Environmental and Social Systems Assessment (ESSA) India: Tamil Nadu Health System Reform Program The World Bank i ABBREVIATIONS ANC Antenatal Care ASHA Accredited Social Health Activist BMW Bio-Medical Waste BMWM Bio-Medical Waste Management CMCHIS Chief Minister’s Comprehensive Health Insurance Scheme CPF Country Partnership Framework CPR Contraceptive Prevalence Rate CTF Common Treatment Facility DIMH Directorate of Indian Medicine and Homeopathy DLI Disbursement-Linked Indicator DME Directorate of Medical Education DMRHS Directorate of Medical and Rural Health Services DoF Department of Finance DoHFW Department of Health and Family Welfare DPH Directorate of Public Health ELCOT Electronics Corporation of Tamil Nadu EMS Emergency Medical Services ESSA Environmental and Social Systems Assessment ETP Effluent Treatment Plant FM Financial Management GDP Gross Domestic Product GoI Government of India GoTN Government of Tamil Nadu HDI Human Development Index HDR Human Development Report HMIS Health Management Information System MCH Maternal and Child Health MIS Management Information System MMR Maternal Mortality Ratio MoHFW Ministry of Health and Family Welfare NABH National Accreditation Board for Hospitals & Healthcare Providers NCD Noncommunicable Diseases NFHS National Family Health Survey NHM National Health Mission NITI National Institution for Transforming India NQAS National Quality Assurance Standards OBC Other Backward castes PAP Program Action Plan PDO Project Development Objective PforR Program for Results PHC Primary Health Center PMU Program Management Unit PSC Program Steering Committee ii PWD Public Works Department RCH Reproductive and Child Health RMO Resident Medical Officer RTI Right to Information SBCC Social and Behavior Change Communication SC Scheduled Castes ST Scheduled Tribes TNFSDA Tamil Nadu Food Safety and Drug Administration TNHSP Tamil Nadu Health Systems Project TNHSRP Tamil Nadu Health System Reform Project iii Table of Content Executive Summary .................................................................................................................. vi 1 Introduction ........................................................................................................................ 1 1.1 The State Context ........................................................................................................ 1 1.2 The Health Sector in Tamil Nadu ............................................................................... 2 2. PROGRAM DESCRIPTION ............................................................................................. 2 2.1 Programme Development Objectives AND INDICATORS ........................................... 3 2.2 Program Scope ................................................................................................................. 4 2.3 Geographic Scope of the Program ................................................................................... 5 3 Environmental and Social System Assessment (ESSA) .................................................... 5 3.1 Introduction to ESSA .................................................................................................. 5 3.2 Methodology Adopted for ESSA ................................................................................ 6 3.3 Consultations and Disclosure ...................................................................................... 7 4 Institutional Assessment .................................................................................................... 7 4.1 Borrower’s Past Experience in Managing Environmental and Social Risks .............. 7 4.2 Assessment of Institutional Roles and Capacity Gaps ................................................ 8 4.2.2 Key findings of the institutional assessment on environment and social aspects 13 5 Legal and Regulatory Framework applicable to the Program ......................................... 15 5.1 Environmental and Social Laws, Regulations and Policies ...................................... 15 6 Assessment of Environment and Social Management Systems ...................................... 21 6.1 Assessment of Environment Management Systems ................................................. 21 6.1.1 Environmental management systems in State Programs ................................... 21 6.1.2 Potential Environmental Benefits ...................................................................... 21 6.1.3 Potential Environmental Opportunities.............................................................. 21 6.1.4 Potential Environmental Impacts ....................................................................... 22 6.1.5 Gaps and Risks in the Environmental System ................................................... 24 6.2 Assessment of Social Management Systems ............................................................ 24 6.2.1 Stakeholder Analysis ......................................................................................... 24 6.2.2 Key Social Issues and Concerns ........................................................................ 25 6.2.3 Gender Gap Assessment .................................................................................... 29 6.2.4 Key Social Impacts ............................................................................................ 35 iv 6.3 Key Risks and Gaps and Potential Measures to Align with ESSA Core Principles . 36 6.3.1 Key issues concerning Institutional Strengthening ............................................ 39 7 Assessment of Program Consistency with Core Principles in the Policy on Program for Results Financing ..................................................................................................................... 40 7.1 Environment .............................................................................................................. 40 7.1.1 Core Principle 1. ................................................................................................ 40 7.1.2 Core Principle 2 ................................................................................................. 40 7.1.3 Core Principle 3 ................................................................................................. 40 7.2 Social ......................................................................................................................... 41 7.2.1 Core Principle 4 ................................................................................................. 41 7.2.2 Core Principle 5 ................................................................................................. 41 7.2.3 Core Principle 6 ................................................................................................. 41 8 Consultation and Disclosure ............................................................................................ 42 8.1 Consultation during the ESSA .................................................................................. 42 8.2 Disclosure and Consultation on the Draft ESSA ...................................................... 42 8.3 Disclosure of the Draft and Final ESSA Reports ...................................................... 42 8.4 Citizen Engagement and Grievance Redress Mechanism ......................................... 42 9 Conslusion and Recommendations .................................................................................. 44 9.1 Program Exclusions and Recommendations on Environmental Aspects.................. 44 9.2 Recommendations on Social Aspects ....................................................................... 44 9.3 ESSA’s Recommendations to Program Action Plan................................................. 45 ANNEX 1: SOCIAL SAFEGUARD SCREENING CHECK LIST........................................ 48 ANNEX 2: Minutes of essa disclosure and stakeholder consultation workshop – chennai – october 24, 2018....................................................................................................................... 50 v EXECUTIVE SUMMARY Health Sector in Tamil Nadu For a population of about 76 million, the State has a total bed strength of only 32,235 across 330 healthcare facilities under DMRHS, which likely to increase. The number of beds at private hospitals have not been quantified. Despite making good progress in maternal and child health outcomes, vaccination coverage has remained low at 70% for children between age of 12-23 months. The growth in Non-Communicable Diseases (NCD) is putting a dual health burden on the State and an increasing number of road accidents calls for improved pre- and post- hospitalization trauma care support. Overall, spending on the health is low at about 1% of the State’s GDP. Environmental and Social Systems Assessment The World Bank policy and directive on PforR financing requires an environmental and social system assessment (ESSA) of operations financed under the PforR instrument. Accordingly, an ESSA of operations to be financed under the Program was carried out to assess the adequacy of environmental and social systems at the state level in context of the Program boundary. The broad scope of the ESSA was to assess the extent to which the Program systems promote environmental and social sustainability; avoid, minimize, or mitigate adverse impacts on natural habitats and physical cultural resources; protect public and worker safety; manage land acquisition; consider issues related to indigenous peoples and vulnerable groups; and avoid social conflict. Further, it identified required actions for enhancing/strengthening the Program systems and mitigating potential environmental and social risks. The specific objectives of the ESSA included the following: (a) identify potential environmental and social benefits, risks, and impacts applicable to the Program interventions; (b) review the policy and legal framework related to management of environmental and social impacts of the Program interventions; (c) assess institutional capacity for environmental and social management systems within the Program system; (d) assess Program system performance with respect to the core principles of the PforR instrument and identify gaps, if any; and (e) describe actions to be taken to fill the gaps that will be used as inputs to the PAP. ESSA Methodology The ESSA primarily relied on desk review of existing information and data sources, complemented by primary data collection/assessment through consultations/ interviews/ discussions with key stakeholders and field visits to healthcare facilities to capture opinions, anecdotal evidence, functional knowledge, and concerns. The desk review focuses on understanding the existing policy, operational procedures, institutional capacity and implementation effectiveness relevant to the activities under the Program. The desk review also covered the legal and regulatory requirements including those on environmental conservation, pollution control, occupational health and public safety, building construction codes, social inclusion and transparency and accountability mechanism, and social and cultural aspects related to the Program, etc. The desk review included available documents, reports, data, websites etc. vi The primary data collection and assessment involves consultation/ discussion/ interviews with key stakeholders including the key departments/ agency including TNHSP, Directorate of Family Welfare (DFW), Directorate of Public Health and Preventive Medicine (DPH), Directorate of Medical and Rural Health Services (DMRHS), Tamil Nadu State Health Society (TNSHS) including key staff members from NHM, Directorate of Medical Education (DME), Social Welfare Department, and Land Administration Department. The Program design also benefited from the extensive consultation done under the earlier TNHSP project with tribal community in setting up agenda for tribal health Program and which included consultations with various NGOs working on tribal health issues, tribal community and their ‘sangams’, and field visits to tribal areas, and also various government departments including the Health, Tribal Welfare and Forest Departments etc.. Further comments, suggestions and areas that require strengthening was sought during the free and prior informed consultation with NGOs working on tribal health and member of tribal community both men and women during the stakeholder consultation on 24th October 2018 and were also being incorporated and integrated into the Program design. Applicability of the ESSA Core Principles Core Principle 1: Applicable Environmental and social management procedures and processes are designed to (a) promote environmental and social sustainability in the Program design; (b) avoid, minimize, or mitigate against adverse impacts; and (c) promote informed decision-making relating to a Program’s environmental and social effects Summary Findings: Certain interventions under the Program would require mitigation actions and sustainable approaches to better manage Program’s environmental effects. These include, among others: • Issues related to generation, collection, segregation, storage, transport, management and disposal of Biomedical, Solid and Hazardous wastes. This is particularly relevant for facilities in peri-urban and rural areas. • Reducing the risk of contracting infections within healthcare facilities. The upkeep, cleanliness and hygiene of public conveniences in several of the healthcare facilities is deficient and inadequate resulting in sub-optimal infection control. Core Principle 2: Applicable Environmental and social management procedures and processes are designed to avoid, minimize, or mitigate adverse impacts on natural habitats and physical cultural resources resulting from the Program Summary Findings: Whereas interventions proposed under the Program would not impact natural habitats and physical cultural resources, lack of pollution management infrastructure, particularly to treat and release effluents from large hospitals pose the risk of adversely impacting aquatic habitats. Core Principle 3: Applicable Environmental and social management procedures and processes are designed to protect public and worker safety against the potential risks associated with: (i) construction and/or operations of facilities or other operational practices under the Program; (ii) exposure to toxic chemicals, hazardous wastes, and other dangerous materials under the Program; and, (iii) reconstruction or rehabilitation of infrastructure located in areas prone to natural hazard vii Summary Findings: Certain interventions under the Program could expose healthcare providers and beneficiaries to risks associated with exposure to hazardous materials, infections, radiation as well as risks related to construction activities, personal safety etc. This would require integrating mitigation actions in the operational manuals, SOPs, procedures etc. These include, among others: • Improving occupational health and safety practices at healthcare facilities through infrastructure design, construction management, infection control, protocols for addressing accidental spills • Providing protective clothing and personal safety equipment, as required • Ensuring safe storage, segregation, transport and disposal of hazardous wastes Core Principle 4: Not Applicable Land acquisition and loss of access to natural resources are managed in a way that avoids or minimizes displacement, and affected people are assisted in improving, or at least restoring, their livelihoods and living standards. Screening will be conducted in health facilities where any repair, renovation and expansion is planned to avoid any adverse social impact. Summary Findings: There is no land acquisition and/ or resettlement is anticipated under the Program, as the Program does not support any major construction and it is limited to minor renovation and repairs of health facilities. Hence, it is unlikely that any additional land is required beyond the existing footprint of the health facility. Core Principle 5: Applicable Due consideration is given to cultural appropriateness of, and equitable access to, Program benefits giving special attention to rights and interests of Indigenous Peoples and to the needs or concerns of vulnerable groups Summary Findings: The Program further supports the ongoing culturally appropriate tribal health agenda of the state by enhancing the quality of health care across all districts and in addition attempting to bridge inequality in health care provision among the poorer and backward districts of the state through the Program Result Area #1 on quality of care, and #3 on equity. Core Principle 6: Not Applicable Avoid exacerbating social conflict, especially in fragile states, post-conflict areas, or areas subject to territorial disputes Summary Findings: The state has no conflict affected or territorial dispute area. The team does not expect any exclusion of any groups in terms of caste, religion, and/ or geography by the Program activities. In addition, the state has been considered as generally a peaceful state in India with rare incidence of any civil strife or communal violence. Key Findings of Institutional Assessment on Environment and Social Aspects • Management of Biomedical Waste. The primary environmental risks and impacts of the Program centers on the management of BMW generated at the healthcare facilities in the State. The previous Bank funded project built good capacity and made significant advances in management of BMW. The compliance with the provisions of the main regulatory instruments, the Bio-Medical Waste Management Rules, 2016 and the Bio- Medical Waste Management (Amendment) Rules, 2018, is generally adequate. Common Treatment Facilities (CTF) are regularly collecting wastes for disposal. However, no performance audits for the CTFs have been undertaken. Consumables, viii such as, colored bins and other required items at the healthcare facility levels are available and optimally used. • Management of other categories of healthcare wastes. These is limited institutional capacity to deal with other kinds of wastes generated at healthcare facilities, such as solid wastes, hazardous wastes, E-wastes and plastic wastes. These issues are gaining prominence and will require an integrated approach to manage all kinds of wastes. • There is good institutional capacity for addressing inequity, inclusion and gender issues of the health sector. With the implementation of earlier World Bank-supported Tamil Nadu Health Systems Project (TNHSP), TNHSP Society has experience in efficiently coordinating with other Directorate and societies under the health department and with other departments to implement the Program activities including addressing inequity, inclusion issues, gender issues and other social aspects. TNHSP had also coordinated the implementation of the Tribal Health program under the earlier Bank-supported project in an effective manner and helped mainstream it into the DOHFW’s program after the closure of the project. However, with the change in the financing instrument i.e. PforR, there is a need to further strengthen the inter- institutional coordination mechanism. Legal and Regulatory Framework • The provisions of the existing environmental legal and regulatory framework are adequate but require enabling institutional and technical capacity to comply with. While the provisions of the Biomedical Waste Management & Handling) Rules, 1998 – as amended up to March 2018 are being implemented, provisions of other relevant environmental Acts, such as, hazardous, solid, plastic and E-waste Rules 2016 require additional capacity building efforts. Efforts are required to improve the monitoring of the management of different kinds of wastes. • The existing legislative framework is adequate to ensure social sustainability of the protection of interest of marginalized and vulnerable population including the SC and ST population. It ensures (a) protection of the interest of SC and ST population, (b) non-discrimination based on religion, race, caste, and gender, and (c) transparency with right to information, (d) right to fair compensation in case of land acquisition. Tamil Nadu also has separate act for eviction of unauthorized occupants from public premises which defines the process, powers, nature of penalty and liabilities. Assessment of Environmental and Social Management Systems • No state level health policy that define clear goals and objectives to deal with the environmental issues of the health sector. The issue of growing loads of wastes generated from healthcare facilities, especially large hospitals, requires focused attention. Apart from management of biomedical wastes, other solid, hazardous, plastic and liquid wastes 1 are not managed adequately. The health sector is conspicuous in missing from the Tamil Nadu State Environment Policy 2017 which stresses on integrating environmental concerns in five development sectors. 