World Bank Documentdocuments.worldbank.org/curated/en/... · 7/18/2016 · SHRDC State Health Data...
Transcript of World Bank Documentdocuments.worldbank.org/curated/en/... · 7/18/2016 · SHRDC State Health Data...
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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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i
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
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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
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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
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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
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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.
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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
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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
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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.
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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
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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.
Indicator 5: Original,
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
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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
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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
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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
Indicator 1: Original,
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.
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Indicator 2: Original
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
Date achieved April 2010 9/30/2013 3/31/2014
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
Date achieved April 2010 9/30/2013 9/30/2014
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
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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
Date achieved April 2010 9/30/2013 3/31/2014
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
Indicator 11: new at
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
Comments SURPASSED by 103% of target
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Indicator 12: new at
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
Comments SURPASSED by 110% of target
Indicator 13: new at
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.
Indicator 16: new at
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.
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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.
Indicator 18: new at
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+)
screened for hypertension
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+
screened for hypertension
(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.
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xviii
Indicator 19: new at
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
Indicator 22: New at
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.
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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.
Indicator 25: Original
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
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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.
Indicator 26: New at
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
Indicator 27: New at
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)
Indicator 28: New at
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
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xxi
Indicator 29: New at
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
Indicator 30: New at
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.
Indicator 31: New at
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
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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
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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.
Indicator 36: new at
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
6 10/18/2007 Satisfactory Moderately Satisfactory 18.98
7 04/09/2008 Satisfactory Satisfactory 22.80
8 10/09/2008 Satisfactory Satisfactory 29.54
9 03/23/2009 Satisfactory Moderately Satisfactory 42.93
10 09/18/2009 Satisfactory Moderately Satisfactory 63.64
11 04/21/2010 Satisfactory Moderately Satisfactory 88.24
12 05/14/2011 Satisfactory Satisfactory 113.87
13 06/06/2011 Satisfactory Satisfactory 113.87
14 02/09/2012 Satisfactory Satisfactory 135.03
15 09/12/2012 Satisfactory Satisfactory 145.13
16 04/27/2013 Satisfactory Satisfactory 166.22
17 08/17/2013 Satisfactory Satisfactory 170.88
18 01/15/2014 Satisfactory Satisfactory 178.05
19 07/30/2014 Satisfactory Satisfactory 186.77
20 10/06/2014 Satisfactory Satisfactory 186.77
21 12/15/2014 Satisfactory Satisfactory 195.33
22 06/16/2015 Satisfactory Satisfactory 199.45
23 09/02/2015 Satisfactory Satisfactory 207.67
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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.
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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))
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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.
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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.
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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
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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
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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.
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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;
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(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
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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
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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 hand- over
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.
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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).
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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.
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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.
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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.)
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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
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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.
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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.
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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
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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
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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
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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.
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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
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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.
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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).
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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
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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.
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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.
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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).
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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
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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
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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
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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.
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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.
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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
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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.
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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
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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.
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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.
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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
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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
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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
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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
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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.
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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.
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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)
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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
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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.
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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.
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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.
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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.
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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)
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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
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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
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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
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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,
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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.
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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.
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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.
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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
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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.
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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.
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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
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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%
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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.
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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.
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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.
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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
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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.
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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
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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.
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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.
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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
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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).
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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
Scheduled Tribe (ST) 96.2 93.3
Scheduled Caste (SC) 71.4 96.9
Other backward classes (OBC) 83.8 97.4
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
Scheduled Tribe (ST) 13.1 15.5
Scheduled Caste (SC) 39.8 55.7
Other backward classes (OBC) 43.6 57.4
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.
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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.
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Annex 10. Tamil Nadu Key Indicators – National Family Health Surveys 2015 and 2005
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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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MAP
I N S E R T
M A P
H E R E
AFTER APPROVAL BY SENIOR GLOBAL PRACTICE DIRECTOR
AN ORIGINAL MAP OBTAINED FROM GSD MAP DESIGN UNIT
SHOULD BE INSERTED
MANUALLY IN HARD COPY
BEFORE SENDING A FINAL ICR TO THE PRINT SHOP.
NOTE: To obtain a map, please contact
the GSD Map Design Unit (Ext. 31482)
A minimum of a one week turnaround is required