The World Bank Report No: ISR4727 Implementation Status & Results India India: Rajasthan Health Systems Development Project (P050655) Public Disclosure Copy Operation Name: India: Rajasthan Health Systems Development Project Project Stage: Implementation Seq.No: 16 Status: ARCHIVED Archive Date: 21-Sep-2011 (P050655) Country: India Approval FY: 2004 Product Line: IBRD/IDA Region: SOUTH ASIA Lending Instrument: Specific Investment Loan Implementing Agency(ies): Department of Medical, Health and Family Welfare Key Dates Board Approval Date 11-Mar-2004 Original Closing Date 30-Sep-2009 Planned Mid Term Review Date 21-Jul-2007 Last Archived ISR Date 21-Sep-2011 Effectiveness Date 21-Jul-2004 Revised Closing Date 30-Sep-2011 Actual Mid Term Review Date 30-Jul-2007 Project Development Objectives Project Development Objective (from Project Appraisal Document) PDO1: Increase access to health care of poor (BPL) and underserved population by upgrading health care facilities in the remote areas, promoting public private partnership and improving health care seeking behavior through demand side interventions. PDO2: Improve the effectiveness of health care through strengthened institutional framework for policy development, program implementation and management capacity, and increase in the quality of health care. Has the Project Development Objective been changed since Board Approval of the Project? Yes No Component(s) Component Name Component Cost 1. PROJECT MANAGEMENT, POLICY DEVELOPMENT AND CAPACITY BUILDING 19.97 2. DEVELOPMENT OF PRIMARY AND SECONDARY HEALTH CARE SERVICES IN THE PUBLIC 52.70 SECTOR 3. HEALTH CARE INNOVATIONS FOR THE DISADVANTAGED 33.31 Public Disclosure Copy Overall Ratings Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory Overall Risk Rating Implementation Status Overview The Rajasthan Health Systems Development Project (RHSDP) was approved in March 2004 (SDR 61 million, US$ 89 million) and was extended in 2009 by two years, with a closing date of September 30, 2011. Due to savings stemming from exchange rate changes as well as partial completion of some project activities during the extension phase, SDR 6.875 Page 1 of 6 The World Bank Report No: ISR4727 million was canceled from the credit, so that the final credit amount is SDR 54.125 (US$ 84.5 million). RHSDP has made a significant contribution to revitalizing and strengthening the health system in the state. In the past decade, in tandem with increased government health spending to which the project contributed, health indicators have improved significantly. For example, the infant mortality rate fell from 67 per 1,000 live births in 2004 to 43 in 2010-11, and the proportion of deliveries taking place in health facilities rose from 30% in 2002-04 to 71% in 2009. Through capital investments and technical assistance, the project has largely achieved its development objectives, supporting health service Public Disclosure Copy delivery to disadvantaged populations, particularly secondary-level care. The project rolled out several activities in nine focus districts located in desert areas and/or with significant tribal populations to support achievement of its first objective, which is to increase access of the poor (BPL) and the under-served population to health care. These activities included outreach camps in difficult to reach areas; provision of counseling services to facilitate information and physical access of disadvantaged populations; behavior change training for service providers; and several print, electronic and interpersonal communication campaigns for encouraging preventive, promotive and curative behaviors. Data available from Hospital Management Information Systems of 238 project-supported health facilities indicates that, as a proportion of total outpatients and inpatients, attendance of below-poverty-line (BPL) patients doubled during the project lifetime. Moreover, inpatient attendance of patients from scheduled tribes has trebled during the period. Achievement of the second project objective, which is to improve effectiveness of health care through institutional development and increase in quality of health care, is indicated by the sharp increase in the number of public facilities conducting more than 10 deliveries --the infrastructural and skill up-gradation supported by the project and improved staffing and availability of appropriate skill mix at government health facilities since baseline, contributed to this. The capacity developed by the project within government has been harnessed by the state to establish the Rajasthan Medical Services Corporation and roll out of a scheme for free medicines to all patients at public health facilities. The project has also catalyzed the development of a drug logistics and supply chain management system in the state and introduced a concept for institutionalization of zonal medical equipment maintenance and management workshops in the state. The state government has taken steps to continue project-supported activities, such as outreach camps, and effectively maintain capital investments. Locations Country First Administrative Division Location Planned Actual India Rajasthan Rajasthan ✔ India Rajasthan State of Rajasthan Results Project Development Objective Indicators Indicator Name Core Unit of Measure Baseline Current End Target Percentage of BPL populations among out Text Value 8.7% 16.6% 17% patients seen at all project facilities ie district hospital (DH) and sub district hospitals (SDH Date 01-Jan-2006 30-Jun-2011 30-Sep-2011 and CHC). Comments data available from 234 Revision of legal agreement facilities for June 2011 of December 2009 indicates Public Disclosure Copy target of 17%; Aide Memoire of