The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) Tamil Nadu Health System Reform Program (P166373) SOUTH ASIA | India | Health, Nutrition & Population Global Practice | Requesting Unit: SACIN | Responsible Unit: HSAHN IBRD/IDA | Program-for-Results Financing | FY 2019 | Team Leader(s): Rifat Afifa Hasan Seq No: 5 | ARCHIVED on 26-Mar-2021 | ISR45249 | Created by: Rahul Pandey on 11-Jan-2021 | Modified by: Rifat Afifa Hasan on 17-Mar-2021 Program Development Objectives PDO Table Program Development Objective (from Program Appraisal Document) The Program Development Objective (PDO) is to improve quality of care, strengthen management of non-communicable diseases and injuries, and reduce inequities in reproductive and child health services in Tamil Nadu. Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Satisfactory Moderately Satisfactory Implementation Status and Key Decisions There has been some progress in a few activities of the Tamil Nadu Health System Reform Program (TNHSRP), but limited progress on many other key activities in the last eight months is likely to make achievement of Year 2 Disbursement-Linked Results difficult, especially those which are timebound. The following describes the status under each of the results area:  Results Area #1 - Improved Quality of Care: A phased rollout plan for NQAS facility certification for the entire Program period was shared, and progress will be accelerated in the upcoming months. The Tamil Nadu Quality of Care Strategy (QoCS), approved in March 2020, is yet to be launched. There has been a significant delay in developing an operational plan, including a governance structure, for both the QoCS and the Policy for Continuous Professional Development for the health workforce (TAN-QuEST).  Results Area #2 - Strengthened Management of NCDs and Injuries: The GoTN has made significant achievements in trauma care, having procured 745 ambulances, initiated training of personnel to implement Canadian Triage and Acuity Scoring system (CTAS) and of Emergency Medical Technicians in Advanced Trauma Life Support for Advanced Life Support ambulances. Revisions on priority dispatch protocols and implementation of the regional trauma and emergency care system are progressing well overall, and implementation of the IT-based trauma registry is being expedited. The GoTN is also commended for finalizing the STEPS survey during the pandemic. Preliminary analysis of the STEPS survey has been completed and a final report will be available by end of February 2021. However, the Tamil Nadu NCD Strategy, approved in March 2020, is yet to be launched. An operational plan for it needs to be finalized and the NCD Strategy implemented in earnest.  Results Area #3 - Reduced Inequities in Reproductive and Child Health (RCH): Utilization of RCH services are rebounding after initial COVID-19-related setbacks. The ongoing RCH constraints assessment is expected to be completed by June 2021 and will inform the development of an appropriate social and behavior change communication (SBCC) strategy and other interventions to strengthen RCH service delivery, especially in the priority districts.  Cross-Cutting Initiatives to achieve results across the results areas: The GoTN has made progress in developing an environment strategy which is expected to be finalized and adopted by March 2021. While satisfactory progress has been made on procurement- related activities of the Program Action Plan (PAP), financial management-related actions have not progressed as much. All policies and strategies developed in Year 1 of the Program need to be launched. While the operational plan for the Operational Research Program Guidelines has been developed, the same needs to be done for the remaining policies and strategies. There has been no progress on developing a detailed data model and detailed design specifications for an integrated Health Management Information System (HMIS), and there has been very limited progress on the district and state health assemblies. While progress has been impeded understandably by COVID-19 related challenges, inadequate institutional and implementation arrangements have also contributed to its stagnation. The Task Forces and Working Groups that had been constituted are no longer functional, and the reforms encapsulated in the TNHSRP are not effectively overlaid onto the Department of Health and Family Welfare’s own program. In order for TNHSRP to 3/26/2021 Page 1 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) get back on track and achieve the expected results during the remainder of the Program period, strong leadership, close coordination and effective management is required.. Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P166373 IBRD-89340 Effective USD 287.00 287.00 0.00 52.74 234.26 18% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P166373 IBRD-89340 Effective 19-Mar-2019 04-Jun-2019 29-Jul-2019 31-May-2024 31-May-2024 DLI Disbursement Achievement Disbursed amount in Disbursement % for DLI ID DLI Type Description Coc DLI Amount Status Coc DLI Loan: IBRD89340-001 DLI1 Impl of imr in Pri Sec Partially 1 Regular USD 43,732,000.00 11,000,000.00 25 % Tert fac Achieved DLI2 Inc no of Pub Fac Partially 2 Regular USD 38,200,000.00 11,253,000.00 29 % with Certifi Achieved DLI3 Inc Shr of adult Hyp Partially 3 Regular USD 48,885,500.00 8,985,500.00 18 % Diab under Cnt Achieved DLI4 Impr Prov of Trauma Partially 4 Regular USD 17,715,000.00 2,035,000.00 11 % Care Serv Achieved DLI5 Inc Util Reprod Child 5 Regular USD 56,500,000.00 Not Achieved 0.00 Serv Prio Dis DLI6 Strgn Cont, Qual, Partially 6 Regular USD 36,500,000.00 6,000,000.00 16 % Access Dec Mak Achieved DLI7 Strgn Coord, Integ, Partially 7 Regular USD 30,750,000.00 8,750,000.00 28 % Perf bas Mgt Le Achieved DLI8 Inc transp, account, Partially 8 Regular USD 14,000,000.00 4,000,000.00 29 % Citi Eng Achieved Program Action Plan Increase bidder participation: (i) establish procurement complaint redressal system; and (ii) organize annual supplier Action Description forum/conferences Source DLI# Responsibility Timing Timing Value Status TNMSC, ELCOT, Fiduciary Systems Recurrent Continuous Completed PWD 3/26/2021 Page 2 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) Completion Measurement (i) procurement complaint redressal system established; (ii) annual supplier forum/conferences organized (i) completed by all three procurement agencies - TNMSC, TNPWD and ELCOT Comments (ii) completed by all three procurement agencies - TNMSC, TNPWD and ELCOT Strengthen FM capacity in NHM: (i) assessment to identify gaps in staffing and policies; (ii) training programs for Action Description accounting staff; (iii) greater use of expenditure module of PFMS; (iv) strengthen concurrent audit system. Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems NHM Society Recurrent Continuous Delayed Completion Measurement (i) gap assessment report; (ii) training programs organized; (iii) PFMS usage report; and (iv) concurrent audit report (i) Virtual training program on accounting and PFMS to be organized during Q2&Q3 is yet to start. Comments (ii) NHM State Society was supposed to initiate the process to develop audit manuals / detailed audit checklists and audit ToRs-this is also delayed Enhance transparency: (i) publicly disclose contract awards of value greater than INR 20 Million (approx. US$ Action Description 285,720); and (ii) collate information on fraud and corruption-related complaints and provide information to WB on a quarterly basis Source DLI# Responsibility Timing Timing Value Status TNMSC, ELCOT, Fiduciary Systems PWD; Secretariat, Recurrent Continuous Completed DOHFW (i) report on disclosure by the procurement agencies; and (ii) quarterly report on fraud and corruption-related Completion Measurement complaints (i) completed by all three procurement agencies - TNMSC, TNPWD and ELCOT Comments (ii) Information shared till the last quarter. Action Description BMWM: performance audits for the CTFs have to be undertaken Source DLI# Responsibility Timing Timing Value Status Environmental and Social TNHSRP PMU Recurrent Yearly Completed Systems Completion Measurement Annual performance audit conducted and reports publicly disclosed by the competent authority Comments TN Pollution Control Board has completed audit from 2016-2019 for CTFs and shared Action Description Introduce continuous refresher trainings on biomedical and other waste management Source DLI# Responsibility Timing Timing Value Status 3/26/2021 Page 3 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) Environmental and Social TNSHRP PMU and Recurrent Continuous In Progress Systems DME Completion Measurement New refresher training course rolled out for healthcare staff across all healthcare facilities The DoHFW has provided trainings to health workers on COVID-19 waste management, infection control and PPE Comments management. However, regular biomedical waste management, especially related to liquid wastes, needs more attention. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance Moderate Moderate Moderate Macroeconomic Low Moderate Moderate Sector Strategies and Policies Moderate Moderate Moderate Technical Design of Project or Program Moderate Moderate Moderate Institutional Capacity for Implementation and Low Moderate Moderate Sustainability Fiduciary Moderate Moderate Moderate Environment and Social Moderate Moderate Moderate Stakeholders Low Low Low Other Low High High Overall Moderate Moderate Moderate RiskComments Comments The risks have been reassessed and confirmed to remain the same. Results PDO Indicators by Objectives / Outcomes Improved Quality of Care and Reduced Equity Gaps in Reproductive and Child Health IN00946175 ►Increased number of public facilities with quality certification (primary, secondary, and tertiary) (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target (i) Tertiary i) Tertiary (i) Tertiary facilities (i) Tertiary facilities facilities with entry level facilities with entry level with entry level NABH Value with entry level NABH NABH accreditation: 0 NABH accreditation: 0 certification: 7 accreditation: 0 (ii) Secondary (ii) Secondary (ii) Secondary facilities facilities with NQAS facilities with NQAS with NQAS 3/26/2021 Page 4 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) (ii) Secondary certification: 27 out of certification: 29 out of certification: 70 of facilities with NQAS which 8 are in priority which 8 are in priority which 14 are in the certification: 3 districts districts priority districts (iii) Primary facilities (iii) Primary (iii) Primary (iii) Primary facilities with NQAS certification: 4 facilities with NQAS facilities with NQAS with NQAS certification: 36 out of certification: 36 out of certification: 300 of which 11 are in priority which 11 are in priority which 60 are in the districts districts priority districts Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 This indicator measures the number of facilities receiving quality certification during the Program period. Specifically, it monitors the: • number of medical colleges (tertiary facilities) with entry level NABH certification; • number of District Head Quarter, Taluk and non-Taluk Hospitals (secondary facilities) with full Comments NQAS certification; • number of CHCs and PHCs (primary facilities) with full NQAS certification. The indicator also monitors the number of facilities of each level receiving quality certification in priority districts. The priority districts are: Ariyalur, Dharmapuri, Ramanathapuram, The Nilgris, Theni, Thoothukkudi, Tirunelveli, Tiruvannamalai, Virudhunagar. IN00946310 Tertiary facilities with entry level NABH certification (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 7.00 Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 IN00946314 Secondary facilities with NQAS certification (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target 27 out of which 8 are in 29 out of which 8 are in 70 of which 14 are in Value 3.00 priority districts priority districts the priority districts Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 IN00946319 Primary facilities with NQAS certification (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target 36 out of which 11 are in 36 out of which 11 are in 300 of which 60 are in Value 4.00 priority districts priority districts the priority districts Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 Improved Quality of Care IN00946306 ►Improved scores in quality dashboard for primary, secondary, and tertiary level facilities (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target to be measured after NA – to be measured after to be measured after quality scorecard is Value quality dashboard is quality dashboard is To be established established – piloting in established established. progress Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 A quality dashboard will be developed for primary, secondary, and tertiary level facilities in Year 1. This Comments indicator will track the improvement on the quality dashboard score of these facilities on an annual basis. The baseline and target scores will be established once the dashboard is developed. 3/26/2021 Page 5 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) Strengthened Management of Non-Communicable Diseases and Injuries IN00946309 ►Increased screening in public sector facilities for cervical and breast cancers (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Cervical cancer: 3.8% Cervical cancer: 13.47% Breast cancer: 5.8% Breast cancer: 17.25% Cervical cancer: 15.8% Cervical cancer: 30% Value Breast cancer: 19.5% Data reported for Apr- Breast cancer: 30% Date reported for Apr-19 20 to Nov-20 to Mar-20 Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 % of women age 30+ screened for cervical and breast cancer in public sector facilities Numerator: number Comments of women age 30+ screened for cervical/breast cancers in public sector facilities Denominator: number of women age 30+ IN00946313 Cervical cancer (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 15.80 13.47 3.80 30.00 Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 IN00946317 Breast cancer (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 19.50 17.25 5.80 30.00 Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 Improved Quality of Care and Strengthened Management of