public

resistance. Project decided to drop this sub-component –

initial traction lost.

Component 3: Building Capacity for Oversight and Management of the Health System

(USD 60.86 million)

Sub-Component 1: Strengthening Monitoring and Evaluation

Strengthen the HMIS

Develop a new computerized

HMIS system, pilot it, and

install it across the state.

HMIS software developed, hardware installed, and full

system rolled out in phases (December 2008 onwards)

HMIS comprises (i) HMS which automates data on all

clinical activities public health care facilities; (ii) MIS

online reporting platform for clinical and ancillary support

56

Provide training at all levels

on how to use and maintain

the system.

services, national health programs and administrative

information for all public health facilities; (iii) CMS data

on academic activities of government medical colleges;

(iv) UAS for data from Dr. MGR Medical University; and

(v) customized websites for government medical colleges.

Established a central helpdesk with adequate staffing.

DoHFW appointed IT coordinators in all districts, and e-

core teams in hospitals to solve IT issues.

GoTN issued government orders for (i) implementation,

sustainability and usage, (ii) responsibility of end users,

(iii) budgetary provisions for maintenance and support,

(iv) removal of manual records, (v) creation of new posts

at district and state level to support ICT interventions, (vi)

instructing Heads of Departments and Directorates to use

data from HMIS for purpose monitoring, review and

analysis, and (vii) formation of a dedicated team at the

Directorate.

HMIS full function: HMS in 264 secondary care

hospitals; MIS in 274 GHs, 70 municipal dispensaries, 67

medical colleges and 1,889 PHCs; CMS in 20 government

medical colleges; and UAS in TN Dr. MGR Medical

University. HMS for DME institutions was also

completed.

Monthly reporting of hospital-level data on service

utilization on-going through the ISMRs - all 264

secondary level hospitals report on 20 Quality of Care

Indicators monthly using HMIS.

GoTN integrated HMIS with e-TAAL (Electronic

Transaction and Analysis Layer), completed transaction

count of HMIS is reflected in national Govt. e-TAAL site.

SHDRC set up as a central repository of data, collate,

mine and run higher order analytics on data from 20+

Directorates, and provide easy to use dashboards for

various levels of administrators and managers in the

health department, to drive and complement evidence-

based planning, budgeting, and management, forecasting,

monitoring and review in DoHFW.

Carry out independent

evaluations of selected project

activities to assess

innovations including surveys

on NCDs, patient satisfaction

and out-of-pocket spending.

Baseline, mid-line and end line patient satisfaction and

quality of care surveys were done, and actions taken to

address gaps in services.

Evaluations of NCDs completed (see above)

OOP survey not done because data are collected by NSSO

Comprehensive assessment of infection control and waste

management systems in public health sector done,

57

covering policy and operating environment, efficiency

and effectiveness of training through Regional training

Centers, improvements in knowledge of health personnel,

and impact of practices of bio-medical waste management

in public health facilities of TN

Sub-Component 2: Improving Quality of Care

(a) Develop and implement

quality indicators,

(b) monitor quality of

services through base-line,

mid-term and endline surveys

(c) Establish Quality

Improvement Circles in

health facilities to track

progress on indicators,

monitor implementation of

maternal death audit, medical

audit and prescription audit;

(d) Develop protocols to

improve management of key

problems (e.g. hypertension,

smoking cessation, cervical

cancer, hemorrhage,

emergency care, etc.) and

train providers in use of

protocols and manuals, and

rational drug use.

(e) Develop hospital

inspection checklists, set up

panels of experts to do

regular inspections and

provide feedback.

All 267 health institutes report monthly on 20 efficiency,

performance and quality of care indicators, and are ranked

A, B, C and D. C and D scores trigger additional support

and guidance to Chief Medical Officers of to bring the

hospital back on track in performance, efficiency and

quality of care.

Quality Circles of Excellence (QCE) established and

institutionalized in 267 secondary health facilities in the

state with representation from all cadres of personnel in

the health institution. They hold monthly meetings,

review data and issues affecting quality, and discuss their

resolution.

Developed protocols for improved management of key

health service delivery activities supported under the

project, and trained health service staff at all levels in the

use of protocols and manuals.

Trained health personnel of secondary hospitals to

improve quality of care, including in hospital

management, rational use of drugs and skills-based

training: 80 CMOs in hospital management; 739 staff in

hospital administration; 1,692 staff in Quality Indicators;

1,915 in rational use of drugs.

Trained and retrained 398,285 health personnel (October

2010-June 2015).

12 hospitals accredited (3 full and 8 progressive level

accreditation, and 1 entry level accreditation); more

hospitals completed final assessment and awaiting

decision/feedback from Quality Council of India.

Strengthened clinical laboratory services in secondary

care hospitals and medical college hospitals by (a) initial

PPP with private agency, to provide services at regional

laboratories in 5 District Head Quarters Hospitals, later

transferred the activity to the Directorate of Medical and

Rural Health Services (b) supplied necessary equipment

for laboratories in all secondary care hospitals in TN.

Provide to hospitals: (i) basic

amenities; (ii) equipment and

inputs; (iii) train technical and

Mentioned in the PAD under this component, but addressed

under Component 4, sub-component 1. See below.

58

Managerial staff at all levels

Strengthen regulation of

public and private hospitals

building on the existing

regulatory system: help

GOTN implement stronger

oversight system for both

private and public facilities.

Strengthened capacity of DoHFW to manage and support

the accreditation process.

The PAD noted that “Regulation of the private sector would

take longer than that in the public sector and would depend on

certain factors beyond the scope of the Project.”

Sub-component 3: Strengthening Healthcare Waste Management

Install hospital waste

management system in all

hospitals per GO1guidelines

Train health personnel at all

levels of facilities in

healthcare waste management

Implement guidelines on

proper segregation and color-

coding, transport, and

disposal. (PPPs with NGOs)

HCWM plan implemented by 449 public health

institutions, consistent with the GoI’s Biomedical Waste

(Management and Handling) (Second Amendment) Rules,

2000 which details good practices to be followed and all

roles and responsibilities for effective disposal of health

care waste. Implementation was phased. First, a pilot was

done in 11 hospitals in 2 districts over 2 years, and the

experience evaluated independently, gaps identified and

corrected. Phase two scaled up in 449 public health

institutions (270 secondary care, 41 tertiary care, 130

thirty bedded PHCs and 8 ESI hospitals).

Over 49,500 health personnel were trained and re-trained,

in identification, collection, segregation, disinfection, and

disposal of health care waste and maintenance of records,

through a network of 11 Regional Training Centers in

medical colleges (7 government and 4 private but only 2

private were active at the end), which were strengthened

for sustainability of training.

Training complemented by behavior change campaign.

Established effective coordination with municipal bodies

and the State Pollution Control Board, which performs

annual quality assurance inspections of all treatment

facilities.

Established PPPs with 30 Common Treatment Facilities

(CTF) for collection, disinfection and disposal of waste in

secondary level institutions. Till 2013, project provided

all hospitals with consumables, equipment and personal

protective gear for ICWM, including per bed or per

kilogram cost for disposal of health care waste to CTFs.

Since 2013, the flexifund of National Health Mission has

paid for ICWM in all institutions, including payments to

CTF. ICWM implementation and monitoring handed over

to the Directorate of Medical and Rural Health Services

and Directorate of Public health and Preventive Medicine.

59

Comment: management of health care waste institutionalized and strengthened in public health

institutions, (a key element of Bank’s mandatory Environmental Management Plan),

contributing to safer, and more effective health care.

Sub-component 4: Building Capacity for Strategy Development and Implementation

Set up Strategic Planning

unit to identify issues,

generate and evaluate options

to improve HS performance

(eg strategic planning, HR,

commission operational and

policy research, study key

issues for effective

implementation of project

activities to achieve

desired output

Established a functional Strategic Planning Cell (SPC)

as a think tank for GoTN, and to lead significant aspects

of various health delivery interventions supported under

TNHSP. Before project closed, SPC/TNHSP prepared

proposals to Government for issue of Government Orders

for handing over TNHSP programs to the Directorates of

the DoHFW and for sanction of budgets.

Tamil Nadu Medical Code was revised by SPC.

Conducted end line evaluation studies on CEmONCs and

tribal health activities, quality of care, patient satisfaction,

infection control and waste management.

Establish PPP wing in GoTN

to promote inclusive

partnerships with the private

sector in provision of

healthcare, especially in hard

to reach areas with low access

to government health care

services, and in sectors where

co-ordination is essential. The

wing would also manage and

monitor all PPP contracts

signed under the project.

A PPP Wing was established by SPC.

Evaluation studies of the PPPs were carried out for: 2

pilot PPPs for health care waste treatment; 2 PPPs for bed

grant schemes, 2 PPPs for sickle cell anemia and several

PPPs for mobile van outreach programs in tribal areas;

PPP for emergency transport (ambulance); and several

PPPs for the provision of patient counsellors at

CEmONCs and non-CEmONCs facilities

Number of performance based contracts delivering health

care services increased during the AF by 37 (target was 9

PPP contracts) -- 5 contracts for Regional Diagnostic

Labs, 2 Housekeeping services contracts and 30 CTF

contracts for handling hospital waste.

Conduct a Health Insurance

Pilot to explore feasibility of

providing community-based

health insurance on a

reasonable scale

Pilot not done because new Chief Ministers Health

Insurance Scheme was set up and rolled out widely with

full administrative support from the project.

International Conference on Health Systems Financing

(May 6 – 10, 2010) held in Chennai with participation

from GoI, GoTN, other states across India, international

and bilateral development partners and others to discuss

implementation issues, share international experiences to

promote good practices, and guide national and state

policies for improving health systems.

Strengthen Project

Management Unit to enable

PMU to track progress and

carry out project procurement

and financial management

activities.

Added staff to PMU

PMU monitored and reviewed regularly project activities

including ISMR and grading of hospitals, outsourcing of

housekeeping services, quality of care activities, poison

treatment centers.

60

To be a useful pioneer

project, experience must be

shared

TNHSP Stakeholders Workshop (August 28-29, 2015) in

Chennai took account of the project’s performance,

disseminated experiences, discussed post-project plans.