1 Only 14 out of a total of 90 healthcare facilities with a bed strength of over 100 have Effluent Treatment Plans ix • Continuous education and training on biomedical waste management is lacking. Apart from inclusion of modules on BMW management in the formal medical education, there are inadequate opportunities for continuous training of medical staff. It is difficult to assess the level to which personal safety standards, especially when working with infectious diseases, chance needle pricks etc., are being adhered to. • The Program has low likelihood of any negative social impacts . The Tribal Health program initiated under the World Bank supported TNHSP during 2005-15 has been effectively mainstreamed into the department program after the closure of the project and includes regular activities such as provision of ASHAs in tribal/ difficult areas, creating birth waiting rooms in tribal PHCs and linking with 108 ambulances to ensure tribal mother reach the delivery point on time, running mobile medical units in tribal areas, placing of tribal counsellors in government hospital in tribal districts, strengthening emergency referral system from tribal PHCs, and screening of adolescent tribal children and unmarried school dropouts above the age of 14 in 30 selected tribal blocks in 13 Districts for early detection of Sickle Cell, Anaemia & Thalassemia which are common diseases among tribal population. • The key social issues identified are related to inequalities in health sector on account of maternal and child health (MCH) outcomes, and issues related to quality of health care provision. These are being addressed through quality of care and equity results areas of the Program. Though the program will be implemented across all districts in the state of Tamil Nadu, to address geographic disparities on account of MCH and quality related issues, special focus will be maintained in select nine priority districts which constitute the bottom quintile of the MCH indicators in the state and other poorer districts with relatively larger proportion of tribal population, and includes Virudhunagar, Thoothukkudi, Tirunelveli, Theni, Ramanathapuram, Ariyalur, The Nilgiris, Dharmapuri, and Tiruvannamalai districts. This also helps in the Program addressing the gender gaps with respect to reproductive health in the priority (low-performing) districts. In addition, addressing another gender concern by focusing on the specific disease concern of women (cervical and breast cancer) by the Program. Conclusion and Recommendations The ESSA concludes that the Program has moderate environmental and social risk. The Program risks on dealing with BMW are reasonably covered but will require efforts to address other environmental challenges emerging from the health sector. The institutional setup has the potential to develop required capacity to deal with the potential environmental risks and challenges. The Program has low likelihood of any negative social impacts. There is no land acquisition is anticipated as the Program does not support any major construction and it is limited to minor renovation and repairs. Hence, it is unlikely that any additional land is required beyond the existing footprint of the health facility. The result areas focus on quality of health care across the state and bridging inequalities in priority districts and bottom most quintile on MCH indicators and other poorer tribal districts. ESSA DLI/Program Actions The ESSA proposes the following DLI/Program Actions. x • DLI: Develop an Environment Strategy for the Health Sector in Tamil Nadu. The proposed environment strategy for Tamil Nadu will include provisions/ways to improve the efficiency of healthcare delivery by addressing issues such as waste management, resource efficiency, type-design of healthcare facilities, especially the wellness centers proposed by the State, effluent and hazardous pollution by expanding the pollution management set-up, particularly Effluent Treatment Plants, greenhouse gas emission footprint etc. The strategy will include an institutional capacity building plan, including a human resource plan and integration of healthcare waste management with the State’s HMIS. • Program Action 1: Introduce continuous refresher trainings on biomedical and other wastes management. Provide targeted training and refresher training for staff at all levels and cross all healthcare facilities in managing biomedical, hazardous, plastic and other solid wastes. • Program Action 2: Performance audits of CTFs. Carry out annual audit of CTFs, to assess the performance of BMW segregation, collection and transportation, performance of CTFs in line with the BMW Rules, 2016 and overall environment management of CTFs. xi Environmental and Social System Assessment Tamil Nadu Health System Reform Project 1 INTRODUCTION 1. Tamil Nadu ranks among the high-performing states in India with respect to human development as well as health index, attaining 3rd rank on the Human Development Index among all states in India (2014) and again 3rd rank among states on the NITI Aayog Health Index (2018). The Government of Tamil Nadu (GoTN) has made a concerted effort to strengthen public sector health service delivery, which is reflected as improved results in many areas. The earlier World bank supported TNHSP, a US$210 million project over 2005-2015 period, also contributed towards making significant improvements in maternal and child health services and enabled the GoTN to pilot several initiatives to address the growing burden of NCDs. While, there is overall improvements in health care delivery in many areas, with the proposed Program, GoTN wants to further strengthen management of NCDs, and to engage on a more advanced agenda with systems-based approach for improving the quality of health service delivery. 1.1 The State Context 2. Tamil Nadu is the sixth most populous state in India with 48 percent of the population residing in urban areas. Between 2000 and 2010, population grew by 15.6 percent, but the total fertility rate has declined from 2.2 to 1.6 in 2015-16. According to the 2011 Census of India, Scheduled Castes represent 20 percent of Tamil Nadu’s population, Schedul ed Tribes (ST) comprise 1.1 percent, Other Backward Castes (OBCs) form 68 percent, and others constitute 10.5 percent. There are 36 different tribes, present in almost all the districts, across 2860 villages located in 63 blocks of the state. The Nilgiris district has the highest percentage of STs (4.5%), particularly PVTG2s, has the lowest population overall as well as the lowest population density, followed by Dharmapuri district (4.2%). Most of the tribal communities are small in size and the exceptions are the Irulas and the Malaiali. Todas with a population of about 2000 and Kotas with a population of less than 500 are PVTGs. Although they are found across the state, their major presence is in the north, central and western parts of the state. Majority of the tribal population in Tamil Nadu live in hilly ranges viz., Eastern Ghats, Western Ghats and the discontinuous hill tracts adjoining the plains and the hills. 3. Tamil Nadu has experienced steady economic growth and poverty3 has declined considerably over the last few years. Tamil Nadu ranks among the high-performing states in India with respect to human development, attaining 3rd rank on the Human Development Index among all states in India (2014). This achievement is reflected in high literacy (80 percent) and vastly improved health outcomes. The Government of Tamil Nadu has set high standards for itself with the Vision 2023 document envisaging inclusive growth with 2 Particularly Vulnerable Tribal Groups 3 Around 12 percent in 2012 (World Bank estimates). 1 six-fold increase in per capita incomes in real terms to reach the level of current median income of the upper middle-income countries and also to attain a human development index comparable to that of the developed countries by 2023. 4. The State is comprised of 32 districts and 10 corporations. Based on the State’s Human Development Index, which is a composite measure of attainment in three core dimensions of well-being: education, health and income, the five worst-performing districts were: Thiruvarur (HDI of 0.568), Villupuram (0.561), Theni (0.539), Perambalur (0.447), and Ariyalur (0.282). In addition, Ramanathaparum and Virudhunagar districts have been included in NITI Aayog’s list of 115 aspirational districts in India, requiring substantial improvements. 1.2 The Health Sector in Tamil Nadu 5. For a population of about 76 million, the State has a total bed strength of only 32,235 across 330 healthcare facilities under DMRHS, which is likely to increase. The number of beds at private hospitals has not been quantified. Despite making good progress in maternal and child health outcomes, vaccination coverage has remained low at 70% for children between age of 12-23 months. The growth in Non-Communicable Diseases (NCD) is putting a dual health burden on the State and an increasing number of road accidents calls for improved pre- and post-hospitalization trauma care support. Overall, spending on the health is low at about 1% of the State’s GDP. 2. PROGRAM DESCRIPTION 6. Tamil Nadu’s health program is anchored in its Vision 2023 and built around the Sustainable Development Goal (SDG) 3: “to ensure healthy lives and promote wellbeing for all at all ages.� For the priorities set out in Vision 2023, the broader government program is comprised of the work-programs implemented by seven key Directorates and Societies (out of ten) with a combined estimated budget of US$8.2 billion over the next five years. These include TNHSP Society, National Health Mission (NHM), Directorate of Medical Education (DME), Directorate of Medical and Rural Health Services (DMRHS), Directorate of Public Health (DPH), Directorate of Indian Medicine and Homeopathy (DIMH), and TN Food Safety and Drug Administration (TNFSDA). Their work-programs are critical to the achievement of results envisaged under the above-mentioned policies and vision documents. 7. The proposed Program (“P�) is a well-defined subset of the government program (“p�) aiming specifically to achieve SDG 3 targets 3.4, 3.6, 3.7 and 3.8.4 The Program comprises interventions to achieve SDG 3 targets related to reducing mortality from NCDs and 4 SDG target 3.4 to reduce by one third by 2030 premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being; 3.6 to halve by 2020 the number of global deaths and injuries from road traffic accidents; 3.7 to ensure by 2030 universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes; and 3.8 to achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. 2 injuries, providing universal access to reproductive health services, and ensuring quality services as part of UHC. Such interventions are reflected in nine expenditure categories of the 2019-2024 work program of the seven directorates and societies (see technical assessment summary for details). The budget for the Program over the next five years is estimated at USD 5.3 billion, of which IBRD financing would be USD 287 million, representing 5.4 percent of the Program budget. The specific expenditure categories included in the Program are salaries, payments for professional and special services, advertising and publicity, training, minor works, repairs and maintenance, and consumables to a limited extent (machinery and equipment, materials and supplies, and computers and accessories). Exclusions from the Program are major constructions, medicines, the JICA- financed TNUHP, and high-risk activities. The latter are defined as activities which (a) are judged to likely have significant adverse impacts that are sensitive, diverse or unprecedented on the environment and/or affected population; and (b) involve procurement of goods, works and services under high-value contracts. The duration of the Program is 5 years (2019 -2024). 2.1 Program Development Objectives and Indicators 8. The Program Development Objective (PDO) is to improve quality of care, strengthen management of non-communicable diseases (NCDs) and injuries, and reduce inequities in reproductive and child health services in Tamil Nadu. The following indicators will be used to measure the achievement of the PDO: a) Accreditation of public health facilities (primary, secondary and tertiary) [of which in priority districts] b) Score in quality dashboard for primary, secondary and tertiary level facilities c) Utilization of diagnostic services in public sector facilities for cervical and breast cancers d) Patients with hypertension or diabetes whose blood pressure or blood sugar are under control e) Provision of 24x7 trauma care services f) Utilization of reproductive and child health services in priority districts 9. In addition, the Disbursement Linked Indicators (DLIs) for the Program are as follows: Foundational DLIs i. Development and adoption of policies, strategies, guidelines and other foundational activities Quality of Care DLIs ii. Accreditation of public health facilities (primary, secondary and tertiary) iii. Quarterly reporting of quality dashboard at facility (primary, secondary and tertiary) and aggregate levels iv. Implementation of other quality improvement initiatives NCDs and Injuries DLIs 3 v. Patients with hypertension or diabetes whose blood pressure or blood sugar are under control vi. Implementation of performance-based incentive mechanism in primary health centers vii. Provision of 24x7 trauma care services Equity DLIs viii. Utilization of reproductive and child health services in priority districts Cross-Cutting DLIs ix. Strengthening content of, access to and use of HMIS x. Operational research to inform implementation and decision making xi. Annual District and State Health Assemblies for voice, agency and accountability 2.2 Program Scope 10. While the priority interventions discussed below in the Program scope are categorized by results areas, many of them will support systematic reforms with cross-cutting outcomes. Included in this are: (i) strengthening, integration, transparency and use of data systems; (ii) development of an online quality of care dashboard for all levels of health facilities; (iii) strengthening and scaling up of quality assurance mechanisms; (iv) introduction of a performance appraisal system and mechanism to incentivize performance; (v) strengthening of the continual medical education program; (vi) strengthening of health administration; and (vii) district and state health forums for community voice and agency using the Panchayati Raj system. These interventions aim to improve the planning and management of the health sector, strengthen institutions and enhance state capacity to address “how� the sector operates rather than “what� specifically it does. Good practices and innovations from Tamil Nadu are being scaled up while others from around the world are being introduced into the Program to improve management of the public health sector, increase transparency, and strengthen accountability. These key “hows� will enable Tamil Nadu to move from a focus on access to an increasing focus on quality of care. These systematic reforms will also better position the state to tackle emerging disease patterns that require a different approach to service delivery while simultaneously closing the remaining gaps on last mile delivery of basic RCH services. 11. The key result areas of the program are as below. Results Area #1: Quality of Care • Improved score in quality dashboard • Improved hygiene, sanitation and waste management practices • Increase in NQAS/NABH accreditation • Quarterly reporting of quality dashboard for primary, secondary, and tertiary facilities and collation at aggregate levels • Implementation of quality improvement initiatives 4 • Increase in % of health providers annually receiving CME Results Area #2: Non-Communicable Diseases, Mental Health & Injuries • Increased utilization of diagnostic services (passive screening) in public sector facilities • Patients with disease under control • Increased awareness of NCD risk factors NCDs and mental health • % of red category patients at the hospital arriving in an ambulance • % of patients with head injury undergoing a CT scan within 45 minutes of reaching the hospital • % of patients with trauma undergoing e-FAST (focused abdominal sonography in trauma) within 30 minutes of reaching the hospital) • Better equipped ambulance system to improve pre-hospital care • Provision of 24x7 trauma care services Results Area #3: Equity • Reduced inequities in utilization of select MCH services between top and bottom quintile of districts • Increased provision of select MCH services at primary and secondary facilities in priority districts (bottom quintile of districts on select MCH services) 2.3 Geographic Scope of the Program 12. The Program will be implemented across all districts in the state of Tamil Nadu. However, to address geographic disparities, special focus will be maintained in select nine priority districts i.e. Virudhunagar, Thoothukkudi, Tirunelveli, Theni, Ramanathapuram, Ariyalur, The Nilgiris, Dharmapuri, and Tiruvannamalai. 