Non-Communicable Diseases and Injuries IN00946307 ►Increased share of adults with hypertension or diabetes whose blood pressure or blood sugar are under control (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target to be measured after Hypertension under STEPS is implemented control: 3 percentage – final report of the point increase from NA - to be established to be measured after STEPS survey will be baseline Value after STEPS is STEPS is implemented submitted by January, Diabetes under implemented in 2019 2021 which will be used control: 6 percentage as the baseline for point increase from NCDs in Tamil Nadu baseline Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 (i) % of individuals age 30+ with hypertension whose blood pressure is under control;(ii) % of individuals age Comments 30+ with diabetes whose blood glucose level is under control. Numerators and denominators specified in the DLI verification protocol. IN00946311 Hypertension under control (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target 3/26/2021 Page 6 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) NA - to best established to be measured after to be measured after 3 percentage point Value after STEPS is STEPS is implemented STEPS is implemented increase from baseline implemented in 2019 Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 IN00946315 Diabetes under control (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target NA - to best established to be measured after to be measured after 6 percentage point Value after STEPS is STEPS is implemented STEPS is implemented increase from baseline implemented in 2019 Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 IN00946318 ►Improved provision of quality trauma care services (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target (i) # of trauma centers (i) # of trauma centers (i) # of trauma centers (i) # of trauma centers using trauma registry: 2 using trauma registry: using trauma registry: 0 using trauma registry: 2 (ii) % of surgical ED 54 (ii) % of surgical ED (ii) % of surgical ED admissions: 6.7% (ii) % of surgical ED Value admissions: 6.7% admissions: 6.7% (iii) % of IFT calls as a admissions: 15% (iii) % of IFT calls as a % (iii) % of IFT calls as a % % of total 108 system (iii) % of IFT calls as a of total 108 system calls: of total 108 system calls: calls: 41.1% % of total 108 system 41.1% 41.1% calls: 30% Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 (i) Number of trauma centers using trauma registry (ii) % of surgical ER admissions in Group A and B facilities* who received surgery within 6 hours in the same institution Numerator and denominator specified Comments in the DLI verification protocol. *Group A surgeries include general, orthopedic, plastic, vascular and neuro surgeries; Group B surgeries are limited to general and orthopedic. (iii) % of inter-facility transfer calls as a % of total 108 system calls Numerator and denominator specified in the DLI verification protocol. IN00946321 # of trauma centers using trauma registry (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 2.00 2.00 54.00 Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 IN00946322 % of surgical ED admissions (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 6.7% 6.7% 6.7% 15% Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 IN00946323 % of IFT calls as % of total 108 system calls (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 41.1% 41.1% 41.1% 30% Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 3/26/2021 Page 7 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) Reduced Equity Gaps in Reproductive and Child Health IN00946308 ►Increased utilization of reproductive and child health services in priority districts (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target (i) Full ANC: 28.8% (i) Full ANC: 28.8% (ii) Fully immunized: (ii) Fully immunized: 57.9% (i) Full ANC: 28.8% 57.9% (i) Full ANC: 41.3% (iii) mCPR: 38.5% (ii) Fully immunized: (iii) mCPR: 38.5% (ii) Fully immunized: Value 57.9% 70.4% To be reported after the (iii) mCPR: 38.5% To be reported after the (iii) mCPR: 43.5% new round of NFHS new round of NFHS data data is available is available Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 This indicator monitors the utilization of select RCH services in the 9 priority districts: Ariyalur, Dharmapuri, Ramanathapuram, The Nilgris, Theni, Thoothukkudi, Tirunelveli, Tiruvannamalai, Virudhunagar. The priority districts were identified based on their performance on RCH indicators and proportion of ST population. Three RCH indicators will be monitored: full immunization, full antenatal care, and use of modern methods of contraception. Numerators and denominators specified in the DLI verification protocol. Full antenatal care Comments (ANC): Pregnant women receiving at least four ANC visits, at least one TT injection, and taken IFA tablets or syrup for 100 or more days. Full immunization: Children 12-23 months receiving vaccinations against tuberculosis, diphtheria, pertussis, tetanus, polio, and measles. Modern contraceptive prevalence rate (mCPR). Modern methods include male and female sterilization, injectables, intrauterine devices (IUDs/PPIUDs), contraceptive pills, implants, female and male condoms, diaphragm, foam/jelly, the standard days method, the lactational amenorrhoea method, and emergency contraception. IN00946312 Full ANC (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 28.80 28.80 28.80 41.30 Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 IN00946316 Fully immunized (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 57.90 57.90 57.90 70.40 Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 IN00946320 mCPR (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 38.50 38.50 38.50 43.50 Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 Intermediate Results Indicators by Results Areas Result #1: Improved Quality of Care IN00946324 3/26/2021 Page 8 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) ►Implementation of quality improvement interventions in primary, secondary, and tertiary care facilities (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target (i) Number of (i) Number of primary, facilities implementing (i) Number of primary, (i) Number of primary, secondary, and tertiary at least 1 endorsed secondary, and tertiary secondary, and tertiary level facilities quality improvement level facilities level facilities implementing at least 1 initiative from the list of implementing at least 1 implementing at least 1 endorsed quality evidence-based endorsed quality endorsed quality improvement initiative interventions specified improvement initiative improvement initiative from the list of in the QoC Strategy: from the list of evidence- from the list of evidence- evidence-based Primary: 570 and based interventions based interventions interventions specified Value Secondary and specified in the QoC specified in the QoC in the QoC Strategy: 0 tertiary:248 ………….. Strategy: 0 ………….. (ii) Strategy: 0 ………….. (ii) (ii) Number of Number of primary, Number of primary, (ii) Number of primary, facilities reporting on secondary, and tertiary secondary, and tertiary secondary, and tertiary quality dashboard facilities reporting on facilities reporting on facilities reporting on quarterly: Primary: 570 quality dashboard quality dashboard quality dashboard and Secondary and quarterly: 0 quarterly: 0 quarterly: 0 tertiary: 248 Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 This indicator tracks the implementation of at least one endorsed quality improvement initiative from the list of evidence-based interventions specified in the QoC Strategy and the number of facilities reporting on the quality dashboard quarterly. The indicator monitors each intervention at the primary and secondary/tertiary facilities. The quality dashboard will include indicators to measure quality of care along the three dimensions Comments of quality: structural inputs, clinical processes, and patient outcomes. The GoTN and the World Bank will develop this dashboard jointly. The indicators will vary by level of facility. Following development of the dashboard, primary, secondary, and tertiary facilities will be monitored for quarterly reporting on the quality dashboard. Numerators and denominators specified in the DLI verification protocol. IN00946327 ►Piloting of patient experience questionnaire for secondary & tertiary care facilities (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 10.00 Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 A detailed patient experience questionnaire – expanding the concept of the Mera Aspatal survey to measure patient satisfaction – will be developed for patients visiting secondary & tertiary facilities. This indicator will Comments track the % of secondary & tertiary facilities piloting this patient experience questionnaire. Numerator: number of secondary & tertiary facilities piloting the patient experience questionnaire. Denominator: total number of secondary & tertiary facilities Result #2: Strengthened Management of Non-Communicable Diseases and Injuries IN00946330 ►Increased share of primary & secondary facilities with at least one staff trained on mental health (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 40.00 Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 This indicator measures the % of primary & secondary facilities with at least one staff trained on mental Comments health. Numerator: number of primary & secondary facilities with at least one staff receiving face-to-face 3/26/2021 Page 