Developed and disseminated publications on TNHSP

activities and innovations: Training Manual on Quality of

Clinical Care Indicators, Handbook on Infection Control

and Biomedical Waste Management, Health Management

Information system, Documentation and Dissemination of

a Best Practice, and Standard Treatment Guidelines

Manual. Project staff also participated and contributed to

inter- and intra-state workshops.

Many delegations from other states, and development

partners (Bill and Melinda Gates Foundation, JICA,

USAID etc) have come to see the programs set up under

the project, and emulated them elsewhere.

Component 4: Improving the Effectiveness and Efficiency of the Public Sector to Deliver

Essential Services (USD 73.28 million)

Sub-component 1 : Rationalization of Secondary Care Facilities

Refurbish and upgrade secondary care hospitals to

ensure functioning basic

amenities (water, sanitation

and electricity), and ability to

provide care per new service

norms for each grade of

hospital.

Completed all planned civil works (35 Phase I secondary

care hospitals; 190 hospitals in Phase 2, maternity blocks

in 8 government medical colleges, and the Annex building

of the Directorate of Medical Services).

Civil works in 8 CEmONCs in medical colleges and 12

hospitals undergoing NABH accreditation were

completed under the AF.

Provide equipment required

to deliver services per norms. Provided essential hospital equipment required to deliver

services per norms for secondary level hospitals. In total,

constructed, renovated and/or equipped 2,330 health

facilities (1,889 PHCs, 274 GH, 100 medical dispensaries

and 67 medical college hospitals (throughout project)

Sub-component 2: Rationalizing of Equipment

Undertake one-time repair,

after assessing inventory and

repair needs.

Completed. Electronic inventory of about 100,000 pieces of

equipment in hospitals under various departments of DoHFW

enables more efficient equipment management.

Implement a good

maintenance system similar to

Andra Pradesh (through

TNSMC, equipment

suppliers, and local hospital

officials).

Established a system to track and improve utilization,

repair and maintenance of equipment in health care

facilities. Annual maintenance contracts for complex

expensive equipment, regional workshops manned by in-

house biomedical engineers and technicians to service

moderately complex equipment and to manage Annual

Maintenance Contracts (AMCs) and other ad hoc

61

contractors, and assist hospitals in training users in basic

maintenance and care of equipment.

Recruited and trained 48 biomedical engineers to maintain

and manage medical equipment. They liaise closely with

TNMSC, TNHSP and equipment manufacturers and

suppliers, and manage equipment repairs.

AF: Strengthen equipment

and pharmaceuticals

management

TNMSC’s capacity for managing pharmaceuticals and

medical supplies using World Bank procurement

procedures was strengthened under the project. The new

HMIS provides real time data on pharmaceuticals use and

inventory, which could enables better management of

pharmaceuticals.

Sub-component 3: Human Resource Planning and Development

Establish and implement new

staffing norms, conduct

extensive training of

government staff, including

management training for

hospital administrators.

Revised and rationalized manpower service norms.

Recruited 1,212 NCD staff nurses under contracts for

Phase II hospitals (IDA financed), 562 staff nurses for

CEmONCs and 1,132 NCD staff nurses for Phase 1

districts (GoTN financed) during Additional Financing, in

accordance with established staffing norms to improve

overall efficiency and performance. GoTN has taken on

salaries of additional staff from own resources and

financing of NHM.

Trained and re-trained 398,285 health professionals

(during Additional Financing, Oct 2010-June 2015) to

enhance capacity of the public health system and to

enhance skills and improve quality of care in all areas

supported by TNHSP. These included senior medical

officers and administrators, doctors, nurses, clinical,

paramedical and laboratory technicians, health personnel

in bio-medical waste management, medical assistants,

ANMs, counsellors, pharmacy staff, HMIS staff and

administrative assistants. Most training was done by

reputable organizations recruited from outside. Substantial

training activities were also undertaken during the original

project (2004-2010) to improve skills and knowledge of

health personnel.

Carry out activities to

improve staff morale and

courtesy to patients and set up

incentive measures.

Trained service providers in interpersonal communication

to encourage team effort and role clarity and recognition.

Subcomponent 4: Enhancing Management of Public Facilities (dropped at AF)

Twin hospitals with well-

known private hospitals.

Provide incentives to hospital

Established a performance grading system of hospitals to

identify and resolve bottlenecks and improve performance

in hospitals experiencing difficulties/ performing poorly.

62

administrators for high

performance.

Where twinning is not

feasible (no private hospitals

available), consider/test other

ways to improve performance

of lagging public facilities

tested, including: eg

improvement budget fund,

PPP contract with NGOs to

operate the facility, recruit a

hospital manager or

consultant on a performance-

linked contract.

Introduced PPPs to provide and manage health services

including operation of ambulances financed under the

project, free hearse service, housekeeping services,

laboratory diagnostic services, tribal mobile outreach

services, screening and treatment of sickle cell anemia,

counseling services for tribal patients, and a bed grant

scheme.

Outsourced Housekeeping Services in 48 secondary care

hospitals to a competitively selected vendor (cleaning,

sanitation, security, assistance in electrical, plumbing,

catering, cooking, laundry, gardening and carpentry

services). The contract was handed over to the Directorate

of Medical and Rural Health Services.

63

Annex 3. Economic and Financial Analysis

The economic and financial analysis of the project in the PAD consisted of a qualitative

discussion of the major components, pointing out that the CEmONCs could save lives at low

cost; that NCDs imposed a significant economic burden through lost productivity and thus

programs to address NCDs could reduce DALYs lost in a cost-effective manner; and

infrastructure investments would be pro-poor. There was also a brief discussion of project

implications for future recurrent spending, the affordability of Borrower funding to the project,

and financial sustainability assessed by placing project costs in the context of the overall health

budget. No economic rate of return (ERR) or net present value (NPV) was calculated.

The economic analysis of this ICR updates and extends this analysis. It assesses the major

project components through an economic lens, including the following: (1) recurrent costs and

budgetary implications; (2) cost-effectiveness considerations; (3) cost-benefit considerations; (4)

efficiency considerations; (5) equity considerations. The key message is that the available

evidence suggests there were significant economic returns from the project and no major red

flags related to economic impact.

The economic rationale for public spending in the health sector should be noted at the outset.

There are many issues, including insurance market failures, market power among the providers

of medical care, externalities associated with some health goods, newer behavioral economic

theories that emphasize under-utilization of care, and equity considerations. All are cited as

reasons for government intervention. These factors help explain why over 80 percent of health

spending in high-income countries is typically public (i.e., financed through general taxes or

social health insurance). In India the share is just half this amount, but can be expected to trend

upwards over time as it pursues an increasingly MIC agenda.

During the life of the project, Tamil Nadu enjoyed strong economic growth, even faster than the

robust 7.5% average annual Indian average over the same period. While this trend slowed

during 2011-13, it picked up momentum again in 2014. There are some fiscal challenges,

however, with a deficit of 2.7% of state GDP, and a rising debt to SGDP ratio (although still

moderate at about 20 percent).

Budgetary implications of recurrent costs

The project’s components included both capital investments (e.g., hospital improvements) and

programmatic initiatives (e.g., NCD screening) that imply ongoing recurrent costs that will

endure long after project completion. An important question is whether these costs can be

absorbed in GoTN’s regular health budget.

Counterpart funding amounted to 14% of total project costs, very close to the expected level in

the PAD. This was less than 0.5% of the Tamil Nadu health budget over the course of the

project, and was therefore easily manageable. While the health budget increased significantly in

absolute terms, Tamil Nadu’s budget share for health stayed remarkably constant over the project

64

life, with the share almost identical in 2015-16 as 2005-06 (4.5% vs. 4.6%). The PAD made note

of a declining trend in state health spending in the years preceding project preparation; while the

stability of the health budget share over 10 years is welcome, a higher allocation would have

been preferable given that most LMICs allocate about 6-8% of their budgets to health. However,

with the strong economic growth in the state over the project years, even a constant budget share

provided a substantial increase in the health budget.

During implementation, total project costs reached a peak of 7.6% of the overall health budget

(this was in 2010/11), slightly below the 8.9% peak forecast in the PAD. Over the final three

years, it averaged just 1%, suggesting there will be no major handover issues with respect to

sustainability. This is shown in the table below.

One of the more important sources of recurrent costs arising from the project was the

regularization of nearly 3000 staff nurses from the NCD and CEmONC programs. This was an

important and commendable step, and an important lesson for other projects for ensuring that

achievements will be sustained. Although detailed salary information is not available, the total

cost of these nurses should be far less than 1% of the total health budget.

In brief, as expected at the time of the PAD, the budgetary implications of recurrent costs arising

from TNHSP are relatively small and do not represent a concern going forward.

Table: Project expenditure as a share of total health expenditure

Cost-effectiveness considerations

Cost-effectiveness evidence can help identify “best buys” for achieving health improvements

within a fixed budget. There is a large international literature on the cost-effectiveness of health

interventions that is broadly applicable to Tamil Nadu, even if local studies are not always

available. The project supported many activities – both general and disease-specific – with

varying degrees of cost-effectiveness.

Among high-burden diseases addressed by TNHSP, global evidence drawn from the Disease

Control Priorities21 project (DCP) suggests that the chosen interventions were cost-effective. For

example, cardiovascular disease management (e.g., screening and treatment for ischemic heart

disease) is among the more cost-effective interventions available, with a cost per disability-

adjusted life year (DALY) averted of approximately $1000. Drug treatments for more acute

episodes such as heart attack and congestive heart failure are even more cost-effective, and also

benefited from the project activities. Treatment costs for the more treatable cancers covered by

TNHSP (i.e., breast and cervical) have ratios between $1300-6200 per year of life saved,

compared to $53,000 to $163,000 for less treatable forms. Thus, the project appropriately

21 Laxminarayan, R., et al. (2006). “Advancement of global health: Key messages from the Disease Control

Priorities project”. Lancet 367: 1193-1208.

Year 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16

Share 0.0% 2.6% 2.5% 5.3% 5.2% 5.6% 7.6% 3.1% 3.1% 1.5% 0.7% 0.1%

65

targeted the more cost-effective cancer interventions. In addition, “improved quality of

comprehensive emergency obstetric care” and “neonatal packages” were both identified as

neglected low-cost opportunities in the Disease Control Priorities project, with very favorable

costs per DALY averted.