3 ENVIRONMENTAL AND SOCIAL SYSTEM ASSESSMENT (ESSA) 3.1 Introduction to ESSA 13. The World Bank policy and directive on PforR financing requires an environmental and social assessment (ESSA) of operations financed under the PforR instrument. Accordingly, an ESSA of operations to be financed under the Program was carried out to assess the adequacy of environmental and social systems focusing at the state level in context of the Program boundary. The broad scope of the ESSA was to assess the extent to which the Program systems promote environmental and social sustainability; avoid, minimize, or mitigate adverse impacts on natural habitats and physical cultural resources; protect public and worker safety; manage land acquisition; consider issues related to indigenous peoples and vulnerable groups; and avoid social conflict. Further, it identified required actions for enhancing/strengthening the Program systems and mitigating potential environmental and social risks. 5 14. The ESSA provides a comprehensive review of relevant government systems and procedures that address environmental and social issues associated with the Program. The ESSA describes the extent to which the applicable government environmental and social policies, legislations, Program procedures and institutional systems are consistent with the six ‘core principles’ of OP/BP 9.00 and recommends actions to address the gaps and to enhance performance during Program implementation. 15. The Specific objectives of ESSA are as follows. i. to identify the potential environmental and social impacts/risks/benefits applicable to the Program interventions, ii. to review the policy and legal framework related to management of environmental and social impacts of the Program interventions, iii. to assess the institutional capacity for environmental and social impact management within the Program system, iv. to assess the Program system performance with respect to the core principles of the PforR instrument and identify gaps in the Program’s performance, v. to describe actions to fill the gaps that will input into the Operation Action Plan in order to strengthen the Program’s performance with respect to the core principles of the PforR instrument. 3.2 Methodology Adopted for ESSA 16. The ESSA was prepared based on field visits, consultations with various stakeholders in the field and desk review of existing information and data sources. In addition, primary data collection/assessment was undertaken through consultations/ interviews/ discussions with key stakeholders to capture opinions, anecdotal evidence, functional knowledge, and concerns. Field visits were undertaken in three districts (Chennai, Tiruvallur and Kancheepuram) covering five hospitals5, upgraded PHC and Medical Colleagues and one Common Treatment Facility (CTF). 17. The desk review focused on understanding the existing policy, operational procedures, institutional capacity and implementation effectiveness relevant to the activities under the Program. The desk review also covered the legal and regulatory requirements including those on environmental conservation, pollution control, occupational health and public safety, building construction codes, social inclusion and transparency and accountability mechanism, and social and cultural aspects related to the Program, etc. The desk review included available documents, reports, data, websites etc. 18. The primary data collection and assessment involves consultation/ discussion/ interviews with key stakeholders including the key department/ agency including TNHSP, Directorate of Family Welfare (DFW), Directorate of Public Health and Preventive Medicine (DPH), Directorate of Medical and Rural Health Services (DMRHS), Tamil Nadu State Health 5(i) Government Taluk Hospital Tambaram, Kancheepuram (ii) Rajiv Gandhi Govt General Hospital-Chennai and (iii) Government Taluk Hospital, Tiruvallur: (iv) Sundaram Medical Foundation (Private Hospital); and (V) Sri Ramachandra Hospital, Chennai (Private Hospital) 6 Society (TNSHS) including key staff members from NHM and NUHM, Directorate of Medical Education (DME), nodal officer for HMIS, Social Welfare Department, and Land Administration Department. Comments, suggestions and areas that require strengthening was sought during the free and prior informed consultation with NGOs working on tribal health and member of tribal community during the stakeholder consultation on 24th October 2018. 19. The Program design also benefited from the extensive consultation done under the earlier TNHSP project with tribal community in setting up agenda for tribal health program and which was mainstreamed and expanded under the NHM after the project closure. The Tribal Plan was developed based on extensive consultations with various NGOs working on tribal health issues, tribal community and their ‘sangams’, and field visits to tribal areas, and also various government departments including the Health, Tribal Welfare and Forest Departments etc.. Further discussion with NGOs working on tribal health during the preparation of current Program suggests improvement in access to health services and need for continuing the tribal health program to achieve desired results. 3.3 Consultations and Disclosure 20. Multiple consultations were undertaken with relevant departments, including TNHSP, Directorate of Family Welfare (DFW), Directorate of Public Health and Preventive Medicine (DPH), Directorate of Medical and Rural Health Services (DMRHS), Tamil Nadu State Health Society (TNSHS) including key staff members from NHM, Directorate of Medical Education (DME), Social Welfare Department, and Land Administration Department. A free and prior informed consultation with non-government entities and member of tribal community among other stakeholders was conducted on 24th October in Chennai and included various NGOs working on health and/or with tribal and vulnerable population from different parts of the state and neighbouring areas including from Chennai, Puducherry, Selam, Vellore, Nilgiris, and Ooty; and members of tribal community including members from Nilgiris Particularly Vulnerable Tribal Group (PVTG) Council and Irula tribal society of Nilgiris. The representation from NGOs as well as from tribal community included both men and women. Their comments and suggestions are also being incorporated and integrated into the Program design. 21. The draft report of the ESSA was disclosed through a state-level consultation workshop on October 24, 2018 at Chennai. The draft report was finalized after incorporating relevant suggestions from the stakeholders during the consultation workshop as presented in Annex- 2 of this report. The final report of the ESSA will be disclosed on the website of the Health Department (GoTN) and at World Bank’s external website. 4 INSTITUTIONAL ASSESSMENT 4.1 Borrower’s Past Experience in Managing Environmental and Social Risks 22. GoTN has had more than four decades of experience in working with World Bank and with more than 40 projects (both national and state projects) over this period clearly shows their prior experience in implementation of Bank safeguard policies. GoTN has had a continuous and long engagement with the Bank on health and nutrition projects among other projects. 7 Apart from various national level health programs that are supported by the World Bank where Tamil Nadu is also one of the states for implementation, the TNHSP started in 2005 and closed in 2015. While the TNHSP is closed, the institutional setup is still functional and active with other development partner projects. Over the years, access to health services has increased within the state and management of BMW has also seen considerable improvement at all levels of healthcare facilities. This is indicative of good borrower capacity to deal with the environmental and social aspects of the proposed Program. However, since closure of the previous project, there is no technical specialist in TNHSP for managing the environmental risks and impacts of the proposed Program. However, under the proposed Program two specialists (one Environmental Specialist and one Social Safeguard Specialist) are to be recruited in the PMU. 4.2 Assessment of Institutional Roles and Capacity Gaps 23. Notwithstanding the already built capacity within the borrower’s institutions, a detailed assessment of all the relevant institutional stakeholders was undertaken to identify any critical and/or significant gaps, as well as smaller shortcomings for effectively managing the environmental and social issues of the health sector in Tamil Nadu. In addition to assessing the institutions at the national and state level, the ESSA also looked into some of the ongoing national health programs. The institutional assessment has contributed in coming up with recommendations, Program actions and one disbursement linked indicator that will support the further building of borrower capacity. The table below gives the findings of the institutional assessment. 8 Table: Capacity Gap Analysis of Relevant Institutions Related to the Proposed Program Institution Roles and Responsibilities Capacity Gap Analysis National Level Institutions Department of Health, Ministry ▪ Deals with health care, including awareness campaigns, ▪ No significant gaps identified, as health schemes are of Health and Family Welfare immunisation campaigns, preventive medicine, and quite inclusive and well implemented (MoHFW) public health services ▪ Provides funds under NHM for BMWM ▪ Administratively control many national health programs such on HIV/ AIDs, TB, Cancer, Filaria, Iodine deficiency, Leprosy, Mental health, Blindness and Deafness, Tobacco Control, Vector Borne Diseases, on Prevention and Control of Diabetes, CVD and Stroke, and Universal immunization ▪ Heads many statutory bodies, such as, Medical Council of India (MCI), Indian Nursing Council, Dental Council of India, and Pharmacy Council of India (PCI) Department of Family Welfare ▪ Deals with issues like reproductive health, maternal ▪ No significant gaps identified at the national level, a health, paediatrics, information, education and scheme implementation is at the state level Under MoHFW communications; cooperation with NGOs and ▪ Institutions under its aegis provide technical support international aid groups; and rural health services and guidance for better implementation of national ▪ Responsible for various institutions including the 18 schemes and programs Population Research Centres (PRCs) at six universities and six other institutions across 17 states, National Institute of Health and Family Welfare (NIHFW), International Institute for Population Sciences (IIPS), Central Drug Research Institute (CDRI), and Indian Council of Medical Research (ICMR) Ministry of Tribal Affairs ▪ Nodal Ministry for overall policy, planning and ▪ No significant gaps identified, as the mandate and coordination of programs for development of STs functions of the ministry support welfare of indigenous people 9 Institution Roles and Responsibilities Capacity Gap Analysis Ministry of Social Justice and ▪ Responsible for bringing marginalized sections of the ▪ No significant gaps identified Empowerment society viz. Scheduled Castes, Backward Classes, ▪ Support for marginalized section is well mainstreamed Persons with Disabilities, Aged persons etc.into the in sector programs mainstream of development by making them self-reliant ▪ Investments by the ministry do not result in any ▪ Through the Scheduled Castes Development Bureau, adverse environmental impacts and/or risks implements Scheduled Caste Sub-Plan (SCSP) which is an umbrella strategy to ensure flow of targeted financial and physical benefits from all the general sectors of development for the benefit of SCs State Level Institutions Tamil Nadu Health Systems ▪ Established in 2005 to implement World Bank funded ▪ No significant gaps identified on managing social risks Project (TNHSP) TNHSP and impacts ▪ Supporting other bilateral programs on health sector with ▪ Need to further strengthen the inter-institutional JICA coordination mechanism ▪ Will play a key role in the proposed new Program ▪ Successfully created an agenda of focusing on tribal health which are being followed by the department even after closure of the project under their own budgetary process ▪ On the environmental management side, need to develop technical capacity through recruitment of an expert for overseeing BMWM Directorate of Family Welfare ▪ Helps implement the National Family Welfare Program ▪ No significant capacity gap identified (DFW) in the state to provide maternal and child health care ▪ Monitors prevention of female foeticide and female infanticide Directorate of Public Health ▪ Responsible for the implementation of various national ▪ No significant gaps identified on the social side, as and Preventive Medicine and state health programs services have adequate coverage (DPH) ▪ Plans and implements measures to prevent the occurrence ▪ On the environment side, need to improve reporting on of communicable diseases BMWM form healthcare services 10 Institution Roles and Responsibilities Capacity Gap Analysis ▪ Provisions of primary health care, including the ▪ Need to strategize on dealing with wastes other than Maternity and Child Health Services, Immunisation of BMW children against vaccine preventable diseases, control of communicable diseases, control of malaria, filaria, Japanese encephalitis, elimination of leprosy, iodine deficiency disorder control program, prevention of food adulteration, health check-ups of school children, health education of the community and collection of vital statistics under birth and death registration system and environmental sanitation Directorate of Medical and ▪ Responsibility for rendering medical care services to the ▪ Gaps in institutional capacity to address geographical Rural Health Services public through the Non-Teaching Medical Institutions inequity in accessing health care (DMRHS) ▪ Provides medical services through the grid of 25 District ▪ Need to improve monitoring and reporting on BMWM Head Quarters Hospitals, 162 Taluk Hospitals, 79 Non- ▪ Improve efficiency in energy and water use at the Taluk Hospitals, 12 Dispensaries and 11 Mobile Medical facility level Units. ▪ Besides 23 District T.B. Centres, 5 T.B. Hospitals and 2 TB Clinics and 1 Leprosy Hospital National Health Mission ▪ Works to pool all resources available in implementation ▪ No significant gaps identified on the social side (NHM) of the programs ▪ While adequate funding is provided, need to improve ▪ All national health programs at the State and District monitoring of BMWM level are brought under one umbrella of NHM ▪ Provides funding support for BMWM through CTFs ▪ Has six financing components i.e. (1) NRHM-RCH Flexi pool, (2) NUHM Flexi pool, (3) Communicable disease Flexi pool, (4) Flexible pool for Non-communicable disease (NCD) including Injury and Trauma, (5) Infrastructure and Maintenance, and (6) Family Welfare Central Sector components 11 Institution Roles and Responsibilities Capacity Gap Analysis Directorate of Medical ▪ Responsible for teaching, training and research programs ▪ Capacity for supporting continued medical education Education (DME) in the medical field and patient care services (CME) requires additional efforts ▪ Establishes and maintains well-equipped teaching ▪ Gap in provisioning of continued training and refresher institutions, which are the premier referral centres with training on BMWM for healthcare staff for all levels state-of-the-art equipment and technology Public Works Department ▪ Constructs and maintains buildings of various ▪ Need to enhance capacity in managing issues related to (PWD) Government Departments contracted labor ▪ Will construct or rehabilitate and repair healthcare ▪ Need to improve health and safety of workers at facilities construction sites and follow good construction management practices Adi Dravidar and Tribal ▪ Implements the programs related to the welfare of ▪ No significant gaps identified Welfare Department Scheduled Caste and Scheduled Tribe population in the ▪ TSP planning and implementation with detailed state for their socio-economic advancement guidelines and budgetary process being done well ▪ Nodal department for the formulation and implementation of TSP at State Level Social Welfare Department ▪ Entrusted with ensuring the welfare of the poor, the ▪ No significant gaps identified down-trodden, Women, Children, Senior Citizens and trans-genders ▪ Promotes empowerment and improvement of social status of women State Pollution Control Board ▪ Provisioning of licence to CTF for operating Bio- ▪ Generally, under staffed for adequate monitoring medical treatment facility ▪ No capacity gaps in terms of technical capacity and ▪ Monitoring of compliance with BMWM Rules and role clarity other relvant regulatory instruments 12 4.2.1.1 Relevant National Programs 24. The National Cancer Control Program (NCCP): The NCCP was initiated in the year 1975. Subsequently it was revised in the year 1984-85 with emphasis on primary prevention and early detection of cancer. Various schemes were introduced under the NCCP in order to strengthen cancer control activities in the country. Under the NCCP, Regional Cancer Centres (RCCs) have been established to improve availability of cancer treatment facilities. In order to further enhance the treatment facilities across the country and reduce the geographical gap in the availability of cancer care facilities, newer RCCs are being recognized. 