9 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) training on mental health. Denominator: total number of primary & secondary facilities. The indicator would be reported once the training on mental health starts in this FY (Apr 2020-Mar 2021) IN00946332 ►Establishment of suicide hotline (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2021 TN has a functional toll-free number (104) for counselling on health issues and grievances related to health Comments services. Under the Program, a hotline linked to the 104 health helpline will be developed for counselling related to suicide contemplation and attempts. IN00946333 ►Better equipped ambulance system to improve pre-hospital care -number of ATLS ambulances providing Level 1 care (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 64.00 122.00 122.00 164.00 Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 Comments Number of ATLS ambulances providing Level 1 care during the year. IN00946336 ►Improved capacity of trauma care providers - number of emergency department providers that received Level 3 (BTLS) and Level 4 training (ATLS) (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Level 3: Nurses - 1548; Level 3: Nurses - 165; Level 3: Nurses - 1548; Level 3: Nurses - Doctors - 883. Doctors - 100. Doctors - 883. 9000; Doctors - 6000. Value Level 4: Nurses - 181; Level 4: Nurses - 0; Level 4: Nurses - 156; Level 4: Nurses - 900; Doctors - 134. Doctors - 0. Doctors - 119. Doctors - 600. Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 This indicator measures the number of emergency department providers that received Level 3 (BTLS) and Comments Level 4 training (ATLS) during the year. Result #3: Reduced Equity Gaps in Reproductive and Child Health IN00946326 ►Implementation of updated social and behavior change communication (SBCC) strategy (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 This indicator tracks progress on the implementation of annual workplans developed as part of a Comments comprehensive SBCC Strategy. The SBCC strategy will include messages on NCDs and their risk factors (including mental health), road safety, and RCH in priority districts IN00946329 ►People who have received essential health, nutrition, and population (HNP) services (Number, Corporate) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 922,179.00 722,344.00 3,600,000.00 3/26/2021 Page 10 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) Date 29-Mar-2019 31-Mar-2020 31-Dec-2020 01-Jul-2024 This indicator tracks number of children who have received immunization services (BCG) in the state. Comments IN00946334 Number of children immunized (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 922,179.00 722,344.00 3,600,000.00 Date 29-Mar-2019 31-Mar-2020 31-Dec-2020 01-Jul-2024 Cross-Cutting Results IN00946325 ►Strengthened content, quality, accessibility, and use of data for decision making (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target A detailed model and Conceptual Model and detailed design Conceptual Model and Operational Plan for a specifications for Operational Plan for a Integrated system strengthened and integrated Health strengthened and implemented in all the Value integrated Health Management integrated Health health facilities in 9 Management Information Information System Management Information districts: Yes System (HMIS): (HMIS): not completed System (HMIS) : No developed and approved and expected to be delayed Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 A Conceptual Model and Operational Plan for a strengthened Health Management Information System (HMIS) covering all data sources, data users and data channels including integration with electronic medical records and patient tracking for NCDs will be developed in Year 1. In Year 2, a detailed model and detailed design specifications will be completed based on the Conceptual Model and Operational Plan. In Year 3, a Comments contract will be awarded for development of integrated HMIS, and key modules (electronic health record and reporting) will be piloted in at least 1 primary, 1 secondary, and 1 tertiary facility in a district. In Year 4, the indicator will monitor the implementation of an integrated system in all the health facilities of at least one district (as determined by a GoTN order). In Year 5, the integrated system will be implemented in all the health facilities of up to an additional 8 districts of Tamil Nadu. IN00946328 ►Strengthened coordination, integration, performance-based management, learning, and other cross-cutting functions for better results (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target (i) Operational research program launched with 1 annual call for research proposals issued and selected (i) 1 annual call for proposal awarded: not research