Taking a broader perspective, over the life of the project Tamil Nadu’s overall health budget

became more cost-effective by focusing more on primary care, with its budget share relative to

secondary and tertiary increasing by more than 15 percentage points, while the tertiary share

declined by more than 10 percentage points.

Cost-benefit considerations

A health project’s economic benefits can be estimated in two ways. Improved health outcomes

can contribute to a healthier workforce that raises economic growth and productivity. However

the economic literature emphasizes that the intrinsic (direct) value of a healthier population (as

proxied by rough estimates of willingness to pay for better health) is much more important than

the instrumental (indirect) value that is achieved by way of higher economic output.

Consider first the benefit in higher growth and productivity. A recent study by the Harvard

School of Public Health (HSPH) for the World Economic Forum22 estimated that the economic

loss from cardiovascular disease, diabetes, and cancer across India between 2012 and 2030

would be about US$2.5 trillion. It also analyzed a number of specific interventions, including

the pilot phase of the TNHSP NCD program. It estimated that the return on investment of the

program was well in excess of 15%.

A cost-benefit ratio can also be estimated by converting health gains achieved by a project or

intervention into monetary terms based on the value of health. Although this exercise may sit

uncomfortably with some, it can be useful for policy purposes, and typically serves to underline

the very high value attached to better health. The standard economic approach for quantifying

the benefit of better health in monetary terms is based on the concept of the “value of statistical

life” (or life-year). Studies from around the world suggest that the value of a statistical life-year

is at least five times higher than GDP per capita, which translates into about $11000 in Tamil

Nadu. With this value, and if project spending was on average about $20m per year, then the

project would only have to achieve an average of 2000 additional life years annually to “break

even”. This threshold is very feasible, given that the program generated an estimated 3 million

new hypertension cases identified through screening, 1m diabetes cases, 350,000 cervical cancer

and 153,000 breast cancer cases detected. All this was achieved at a project cost of only

US$19m. Moreover, within the period 2010-2014, there was a 16% decline in maternal

mortality and a 12% decline in neo-natal mortality at those medical colleges that were part of the

TNHSP CEmONC intervention. Thus, even if only 1% of those put on treatment attained one

additional year of life as a result, the benefits would substantially exceed the costs.

In brief, the project appears to have achieved a very favorable cost-benefit ratio. This would be

consistent with an existing literature, most advanced in the US, which has found benefit-cost

22 Bloom, D.E., et al. (2014). Economics of NCDs in India: The costs and returns on investment of interventions to

promote healthy living and prevent, treat, and manage NCDs. World Economic Forum, HSPH.

66

ratios of greater than 6 to 1 for anti-hypertensive therapy and medical management of coronary

heart disease, and greater than 1 to 1 for breast cancer treatment.23 More generally, there is a

large literature suggesting very high rates of return from health spending due to the very high

value that people attach to longer, healthier lives.

Efficiency considerations

A project can contribute to efficiency if it helps to achieve the same health gains at lower cost

(or, equivalently, greater health benefits for the same cost).

Starting with a broad perspective, there is little evidence that the overall health system in Tamil

Nadu is especially wasteful. Health accounts for about 4.5% of total government spending,

which is relatively low compared to many countries (LMICs are usually in the 6-8% range).

And while costs are not high, health outcomes are good, suggesting good value for money is

being achieved. The Tamil Nadu health system also achieves a good balance between primary,

secondary, and tertiary care spending, and indeed over the project life, the share spent on primary

care increased at the expense of tertiary care.

It is also difficult to identify areas where project achievements could have been realized more

cheaply. The major investments were generally made at the appropriate level of care – for

example, CEmONCs were not and should not be developed at the primary care level, whereas

NCD screening should be and was done to a significant extent at lower level facilities.

Moreover, the funded services are helping to address conditions that represent well over half of

the disease burden in Tamil Nadu, so resources were not being misdirected to low-priority

interventions.

In qualitative terms, numerous project activities are likely to have achieved efficiency gains.

Many did so by making investments in the quality of care to strengthen the link between outputs

and outcomes – for example, training 400,000 health care workers, accreditation reforms, a

system to track the utilization, repair and maintenance of equipment, and so on. The project’s

PPP initiatives – for example, for housekeeping and laboratory services, are also likely to have

generated better value for money than previous arrangements. However, concrete data on these

gains are not readily available. As reported in the project indicators, there was a modest

improvement in the bed occupancy rate.

More concretely, improved efficiency was an important objective of the HMIS, and specific

efficiency indicators were developed as part of the HMIS. It is difficult to quantify the

efficiency impact of HMIS in monetary terms, but based on the success of using ISMR to

improve quality of care, the potential is clearly there. The total cost of HMIS over the project

was about $30m, slightly more than 2% of the current Tamil Nadu health budget. Thus the

HMIS would easily pay for itself many times over if it can be leveraged to achieve even small

(e.g., 1%) efficiency gains on an annual basis.

23 Rosen A. et al. (2007). “The Value of Coronary Heart Disease Care for the Elderly: 1987-2002”. Health Affairs

26(1): 111-23.

67

Equity considerations

An improvement in outcomes for the poor and vulnerable was an explicit goal of the project, as

expressed in the PDO. As noted in project indicators, the hospitalization rate of the bottom 40%

increased by about 25%, from 33.4 to 41.9 per 1000. In addition, utilization of CEmONCs by

SC/STs also increased, as per the relevant project indicator. The sub-component on tribal health

only represented a project cost of about $1.8m, and had a positive impact on access to care

within that population. Ambulance services also were intended to have a pro-poor orientation.

68

Annex 4. Bank Lending and Implementation Support/Supervision Processes

(a.) Task Team members

Names Title Unit Responsibility/

Specialty

Lending

Preeti Kudesia Senior Public Health specialist SASHD TTL

Mohan Gopalakrishnan Financial Management Specialist SARFM Financial Management

S. K. Bahl Sr. Procurement Specialist SARPS Procurement

Ruma Tavorath Environment Specialist SASES Environment Safeguards

V. Vemuru Social Development Specialist SASES Social Development

Snehashish Rai Chowdhury Operations Officer SASHD Operational Aspects

Benjamin Loevinsohn Sr. Public Health Specialist SASHD Public Health

Isabella Anna Danel Sr. Public Health Specialist LCSHH Public Health

Sara Gonzalez-Flaveli Sr. Counsel LEGMS Legal

Philip Beauregard Sr. Counsel LEGMS Legal

Shreelata Rao Seshadri Consultant – Social Development Social Development

David Porter Consultant – Biomedical Engineer Biomedical Engineering

Subhash Chakravarty Consultant - Architect Architecture

Nirupama Sarma Consultant – Health Promotion Health

Nina Anand Program Assistant SASHD Administration

Mohammad Khalid Khan Program Assistant SASHD Administration

Supervision/ICR

Bushra Binte Alam Senior Health Specialist GHNDR Task Team Leader

Sangeeta Carol Pinto Operations Officer GHNDR Operations Officer

Ramesh Govindaraj Lead Health Specialist GHNDR Health Specialist

Owen K Smith Senior Economist GHNDR Economist

Ajay Ram Dass Program Assistant SACIN Administration

Arvind Prasad Mantha Financial Management Specialist GGODR Financial Management

Atin Kumar Rastogi Procurement Specialist GGODR Procurement

Rohit Gawri IT Analyst, Client Services ITSCR Information Systems

Sundararajan Srinivasa

Gopalan Senior HNP Specialist GHNDR Task Team Leader

Preeti Kudesia Senior Health Specialist GHNDR Task Team Leader

Vikram Sundara Rajan Senior Health Specialist GHNDR Health Specialist

Maria Gracheva Senior Operations Officer GHNDR Additional Financing

Sushil Kumar Bahl Senior Procurement Specialist SARPS-HIS Procurement

Shanker Lal Senior Procurement Specialist GGODR Procurement

Senapati Balagopal Procurement Specialist GGODR Procurement

Mohan Gopalakrishnan Sr. Financial Management

Specialist GGODR Financial Management

Shashank Ojha Senior e-Government Specialist GTIDR Information Systems

Michael Maurice Engelgau Sr. Public Health Specialist SASHN -

HIS

Non-communicable

diseases

Ruma Tavorath Senior Environmental Specialist GENDR Environment Safeguards

Subhash Chakravarty Consultant Architecture

http://isearch.worldbank.org/oui?qterm=ITSCR

69

Peter A. Berman Consultant GHNDR Health Economist

Maneesha Gupta E T Consultant ISGEG-HIS Information Systems

Benjamin P. Loevinsohn Lead Public Health Specialist GHNDR Health Specialist

Shyama Nagarajan Health Specialist SASHN-HIS Health Specialist

Shreelata Rao-Seshadri Consultant GHNDR Social Development

(b.) Staff Time and Cost

Stage of Project Cycle

Staff Time and Cost (Bank Budget Only)

No. of staff weeks USD Thousands (including travel

and consultant costs)

Lending

FY02 0.4 3.16

FY03 31.12 140.94

FY04 47.21 166.95

Total: 78.73 311.05

Supervision/ICR

FY05 38.35 111.18

FY06 25.4 96.19

FY07 35.36 119.86

FY08 29.18 145.60

FY09 27.38 129.47

FY10 33.09 121.35

FY11 42.04 197.42

FY12 28.75 144.39

FY13 26.04 109.62

FY14 20.27 68.48

FY15 26.91 113.65

FY16 9.47 39.07

Total: 342.24 1,396.33

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Annex 5. Beneficiary Survey Results

See text discussion of Patient Satisfaction.

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Annex 6. Stakeholder Workshop Report and Results

Inaugural remarks

Advantage of the World Bank projects is that they bring in global experience, best

practices, procurement guidelines, and monitoring indicators, put in place a very robust

system and facilitate upscaling of ideas.

Due to the TNHSP and other Government programs, the number of people seeking health

care in both urban and rural areas is higher in Tamil Nadu. Up-take of quality of care

activities in TNHSP was very good.

Government expressed appreciation of the World Bank for its whole hearted and constant

support for ensuring success of the project and that it becomes a model for other states in

India to follow.

Government is committed to continuing all project activities by the DoHFW.