September 2010 indicates revised target of 27% Page 2 of 6 The World Bank Report No: ISR4727 Percentage of ST populations among Text Value 8.3% 24.9% 15% inpatients seen at all project facilities in six tribal districts i.e. DH, SDH, & CHC in sixtribal Date 01-Jan-2006 30-Jun-2011 30-Sep-2011 districts Comments data from 49 facilities in six data from 47 facilities in six Revision of legal agreement Public Disclosure Copy tribal districts tribal districts of Dec. 2009 indicates target of 15%; Aide Memiore of September 2010 indicates target of 23% (aide-memoire Sep. 2010) Percentage of CHCs conducting > 10 Text Value 60% 96.6% 90% deliveries a month Date 01-Jan-2006 30-Jun-2011 30-Sep-2011 Comments 185 CHCs reporting 178 CHCs reporting Percentage of clients (patients and non Text Value 92% respondents from project 94% respondents from project Increasing patients) satisfied with the services received at facilities satisfied with facilities were satisfied with project facilities. behavior of doctors; 85% doctors# behavior and 72% satisfied with behavior of were satisfied with nurses nurses Date 30-Jul-2008 31-Aug-2011 30-Sep-2011 Comments Intermediate Results Indicators Indicator Name Core Unit of Measure Baseline Current End Target Percentage of project facilities reporting (paper Text Value 20% 90.34% 100% based) monthly HMIS reports Date 15-Apr-2006 30-Jun-2011 30-Sep-2011 Comments 215 of 238 facilities reported Percentage of clinical trainings completed Text Value 0% 64% 100% according to plan Date 15-Apr-2006 30-Jun-2011 30-Sep-2011 Public Disclosure Copy Comments Of the total training load of Complete all planned trainings 4503 trainees for 23 trainings, 2866 was successfully completed. Percentage of facilities renovated/ upgraded Text Value 0 100% 100% out of the planned 238 facilities Date 01-Oct-2009 27-Sep-2011 30-Sep-2011 Page 3 of 6 The World Bank Report No: ISR4727 Indicator Name Core Unit of Measure Baseline Current End Target Comments Original phase: 238 health All 302 (238 health facilities+ All 302 works completed facilities renovated + 1 PMU PMU building + 63 works from Public Disclosure Copy building constructed; extension phase) completed Extension phase: 14 Trauma and handed over. centers, 6 ICUs, 19 rehabilitation centers and 24 burns ward proposed Percentage of project facilities that have a Text Value 0% 100% 90% social worker/counselor Date 15-Apr-2006 30-Jun-2011 30-Sep-2011 Comments 131 patient counselors placed in 113 fifty bedded and above project facilities Percentage of project facilities (MRSs) Text Value 0% 86.5% 90% receiving payment form equity fund Date 15-Apr-2006 31-Mar-2011 31-Mar-2011 Comments At extension phase of project decisions were taken to # not provide equity funds to district hospitals which were self sufficient; # provide equity funds to only those RMRS#s which submitted audited statement of accounts for the previous financial year. # equity funds would be suspended after March 2011. Percentage of CHCs/BPHCs staffed according Text Value Doctors: 49.6% (49 facilities Doctors: 47.31%; Nurses/ 90% to agreed norms in tribal areas reporting) Nurses/ANMs: 90% ANMs: 108% and Laboratry (49 facilities reporting) Lab Technicians: 66.7% Public Disclosure Copy tech: 91% (49 facilities reporting) (year 4target 50%) Date 31-May-2006 30-Jun-2011 30-Sep-2011 Page 4 of 6 The World Bank Report No: ISR4727 Comments 47 of 49 facilities reporting. It is now understood that the target for 90% staffing in tribal areas is too ambitious to be achieved within the project Public Disclosure Copy lifetime. Meeting this target calls for substantive reforms in the health and medical education sector which were/ are beyond the scope of the project. It is evident that this target will likely not be met in the coming future as well. Percentage of facilities: (i) implementing their Text Value (i) Training in 10 facilities and (i) 100% 100% health care waste management (HCWM) plan; civil works in another 10 with (ii) 100% (ii) completing the implementation of their completion of deep burial pits HCWM plan and segregation of human waste in color coded plastic bags in these facilities; (ii) 0% Date 15-Apr-2006 30-Jun-2011 30-Sep-2011 Comments (i) Training of project facilities Completion of all planned completed. Additional training activities of PHCs: completed in 9 of 17 planned districts; all IEC materials developed and disseminated to encourage positive behaviours; 281 of 343 secondary health facilities connected to Common Treatment Facilities; all 343 secondary health facilities authorized by State Pollution Control Board. Moreover, study on impact evaluation ofHCWM implementation and Public Disclosure Copy a CTF audit successfully completed. A national level workshop conducted on May 5-6, 2011 for experience sharing on HCWM (ii) 100% of project facilities implementing HCWM plan. 82% of all secondary health facilities implementing HCWM plans. Page 5 of 6 The World Bank Report No: ISR4727 Data on Financial Performance (as of 12-Dec-2011) Financial Agreement(s) Key Dates Project Loan No. Status Approval Date Signing Date Effectiveness Date Closing Date Public Disclosure Copy P050655 IDA-38670 Closed 11-Mar-2004 03-Jun-2004 21-Jul-2004 30-Sep-2011 Disbursements (in Millions) Project Loan No. Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P050655 IDA-38670 Closed XDR 61.00 54.13 6.88 48.96 5.17 90.00 Disbursement Graph Key Decisions Regarding Implementation Public Disclosure Copy The project closed on September 30, 2011, and an Implementation Results and Completion Report (ICR) will be finalized by March 31, 2012. Restructuring History Level two Approved on 14-Sep-2011 Related Projects There are no related projects. Page 6 of 6