25. The National Mental Health Program (NMHP): The Government of India has launched the NMHP in 1982, keeping in view the heavy burden of mental illness in the community, and the absolute inadequacy of mental health care infrastructure in the country to deal with it. 26. National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS): The Non-Communicable Diseases (NCDs) like Cardiovascular Diseases (CVD), Cancer, Chronic Respiratory Diseases, Diabetes and other NCDs are estimated to account for around 60% of all deaths, thus making them the leading causes of death. Therefore, the NPCDCS was launched in 2010 in 100 districts across 21 States, in order to prevent and control the major NCDs. The main focus of the NPCDCS is on health promotion, early diagnosis, management and referral of cases, besides strengthening the infrastructure and capacity building. 27. Tribal sub plan and Scheduled Caste sub plan: The strategy of Tribal Sub Plan (TSP) has been in force since 1974, to ensure adequate flow of plan resources for the development of Scheduled Tribes, while the strategy of Scheduled Castes Sub Plan (SCSP) (earlier known as the Special Component Plan for Scheduled Castes) has been in force since 1979-80, to ensure proportionate flow of plan resources for the development of Scheduled Castes. The revised 2014 guideline for implementation of TSP and SCSP suggests all Central Ministries and Departments to (a) Earmark funds under SCSP and TSP from the plan outlay at least in proportion to the percentage of Scheduled Caste and Scheduled Tribe population in the country, (b) Place the funds earmarked for SCSP and TSP under a separate Minor Head ‘789’ and ‘796’ to ensure their non-diversion to any other scheme, (c) Include only those schemes under SCSP and TSP which ensure direct benefits to individuals or families belonging to Scheduled Castes and Scheduled Tribes, and (d) Only include in the SCSP and TSP outlay for area-oriented schemes which directly benefit hamlets/villages which have more than 40 percent Scheduled Castes and Scheduled Tribes population. 4.2.2 Key findings of the institutional assessment on environment and social aspects 28. Management of Biomedical Waste. The primary environmental risks and impacts of the Program centers on the management of BMW generated at the healthcare facilities in the State. The previous Bank funded project built good capacity and made significant advances in management of BMW. The compliance with the provisions of the main regulatory instruments, the Bio-Medical Waste Management Rules, 2016 and the Bio-Medical Waste 13 Management (Amendment) Rules, 2018, is generally adequate. Within the healthcare premises, sharps, blood and other human tissues, infected materials are disinfected and treated as per regulatory requirements. Consumables, such as, colored bins and other required items at the healthcare facility levels are available and optimally used. At the hospital level waste segregation is practiced and segregated waste is properly stored temporarily within designated dedicated storage room in the healthcare premises from where it is picked regularly and transported to the Common Treatment Facilities (CTF) for final disposal. However, no performance audits for the CTFs have been undertaken. The management of BMW are also the focus of the review by the TNPCB. Despite improvement in BMWM in the State, there is inadequacy in dealing with liquid wastes generated from hospitals. 29. Management of other hazardous wastes, including risk of exposure to radiation. Documentation, procedures and capacity are in place to manage the radiation impacts and risks. On radiation exposure to medical workers and communities, in healthcare facilities, there are proper protection ware and shelter, and portable detectors are provided to monitor and control radiation leakage. For medical radiation equipment, the licensing, safe use, work-site detection, maintenance, emergency response and decommissioning are specifically required and regulated. For radiation contaminated wastes, specific requirements on collection, separation, storage, packaging, transport, and final disposal are required as well. While larger hospitals are equipped with protocols and kit to handle mercury spills, this capacity is required to be built in some of the PHCs. 30. Management of other categories of wastes from healthcare facilities. These is limited institutional capacity to deal with other kinds of wastes generated at healthcare facilities, such as solid wastes, hazardous wastes, E-wastes and plastic wastes. These issues are gaining prominence and will require an integrated approach to manage all kinds of wastes. 31. There is good institutional capacity for addressing inequity, inclusion and gender issues of the health sector. Within the Department of Health and Family Welfare, a few of the Directorates and Societies are the critical actors in implementation of Program activities and achievement of results. With the implementation of earlier World Bank supported health project in Tamil Nadu, the DoHFW in general, and the TNHSP Society in particular has experience in efficiently coordinating with other Directorate and societies including DMRHS, DME, DPH, NHM, DIMH and TNFSDA and with other departments to implement the Program activities including addressing inequity, inclusion issues, gender issues and other social aspects. TNHSP had also coordinated the implementation of Tribal Health program under the earlier Bank supported project in an effective manner and helped mainstreamed that into the department program after the closure of the project. However, with the change in the financing instrument i.e. PforR, there is a need to further strengthen the inter-institutional coordination mechanism. 14 5 LEGAL AND REGULATORY FRAMEWORK APPLICABLE TO THE PROGRAM 5.1 Environmental and Social Laws, Regulations and Policies 32. Several relevant national and state level laws, regulations and policies were analysed to for the proposed Program. The analysis covered whether there are some significant gaps that prevent to realize the environmental and social objectives as included in the ESSA core principles. Table gives the detailed analysis of the legal and regulatory framework applicable to the Program. 33. Adequacy of legislative framework on social aspects. The existing legislative framework is adequate to ensure social sustainability and the interest of marginalized and vulnerable population including the SC and ST population. It ensures (a) protection of the interest of SC and ST population, (b) non-discrimination based on religion, race, caste, and gender, and (c) transparency with right to information, (d) right to fair compensation in case of land acquisition. Tamil Nadu also has separate act for eviction of unauthorized occupants from public premises which defines the process and powers to various authorities in order to evict the unauthorized occupants along with nature of penalty and liabilities. However, a small gap emerges on the policy and legislative frame for eviction of squatters where the World Bank’s policy takes a more humanitarian approach and provides for assistance in terms relief and rehabilitation of squatters. Though, it is unlikely that any additional land is required beyond the current footprint of the health facility, there is an outer chance that health facilities need to evict squatters in order to expand services. 34. Adequacy of legislative framework on environmental aspects. The provisions of the existing environmental legal and regulatory framework are adequate but require enabling institutional and technical capacity to comply with. While the provisions of the Biomedical Waste Management & Handling) Rules, 1998 – as amended up to March 2018 are being implemented, provisions of other relevant environmental Acts, such as, hazardous, solid, plastic and E-waste Rules 2016 require additional capacity building efforts. Efforts are required to improve the monitoring of the management of different kinds of wastes. The ambit of the rules has been expanded to include: (a) camps for vaccination, blood donation, surgical or any other healthcare activity; (b) Phasing out chlorinated plastic bags, gloves and blood bags within two years; (d) Training and immunization for all health care workers regularly; (e) Bar-Coding for bags or containers containing bio-medical waste for disposal; (f) Reporting major accidents; (g) More stringent standards for incinerator to reduce emission of pollutants; (h) Existing incinerators to achieve the standards for retention time in secondary chamber and Dioxin and Furans within two years; 35. Setting up of Common Treatment Facilities for Bio-Medical Wastes. BMW is listed as hazardous waste due to its infectious characteristics. Any activities from temporary storage, 15 transportation, utilizing and final disposal/treatment requires valid license. Government Regulation No. 101/2014 on Management of Toxic and Hazardous Waste regulates the proper management of hazardous waste covering; (i) method of identifying, reducing, storing, collecting, transporting, utilizing, processing, and disposing of hazardous wastes; and (ii) risk mitigation and emergency responses to address environmental pollution caused by hazardous waste. The State Pollution Control Board plays an important role in granting consent to establish and operate licence to the CTF operators, which are largely private sector players. The State has clearly defined procedures and provisions to establish new/additional CTFs for BMW disposal or other facilities (such as landfill) for managing non-hazardous wastes. 16 Table: Environmental and Social Laws, Regulations and Policies that are relevant to the Proposed Program Sl. Applicable Act/ Objective and Provisions Relevance to the Program and key Findings No. Regulation/ Policy 1 The Constitution of India The Indian Constitution (Article 15) prohibits any discrimination Relevant to the overall Program (especially, Articles 15,16 based on religion, race, caste, sex, and place of birth. Article 16 refers and 46) to the equality of opportunity in matters of public employment. Article 46 directs the state to promote with special care the educational and economic interests of the weaker sections of the people, particularly of the Scheduled Castes and the Scheduled Tribes and also directs the state to protect them from social injustice and all forms of exploitation. 2 Bio-medical Waste Schedule 1: Categorization and Management Highly relevant Management(Amendment) Schedule 2: Standards for treatment and disposal of BMW Rules,2018 Schedule 3: Prescribed Authority and duties As per Accreditation requirements, healthcare Schedule 4: Label of containers, bags and transportation of Bio- facilities are required to develop Standard Medical waste Operating Procedures (SOPs) in the handling of medical solid, liquid and radioactive wastes. The provisions under the rules provide for both solid and liquid medical wastes. On solid BMW there is good overall capacity Liquid waste should be treated with 1% hypochlorite solution before and compliance. On liquid BMW, there are discharge into sewers. significant gaps in treatment and disposal of Hospitals not connected to municipal WWTPs should install compact wastewater from hospitals. on-site sewage treatments (i.e. primary and secondary treatment, disinfection) to ensure that wastewater discharges meet applicable The requirements in MoEFCC Notification- thresholds G.S.R.234(E), dated 28th March,2016 are found to be equivalent to the WBG EHS Guidelines for Healthcare Facilities as they cover good international industry practice 17 Sl. Applicable Act/ Objective and Provisions Relevance to the Program and key Findings No. Regulation/ Policy (GIIP) such as labelling and symbols for hazardous materials and waste, waste reduction, segregation, storage, transportation (manifest), treatment and handling (with autoclave, incineration), health workers occupational health and safety and public health and safety. The effluent standards are also equivalent or better than the WBG EHS Guidelines for Health Care Facilities (Performance Monitoring); for example, 100mg/L for COD (India) and 250 mg/L (WBG Guidelines). 3 E-Waste (Management To address leakage of e-waste to informal sector at all the stages of Relevant as it is applicable for consumers or and Handling) Rules 2011 channelization. bulk consumer. The disposal of E-wastes to be as Amendment up to 2018 The 2016 Amendment brought health care facilities (with turnover done at the specified collection centers and over INR 20 crore or more than 20 employees). reported annually. 4 Plastic Waste All institutional generators of plastic waste, shall segregate and store Relevant as hospitals are generators of large Management Rules 2016 the waste generated by them in accordance with the Solid Waste quantity of plastics, including non-reusable Management Rules, and handover segregated wastes to authorized types. waste processing or disposal facilities or deposition centers, either on its own or through the authorized waste collection agency 5 Water (Prevention and Provisions are largely to prevent air and water pollution by not Relevant and largely complied with Control of Pollution) Act releasing untreated effluents and harmful emissions. Most provisions 1974 are already discussed under the Bio-Medical Waste Rules. Air (Prevention and Control of Pollution) Act 1981 Environment Protection Act (nd Rules), 1986 and 1996 18 Sl. Applicable Act/ Objective and Provisions Relevance to the Program and key Findings No. Regulation/ Policy 6 Indian Penal Code (IPC) Section 278 (making atmosphere noxious to health) and Section 269 Relevant (negligent act likely to spread infection or disease dangerous to life, Although individuals would require providing unlawfully or negligently evidence 7 The Indian Medical Provisions are applicable to practising doctors and medical Relevant Council Act 1956 professionals to provide quality service to the patients or healthcare The Indian Medical seekers. Council (Professional Conduct, Etiquette and Ethics Regulations 2002) 8 Right to Information Act, Provides a practical regime of right to information for citizens to Relevant as all documents pertaining to the 2005 secure access to information under the control of Public Authorities. Program requires be disclosed to public. The act sets out (a) obligations of public authorities with respect to provision of information; (b) requires designating of a Public Information Officer; (c) process for any citizen to obtain information/disposal of request, etc. (d) provides for institutions such as Central Information Commission/State Information Commission 9 The Right to Fair Aims to ensure, a humane, participative, informed and transparent Not applicable as no land acquisition or Compensation and process for land acquisition with least disturbance to the owners of the resettlement is anticipated. Transparency in Land land and other affected families and provide just and fair Acquisition, compensation to the affected families whose land has been acquired or Rehabilitation and proposed to be acquired or those that are affected by such acquisition Resettlement Act, 2013 and make adequate provisions for their rehabilitation and resettlement and for ensuring that the cumulative outcome of compulsory acquisition should be that affected persons become partners in development leading to an improvement in their post-acquisition social and economic status. 10 The Sexual Harassment of An act that aims at providing a sense of security at the workplace that Relevant and applicable to all health Women at Workplace improves women’s participation in work and results in their economic directorates and most of the health care (Prevention, Prohibition empowerment. It requires an employer to set up an “Internal facilities. and Redressal) Act, 2013 Complaints Committee� (ICC) and the Government to set up a ‘Local 19 Sl. Applicable Act/ Objective and Provisions Relevance to the Program and key Findings No. Regulation/ Policy Complaints Committee’ (LCC) at the district level to investigate complaints regarding sexual harassment at workplace and for inquiring into the complaint in a time bound manner. The ICC need to set up by ever organization and its branches with more than 10 employees. 11 The Street Vendors The act aims at providing social security and livelihood rights to street Relevant as it becomes applicable if the (Protection of Livelihood vendors. It provides protection of legitimate street vendors from squatters to be removed comes under the and Regulation of Street harassment by police and civic authorities, and demarcation of preview of this act. Vending) Act, 2014 "vending zones" on the basis of "traditional natural markets", proper representation of vendors and women in decision making bodies, and establishment of effective grievance redressal and dispute resolution mechanism. 12 Tamil Nadu Public The act provides for the eviction of unauthorized occupants from Applicable – There is a chance find that health Premises (Eviction of public premises and for certain incidental matters. It defines the facilities in order to expand services may Unauthorized Occupants) process and powers to various authorities in order to evict the require additional land owned by them and Act 1975 unauthorized occupants along with nature of penalty and liabilities. which are occupied by squatters. 13 The Tamil Nadu Street It draws from the national act i.e. The Street Vendors (Protection of Not Applicable Screening will be conducted in Vendors (Protection Livelihood and Regulation of Street Vending) Act, 2014. And health facilities where any repair, renovation of Livelihood and provides social security and livelihood rights to street vendors. It and expansion is planned to avoid any adverse Regulation of Street provides protection of legitimate street vendors from harassment by social impact. Vending) scheme and police and civic authorities, and demarcation of "vending zones" on Rules, 2015 the basis of "traditional natural markets", proper representation of vendors and women in decision making bodies, and establishment of effective grievance redressal and dispute resolution mechanism. 20 6 ASSESSMENT OF ENVIRONMENT AND SOCIAL MANAGEMENT SYSTEMS 6.1 Assessment of Environment Management Systems 36. The assessment of environmental management system is based on the analysis of the applicability of the regulatory framework, potential impacts of the proposed Program and institutional capacities to manage the risks and adverse impacts and to scale up positive outputs and outcomes. 