Interventions in maternal and child health

Intervention to track high risk mothers (first as pilot in 2 districts and then up-scaled to 18

districts) resulted in a marked reduction in MMR in those districts.

During planning for CEmONC services the GIS mapping helped to identify hospitals

where major deaths were taking place.

Provision of human resources proved to be a far greater challenge relative to the

provision of infrastructure.

TNHSP contributed to CEmONCs through construction of maternity blocks, supporting

certification, monitoring and evaluation and through training programs.

The maternal mortality rate in Tamil Nadu has plummeted to half from 2007-08 to 2014-

15 reflecting the success of intervention.

Concern that “at high risk mother camps” take doctors away from secondary and tertiary

care facilities and it leads to shortage of doctors at those centers.

Fluctuations in specialist doctors and in posting staff nurses at CEmONCs are a

significant impediment to service delivery.

Revised training methodology encompassing consolidated and comprehensive training

for staff nurses and doctors, and scaling-up of training for the paramedical workers would

help.

Protocols developed for antenatal and neonatal care and extensive training provided to

doctors and staff nurses, but more needs to be done.

Interventions to reduce the IMR and MMR such as the establishment of CEmONCs

within 30 minutes reach, CEmONC PHC at a rate of one per block, auditing of every

maternal death enabling the identification of the circumstances leading to the death, and

establishment of 24x7 delivery centers in all PHCs were effective.

CEmONCs’ reach to tribal areas was ensured by extending 20 tribal mobile medical

units, birth waiting room in 17 PHCs in the foothills of tribal villages, provision of

feeding and dietary charges for 7 days for AN mothers and an attender in 34 tribal PHCs

and training/placement of 2,650 ASHA workers in 15 tribal/ hard to reach districts. These

interventions helped increase access to health care by tribal populations.

Need for expediting the process of filling up the vacant posts, identification of the

mentors in maternity wings for continuation of quality of care, revision of the training

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methodology to encompass a consolidated and comprehensive approach and replicating

the team approach.

HMIS

Prior to the HMIS, no real time data was available, evidence based program management

was stalled, retrieval of old manual records was ineffective and time consuming.

Human resource constraint needs addressing as the entire program is handled by 5

medical officers with the help of one ELCOT Deputy Manager.

Ways needs to be found to improve receptivity by hospital staff, connectivity and server

stabilization, and basic computer knowledge.

To augment and expedite the standardization, there should be mapping of existing

process and rationalization of input forms.

To minimize fragmentation of vendors, efforts are needs to ideally have single vendor for

IT infrastructure.

Bank contributed immensely in the implementation of HMIS by providing key inputs and

support in defining the functional requirements of different modules, supporting the

capacity building process, promoting collaboration with non- governmental sectors and

external experts at different stages of application development, and in the adoption of the

quality assurance mechanism.

Next actions should include: bringing down the number of vendors, recruiting project

management from within the TNHSP team, retaining the HMIS team until the system

reaches the self-sustainable level, taking stock of the Phase I inventory and starting to

plan replacement of IT equipment’s during phase 1 implementation, and immediately

starting the procurement process of System Integrator.

Successful implementation of the College Management Information System was a

milestone in Tamil Nadu’s medical education. A strong IT team is now needed to handle

the CMS application where it will help the future generation.

Health care waste management (HCWM)

From a pilot program, the HCWM was up-scaled to 449 health facilities. Over 49,000

health staff were rained/retrained in Regional Training Centers.

Sustainable training and retraining of health staff at regular intervals was recommended.

Accreditation

The main objective of accreditation is to improve the quality of treatment and provide the

safety for patients and employees. The process helps to rectify the defects. Out of 46

hospitals taken up by the GoTN for accreditation, 15 hospitals are already in the final

stage of accreditation.

Quality in health care system

TNHSP immensely contributed to skills development in the health sector.

Development of an Infection Control and Waste Management System was a milestone

achievement.

Various manuals were prepared and published.

Quality of care indicators were developed and are being used to monitor the quality of

care prevailing in the hospitals.

73

TNHSP provided training to improve interpersonal communication.

ISMRs were introduced and are being prepared every month; data is used to also grade

hospitals.

Poison treatment centers were established.

Introduction of Quality Assurance System for laboratory investigations was introduced.

Introduction of a system for the rational use of medicines was introduced.

Ongoing attention is needed to change the mind-set of the Health Care providers for new

activities.

Reports prepared in the health sector need to be validated systematically.

Training on administrative procedures needs to be provided to the CMOs.

Increased recruitment of specialists and staff nurses is needed.

Universal health coverage

For policy makers, the ultimate goal is that all citizens have access to health care which is

the basis of Universal Health Coverage.

Focus should be on ensuring services to the bottom quintile of population as they suffer

the most.

The idea the Government of Kerala adopted was to identify top 20 percent of conditions

which constitute 80 percent of morbidity in the state (22 conditions were identified that

caused 70-80% of morbidity). In Kerala, government emphasized training of doctors to

manage the disease conditions, which causes 80 percent of morbidity, at the PHC level,

and to also ensure adequate supply of essential medicines including insulin and NCD

related drugs at the PHC level.

It was suggested that traditional institutions namely the health service centers (HSCs) and

ICDS centers need to be focused and further strengthened to sustain the gains made in

maternal and child health including immunization and family welfare, to strengthen the

capability of infectious diseases case management systems in secondary and tertiary

facilities, and consider making the insurance mechanism universal so that all facilities may

be able to generate adequate resources.

It was suggested that the Chief Minister’s Comprehensive Health Insurance Scheme can

be a tool to extend universal health care, perhaps by expanding the scheme to include

middle class, package of essential services and possibility of shifting towards primary care

and offering financial protection to the population.

End line studies

NCD interventions:

Patient exit survey showed a sharp increase from baseline in the proportion of patients

who received drugs for 30 days from PHCs (range of 40% in Theni to around 90% in

Villupuram).

A high proportion of patients also received dietary counselling from nurses and doctors at

the PHC level.

The proportion of patients who adhered to their drug regimen also increased.

As a result of NCD awareness interventions, a high percentage of individuals are aware of

the harmful effects of tobacco and salt.

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Recommendations: (i) Sustain diabetes and hypertension screening in the public sector and

support with adequate infrastructure and human resources. (ii) Improve cervical cancer

and breast cancer screenings through better awareness and improvements to the health

system. (iii) Strengthen follow-up mechanisms post-screening. (4) Ensure that NCD

nurses are posted in order to continue service delivery, and ensure availability of adequate

drugs for 30 days for patients. (5) Sustain induction and refresher trainings; with doctors,

focus on case management to improve prescription practices around achieving blood

pressure control and glycemic control, and on targeting organ complications; with nurses,

focus on screening/ counselling skills. (6) Develop patient-focused education programs for

diabetes and hypertension to improve treatment and adherence rates. (7) Utilize TV as key

information source during campaigns, and focus on obesity and physical activity,

importance of long-term treatment and adherence for patients, cancer screening, and other

important changes in behavior. (8) Actively involve health workers in awareness programs

and explore other innovative ways of engaging communities in behavior change

campaigns.

End line assessment of quality of care and patient satisfaction in the hospitals under the project:

Significant improvements from baseline to end line: (1) in infrastructure at the hospitals

(accessibility, power, water, and equipment), (2) in the availability of services, such as

laboratory services, pharmacy services, and emergency services, a reduction in time taken

to register, better conditions of wards and toilets, (3) a sharp increase in patient’s

engagement with IEC materials, (4) around half of health facility workers believed that

they would benefit from further training, and health workers felt that there could be an

improvement in their residential quarters, (5) health workers believed that there were

improvements in supervision and the frequency of staff meetings, (6) in the satisfaction

with infrastructure, staff behavior and treatment outcomes (however, in-patients appeared

more satisfied with services than out-patients), and (7) patients chose government

services due to their perceptions of good quality, affordability and accessibility,

availability. However, some study respondents expressed concerns with hospitals in some

districts regarding treatment outcomes, communication skills and dual practice of

doctors.

Recommendations included (i) improvements in the conditions of diagnostic services,

imaging services and facility vehicles, (ii) further sensitization of public regarding health

services offered by the health facility, such as NCD services, (iii) ensure good behaviour

of staff to public such as communication skills, particularly at registration, (iv) ensure

availability of water and soap in toilets and overall cleanliness of toilets, (v) reduce

waiting times by re-visiting registration process flowchart.

Evaluation of CEmONC and Tribal Health activities

Achievements of CEmONCs: (1) Overall reduction in the MMR from 109 to 68 in the

past 10 years, increases in LSCS and night-time LSCS, increases in institutional

deliveries and increases in treatment for pregnancy complications. (2) Increases in

maternal admissions and complicated maternal admissions. (3) Efficiency (utilization of

equipment) also improved - a sharp increase in the utilization of scans for

Obstetrics/Gynecology cases from 2011-2012 onwards, attributed to the supply of

equipment and training. (4) In terms of quality of care, high proportions of women

75

reported receiving antenatal care, having birth companions when eligible, having their

babies weighed at birth, and having access to NICU facilities when required. (5) In terms

of patient satisfaction, patients reported that the availability of free treatment was a

primary reason for selecting government facilities, followed by good quality of care.

Patients however reported that the provision of bed linens, the regular changing of sheets,

and the cleanliness of toilets were inadequate.

Achievements of tribal health initiatives: (1) Implementation of Mobile Outreach

Services, Counselling Services, the Bed Grant Program and the Sickle Cell Anemia to

improve access to health services. Patients reported an increase in lab visits, and

improvements in the quality of services. There has also been a sharp increase in patients

counselled through the Counselling Program. Responsibilities of these Counsellors have

also increased considerably. However, language was considered as major barrier for

availing services from the counsellors of other communities. The Sickle Cell Anemia

intervention seemed to have a strong impact, through increased awareness of disease

status and reported effectiveness of treatment. Patients also appeared satisfied with the

Bed Grant Programme, and a high proportion of patients reported using the facilities for

deliveries and ailments such as fever, headaches, etc.

Recommendations for CEmONCs: (1) Clean linen and regular changing of bed sheets for

new mothers and babies, and cleanliness of toilets for new mothers. (2) Availability of

blood transfusion services for all patients. (3) Consider connecting health workers at the

field level for effective monitoring of complicated cases. (4) Explore the use of effective

induction and acceleration of labor in order to bring down caesarian section rates, and

encourage vaginal delivery wherever possible. (5) Consider separate ICU for CEmONC

to handle the critical and high risk cases. (6) Examine whether inputs, such as human

resources and number of beds, are in line with the increase in patient demand for

CEmONC services. (7) Consider the use of staff exclusively focused on recordkeeping,

which would allow for nurses to spend more time on patient care. (8) Consider increasing

the posting of CEmONC trained MBBS doctors at CEmONC centers for more basic care,

so that specialists can focus on advanced cases. (9) Consider the use of a non-medical

team to follow up on referred cases and newborns (for at least one month post discharge).

(10) Medical doctors posted at PHCs should be adequately trained for early referral in

case of complicated deliveries.

Recommendations for tribal health care: (i) Mobile Outreach Services (MOS) should

include antenatal care, the full immunization schedule and reducing anemia among

adolescent girls. (ii) Increase awareness of program amongst doctors and paramedics, and

ensure the selection of NGOs based on performance and willingness to reach remote

areas. (iii) Explore the use of separate areas for counseling, provide periodic refreshers to

counselors, and provide rewards for good performance. (iv) Integrate the work of the

Counseling program with the MOS, and with other health workers such as Village Health

Nurses. (v) Continue Bed Grant Program given comfort of tribal communities in

accessing facilities run by organizations known to them/in their area. (vi) Expand

awareness programs for the Bed Grant Scheme to increase utilization. (vii) Consider

taking advantage of strong internet connectivity by developing online programs, and

uploading daily case reports.

Assessing the Training and Practices on Infection Control and Waste Management (ICWM)

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Observed 100% coverage of the ICWM initiative in all sampled hospitals, 95% training

coverage in sampled hospitals, increased practice of labelling of bins, increased

availability of storage room for waste, and improved knowledge levels on waste

segregation and use of personal protective equipment.

Infection control officers and infection control committees have been installed and are

operational.

Recommendations:

Examine continued use of needle destroyers.

Ensure that all hospitals obtain authorization and renew authorization with the State

Pollution Control Board.

In hilly areas, consider the use of deep burial facilities, in consultation with the State

Pollution Control Board.

Consider the use of online refresher courses on the management of bio-medical waste and

incorporate videos in the training.

The Regional Training Centres should conduct quarterly consolidation of pre- and post-

tests conducted, and TNHSP should provide regular feedback, through reviewing reports,

surprise visits and regular checks.

Staff should be repeatedly motivated by their managers to use protective gear.

Examine the considerable under-reporting of needle stick injuries at hospitals.

Ensure the availability of bio-medical waste storage rooms with clearly demarcated

spaces that are accessible by vehicles, and with separate exits for the waste collection.

Ensure that responsibilities and roles for Infection Control Officer are clearly defined,

and that these individuals are supported by the hospitals.

Public private partnerships Tamil Nadu Chief Minister’s Comprehensive Health Insurance Scheme

A four year old scheme, and provides financial protection to families earning less than Rs

72,000 per annum. Its execution entrusted to three TPAs: Vital Healthcare, MD India,

and Medi Assist India.

The program was recently extended to cover marginalized populations such as differently

abled persons, refugees from Sri Lanka, widow pensioners and old age pensioners.

It also provides treatment for highly technical procedures. Follow up procedures are also

covered by the scheme in case of certain major procedures, surgeries and treatments.

Health camps are conducted once a month to identify and register eligible patients.

Quality assurance measures include medical audits, standardized procedures, periodic

review of medical/technical guidelines by experts and constant vigilance to prevent

money collection from the beneficiaries.

Outsourcing of housekeeping services:

Because of poor sanitation services in government hospitals, housekeeping services were

outsourced to a competitively selected firm for four district government hospitals for two

years.

The exercise resulted in an improvement of physical cleanliness, better safety and crowd

regulations, and a rise in the satisfaction levels among patients and providers, as well

resulted in cost effectiveness for TNHSP.

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Key gaps in the pilot included variations in compliance among the facilities, unplanned

allocation of human resources, weak procedures used by the agency and improper

placement of security staff.

Based on overall positive results obtained from the pilot, TNHSP outsourced

housekeeping services for 48 hospitals. The scaled-up program included carrying out of

quality measures such as electronic reporting, biometric attendances for housekeeping

personnel, appointment of nodal officer and regular training of housekeeping personnel

and supervisors.

Weekly reviews were held of the vendor where compliance issues were sorted out.

TNHSP has derived following results from this outsourcing experience: cleaner hospitals,

cleaner toilets, proper biomedical waste management, proper parking of vehicles within

hospital premises, zero theft incidences involving hospital goods, and improvement in the

aesthetic appearance of the hospitals.

Following issues have emerged: frequent attrition of housekeeping personnel, carrying

out personal work of providers during hospital duty hours, insufficient use of chemicals,

lesser use of modern equipment, and variation of wages among the districts. These issues

are being sorted out on an ongoing basis with the contractor.

There were three additional presentations under the PPP:

Leveraging PPP for technology & innovations (emergency ambulance services)

Free hearse service

Impact of STEMI and need for upscaling

Tribal health

Secretary, Nilgiris Adivasi Welfare Association (NAWA) described the range of

programs available to tribal populations, including mobile outreach and the Sickle Cell

Anemia Interventions.

Discussed the innovative use of retired health workers given difficulties in recruiting

health personnel to hill areas.

Concluded that PPPs in partnership through NGOs in Tribal Health is cost effective and

result oriented.

Non Communicable Diseases Scaling up of Non-communicable diseases intervention program:

A large scale program covering four NCDs (hypertension, diabetes, cervical cancer and

breast cancer) throughout the state was first of its kind in the entire country.

Key lessons learnt from the NCD pilots that informed the scaled up program were: (a)

ensure dedicated human resources, (b) ensure uninterrupted supply of reagents and drugs

with additional funding, (c) ensure maintenance of equipment, (d) carry out periodic

reorientation of staffs, (e) ensure follow up of patients with suspected cancers on

screening, and (f) improve the data quality and analysis and corrections of reports at the

district level.

NCD program was carried out in coordination with various departments including the

educational department, rural development department, labor department, ESI and

municipal administration and corporation.

78

Self-help group women were sensitized on NCDs and were encouraged to go for

screening in collaboration with the rural development department.

Major challenges during implementation were: (1) Human resources and capacity

building issues, (2) Structural issues - Identifying space for conducting procedures and

privacy for women, (3) Data issues - HMIS issues in PHCs, (4) Procedural/protocol

issues, (5) Social issues, (6) Budget issues, (7) Procurement cum logistic issues, (8)

Administrative issues, (9) Integration of levels of health care, and (10) Follow up issues.

Recommendations:

Outsourcing of Human resources to overcome the attrition of NCD staffs.

Periodic training for addressing knowledge gaps and skills.

Use of the Chief Minister’s Insurance Scheme for diagnostic and treatment services

and conducting outreach programs.

Strengthening IEC activities and sensitizing self-help groups.

Frequent meetings between NCD team and TCS, inspections and video conferencing.

Display boards for beneficiaries to inform the services available.

Comprehensive exit plan to sustain the program through (NHM- NPCDCS).

Implementation challenges and resolution in the NCD Program (TNHSP): Experience from

concurrent evaluation

Major challenges (input indicators): staff nurses were posted in other departments,

inadequate lab technicians, delay in procurement of equipment, not prescribing the

available drugs for 30 days due to fear of stock-outs, challenges in implementing HMIS

due to lack of computers in NCD clinics etc.

Major challenges (process indicators): statistics were shown based on the total number

of people screened for hypertension and diabetes in phase 1 districts of Tamil Nadu from

October 2012 to September 2013 and the average follow up visits of those screened

positive for hypertension and diabetes from October 2013 to August 2014

Major challenges (cancer screening): inadequate trained nurses, high false negatives,

lack of involvement of health workers in follow ups.

Other challenges (data usage): poor quality data generated from the facilities, time delay

in receiving the data from all facilities, poor adherence to registers/ reporting formats.

Challenges (patients’ perspective): long waiting time in the facility, frequent visits for

drugs and low awareness regarding the need for long term treatment.

Despite these challenges, the overall program was satisfactory because of strong political

and administrative will, dedicated program managers at state/ district level, rolling out

NCD program in all institutions across the state, uninterrupted and good quality drugs,

NCD awareness messages reached the remote areas with the help of dedicated NCD

nurses and highly motivated doctors.

Recommendations:

Train staff nurses to collect/analyze the lab samples.

Ensure availability of adequate stock of NCD drugs.

Access to computers to NCD nurses in the PHCs.

Train doctors to stick on to the protocols to improve adherence.

Purchase of consumables at the local level.

Incentives for the VHN who take women to hospitals for diagnostic work up.

79

Weekly report, monthly data analysis and shared state level summary to ensure good

quality data.

Ensuring patient adherence in hypertension and diabetes

Many people have been successfully screened for Hypertension, Diabetes, Cancer cervix

and Cancer breast and the present approach has reached a point of saturation.

There is a need to reach the public through the private sector and missing follow ups at

present is a major challenge (missed monthly follow ups, non-adherence of daily dose

drugs, unawareness of the monthly, half-yearly and annual checkups, difficulty in

identifying the beneficiary and in data/ tracking). Impact of non-adherence (extent to

which a person’s behavior- taking medication, following a diet or making healthy

lifestyle changes does not correspond with agreed upon recommendations from a health

care provider) leads to significant treatment failures, costly second line management,

increase in cardio vascular hospitalization and increased CVD mortality. Adherence can

be improved by a SIMPLE strategy -- Simplify the regimen, Impart knowledge, Modify

patient’s beliefs and behavior, Provide communication and Trust, Leave the bias and

evaluate the adherence.

Under the current NCD program, patients are tracked by the NCD staff nurses, the

positive individuals’ list is shared with the Village Health Nurse for tracking them in the

field, and online tracking is also done with the help of HMIS. Incentives are provided to

the NCD staff and VHNs for tracking patients. Training is given for the staff/ Medical

Officers on how to use the HMIS platform and on updating the entries

Recommendations:

Need for daily mobile based alerts/SMS.