6.1.1 Environmental management systems in State programs 37. Generation of biomedical wastes across the healthcare facilities is projected to grow. With the objectives of providing quality care and better service delivery, the generation of BMW are projected to grow exponentially over the next 6 to 8 years. The current waste management infrastructure will require substantial investments to handle, store, manage and dispose the wastes of the health sector to accommodate increased BMW. Trends in Biomedical Waste Generation - Recent and Projected Source: TNHSP 3000 2500 2000 Tonnes 1500 1000 500 0 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Year 6.1.2 Potential Environmental Benefits 38. The proposed Program is expected to scale up positive environmental benefits in the health sector. It will help improve quality of health services covering aspects of better environmental hygiene and waste management. Along with the improvement and specialization of health services, it is expected that standardized hospital management practices for medical waste, occupational safety and health, and that the collection and transportation of medical wastes in rural areas will be improved. 6.1.3 Potential Environmental Opportunities 39. The proposed Program offers several opportunities to build technical capacity of healthcare facilities and staff in reducing threats and risks of environmental pollution and infections. It will pave the way to create liquid waste management infrastructure in the state, support hospitals to undertake improvements of its infrastructure for reducing its energy and 21 emission footprint, provide training for control of infection and personal safety from occupational hazards and improve reporting on waste generation and management. 6.1.4 Potential Environmental Impacts 40. Bulk of the proposed activities to be supported under the proposed Program will not have any significant negative impacts. These are not expected to take place in and/or encroach/degrade sensitive habitats, be located in sensitive areas of high biodiversity value, or affect areas protected for physical cultural resources. Nonetheless, some of the activities supported under the PforR have potential negative impacts and risks associated with construction of the physical infrastructure, including rehabilitation and upgradation and operation of existing healthcare facilities. 41. Construction Impacts. Environmental impacts, including dust, noise, non-hazardous solid waste, wastewater, and social disturbance such as traffic safety and congestion, and construction safety concerns may occur during construction/rehabilitation of the limited physical works supported under the Program. These impacts are envisaged to be low to moderate, temporary or site-specific and can be mitigated with readily available measures. The table below gives a summary of possible adverse impacts and risks. Table: Potential Environment Effects and Risks Associated with Construction Activities Environmental Potential Program Activities Level of Concern Issues Dust, noise, Construction of physical works Level of concern: Minimum general solid within healthcare facilities will Such effects are site-specific and can be waste, wastewater cause dust, noise, wastewater and effectively mitigated by measures such as general solid waste. Given the water spray, dust-net, site-fencing, vehicle location of the works, the visitors cleaning; use of low-noise equipment. and patients, particularly the Prohibition of construction during night inpatients, may be exposed to time, construction site settling tanks and noise and dust during effluent discharge municipal sewers, and construction/rehabilitation of the collection and transportation of general structures within the facilities. solid waste in a timely manner. The construction contract should include relevant clauses to address this issue and the contractor shall be supervised to avoid such potential impacts. Social Healthcare facilities may be Level of concern: Minimum disturbance, located in densely populated Given the limited scale of construction including influx urban area, and the construction activities, no significant influx of labor is of workers, traffic of the structures/rehabilitation anticipated during construction. safety and will be within the boundary of congestion, the hospitals. The safety of the construction patients, visitors and staff will be safety affected by the transportation of materials and the construction activities. 22 42. Operational Impacts and Risks. The activities under the Program include the operation of mostly existing health facilities, procurement of medical equipment and delivery of diagnostic, surgical and related medical services. The operational phase may have certain impacts and risks, including: (i) medical and other solid and liquid waste within healthcare facilities; (ii) transport and disposal of medical solid wastes; (iii) radiation leakage, handling of radiation contaminated wastes; (iv) medical waste water; and (v) air emissions in healthcare facilities. If not well managed, these activities will pose a threat to the environment, public health and occupational safety. The table below gives a summary of possible adverse impacts and risks. Table: Level of Concern with Potential Environment Impacts and Risks Associated with Operation and Use of Healthcare Facilities Environmental Current Status Level of Concern Impacts/ Risks Infections, Quantum of medical solid waste is Level of concern: Moderate hygiene, odour likely to increase with expansion of In most district level healthcare from BMW within services in hospitals. facilities, medical waste is collected and healthcare For healthcare facilities below packaged by medical workers, and facilities District levels, while the quantity temporarily stored at designated places. will increase, the composition of Below district level, there is a need to the medical solid waste will not strengthen BMWM systems, including change substantially. medical waste categorization, waste For the HCF at state and municipal management plan, trainings and levels, the quantity and reporting. composition of the medical solid waste to be generated are expected to be slightly changed. Infections and Most hospitals are not treating Level of concern: Substantial pollution from liquid wastes before releasing into New ETPs and upgrading of some of the untreated liuid the municipal drains or release into older ones (as necessary) is required for BMW released the environment; only 14 hospitals ensuring that treated effluent will meet from healthcare are having ETPs. This has adverse applicable standards. The flow and facilities impacts and risks for surface water, composition of the medical wastewater groundwater, streams and wetlands. should be monitored regularly. A strategy is required for addressing this risk. Exposure to Use of medical imaging or Level of concern: Moderate radiation radiotherapy equipment, if not well Procedures and capacity are in place in managed or protected, can lead to terms of managing the radiation impacts radiation exposure and/or radiation and risks. For equipment, the licensing, contaminated materials (including safe use, work-site detection, liquids, paper, medical gloves), maintenance etc. are generally being resulting on concerns for public done. and community health. The risk is For radiation contaminated wastes, higher in urban areas where such specific requirements on collection, equipments are available. separation, storage, packaging, transport, and final disposal are in place. Air emissions: Separate boiler for heating system Level of concern: Moderate are operated to provide heating for Energy footprint can be substantially inpatient building and hot water for lowered by switching healthcare laundry and bathing, as well as facilities to solar power systems. 23 Environmental Current Status Level of Concern Impacts/ Risks steam for sterilization. Both electric and fuel-based boilers are being used. Diesel genrators for back-up power are also used resulting in occasional emissions. 6.1.5 Gaps and Risks in the Environmental System 43. No state level health policy that define clear goals and objectives to deal with the environmental issues of the health sector. The issue of growing loads of wastes generated from healthcare facilities, especially large hospitals, requires focused attention. Apart from management of biomedical wastes, other solid, hazardous, plastic and liquid wastes6 are not managed adequately. The health sector is conspicuous in missing from the Tamil Nadu State Environment Policy 2017 which stresses on integrating environmental concerns in five development sectors. 44. Continuous education and training on biomedical waste management is lacking. Apart from inclusion of modules on BMW management in the formal medical education, there are inadequate opportunities for continuous training of medical staff. It is difficult to assess the level to which personal safety standards, especially when working with infectious diseases, chance needle pricks etc., are being adhered to. 45. The efficacy of the functional CTFs has not been assessed. While CTFs are now operational to handle final management and disposal of BMW, no assessment of their performance has been undertaken. It is critical to assess this, as new CTFs will be required with the expansion of the healthcare facilities and expected higher generation of BMW. 6.2 Assessment of Social Management Systems 6.2.1 Stakeholder Analysis 46. The key stakeholders for the Program include DoHFW along with its various Directorates and societies including TNHSP, DMRHS, DME, DPH, NHM, DIMH, TNFSDA, and the Department of Finance (DoF). While the PMU is housed in TNHPS, the DMRHS is primarily responsible for secondary health care facilities (i.e. District and regional health care facilities), the DME is responsible for tertiary health care facilities (i.e. medical and nursing colleges and associated facilities) and the DPH is responsible for the primary health care facilities (i.e. PHC, CHC and sub -centres). The NHM state health society implements that national health mission program and involve health care facilities managed by other directorates to deliver the program. The DIMH implements the Indian system of medicine related programs and TNFSDA is responsible for food safety and drug administration related aspects of health care services. The primary stakeholders include the community as 6 Only 14 out of a total of 90 healthcare facilities with a bed strength of over 100 have Effluent Treatment Plans 24 a whole (including the tribal population), and the civil society actors working on health especially in poor and vulnerable pockets and in tribal areas. 47. As mentioned above, the TNHSP, DMRHS, DME and NHM will be responsible for implementing activities related to quality of care improvements (Results Area 1); TNHSP, DMRHS, DME, DPH and NHM will be responsible for implementing activities related to NCDs and injuries (Results Area 2); TNHSP, DPH, NHM, DIMH and TNFSDA will be primarily responsible for implementing the activities related to closing equity gaps (Results Area 3). 48. There is satisfactory institutional capacity among the functionaries of the participating health directorates on implementing the Program activities and addressing the social concerns including the tribal health components. The guidelines and procedures are defied and being followed. However, the proposed Program intends to build overall capacity of the health care functionaries of all participating Directorates and society by promoting continued medical education (CME) and helping develop policy and strategy to strengthen the gap areas in quality health care service provision. 6.2.2 Key Social Issues and Concerns 49. The Program has low likelihood of any negative social impacts. The key social issue identified is related to inequalities in health care services in different districts in Tamil Nadu and is prioritized under the equity Result Area of the Program. The key sub-topics assessed under the ESSA is as below to assess the applicability of the ESSA’s core principles. 6.2.2.1 Tribal Health Program in the State 50. The World Bank supported TNHSP during (2005-15) had successfully created an agenda of focusing on tribal health which are being followed and expanded by the DoHFW even after closure of the TNHSP under their own budgetary process. A total of 173 PHCs and 611 health centres serves the predominant tribal population living in Tamil Nadu. The ongoing tribal health activities include (a) provision of Accredited Social Health Activists (ASHAs) in tribal/ difficult areas and about 2650 ASHAs are engaged in tribal/ hilly/ remote /difficult PHCs to motivate community especially pregnant mother towards ante natal care; (b) Birth waiting room in 17 PHCs to ensure tribal mother reach the delivery point on time and can be admitted two weeks before the delivery date. This is further linked with four-wheel drive 108 ambulances; (c) Tribal Mobile outreach services – there are 396 Mobile Medical Units are being operated in Tamil Nadu, and to Mobile Outreach Services in tribal areas additional 20 mobile medical units are being operationalized through NGOs in tribal blocks; (d) Referral Services in Tribal Districts - the state has a well-established emergency referral transport system established through TN-EMRI to transport from health facility to another health facility for emergency care; (e) Tribal Counsellors - Tribal Counsellors have been placed in the 10 Government Hospitals in the tribal districts to create awareness on health and its determinants among tribal community; and (f) Screening of adolescent tribal children studying in 10th, 12th standard and unmarried school dropouts above the age of 14 in 30 selected tribal blocks in 13 Districts since November 2017 for Hemoglobinopathies for early detection of Sickle Cell, Anaemia & Thalassemia which are 25 common diseases among tribal population. While there have been several initiatives being implemented, there is still a long way to bridge the gap. 6.2.2.2 Inequality in Health 51. At the aggregate level, Tamil Nadu performs well on health indicators relative to other states in India; however, the disaggregated data reveal poorer health outcomes, access to and utilization of health services among tribal populations, urban poor, and those living in select districts, reflecting socioeconomic, geographic and ethnic disadvantages. Child mortality, for example, is substantially higher among the Scheduled caste and tribes and those residing in rural areas (see Figure 5.1). Figure (5.1): Child Mortality, 2015-16 35% 31.0% 30.2% Deaths per 1000 live births 30% 26.9% 23.6% 24.8% 23.4% 25% 22.6% 20.3% 17.4% 18.4% 17.8% 16.9% 20% 14.2% 15% 12.3% 11.1% 10% 5% 0% Scheduled Other Urban Rural Tamil Nadu Caste & Tribe backward class Neonatal mortality (NN) Infant mortality Under-five mortality Source: NFHS-4 (2015-16) 52. Quality of antenatal care also varies by district. While on average only 43 percent of pregnant women receive all recommended services during ANC, this ranges from 14 percent in Virudhunagar to 66 percent in Krishnagiri (Figure 5.2). Similarly, only 40 percent women in Virudhunagar seek antenatal care in the first trimester compared to 84 percent of women in Tirupur. Figure (5.2): Components of antenatal care by district, 2015-16 26 100 Share of pregnant women (%) 90 80 70 60 50 40 30 20 10 0 4 or more ANC ANC in first IFA for at least Two or more TT Full antenatal Postnatal check visits trimester 100 days injections during care within 2 days pregnancy Source: NFHS-4 (2015-16) 53. Similar variation is observed for child health indicators, with coverage of basic vaccination among children 12-23 months ranging from 39 percent in Nagappatinam to 93 percent in Tirupur. Stunting varies from 17 percent in Kanyakumari to 37 percent in Ariyalur. Figure (5.3): Key Child Health Indicators by District in Tamil Nadu, 2015-16 100 80 60 40 20 0 All basic vaccinations Stunting Children with anaemia (<11.0 g/dl) Source: NFHS-4 (2015-16) 54. Utilization of health services is slightly lower among the Scheduled Tribes. For instance, 77 percent of pregnant women attend four or more ANC visits as compared to the state average of 81 percent. The timing of ANC also differs, with only 56 of pregnant women from Scheduled Tribes seeking ANC in the first trimester. While almost all women are given IFA during ANC, uptake of this intervention is low – only half of women from the Scheduled Tribes take IFA for at least 100 days during pregnancy (compared to the state average of 64 percent). 27 Table (5.1): Utilization of health services During Pregnancy by different Caste Groups 4 or more ANC in first Two or more IFA for at Full ANC visits trimester TT injections least 100 during days pregnancy Scheduled caste 79.6% 63.4% 66.7% 61.6% 44.2% Scheduled tribe 77% 55.5% 51% 52.8% 33.4% Other backward class 81.9% 64.2% 65.3% 65.2% 45.6% Other 85.6% 75.9% 64.1% 68.9% 50.7% Tamil Nadu 81.2% 64.0% 65.4% 64.0% 42.7% Source: NFHS-4 (2015-16) 55. There are notable differences in the incidence of NCDs by gender and socio-economic status. The incidence of diabetes and cancer is slightly higher among men than women. While the prevalence of NCDs appears to be more concentrated among the wealthier quintiles for women, the opposite is true for men. The prevalence of asthma and heart disease is almost three times higher among men in the poorest quintile than in the richest quintile (Figure 5.4). Figure (5.4): Prevalence of NCDs among women and men ages 15-49 (%) 10% Share of women ages 15- 8% 6% 5% 4% 4% 4% 49 (%) 4% 3% 3% 4% 4% 3% 2% 3% 3% 3% 2% 2% 2% 2% 2% 1% 1% 1% 0% 1% 1% 0% 0% 0% Diabetes Asthma Thyroid disorder Heart Disease Cancer Q1 (poorest) Q2 Q3 Q4 Q5 (wealthiest) 10% 9% Share of men ages 15- 8% 6% 6% 6% 5%5% 4%4% 3% 4% 49 (%) 4% 3% 3% 2%2% 2%3%2% 3% 2% 2%2% 1% 1% 1% 1% 1% 2% 0% Diabetes Asthma Thyroid disorder Heart Disease Cancer Q1 (poorest) Q2 Q3 Q4 Q5 (wealthiest) 56. Other factors contributing to health outcomes are also emerging from level of education, standard of living, income disparities and poverty, and gender inequalities. While many of the sub-indicators are interlinked, the human development index, the gender inequality index and the multidimensional poverty index showcase the poorer districts contributing 28 more towards overall health outcomes. Districts such as Ariyalur, Perambalur, Theni, Villupuram, Tiruvannamalai, and Nilgiris falls in the bottom of most of the indices. Figure (5.5): Districts according to HDI, GII, MPI and FSI Index (2017) 1 0.9 0.8 0.7 0.6 Index 0.5 0.4 0.3 0.2 0.1 0 Human Development Gender Inequality Index Multi-dimentional Food Security Index (FSI) Index (HDI) (GII) Poverty (MPI) Index Source: Tamil Nadu HDR 2017 57. In addition, to the inequalities, which are evident from the various indicators above, on average, there is roughly a 30-percentage point difference between the top 20% and bottom 20% of districts on the use of reproductive health services. In addition, the quality of health care has been a concern and varies across primary, secondary and tertiary care and across districts which are also being addressed by the Program. 