Train the patients as the “front line workers” and create a patient support group.

Electronic tracking through mobile apps.

Involvement of private sector and collaboration with health related sectors like

nutrition, education, food safety, local bodies etc.

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Implementation Completion Review Workshop with Stakeholders, August 28-29, 2015,

Chennai - List of Invitees Name Title, Agency

Mr. Bhaskar Dasgupta Director (MI Division), Department of Economic Affairs,

Ministry of Finance, GOI

Dr. Manivannan Deputy Drug Controller of India, Central Drug Standards

Control Organization, South zone, GoI

Dr. C. Vijayabaskar Hon’ble Minister for Health, GoTN

Dr. Girija Vaidyanathan,

I.A.S.

Commissioner for Land Acquisition, Former Health Secretary

& Mission Director, NHM, GoTN

Mr. K. Shanmugam, I.A.S. Principal Secretary, Finance, GoTN

Dr. J. Radhakrishnan, I.A.S. Health Secretary, GoTN

Mr. P.W.C. Davidar, I.A.S. P & AR Secretary, Former Project Director, TNHSP.

Dr. S. Vijayakumar, I.A.S. Secretary, Animal Husbandry, Dairy and Fisheries, Former

Project Director, TNHSP.

Mr. Pankaj Kumar Bansal,

I.A.S.

Managing Director, Chennai Metro Rail Limited, Chennai,

Former Project Director, TNHSP.

Mr. M. S. Shanmugam, I.A.S. Joint Secretary and Additional Secretary to Government,

Industries Department, Former Project Director, TNHSP.

Dr. K. Elangovan, I.A.S. Secretary to Government, Health and Family Welfare

Department, Government of Kerala

Dr. Himanshu Bhushan Director & Head, PHA Division, NHSRC, Delhi.

Mr. Prasanth Subrahamanian Sr. Consultant, PHA Division, NHSRC, Delhi.

Dr. Bontha V Babu Senior Scientist, ICMR

Dr. Harsh Sharma Additional Project Director, UP Health Systems Project

Dr. B. K. Verma Assistant Director, UP Health Systems Project

Dr. Thiru. S. Ramakrishanan Advisor, NISG , Former Director General, C DAC

Dr. V. R.Muraleedharan Professor, Department of Humanities and Social Sciences. IIT

Madras

Dr. N. Devadasan President, IPHI, Bengaluru

Director and officials of Medical and Rural Health Services

Director of Medical Education and key Officials

Director and officials Public Health and Preventive Medicine

National Institute of Epidemiology (ICMR), Chennai

Vice-Chancellor, Tamil Nadu Dr. M.G.R. Medical University

Deans of Medical colleges and Hospitals (20)

Joint Directors of Health Services of all Districts (31)

Deputy Directors, Health Services -all 42 Health Unit Districts

District Project Management Coordinators of all Districts (31)

Director of Drug Control and key Officials

Commissioner of Indian Medicine and his key Officials

Officials from Director of Family Welfare

Officials from National Rural Health Mission, Tamil Nadu

Officials from Director of Medical and Rural Health Services

Officials from Tamil Nadu Medical Services Corporation Ltd.

Officials from Tamil Nadu AIDS Control Society

Officials from Anna Institute of Management

Professor of Medicine, Poison Treatment Centre, Madras

Medical College

Professor of Cardiology, Stanley Medical College, Chennai

81

Professors from Institute of Obstetrics & Gynaecology, KG

Hospital, RSRM Hospital and Institute of Child Health.

National Institute of Epidemiology (ICMR), Chennai

Dr.Ajith Mullasari, Director, Dept. of Cardiology, Madras

Medical Mission

Officials from Public Works Department

Officials from Electronics Corporation of Tamil Nadu

Principals of Public Heath Training Centers (2)

Nodal Officers of Regional Training Centers for ICWM (9)

M/s. Krystal Integrated Services Private Ltd, Mumbai

Officials from Tata Consultancy Services

Officials from Accenture Services Private Ltd.

Tribal Development NGOs (4)

108 Emergency Management Services – EMRI Officials

Indian Red Cross Society (IRCS), Tamil Nadu State Branch

Officials from United India Insurance Company and Third

Party Administrators, M/s Medi India, Medi Assist and Vidal

Officials from Tamil Nadu Corporation for Women

Development

Officials from Sarva Shiksha Abhiyan

Officials from Bharat Sanchar Nigam Limited (BSNL)

Officials from Cancer Institute, Adyar

Officials from Tamil Nadu Health Systems Project (TNHSP)

Former Officials of TNHSP including Finance Officers who

worked during the various phases of the Project spanning

planning stage, initial implementation period, launching of

pilot schemes, scaling up & so on.

Consultants hired for conducting evaluation studies of various

project activities during the entire Project period

Certain Vendors who have supplied equipment and electronic

items

Hospital Superintendents, Chief Medical Officers, Nodal

Officers & Assistant Nodal Officers for Accreditation from

Government Hospitals Tambaram, Cuddalore, Hosur, Erode,

Manaparai, & Aruppukottai

Ms. Sai Subashri Raghavan Solidarity and Action Against The HIV Infection in India

Dr. Varun Goyal Solidarity and Action Against The HIV Infection in India

Dr. Bushra Binte Alam Task Team Leader, TNHSP, World Bank

Dr. Preeti Kudesia Former Task Team Leader, TNHSP, World Bank

Dr. Ramesh Govindaraj Lead Health Specialist, World Bank

Ms. Sangeeta Carol Pinto Operations Officer, World Bank

Mr. Atin Rastogi Procurement Specialist, World Bank

Mr. Rohit Gawri I.T. Specialist, World Bank

Mr. Owen Smith Senior Economist, World Bank

Ms. Shreelata Rao Sheshadri Social Development Consultant, World Bank

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Annex 7. Summary of Borrower's ICR

Project Implementation

The project met its development objectives as is evidenced in its achieving all agreed results

from the original and additional financing period.

Component I Increasing Access to and Utilization of Health Services

1. Subcomponent 1 (Reduction of Maternal and neonatal mortality) increased the number of

complicated maternal admissions, number of ultra-sonograms, number of blood transfusions,

number of night caesareans and reduced referral outs from hospitals. The MMR declined

from 111 to 79 during the period 2004 to 2013 and the IMR from 37 to 21 during the period

2005 to 2013.

2. Subcomponent 2 (Improving Tribal Health) increased access to health care for the Tribal

population through the provision of mobile outreach health services, sickle cell anemia

intervention program, bed grant scheme for NGO-run hospitals in Tribal areas and Tribal

patients’ counselors in health facilities.

3. Subcomponent 3 (facilitating use of hospitals by the poor and the disadvantaged) posted a

total of 492 Patient Counselors in CEmONCs (Comprehensive emergency Obstetric and

Newborn Care) and hospitals located in the Tsunami affected districts. The counselors

guided patients and counseled them on preventive and promotive health behaviors. However,

their services were discontinued from October 2011. Ambulance Services with 700+

ambulances were established to provide emergency transportation in the state. A fleet of 63

mortuary vans provided free hearse services in state. Housekeeping services in 48 large

government hospitals and regional diagnostic laboratories in five district headquarters

hospitals were outsourced as a PPP model.

Component II Developing Effective models to Combat Non Communicable Diseases and

Accidents

4. Subcomponent 1 (Health Promotion). Worksite, school based and community based

interventions were rolled out to promote healthy lifestyles in support of the NCD program.

More than 50% of the eligible state population has been sensitized on risk factors of NCDs

and counseled on healthy life styles. The behavior change communication activities resulted

in an increased number of people accessing the health facilities as evidenced from the end

line survey reports for CEmONCs, Tribal Health and NCD Programs.

5. Subcomponent 2 Pilot testing and state-wide scale up of Non Communicable Diseases (NCD)

control directly benefitted an increased number of persons who were screened for

hypertension, diabetes, and cancers of the breast and cervix. All screened positive patients

were offered treatment preventing complications like stroke, myocardial infarction, kidney

failures, full blown cancers etc.

6. Subcomponent 3 was dropped to prevent duplication of interventions carried out by the

World Bank funded road sector project in Tamil Nadu. A Helmet usage survey in ten major

cities was conducted for ten months. A workshop on Road Traffic Accidents Prevention and

trauma care was conducted in 2006. Dedicated ‘Poison Treatment Centers’ were set up in 66

secondary care hospitals, in addition to such centers in all medical College Hospitals.

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Component III Building Capacity for Oversight and Management of the Health System

7. Subcomponent 1 Monitoring and Evaluation developed and successfully deployed a

comprehensive Health Management Information System across the entire public health

system in the state to facilitate management of hospital functions and public health

management. Staff were trained in the use of the system, and a helpdesk was set up to

provide both backend and user support.

8. Subcomponent 2 (Improving quality of care) A set of quality care indicators were introduced

and health care providers trained on its use. Monthly reports were collected and feedback to

the hospitals was provided after analysis, this resulted in a marked improvement in the

performance and quality of activities in the hospitals. Quality was further improved by

institutionalizing quality improvement circles in project facilities. Several protocols,

guidelines and capacity strengthening programs were initiated under the project. Twelve

large government hospitals secured accreditation from the National Board of Accreditation

for Hospitals.

9. Subcomponent 3 (Health care Waste Management) Government of Tamil Nadu developed

and implemented an integrated infection control and waste management plan with

operational procedures, standardized protocols and training modules to institutionalize a

comprehensive Infection Control and Waste Management system in all Government Health

Institutions in Tamil Nadu.

10. Subcomponent 4. Strategy Development and Implementation consists of (i) Establishing a

Strategic Planning Unit. The Strategic Planning Cell was established within the Project

Management Unit as a think tank for the project and to undertake studies and policy research

for improving the efficiency and effectiveness of the Health Systems. (ii) Establishing

Public-Private Partnership (PPP) wing for fruitful partnerships with all non-governmental

stakeholders in Health. (iii) Conducting a Health Insurance Pilot. The Project Implementation

Plan had proposed a pilot community based Health insurance scheme. However the

Government of Tamil Nadu implemented a Health insurance scheme with their own budget

from 2009. Hence, while financing for this activity was no longer supported by project,

administration of the scheme was done by TNHSP. (iv) Strengthening Project Management.