58. The Program has identified, nine priority districts to address geographic disparities on account of MCH and quality related issues, special focus will be maintained in select nine priority districts which constitute the bottom quintile of the MCH indicators in the state and other poorer districts with relatively larger proportion of tribal population, and includes Virudhunagar, Thoothukkudi, Tirunelveli, Theni, Ramanathapuram, Ariyalur, The Nilgiris, Dharmapuri, and Tiruvannamalai district. 6.2.3 Gender Gap Assessment 59. Women in Tamil Nadu have experienced mixed progress. While the maternal mortality in the state is low at 66 (per 100000 live births) and declining. Moreover, women in Tamil Nadu are better educated than in many other states, with reduction in gender gap from 18 percent in 2001 to 13.4 percent in 2011. While there is no gender gap in schooling up to higher secondary level, there is marginal gap of 6-10 percent in higher education. The female workforce participation in Tamil Nadu is higher than the national average at 40 percent. Participation in decision making by women is also high in Tamil Nadu with more than three-fourths of women participate in decisions about their own health care, major 29 household purchases (76% each) and visits to their own family and relatives (78%) 7. In addition, while the local bodies election in Tamil Nadu in 2011 resulted in 7 percent higher women than the mandated one-third reservation, the Tamil Nadu government has further passed bill in June 2016 for 50 percent reservations for women in local bodies election8. 60. Preliminary analysis of data suggests that there are three distinct areas which suggests gender gaps in health care services and includes (1) Services for specific diseases related to women, such as cervical or breast cancer, (2) Utilization of health insurance among female patients, and (3) Health sector response to gender based violence. 61. With respect the project and the health sector in Tamil Nadu, the key gaps identified is the services for specific diseases related to women, such as cervical and breast cancer. The National Cancer Control program describes common sites for cancer in India are oral cavity, lungs, oesophagus and stomach in males and cervix, breast and oral cavity among females. Also, over 70 percent of the cases report for diagnostic and treatment services in advanced stages of the disease, resulting in poor survival and high mortality rates. In Tamil Nadu, it accounts for 4.6 percent – 10.9 percent of all the deaths in 20169. (1). Gaps in Preventive and Curative Services for Cervical or Breast Cancer: 62. Both breast and cervical cancer is a major cause of cancer mortality in women and more than a quarter of its global burden is contributed by developing countries. Cervical cancer and breast cancer are the most common cancer among women in India. While the breast cancer constitutes about 19 – 34 percent of all cancers among women in India, the cervical cancer contributes to approximately 6 – 29 percent of all cancers in women. Screening for cancer is known to reduce mortality by early detection and treatment. In Tamil Nadu, 23 percent of women have ever undergone an examination of the cervix, 15 percent have ever undergone a breast examination, which is among the lower side compared to other southern states and closure to central, eastern and north-eastern states. Figure (5.6): Percentage of women age 15-49 who have ever undergone Cervix or Breast examinations 7 NFHS-4 (2015-16) 8 https://timesofindia.indiatimes.com/city/chennai/65000-women-to-hold-power-in-Tamil-Nadu-local- bodies/articleshowprint/52646684.cms 9 https://www.healthdata.org/sites/default/files/files/policy_report/2017/India_Health_of_the_Nation%27s_States _Report_2017.pdf 30 70% 61.3% 60% Percentage Women 50% 40% 33.6% 33.4% 31.9% 30% 23.1% 22.3% 20% 15.6% 12.8% 15.4% 9.4% 9.8% 10% 5.1% 0% Andhra Pradesh Karnataka Kerala Tamil Nadu Telangana India Cervix Breast Source: NFHS-4 (2015-16) 63. Distribution of states with proportion of women between the age group of 15-49 years have ever gone through the screening of cervix and/ or breast for cancer, suggests Tamil Nadu figure very much close to national average, which is a sharp contrast of Tami l Nadu’s performance on other health indicators. Figure (5.7): Distribution of States with Percentage of Women age 15-49 who have ever undergone Cervix or Breast examinations 70% 60% Percentage Women 50% (15-49 yr Age) 40% 30% 20% India 22.3% 23.1% TN 15.4% TN 10% 9.8% India 0% Cervix Breast Source: NFHS-4 (2015-16) (2). Gender Gap in Utilization of Health Insurance in Tamil Nadu 64. While the universal healthcare coverage provides healthcare and financial protection to all citizens and expected to help facilitate gender equity in health care. However, various studies across India and from Tamil Nadu suggests a gender gap in utilization of health insurance. The process evaluation of the Chief Minister's Comprehensive Health Insurance Scheme (CMCHIS), Tamil Nadu, suggests that over the 2012-13 to 2015-16 period, the overall claims have grown by 38.2 percent. In absolute terms, the claims by male and female beneficiaries have increased by 50.0% and 20.4%, respectively, over the same years10. The rate of increase in claims by males is greater than that of females, and as result, 10 Process Evaluation Report: Chief Minister's Comprehensive Health Insurance Scheme, Tamil Nadu. June 2017. https://www.researchgate.net/profile/VR_Muraleedharan/publication/317492205_Process_Evaluation_Report_ 31 the share of female beneficiaries to the total claims has fallen from 39.7% (in 2012-13) to 34.6% (in 2015-16). Figure (5.8): Utilization of Health Insurance Among Male and Female 70% 64% 66% 65% 60% 60% 50% 40% Percentage Claim 40% 36% 34% 35% 30% 20% 10% 0% 2012-13 2013-14 2014-15 2015-16 Male Female Source: Process Evaluation Report: Chief Minister's Comprehensive Health Insurance Scheme, Tamil Nadu. June 2017. TNHSP/ USAID. 65. Discussion with CMCHIS suggests, that the earlier system had a pull-down menu for male and female for the claim, and given the card is in the name of the head of the family (mostly male) the default entry for every card no. is the head of the family and their corresponding gender i.e. mostly male. In case of claim if it is not changed for the particular member of the family, it takes the default, which actually skews the data in favour of male. Noticing this, CMHIS has recently corrected the software. However, CMHIS do agree that there is gender gap in utilization of health insurance, and to which they have already initiated measures such as awareness generation using mass IEC campaigns and social mobilization using Village Health Nutrition Day (VHND) mechanism. (3). Health sector response to gender-based violence 66. In Tamil Nadu the areas that also needs attention for the health sector response is gender- based violence and more specific the domestic violence or intimate partner violence (IPV) especially when it is about 45.6 percent of women between the age group of 15-49 years have faced either physical or sexual violence at least once in their lifetime (NFHS-4, 2015- 16) and of which about 8 percent faced sexual violence. Majority of ever married women facing physical violence is on account of spousal violence or IPV (40 percent) which is marginally lowered from 42 percent during the NFHS-3 (2005-06) period. What is more surprising is the comparative sketch with some of the low-income states. While there is drastic drop in spousal violence in States such as Bihar, Assam, Madhya Pradesh, Tripura and West Bengal, there was only a 1.3 percent (41.9 to 40.3 percent) drop in Tamil Nadu between 2005-06 to 2015-16 period11. Chief_Minister's_Comprehensive_Health_Insurance_Scheme_Tamil_Nadu/links/593bd312458515e398ed313e/ Process-Evaluation-Report-Chief-Ministers-Comprehensive-Health-Insurance-Scheme-Tamil-Nadu.pdf 11 NFHS-4, 2015-16 32 67. About one-quarter of women who have experienced spousal physical or sexual violence have suffered injuries as a result of the violence, and the most common type of injury is cuts, bruises, or aches. However, the long-term consequences of intimate partner abuse have been well documented and resulting in post-traumatic stress disorder (PTSD) and depression. Only 14 percent of women who have ever experienced physical or sexual violence by anyone have sought help. Over three-fourths (76 percent) of women have neither sought help nor told anyone about the violence. Abused women who have sought help most often seek help from their own families. Only 1 percent of abused women who sought help for the violence sought help from the police (NFHS-4). 68. There have been several health care service provision examples of screening for domestic violence and providing services and/or referrals within the primary or secondary health care settings in India and other neighbouring countries. The recent one being the Sakhi – One stop centre12 initiated by Ministry of Women and Child, Government of India in April 2015, to provide a comprehensive service to the aggrieved and have already sanctioned about 236 such OSCs till FY 2017-18 (of which 170 was operational by 1st Jan 2018), and another 198 in FY 2018-19 and plans to sanction additional 284 in FY 2019-20. With these 718 OSCs, it plans to ensure at least one in each district. Of the 6 such centres sanctioned in Tamil Nadu till FY 2017-18, only one was operational on 1st Jan 201813. 69. Discussion with Joint Director (JD), Social Welfare Department (SWD), Tamil Nadu looking after the ‘Sakhi-One Stop Services’ informed that of the 6 OSC centres sanctioned, one in Tambaram (Chennai) is functional (in a temporary facility) as the new centre is under construction, on the remaining five the land and people are identified, and they are being initiated. However, for the remaining 26 districts place for OSC is identified and proposal is forwarded to Govt. of India. In each of these centres it is currently staffed by five persons i.e. a centre administrator, two family councillors, a legal councillor, an IT person and a Multipurpose worker. A department is request for Government order (GO) for permanent position of a person from police and a permanent legal person. The JD SWD informed that in order to create awareness both mass media (poster at prominent places, in Metro trains and buses, radio jingles etc, and inter personal communication is being used. Experience from Tambaram OSC suggests that over the last one year about 107 cases have registered. A linkage has also been setup with Tambaram hospital where the CMO and another doctor has been nominated as the point person for all health services to the Tambaram OSC centre. 12 http://wcd.nic.in/schemes/one-stop-centre-scheme-1 13 http://nari.nic.in/sites/default/files/170-Operational%20OSCs-10.1.2018.pdf 33 70. Across the country, most of the OSCs are setup inside hospital settings and in some states in District Collectors office or other Government offices, and already collaborated with health sector for necessary responses e.g. Tambaram OSC has linked with Tambaram Hospital with CMO and another doctor acting as point person for all necessary services. While the OSCs is each district are still being established and made operational, it is too early to identify gaps in collaboration with health. 6.2.3.1 Addressing Gender Gap 71. With respect the project and the health sector in Tamil Nadu, the key gender gap identified is the health services for specific diseases related to women such as cervical and breast cancer. The poor screening for cervical and breast cancer so far has been largely because of lack of awareness about the disease as well as lack of screening and diagnostic services being available at the health care facilities. To address this, the project prioritized cervical, breast and oral cancer screening, detection and treatment by strengthening health care facilities, lab services for diagnostics, building capacity of the health care providers on non- communicable disease (NCD) services including cervical, breast and oral cancer, developing and implementing associated guidelines and protocols, and awareness generation among community especially among women on the risks associated through social and behaviour change communication (SBCC). This is evident from the project result chain with the key outcome indicator on NCD (Ref: Result Area #2 indicator) reflecting improved utilization of diagnostic services for cervical, breast and oral cancer among others. The NGOs participated in the stakeholder consultation workshop highly appreciated the Program agenda of working on Cervical and Breast cancer as that being one of the key areas that they have been pursuing with Government for quite some time. 72. In addition, another gap area identified includes status of reproductive health in low- performing districts. While the state average for these mother and child care (MCH) indicators i.e. full ante-natal care (ANC), prevalence of modern contraceptive method, and full vaccination looks good, there is roughly a 30-percentage point difference between the top 20% and bottom 20% of districts on the use of these services. This is largely because of lack of awareness and knowledge among women in the reproductive age about modern contraceptive methods, quality of antenatal care (ANC) being poor across districts, and lack 34 of knowledge about the immunization schedule. The project is also trying to close this equity gap in priority (low-performing) districts by enhancing specific services by undertaking gap analysis and reasons for the same to inform the facility improvement plans, conducting household survey in priority districts to assess demand-side constraints in MCH service utilization across communities, establishment of maternity stay wards in PHCs in remote and hilly tribal areas, and strengthening mobile dispensaries for urban poor, slum and remote areas. To bridge the equity gap, the demand side interventions of the Program include the development and implementation of the SBCC strategy tailored to the target community and the priority districts. the These are embedded in results area #3 on equity with outcome indicator being “Reduced inequities in utilization of select MCH services between top and bottom quintile of districts�. 73. While the Gender based violence (GVB) has been identified as one of the initial challenges in Tamil Nadu, another program lead by MWCD (GoI) nationally and by Social Welfare department (GoTN) in Tamil Nadu with more comprehensive response strategy to address this gap through One Stop centre (OSCs) - a sub-scheme of Umbrella Scheme for National Mission for Empowerment of Women. Popularly known as Sakhi, being implemented since 1st April 2015. These OSC Centres are being established across the country in each district to provide integrated support and assistance under one roof to women affected by violence, both in private and public spaces in phased manner. The OSC Centres are integrated with a Women Helpline to facilitate access to services. The services includes – (a) Emergency Response and Rescue Services - OSC will provide rescue and referral services to the women affected by violence, (b) Medical assistance in collaboration with nearest health facility, (c) Assistance to women in lodging FIR / NCR/ DIR, (d) Psycho - social support/ counselling, (e) Legal aid and counselling, (f) Provide temporary shelter facility to aggrieved women, and (g) Provide video conferencing facility - to facilitate speedy and hassle free police and court proceedings. 74. Within this strategy, the role of health department is limited to providing linkage of One Stop Centers (OSC) to nearest health facility for any medical assistance such as women affected by violence would be referred to the nearest Hospital for medical aid/examination which would be undertaken as per the guidelines and protocols developed by the Ministry of Health and Family Welfare. Discussion with Tambaram OSC in Chennai and Social Welfare Dept, GoTN, suggests no felt gap with health facility linkages. And hence, no additional response designed under the proposed Program for GBV. 6.2.4 Key Social Impacts 75. Overall the Program has low likelihood of any negative social impacts. There is no land acquisition anticipated under the Program. The Program does not support any major construction and it is limited to minor renovation and repairs of existing building. Hence, it is unlikely that any additional land is required beyond the existing footprint of the health facility. The Program further aims to enhance positive social outcome by addressing the issues related to inequalities in health services and quality of health care provision in poorer and backward districts are being addressed through quality of care and equity result area of 35 the Program. The table below presents the key social risks and gaps with respect to main activity clusters of the Program and potential measures to align with ESSA core principles. 6.3 Key Risks and Gaps and Potential Measures to Align with ESSA Core Principles Sl. Activity Cluster Key Risk and Gaps Potential Measures to align No. with ESSA Core Principles Result Area-1: Quality of care 1 Accreditation for primary-, Environment To align with core principle secondary-, and tertiary-level Accreditation process involves #1, an environment strategy is health facilities in the public improving the BMWM and proposed that will have sector - National Quality other environmental hygiene so enabling provisions to fill the Assurance Standards (NQAS) it will be beneficial. identified gaps for primary- and secondary-level Not all facilities are ready for facilities and National accreditation and will require Accreditation Board for substantial investments; there is Hospitals & Healthcare no intermediate certification to Providers (NABH) for tertiary- improve on environmental level facilities (medical parameters. colleges). Social The proposed activities will benefit the people at large with improved quality of health care infrastructure and services. 