A four tier management structure was created with (a) State Empowered Committee; (b)

Project Steering Committee; (c) Project Management Unit and (d) District Project

Management Unit.

Component IV Maximizing the Efficiency of the Public Sector to deliver essential services

11. Subcomponent 1 Rationalization of Secondary care facilities was achieved by supporting

works at 225 project facilities, and CEmONCs at eight Government Medical Colleges.

Necessary infrastructure and equipment was also provided to all project hospitals based on

detailed facility surveys and agreed criteria.

12. Subcomponent 2 Rationalizing of equipment was achieved with the provision of equipment

and establishment of systems to maintain and manage these through a cadre of bio-medical

engineers. This enhanced the provision of services, reduced referral outs and resulted in

improved patient satisfaction.

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13. Subcomponent 3 Human Resource Planning & Development involved training as the core

activity. Training for specialists and paramedical staff for CEmONCs, tribal counselors,

specialists and paramedical staff for deployment of NCD screening and treatment program,

all clinical and administrative staff in the public health system in Health Management

Information Systems, all staff in public health institutions in the state on Infection Control

and Waste Management, staff of project supported facilities in Quality of Care; bio-medical

engineers in equipment maintenance and management; as well as Human Resource

Development was undertaken in the project. Training modules were developed and feedback

obtained from the trainees on the quality and usefulness of the program. This was the first

time in the history of Health Department that such a massive training program on diverse

subjects to improve health care service delivery was undertaken. This improved the

performance of the health care providers.

14. Subcomponent 4 Enhancing Management of Public Facilities. The project successfully

improved the management of project hospitals through (a) provision of hospital management

training to doctors, ministerial staff and nurses (b) enhancing financial powers of the chief

medical officers for condemnation (c) reviewing monthly performance reports from HMIS

for all project hospitals (d) grading of hospitals into A,B,C & D categories based on

performance and providing support to C & D categories for improving performance (e)

periodic inspections and reviews of the hospitals (f) medical and prescription audits; and (g)

computerized inventory management of stores.

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Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders

NA

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Annex 9. Details on NSS 2004 and NSS 2014 Data on Access and utilization of health

services by poorest 40% and scheduled tribe (ST) populations in Tamil Nadu

The important project goal of improving access and utilization of health services by poor,

disadvantaged and tribal groups was measured as changes among the (a) poorest 40% of the

population (bottom two quintiles) and (b) Scheduled Tribes in:

i. Proportion of population reporting ailment in last 15 days

ii. Percentage of those reporting illness accessing any form of care

iii. Number of hospitalization cases per 1000 in (a) the private sector and (b) public sector.

Data Source and Sample

Data from two nationally representative surveys conducted by the National Sample Survey

Organization (NSSO) is used to understand the access and utilization of health services by poor

and tribal groups:

Survey on Morbidity and Health care, NSS 60th round (January - June 2004)

Survey on Social Consumption: Health, NSS 71st round (January - June 2014)

Table 1: Description of sample size for Tamil Nadu, NSS 2004 and 2014

Sample households Sample persons

Sample persons

hospitalized in last 365

days

Sample persons

reporting any ailment

in last 15 days

NSS 2004 Total ST Total ST Total ST Total ST

Rural 2540 63 10348 247 1090 22 1100 5

Urban 2599 15 10946 56 1104 5 1255 1

All 5139 78 21294 303 2194 27 2355 6

NSS 2014 Total ST Total ST Total ST Total ST

Rural 1960 45 8237 197 1604 31 1288 19

Urban 1957 10 7853 43 1588 5 1657 8

All 3917 55 16090 240 3192 36 2945 27

Results

Indicator 1: Proportion of persons reporting ailment in last 15 days

Table 2 reports the proportion of persons reporting an ailment24, measured as the number of

living persons reporting ailment (per 1000 persons) during 15-day reference period by different

background characteristics for 2004 and 2014. For the State as a whole, in 2004, 9.4 percent

individuals have reported any ailment during the reference period of last 15 days and this has

increased to 16.5 percent in 2014.

24 Due to the change in coverage and difference in concepts and definitions in some important parameters in the two

rounds, the results of NSS 71st round are not strictly comparable with the results of NSS 60th round. This is

applicable to the indicator of persons reporting ailment in last 15 days (see Annexure 1 for details).

87

Table 2: Reporting of any ailment in last 15 days by social group and wealth quintile in

Tamil Nadu, NSS 2004 and 2014

NSS 2004 NSS 2014

Background characteristics % ailing % ailing

Place of residence

Rural 9.5 14.6

Urban 9.6 18.4

Social group

Scheduled Tribe (ST) 0.8 10.3

Scheduled Caste (SC) 9.1 13.1

Other backward classes (OBC) 10.0 17.3

Others 8.6 30.7

MPCE Quintiles

Lowest 8.2 12.5

Second 8.8 14.0

Third 8.0 15.5

Fourth 12.1 18.3

Highest 10.9 22.8

MPCE group

Lower 40% 8.5 13.2

Upper 60% 10.2 18.7

All 9.5 16.5 Note: MPCE – monthly per capita consumption expenditure information as available in the NSS 2004 and NSS

2014 surveys. The MPCE quintiles are constructed using the MPCE distribution of all households of the State (rural

+ urban) as reference distribution.

In 2004, around 0.8 per cent of ST persons have reported any ailment and in 2014 this has

increased to 10.3 per cent. It may be noted that the sample size of ST persons (see Table 1) is

smaller than other groups because of its relatively low share of 1.1 percent in the State’s total

population (as per Census of India, 2011).

The reporting of ailments is noted to vary across quintiles of monthly per capita expenditure

(MPCE). In 2004, about 8.5 per cent of persons in the bottom two MPCE quintiles (poor 40 %)

reported of any ailment during the last 15 days whereas this proportion has increased to 13.2 per

cent in 2014. However, the reporting of ailments is higher among the richer 60% individuals in

both periods.

Indicator 2: Percentage of spells of ailment treated on medical advice in last 15 days

Table 3 reports the percentage of spells of ailment treated on medical advice during 15-day

reference period by different background characteristics for 2004 and 2014. For the State, in

2004, 81.3 percent spells of ailment reported during the reference period of last 15 days were

treated on medical advice. This proportion has increased to 97.3 percent in 2014 with

considerable narrowing of rural-urban differential.

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Table 3: Percentage of spells of ailment treated on medical advice by social group and

wealth quintile in Tamil Nadu, NSS 2004 and 2014

NSS 2004 NSS 2014

Background characteristics % treated % treated

Place of residence

Rural 78.4 96.5

Urban 86.6 98.0

Social group




Others 90.8 100.0

MPCE Quintiles

Lowest 76.1 98.5

Second 75.9 96.6

Third 79.5 96.1

Fourth 81.6 99.2

Highest 90.4 97.0

MPCE group

Lower 40% 76.0 97.5

Upper 60% 84.2 97.3

All 81.3 97.3 Note: MPCE – monthly per capita consumption expenditure information as available in the NSS 2004 and NSS 2014

surveys. The MPCE quintiles are constructed using the MPCE distribution of all households of the State (rural +

urban) as reference distribution.

In 2004, 96 per cent of spells of ailment among ST persons are reportedly treated, in 2014 it was

93.3 per cent. The proportion of ailments treated during 2014 is lower among STs than the

estimates for other social groups. It may be noted that the proportion of ailments treated among

STs in 2004 is estimated to be much higher than other social groups but this may be affected due

to small sample (see Table 1).

In 2004, there was a clear income-gradient in treatment of ailments with considerable

disadvantages for poor individuals. However, the estimates for 2014 reveal significant reduction

in rich-poor gap in treatment seeking for reports of ailment. In 2004 about 76 per cent cases of

ailments among the poorer 40% individuals were treated on medical advice and this proportion

has significantly increased to 97.5 per cent in 2014. The bridging of gap in treatment seeking for

ailments both across social groups and across income class emerges as a noteworthy feature of

the Tamil Nadu health system.

Indicator 3a: Cases of hospitalization per 1000 persons during the last 365 days

Table 4 reports the number of hospitalization cases per 1000 persons during the 365-day

reference period by different background characteristics for 2004 and 2014. For the State, in

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2004, 41.9 cases of hospitalization per 1000 persons is reported during the reference period of

last 365 days. This proportion has increased to 56.2 per 1000 persons in 2014 but there is an

increasing rural-urban differential in hospitalization cases.

Table 4: Cases of hospitalized per 1000 persons during the last 365 days by social group

and wealth quintile in Tamil Nadu, NSS 2004 and 2014

NSS 2004 NSS 2014

Background characteristics Cases per 1000 Cases per 1000

Place of residence

Rural 42.0 53.7

Urban 41.8 58.8

Social group




Others 39.0 69.5

MPCE Quintiles

Lowest 29.1 43.2

Second 37.8 40.6

Third 46.4 57.1

Fourth 48.5 65.6

Highest 48.1 76.9

MPCE group

Lower 40% 33.4 41.9

Upper 60% 47.6 66.0

All 41.9 56.2 Note: MPCE – monthly per capita consumption expenditure information as available in the NSS 2004 and NSS 2014

surveys. The MPCE quintiles are constructed using the MPCE distribution of all households of the State (rural +

urban) as reference distribution.

In 2004, hospitalization among ST population was estimated to be 13.1 per 1000 persons. This

is significantly lower than other social groups including the SC population. Importantly, the

2014 survey finds only a small increase in the hospitalization cases among the ST population and

it is estimated to be 15.5 cases of hospitalization per 1000 persons. However, there is significant

increase in utilization of inpatient care among other social groups.

Similar to all treatment-seeking for ailments, it is noted that there is a significant income gradient

in utilization of hospital-based care and the rich-poor gap has increased between the two survey

periods. In 2004 about 33.4 hospitalization cases per 1000 persons were reported among the

poorest 40% population and 47.6 among the richer 60%. In 2014 hospitalization cases among

poor 40% have increased to 41.9 per 1000 whereas the same has increased to 66.0 hospitalization

cases per 1000 among the richer 60%. Clearly, the absolute differential among the rich and poor

in hospitalization cases has widened between 2004 and 2014.

90

Indicator 3b: distribution of hospitalization cases by type of hospital (public or private)

Table 5 presents the distribution of hospitalization cases by type of hospital (public and private

sector) and by different background characteristics for 2004 and 2014. For the State, in 2004,

39.5 per cent of the hospitalization cases were in public sector and 60.5 per cent cases were in

private hospitals. The proportion of hospitalization in private sector has increased in recent

years. In 2014, the share of public hospitals in total hospitalization is estimated to be 34.6 per

cent whereas the share of private hospitals has increased to 65.4 per cent.

Table 5: Per 1000 distribution of hospitalization cases during the last 365 days by type of

hospital and by social group and wealth quintile in Tamil Nadu, NSS 2004 and 2014

NSS 2004 NSS 2014

Background characteristics Public Private Total Public Private Total

Place of residence

Rural 40.8 59.2 100.0 40.4 59.6 100.0

Urban 37.2 62.8 100.0 29.3 70.7 100.0

Social group

Scheduled Tribe (ST) 54.7 45.3 100.0 54.5 45.5 100.0

Scheduled Caste (SC) 60.3 39.7 100.0 54.8 45.2 100.0

Other backward classes (OBC) 33.8 66.2 100.0 29.2 70.8 100.0

Others 21.5 78.5 100.0 10.0 90.0 100.0

MPCE Quintiles

Lowest 48.9 51.1 100.0 53.7 46.3 100.0

Second 51.9 48.1 100.0 54.2 45.8 100.0

Third 43.5 56.5 100.0 34.8 65.2 100.0

Fourth 37.9 62.1 100.0 31.9 68.1 100.0

Highest 21.8 78.2 100.0 15.0 85.0 100.0

MPCE group

Lower 40% 50.6 49.4 100.0 53.9 46.1 100.0

Upper 60% 34.4 65.6 100.0 26.3 73.7 100.0

All 39.5 60.5 100.0 34.6 65.4 100.0 Note: MPCE – monthly per capita consumption expenditure information as available in the NSS 2004 and NSS

2014 surveys. The MPCE quintiles are constructed using the MPCE distribution of all households of the State (rural

+ urban) as reference distribution.

There is a significant difference in type of hospital use by social groups. During both the survey

years 2004 and 2014 the ST population have reported relatively higher use of public hospitals

(55 percent) than private hospitals (45 percent). Moreover, the share of public and private sector

in hospitalization has not changed for the ST population whereas there is an increase in

utilization of private hospital care among OBCs and other non-SC/ST groups.

Use of type of hospital for inpatient care is associated with economic status of the individuals. In

2004, among the poor 40% population, about 51 per cent of the hospitalization cases was in

public sector whereas in 2014 this proportion has increased to 54 per cent. However, in case of

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richer 60 per cent population, the use of private sector has increased from 66 per cent in 2004 to

about 74 per cent in 2014. This has also led to a reduced share of public sector in total

hospitalization among the richer sections of the population.

Additional Details

In 2004, disabilities were included as ailments, but in 2014, pre-existing disabilities were not

included:

“[D]ue to the change in coverage and difference in concepts and definitions in respect of some

important parameters followed in the two rounds, the results of NSS 71st round are not strictly

comparable with the results of NSS 60th round. While making any comparison, these differences

may be taken into consideration. In the 60th round and earlier surveys on health, persons with

disabilities were regarded as ailing persons. In this round, pre-existing disabilities were

considered as chronic ailments provided they were under treatment for a month or more during

the reference period, but otherwise were not recorded as ailments. Disabilities acquired during

the reference period (that is, whose onset was within the reference period) were, however,

recorded as ailments” (NSSO 2015: pp.2).

The specific instructions for collection of information regarding ailment during last 15 days:

NSS 2004 Schedule 25.0 (Instructions to Field Staff, Chapter 5 page 122)

5.4.11 Column 11: whether ailing anytime during last 15 days: For each member of the

household, it will be enquired whether he/she suffered from any ailment anytime during last 15

days. Those who suffered from any ailment, code 1 will be recorded for them. Otherwise, code

2 will be recorded. It may be noted that some ailments may be treated (either as an inpatient of a

hospital or otherwise) and some untreated - both the cases should be considered here. For

detailed definition of ailments please see para 1.9.46 of Chapter One. It may be further noted that

a person under medication for an ailment during the reference period, whether he/she felt

sick or not, will be treated as ailing;

cases of complications arising during pregnancy or after childbirth will be considered as

ailment;

untreated injuries like cuts, burns, scald, bruise etc. of minor nature will not be covered,

if the informant does not consider them to be severe enough.

NSS 2014 Schedule 25.0 (Instructions to Field Staff, Vol.I: NSS 71st Round C-14)

3.4.12 Column 11: whether suffering from any chronic ailment (yes-1, no-2): To make

entries in column 11, the following questions should be asked for each household member:

Has the member been experiencing symptoms – persisting for more than one month on the

date of survey – indicating any problem caused by an ailment affecting any organ of the body?

[Exclusions: (i) Minor skin ailments (ii) Cases of headache, body ache, and minor gastric

discomfort after meals, even if of a long-standing nature, unless the patient insists that they cause

restriction of his/her activity. (iii) Disabilities such as congenital blindness.]

IF YES, then the member is suffering from a chronic ailment on the date of survey enter 1 in

col.11 Proceed to the next household member.

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IF NOT,

Has the member been taking a course of treatment on medical advice for a period of one

month or more and continuing as on the date of survey, aimed at alleviation of the symptoms of

any ailment? (Such treatment may have resulted in non-appearance of symptoms that would

otherwise have appeared, during a part of the last one month, or the entire month.) [No

exclusions. Treatment of pre-existing disabilities included.]

IF YES, then the member is suffering from a chronic ailment on the date of survey enter 1 in

col.11 Proceed to the next household member.

OTHERWISE, enter code 2 in col.11 Proceed to the next household member.

3.4.12.1 A chronic ailment may affect the stomach, lungs, nervous system, circulation system,

bones and joints, eye, ear, mouth or any other organ of the body. A list of symptoms associated

with various types of diseases and their codes is given in Table 3.1 (page C-16) for better

understanding and reference. This list is not, however, meant to be exhaustive.

3.4.13 Column 12: whether suffering from any other ailment any time during last 15 days

(yes-1, no-2): For each member (irrespective of entry in col.11) it will be asked:

During the last 15 days, did the member feel any problem relating to skin, head, eyes, ears, nose,

throat, arms, hands, chest, heart, stomach, liver, kidney, legs, feet or any other organ of the

body? If so, code 1 will be put in col.12, irrespective of how many such ailments the member has

suffered from. Note that

For the purpose of col.12, chronic ailments will be excluded.

A disability (e.g. vision loss) whose onset was during the last 15 days will be covered.

Ailments include injuries as well as illness, and may be treated or untreated.

A person who took medical advice or was under medication on medical advice for an

illness or injury at any time during the reference period, whether he/she felt sick or not,

must be considered as ailing (an exception is medicines given as part of routine pre-natal

or post-natal care in cases of normal pregnancy without complications).

Cases of complications arising during pregnancy or after childbirth will be considered as

ailment.

Each case of childbirth will be considered as a special case of ‘ailment’ (of the mother) in

this survey to facilitate collection of some important data on childbirth.

Untreated injuries like cuts, burns, scald, bruise etc. of minor nature (that is, not

considered severe by the informant) will not be covered.

Reference:

NSSO (2015) Key indicators of social consumption in India: Health, NSS 71st round, National

Sample Survey Office, Ministry of Statistics and Programme Implementation, Government of

India, New Delhi.

93

Annex 10. Tamil Nadu Key Indicators – National Family Health Surveys 2015 and 2005

94

95

96

Annex 11. List of Supporting Documents

Government of Tamil Nadu, 2015. Policy Note 2015-16 (Demand no.19) Health and

Family Welfare Department (comprehensive update on health and health services)

Government of Tamil Nadu, Health Policy, 2003

Project Appraisal document (PAD), Tamil Nadu Health Systems Project., November 17,

2004.

Development Credit Agreement (Tamil Nadu Health Systems Project) between India and

International Development Association, January 5, 2005

Project Agreement (Tamil Nadu Health Systems Project) between International

Development Association and State of Tamil Nadu. January 5, 2005.

Project Paper (PP) on Additional Financing, Tamil Nadu Health Systems Project, April 5,

2010

Financing Agreement (Additional Financing for Tamil Nadu Health Systems Project)

between India and International Development Association, July 6, 2010

Project Agreement (Additional Financing for Tamil Nadu Health Systems Project)

between International Development Association and State of Tamil Nadu. July 6, 2010.

Aide Memoires of all World Bank missions conducted under the project.

Implementation Status and Results (ISR) documents from the project.

Status Report on Project Activities from TNHSP for World Bank Missions under the

project, May 2015 and August 2015

Revised Results Monitoring Framework (updated as of September 15, 2015) from

TNHSP.

End Line Evaluation of Quality of Care, IPSOS for TNHSP, May 23,2015

End Line Evaluation of Patient Satisfaction Survey, IPSOS for TNHSP, July 31, 2015

End Line Study Report for Package A - Quality of Care, Synovate 2010 for TNHSP

End Line Study Report for Package A - Patient Satisfaction, Synovate 2010 for TNHSP

End Line Study Report for Package A –Health Care Waste Management, Synovate 2010

for TNHSP

Tamil Nadu Health Systems Project – A Milestone in Healthcare, DoHFW, May 2015

TNHSP, Program Implementation Plan for Additional financing, 2010-2013, May 2010

TNHSP, Summary of the Proceedings of the Implementation Completion Review

Workshop with Stakeholders held on August 28-29, 2015, Chennai

TNHSP, Implementation Completion Results Report, January 31, 2016, PMU, DoHFW

World Bank’s Country Partnership Strategy for India, 2013-2017

World Bank’s Country Strategy for India, 2009-2012

World Bank’s Country Strategy for India, 2005-2008. September 15, 2004. Report no.

29374-IN.

World Bank’s Strategy for Health, Nutrition and Population Results, 2007

Government of India, Ministry of Health and Family Welfare, National Family Health

Survey 4 2015-2016. State Fact Sheet, Tamil Nadu. International Institute for Population

Sciences, Mumbai, 2016.

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