2 Program also supports Environment To align with core principles interventions that form a Lack of adequate training #1 and #3, training facilities comprehensive set of approaches facilities and low frequency ofwill be expanded, and in achieving the quality of care refresher trainings on BMWM refresher trainings will be and include (a) strengthening and OHS introduced; hospital continuous medical education; accreditation will be (b) developing and disseminating Social supported and overall clinical protocols/guidelines and Low likelihood of any negative environmental hygiene will clinical decision support tools; social risks with the proposed be improved (c) monitoring quality of care activities. using facility dashboards for public reporting; (d) introducing and scaling up quality improvement initiatives (including performance-based incentives, quality committees, hospital quality networks and other interventions). Result Area-2: Management of Non-Communicable Diseases and Injuries 3 Continuation and further scaling- Environment To align with core principles up of the NCD initiatives Enhanced diagnostic abilities #1 and #3, training facilities previously supported by the and facilities do not pose any will be expanded, and World Bank, mainstreamed into specific environmental risk or refresher trainings will be Tamil Nadu’s health sector impact. Systems to manage of introduced; hospital 36 Sl. Activity Cluster Key Risk and Gaps Potential Measures to align No. with ESSA Core Principles activities and fed into the BMW will be strengthened in accreditation will be NPCDCS; Tracer conditions for the healthcare facilities. supported and overall NCD response supported by the environmental hygiene will Program include hypertension, Social be improved. diabetes, cervical cancer, breast Low likelihood of any negative cancer, oral cancer, and mental social risks with the proposed health. And development of activities.. Some of the NCD care cascades for selected activities related to enhancing tracer conditions (for example, the screening services for hypertension and diabetes); cervical and breast cancers will Strengthening NCD service help address the gender gap delivery at the lowest level identified. through health and wellness centres and PHCs; Strengthening of lab services; Improving health provider capacity to address mental health; Improving data on NCDs and mental health for better planning and management. 4 Strengthening social and Environment Not Applicable behavior change communication No environmental risks and (SBCC). As part of the SBCC gaps strategy, patient support groups and other patient empowerment Social mechanisms will be established No social risk and gaps. to transform patients, especially those with chronic conditions, from being passive recipients of care into proactive participants who are equipped with knowledge and skills for self- management of their conditions. 5 Implementation of the Environment Not applicable Emergency Medical Services No environmental risks and (EMS) work plan, including gaps. BMW generated during emphasis on further emergency services and patient strengthening the 108 ambulance transfer in ambulances are service to improve pre-hospital addressed at the hospital, up on care, provision of 24x7 trauma arrival of the ambulance care services at Level 1 and Level 2 emergency departments to Social improve in-hospital care, and No social risk and gaps. establishment of a trauma registry. Initiative to provide Level 3 and Level 4 training to emergency department trauma care providers and other health care workers to strengthen both pre- hospital and in-hospital care. 37 Sl. Activity Cluster Key Risk and Gaps Potential Measures to align No. with ESSA Core Principles Result Area-3: Closing Equity Gaps in Reproductive and Child Health 6 Reduce inequities between This will help bridge the Already aligned with ESSA districts focus on a combination inequity between the bottom core principle #5 with of supply- and demand-side quintile districts with top culturally appropriate SBCC interventions to support increased quintile districts on tailored to priority districts utilization of RCH services. reproductive child health and special focus to nine services. However, in order to poorer districts including the Supply-side interventions upgrade the infrastructure for districts with tribal include improved budget NQAS accreditations, some of population. allocations for priority districts, the facilities may need to better provision of RCH services undertake minor civil works as measured by NQAS towards repair and renovations. accreditation of primary and And hence, there is an outer secondary care facilities and chance that the facility requires establishment of maternity stay its own land and there may be wards in remote areas. Demand squatters on the same. side interventions include the development and implementation of the SBCC strategy tailored to these priority districts. Cross-cutting Areas 7 Program also supports Environment Integration of BMW systematic, cross-cutting reforms No specific environmental risks reporting with HMIS will which will impact the above or gaps identified. align with core principle #1. three results areas as well as the Already aligned with core health sector more broadly. Social principle #5 by giving special These include: (a) strengthening The activities related to focus to community voice and HMIS, (b) increasing enhancing the citizen agency to monitor the transparency and accountability engagement through district Program outcome. with increased quantity, better and state health assemblies quality and better use of data; which are civic forums built on (c) strengthening health the Panchayati Raj system to administration and management boost citizen voice and agency. at different levels, including improving integration/ coordination between different health directorates as well as between centrally-sponsored schemes and state-financed efforts (d) conducting annual district and state health assemblies which are civic forums built on the Panchayati Raj system to boost citizen voice and agency and catalyse a social movement in health and (e) supporting operational research, implementation research, and health system research to inform decision-making, enable course 38 Sl. Activity Cluster Key Risk and Gaps Potential Measures to align No. with ESSA Core Principles corrections and generate lessons for Tamil Nadu as well as other states. 6.3.1 Key issues concerning Institutional Strengthening 76. As mentioned earlier, there is satisfactory institutional capacity among the functionaries participating health directorates on addressing the social concerns including the tribal health components of the ongoing program. The guidelines and procedures are defined and being followed. However, the proposed Program intends to build overall capacity of the health care functionaries of all participating Directorates and Society(ies) by promoting continued medical education (CME) and helping develop policy and strategy to strengthen the gap areas in quality health care service provision. In addition, with the change in the financing instrument i.e. PforR, there is a need to further strengthen the inter-institutional coordination mechanism for better Program outcome. The institutional capacity to address environmental issues will require strengthening on some specific areas. For example, in the management of liquid wastes from hospitals and improved capacity for monitoring and reporting on the BMWM across the healthcare facilities. 39 7 ASSESSMENT OF PROGRAM CONSISTENCY WITH CORE PRINCIPLES IN THE POLICY ON PROGRAM FOR RESULTS FINANCING 7.1 Environment 7.1.1 Core Principle 1: Assessment of the degree to which the Program Systems promote environmental sustainability in the Program design; avoid, minimize or mitigate against adverse impacts; and promote informed decision-making relating to a Program’s environmental effects. 77. This is determined as applicable. Certain interventions under the Program would require mitigation actions and sustainable approaches to better manage Program’s environmental effects. These include, among others: (i) Issues related to generation, collection, segregation, storage, transport, management and disposal of Biomedical, Solid and Hazardous wastes. This is particularly relevant for facilities in peri-urban and rural areas; and (ii) Reducing the risk of contracting infections within healthcare facilities. The upkeep, cleanliness and hygiene of public conveniences in several of the healthcare facilities is deficient and inadequate resulting in sub-optimal infection control. 7.1.2 Core Principle 2: Assessment of the degree to which the Program systems avoid, minimize, and mitigate against adverse impacts on natural habitats and physical cultural resources resulting from the Program 78. This is determined as applicable. Whereas interventions proposed under the Program would not impact natural habitats and physical cultural resources, lack of pollution management infrastructure, particularly to treat and release effluents from large hospitals pose the risk of adversely impacting aquatic habitats. 7.1.3 Core Principle 3: Assessment of the degree to which the Program Systems protect public and worker safety against the potential risks associated with (a) construction and / or operation of facilities or other operational practices developed or promoted under the Program; (b) exposure to toxic chemicals, hazardous wastes, and otherwise dangerous materials; and (c) reconstruction or rehabilitation of infrastructure located in areas prone to natural hazards. 79. This is determined as applicable. Certain interventions under the Program could expose healthcare providers and beneficiaries to risks associated with exposure to hazardous materials, infections, radiation as well as risks related to construction activities, personal safety etc. This would require integrating mitigation actions in the operational manuals, SOPs, procedures etc. These include, among others: (i) Improving occupational health and safety practices at healthcare facilities through infrastructure design, construction management, infection control, protocols for addressing accidental spills; (ii) Providing protective clothing and personal safety equipment, as required; (iii) Ensuring safe storage, segregation, transport and disposal of hazardous wastes; (iv) Environmental considerations: 40 waste management; (v) worker and public health and safety focusing on emergency response; patient safety focusing emergency response. 7.2 Social 7.2.1 Core Principle 4: Land acquisition and loss of access to natural resources are managed in a way that avoids or minimizes displacement, and affected people are assisted in improving, or at least restoring, their livelihoods and living standards. 80. Though there is no land acquisition and/or resettlement is anticipated under the Program, as the Program does not support any major construction and it is limited to minor renovation and repairs of health facilities. Hence, it is unlikely that any additional land is required beyond the existing footprint of the health facility. Screening will be conducted in health facility where any repair, renovation and expansion is planned to avoid any adverse social impact. Screening will be conducted by health facility in-charge with guidance from social safeguard specialist at the TNHSRP PMU. 7.2.2 Core Principle 5: Due consideration is given to cultural appropriateness of, and equitable access to, Program benefits giving special attention to rights and interests of Indigenous Peoples and to the needs or concerns of vulnerable groups. 81. The Tribal Health program initiated under the World Bank supported TNHSP during 2005- 15 has been effectively mainstreamed into the department program and expanded after the closure of the project and includes regular activities such as provision of ASHAs in tribal/ difficult areas, creating birth waiting rooms in tribal PHCs and linking with 108 ambulances to ensure tribal mother reach the delivery point on time, running mobile medical units in tribal areas, placing of tribal counsellors in government hospital in tribal districts, strengthening emergency referral system from tribal PHCs, and screening of adolescent tribal children and unmarried school dropouts above the age of 14 in 30 selected tribal blocks in 13 Districts for early detection of Sickle Cell, Anaemia & Thalassemia which are common diseases among tribal population. 82. The proposed Program further intends to strengthen the health care delivery across state including in the districts with tribal population overall quality of health care in primary, secondary and tertiary health care facilities, and addressing inequities in MCH service utilization in nine priority districts which constitute the bottom quintile of the MCH indicators in the state and other poorer districts with relatively larger proportion of tribal population, and includes Virudhunagar, Thoothukkudi, Tirunelveli, Theni, Ramanathapuram, Ariyalur, The Nilgiris, Dharmapuri, and Tiruvannamalai district. This is further supported by with a more comprehensive SBCC strategy that includes multiple layers of engagement with patients, health providers and communities through various channels of communication tailored to the priority districts. 7.2.3 Core Principle 6: Avoid exacerbating social conflict, especially in fragile states, post-conflict areas, or areas subject to territorial disputes. 41 83. Not Applicable, as the state has no conflict affected or territorial dispute area. The team does not expect any exclusion of any groups in terms of caste, religion, and/ or geography by the Program activities. In addition, the state has been considered as generally a peaceful state in India with rare incidence of any civil strife or communal violence. 8 CONSULTATION AND DISCLOSURE 8.1 Consultation during the ESSA 84. As part of the ESSA preparation, discussions and consultations were conducted with key stakeholders including the key departments/ agency including TNHSP, Directorate of Family Welfare (DFW), Directorate of Public Health and Preventive Medicine (DPH), Directorate of Medical and Rural Health Services (DMRHS), Tamil Nadu State Health Society (TNSHS) including key staff members from NHM, Directorate of Medical Education (DME), Social Welfare Department, and Land Administration Department. Comments, suggestions and areas that require strengthening was sought during the free and prior informed consultation with NGOs working on tribal health and member of tribal community during the stakeholder consultation on 24th October 2018. 8.2 Disclosure and Consultation on the Draft ESSA 85. The findings of ESSA were disclosed in a disclosure workshop organized in Chennai on 24th October 2018. The participants included representative from various Government Departments including from TNHSP Society, NHM, CMCHIS, Social Welfare Department, State Resource Centre for Women (SRCW, Tamil Nadu) and One Stop Centre (OSC), DPH, DMS, DMRHS, DHFW, Tribal Welfare Directorate, Tamil Nadu State AIDS Control Society (TANSACS), ELCOT, PWD, and TNUHP; health facilities and research Institutions such as Madras Medical College and General Hospital Tambaram (Chennai); representatives from various NGOs working on health and/or with tribal and vulnerable population – SAATHII (Chennai), Community Seva Centre (Puducherry), Bharthi (Selam), Sudar Oli Trust (Vellore), Nilgiri Adivasi Welfare Association (NAVA), Kotagiri (Nilgiris), Toda women sangam federation (Ooty); and members of tribal community including members from Nilgiris Particularly Vulnerable Tribal Group (PVTG) Council and Irula tribal society Nilgiris. Representative from health Directorates also included officer responsible for planning and implementation of Bio-medical waste management in the health facilities. Details are presented in Annex -2. 8.3 Disclosure of the Draft and Final ESSA Reports 86. The final report of the ESSA will be disclosed on the website of the Health Department (GoTN) and at World Bank’s external website prior to appraisal. 8.4 Citizen Engagement and Grievance Redress Mechanism 87. Citizen Engagement. The Program aims to improving accountability and empowering citizens through the Annual District and State Health Assemblies and are aligned with best 42 global practices. This will improve voice and agency of citizens through collective action while also raising the visibility of the health concerns and needs of communities. In the first year of the Program, a framework and detailed plan will be developed to convene State and District Health Assemblies each year. Subsequently, one District Health Assembly would be organized annually in each district and one State Health Assembly would be convened annually. The Assemblies will be organized in a timely manner such that all the district events are completed before the State Health Assembly. This is embedded in the intermediate result indicator #5 and DLI #11 of the Program. Through these state and district health assemblies, the Program also aims to achieve vertical integration of accountability by providing a platform for citizens to engage in health policy. In addition, under the Program, the State will develop policies and guidelines for quality and introduce open-access dashboards for monitoring progress on quality, that will also help in building citizen’s trust in the health systems. This will be further strengthened with a more comprehensive SBCC strategy that includes multiple layers of engagement with patients, health providers and communities through various channels of communication. As part of the SBCC strategy, patient support groups and other patient empowerment mechanisms will be established to transform patients (especially those with chronic conditions) from being passive recipients of care into proactive participants who are equipped with knowledge and skills for self-management of their conditions. To bridge the equity gap, the demand side interventions of the Program includes the development and implementation of the SBCC strategy tailored to the priority districts. 88. Grievance Redressal Mechanism. Along with the Complaint Cell set up by the health ministry of Tamil Nadu (i.e. http://www.tnhealth.org/complaintcell.htm), the 104 health helpline has been providing holistic health information, advice and service improvement to the public. On an average, it receives 2,600 calls a day. From December 2013 to June 2017, the Health Department’s 104 helpline has received a total of 9,18,688 calls from across the State. The person wishes to redress any grievance calls 104 and inform the control room staff. The control room staff records the grievance/ suggestions in the automatic recorder. For the grievances which are to be redressed immediately, the control room staff calls the district grievances cell officer over phone who will in turn contact the hospital concerned to solve the problem. At present, a majority of the complaints are related to delay in the provision of care, the district grievances cell officer nominated for the month are instructed to be responsive to the call swiftly and take action. If grievance cell officer notices any delay even after his/her intervention, s/he would call the state grievances cell officer who would intervene and sort out the issue14. In addition, in case of medical colleges, for registering grievances any one can complaint to Resident Medical Officer (RMO) who takes necessary action for redressing the grievances and report back to the Dean of the medical college in periodic manner. If not satisfied with redressal, one can escalate the matter to the Dean for redressal. 14 http://cms.tn.gov.in/sites/default/files/gos/hfw/hfw_e_90_2008.pdf 43 9 CONCLUSION AND RECOMMENDATIONS 89. The ESSA concludes that the Program has a moderate environmental risk and moderate social risk. The Program risks on dealing with BMW are reasonably covered but will require efforts to address other environmental challenges emerging from the health sector. The institutional setup has the potential to develop required capacity to deal with the potential environmental risks and challenges. The Program has low likelihood of any negative social impacts. There is no land acquisition anticipated as the Program does not support any major construction and it is limited to minor renovation and repairs. Hence, it is unlikely that any additional land is required beyond the existing footprint of the health facility. Screening will be conducted in health facilities where any repair, renovation and expansion is planned to avoid any adverse social impact. The result areas focus on quality of health care across the state and bridging inequalities in priority districts and bottom most quintile on MCH indicators and other poorer tribal districts. In addition, members/ representatives of tribal and other vulnerable community and civil society will be included as part of the district health assemblies to be setup under the Program to review and feedback on Program output and outcome during the implementation. 9.1 Program Exclusions and Recommendations on Social and Environmental Aspects 90. Exclusion of high risk activities. Based on the findings and screening, ESSA has identified two potential investment areas or activities that may have high environmental or social risks, as these activities are likely to have significant adverse impacts on the environment and/or affected people. These two activities are not eligible for including under the Program. These are a. Construction of large buildings; any exception will have to be subjected to a standalone impact assessment and come up with an environmental management plan; and b. Support to establishing municipal landfill and establishment of Common Treatment Facility (CTF) for BMW disposal. c. Any land acquisition and/ or resettlement 91. Strengthening the capacity on Hospital Environmental Management within the TNHSRP PMU is recommended. The Program will recruit and deploy a dedicated qualified environmental expert to develop integrated waste management approach covering solid and liquid wastes and overall environmental management initiatives of the healthcare facilities. This expert will be recruited in the first year and will also support the development of the environment strategy. 9.2 Recommendations on Social Aspects 92. A Social Safeguard Screening Checklist is presented in the Annex-1 of this report that will be applied for where renovations and/or expansions are planned to rule out any adverse social impact. The screening will be conducted by the health facility in charge under the guidance of social safeguard specialist in TNHSP-PMU. 44 93. PMU will recruit and deploy a dedicated and qualified Social Safeguard specialist to oversee the implementation of social safeguard measures especially the screening for any adverse social impacts and coordinating implementation of other social safeguard measures planned under the Program. 94. The project has low likelihood of any negative social impacts. . Based on the assessment, table below presents the key social issues identified and recommendations or the way forward for the same. Key Social Issues Assessment/ Key Findings Recommendations/ Way Identified Forward Tribal health services The Tribal Health program While the ongoing program on initiated by the earlier World tribal health meets the current Bank project in Tamil Nadu has requirements, the proposed been mainstreamed and further Program will further strengthen it expanded to meet the health care with enhancing quality of health requirements. care and bridging the inequity in health services among the most backward and poorer districts in Tamil Nadu including some of the district with tribal population. Inequalities in health The Program has identified The Program has already plan to sector services across inequalities in health care address this through the equity districts services related to MCH as there result area of the Program with is roughly a 30-percentage point identifying nine priority districts difference between the top 20% for specific focus on MCH and bottom 20% of districts on services. This is embedded in the the use of reproductive health result are #3 and DLI #8. services. Quality of health care Quality of health care services The Program has already plan to services especially in has been identified as one of the address this through the quality of poorer districts key issues across the state and in care result area of the Program. poorer districts of the state. This is embedded in the result are #1 and DLI #2 and DLI #3. Addressing gender gap in The key gender gap identified The Program has already plan to health care services are the health services for address this through the quality of specific diseases related to care result area of the Program. women such as cervical and This is embedded in the result are breast cancer, and status of #2 and #3 and DLI #8. reproductive health in low- performing districts. 9.3 ESSA’s Recommendations to Program Action Plan ESSA DLI/Program Actions 45 95. The ESSA proposes the following DLI/Program Actions. • DLI: Develop an Environment Strategy for the Health Sector in Tamil Nadu. The proposed environment strategy for Tamil Nadu will include provisions/ways to improve the efficiency of healthcare delivery by addressing issues such as waste management, resource efficiency, type-design of healthcare facilities, especially the wellness centers proposed by the State, effluent and hazardous pollution by expanding the pollution management set-up, particularly Effluent Treatment Plants, greenhouse gas emission footprint etc. The strategy will include an institutional capacity building plan, including a human resource plan and integration of healthcare waste management with the State’s HMIS. Wider consultations with a range of stakeholders will be undertaken during the preparation of the environment strategy. Adequate budget will be ensured for preparation and implementation of the strategy as it is part of the expenditure framework. • Program Action 1: Introduce continuous refresher trainings on biomedical and other wastes management. Develop new facilities and/or upgrade existing ones to provide targeted training and refresher training for staff at all levels and cross all healthcare facilities in managing biomedical, hazardous, plastic and other solid wastes. Extend the training program to NGOs providing healthcare services in remote rural, tribal and hilly areas. • Program Action 2: Performance audits of CTFs. Carry out annual audit of CTFs, to assess the performance of BMW segregation, collection and transportation, performance of CTFs in line with the BMW Rules, 2016 and overall environment management of CTFs. Responsible Completion Action DLI/PAP Due Date Agency Measurement Year 1 Environment strategy Develop an Strategy finalized and Environment Published, adopted by Strategy for the DLI TNHSP Adopted and the State; and Health Sector under YR2-5, in Tamil Nadu implementation Strategy implemented Year 1 Finalization Introduce New refresher of training continuous training course modules and refresher rolled out for schedules TNHSP trainings on PAP healthcare staff Year 2-5 DME biomedical and across all concurrent other wastes healthcare refresher management facilities training started Year 1 Annual Performance PAP Agency TNHSP performance audits of CTFs contracted for audit reports 46 performance publicly audit disclosed Year 2-5 Annual audits conducted 47 ANNEX 1 SOCIAL SAFEGUARD SCREENING CHECK LIST FOR PRELIMINARY ASSESSMENT OF HEALTH CARE FACILITIES (This screening format needs to be filled under the guidance of health care facility in-charge i.e. Medical Superintendent for District/Regional Hospitals and/or Medical College Hospitals, Medical Officer for CHCs and PHCs, and the ANM for the SCs to rule out any adverse social impacts due to Program intervention.) 1 Name of the District 2 Name of the Block 3 Name of the Health Facility 4 Category of health facility 5 Requirement of Land for any construction Yes/ No beyond exiting land available with the health (If Yes, give details below; In case No – Q.6 to facility Q.11 are not applicable) 6 Is the site identified for the proposed Yes/ No (If Yes, give details below) activities under the Program 7 Area Required (specify unit – acres/ sq.mt/ sq.ft. etc.) 8 Type of Land and ownership details 9 Currently in possession of 10 Number as per land record 11 Is there a need to acquire the land for Yes/ No proposed activities If No, go to Q.No. 13 12 Proposed mechanism for acquiring the land Through Land Acquisition Process/ Direct Purchase/ Lease/ Other mechanism (specify) 13 Are there any squatters living on the land Yes / No (If Yes, give details below) proposed 14 Are there any commercial structures on the Yes/ No (If Yes, give details below) land proposed 15 Is the land being used as common property Yes/ No resources - such as water supply structure; (If Yes, please write details about the structure sanitation structures; power supply and its use by local residential/ commercial/ infrastructure etc. or approach way institutions) 48 16 Is there any encroachment or any claim on Yes/ No the proposed land (If yes, give details of from when and what kind) If Yes, report to TNHSP-PMU for necessary action 17 Any other specific information related to Give details land 18 Is the photograph of the additional Yes/ No construction site/ land enclosed 19 Does the proposed activities require any land Yes/ No acquisition as per point #11 above If Yes, Report to TNHSP-PMU for necessary action 20 Has there been any ‘Yes’ answer to any of Yes/ No the screening point # 13,14 and 15 above If Yes, Report to TNHSP-PMU for necessary action Officer In charge for preliminary screening In-charge of Health care facility Name……………………………. Name: ………………………… Designation: ……………………. Designation: ……………………. Phone No. …………………….. Phone No. …………………….. Signature ……………………… Signature……………………….. Date: ……………………………. Date: ……………………………. 49 ANNEX 2 MINUTES OF ESSA DISCLOSURE AND STAKEHOLDER CONSULTATION WORKSHOP – CHENNAI – OCTOBER 24, 2018 The findings of ESSA were disclosed in a disclosure workshop organized in Chennai on 24th October 2018. The participants included representative from various Government Departments including from TNHSP Society, NHM, CMCHIS, Social Welfare Department, State Resource Centre for Women (SRCW, Tamil Nadu) and One Stop Centre (OSC), DPH, DMS, DMRHS, DHFW, Tribal Welfare Directorate, Tamil Nadu State AIDS Control Society (TANSACS), ELCOT, PWD, and TNUHP; health facilities and research Institutions such as Madras Medical College and General Hospital Tambaram (Chennai); representatives from various NGOs working on health and/or with tribal and vulnerable population – SAATHII (Chennai), Community Seva Centre (Puducherry), Bharthi (Selam), Sudar Oli Trust (Vellore), Nilgiri Adivasi Welfare Association (NAVA), Kotagiri (Nilgiris), Toda women sangam federation (Ooty); and members of tribal community including members from Nilgiris Particularly Vulnerable Tribal Group (PVTG) Council and Irula tribal society Nilgiris. Representative from health Directorates also included officer responsible for planning and implementation of Bio- medical waste management in the health facilities. Participants who were invited but could not join the workshop included representatives from Land Administration Department, Tamil Nadu Pollution Control Board and representatives from Common Treatment Facilities (CTFs) for Bio-medical waste management. A list of participants is appended to the minutes. The workshop started with introductory remarks by Tmt. P. Uma Maheswari, Project Director, TNHSP followed by which the World Bank team presented the findings of Environment and Social Systems Assessment. The comments and suggestions were invited on the findings and the recommendations of the assessment. The key discussion points, comments and suggestion from the participants and next steps that emerged are given in the table below. 50 Comments and Suggestions from Disclosure Workshop Participants and Agreed Next Steps S. No. Comments/Suggestions from Participating How the Program Design Addresses Agreed Next Steps Stakeholders These • Prioritization of cervical and breast cancer • The current Program doesn’t include • NGOs will hold further screening and linking to treatment under the vaccination, the State Government discussion with TNHSRP for Program was appreciated. could bring it under the Program. inclusion of vaccination. • Whether vaccination for cervical cancer is included as part of the Program? • NGOs providing healthcare services in remote tribal • At present the Program design • NGOs will be invited for and hill areas raised the issue of limited doesn’t envisage technical and technical trainings and opportunities for building their own skills. financial support to NGOs. refresher trainings, including • Healthcare facilities provided by NGOs in tribal and • The Program design includes on BMWM. hill areas require them to spend up to 1 Lakh on provisions to disseminate and share • NGOs will take up the issue of BMWM. Can the Program extend financial support technological innovations on BMWM financial support for BMW for this? with TNHSRP to identify potential financial resources, including other than the State budgetary support for BMWM. • Nutritional support provided as part of the tribal • The Program design emphasizes • TNHSRP will facilitate a health program is insufficient to address the issue of quality of care and equity and discussion with NHM and sickle cell anaemia. includes measures to improve the WCD/ Social welfare Dept. on • Tribal, especially among the primitive tribes, don’t health care facilities and services nutritional support through come forward for ANCs and other health care including at the primary level and ICDS program on specific services and require changing their behaviour to backed by the social and behaviour gaps and mechanism to access services. change communication (SBCC) address the same. tailored to the need and socio-cultural context of the priority districts which includes some of the tribal districts 51 S. No. Comments/Suggestions from Participating How the Program Design Addresses Agreed Next Steps Stakeholders These • Participants appreciated the #108 ambulance • The Program design includes several • No specific next steps. system. measures to improve the quality of • The number of referrals from sub-centre to PHC to health care services at the first point CHC/ District Hospital are high resulting in delayed of contact itself. This includes treatment, discomfort to patients and often improving stabilization treatment to deterioration in health condition leading to fatalities. overcome the service deficit on emergency care. • The Program will strengthen screening and tracking of five NCDs for monitoring quality of treatment given. • The Program will track the numbers of referrals made and adjust support to reduce referrals. • Participants appreciated preparation of several • The Program design includes • TNHSRP will ensure wider strategies, including environment strategy and provisions of stakeholder stakeholder consultations. asked for their participating in developing these. consultations while developing these strategies. • Cash incentives for institutional deliveries are • At present the Program doesn’t • Tribal NGOs will hold further limited to government recognized PHCs and include such considerations. discussions with TNHSRP healthcare facilities. This makes tribal households and State Govt. to explore travel long distance for such financial incentives and empanelling of non- during travel complications often arise, sometimes government healthcare fatal. Can the government empanel other healthcare services for such incentives. facilities run by tribal NGOs for cash incentives? • Need to increase postings of doctors and nurses in • The Program design emphasize • The Program will further tribal and hill areas. quality of healthcare that will address explore improving the services of mobile clinics. 52 S. No. Comments/Suggestions from Participating How the Program Design Addresses Agreed Next Steps Stakeholders These • Rounds by mobile clinics are substantially apart availability of qualified professionals leaving a gap in healthcare provisioning. at these facilities. • Inclusion of mental health as part of the Program • Program design will encourage • No specific next steps. was appreciated. collaboration with experienced • What resources are being made available under the agencies/ NGOs such as Sneha, which Program? are already running the suicide help line. • The Tribal Health Resource Centre that was started • The Program welcomes this • Program will ensure that IEC under the erstwhile TNHSP is still functional and suggestion. material is made available at can be used/ referred further when designing the center. activities under the Program especially in priority/ tribal districts. • One Stop Centres under the social Welfare • The Program welcomes this • Program will ensure Department can assist on addressing domestic suggestion. collaboration with such violence and other issues related to health care centers. services on mental health, trauma and suicide. • Participants suggested that best practices and • The Program design includes • TNHSRP will ensure that successful case studies from TNHSRP should be measures for disseminating learnings learnings are widely shared shared with other States in India. nation-wide. across the country. 53 List of participants: Disclosure Workshop 54 55 56 57