proposals completed, GO awaited. issued and selected (ii) Deploying e- proposal awarded. TN Health Policy Value Policies/Strategies: No procurement system in (ii) Development & Developed & adopted TNMSC and 20% of adoption of value of total contracts performance-based of TNMSC under the incentive strategy for Program done through PHCs: Yes. e-procurement: system developed, 20% contract value being ascertained 3/26/2021 Page 11 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 This indicator tracks development and adoption of the following policies, strategies, and activities. Year 1: • TN Health Policy/ Strategy for Vision 2030; • Development and adoption of an Environment Strategy for the Health Sector in Tamil Nadu. Year 2: • Launch of the operational research program with 1 annual call for research proposals issued and selected proposal awarded. • Deploying e-procurement system in TNMSC Comments and 20% of value of total contracts of TNMSC under the Program done through e-procurement. Year 5: • Development and adoption of performance-based incentive strategy for PHCs. Year 3-5: One annual call for research proposals issues and selected proposals awarded. IN00946331 ►Increased transparency and accountability through citizen engagement (voice, agency, and social accountability) (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Districts conducting Districts conducting Districts conducting Health Guideline for state & Health Assembly: 0%. Health Assembly: Value Assembly: 0%. District Health Assembly State Health Assembly: 60%. State Health Assembly: 0 developed & adopted 0 State Health Assembly: 1 Date 01-Nov-2018 31-Mar-2020 31-Dec-2020 01-Jul-2024 Year 2 onward, the indicator will monitor the share of districts conducting health assemblies/forums and Comments whether an annual State Health Assembly was convened. District health assemblies are expected to occur before the State Health Assembly. Numerator and denominator specified in the DLI verification protocol. IN00946335 Districts conducting Health Assembly (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0% 0% 0% 60% Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 IN00946337 State Health Assembly (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 1.00 Date 01-Nov-2018 24-Jul-2020 31-Dec-2020 01-Jul-2024 Disbursement Linked Indicators DLI_IND_TABLE ►DLI 1 Implementation of quality improvement interventions in primary, secondary, and tertiary care facilities (Output, 43,732,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 5 (i) At least 1 health facility implementing at least 1 endorsed Ad hoc implementation of Ad hoc implementation of quality improvement Value quality improvement quality improvement No progress reported initiative from the list initiatives by hospitals initiatives by hospitals of evidence-based interventions specified in the QoC 3/26/2021 Page 12 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) Strategy: US$20,000 for each primary care facility up to 143 facilities and US$30,000 for each secondary and tertiary care facility up to 62 facilities...….(ii) At least 1 health facility reporting on quality dashboard during each quarter of the reporting year: US$14,800 for each additional primary care facility up to 190 facilities and US$22,000 for each additional secondary and tertiary care facility up to 82 facilities from the previous year Date -- 14-Jun-2019 31-Dec-2020 -- Comments ►DLI 2 Increased number of public facilities with quality certification (primary, secondary and tertiary) (Outcome, 38,200,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 5 (i) US$850,000 for every tertiary care facility certified (up to 2 such facilities)…………...( ii) US$160,0 00 for every (i) Tertiary: 0 (i) Tertiary: 0 additional secondary (ii) Secondary: 7 (i) Tertiary: 0 (ii) Secondary: 7 care facility certified (iii) Primary: 21 (ii) Secondary: 3 (iii) Primary: 21 (up to 21 facilities), Tertiary = medical (iii) Primary: 4 Tertiary = medical with an additional colleges Tertiary = medical colleges colleges US$75,000 for each Value Secondary = district, Secondary = district, taluk, Secondary = district, taluk, of the first 2 that are taluk, and non-taluk and non-taluk hospitals and non-taluk hospitals in the priority hospitals Primary = PHCs and CHCs Primary = PHCs and districts...……...(iii) Primary = PHCs and CHCs US$37,00 CHCs 0 for every additional primary care facility certified (up to 79 facilities), with an additional US$15,000 for each of the first 10 that are in the priority districts Date -- 14-Feb-2020 14-Feb-2020 -- 3/26/2021 Page 13 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) Comments ►DLI 3 Increased share of adults with hypertension or diabetes whose blood pressure or blood sugar are under control (Outcome, 48,885,500.00, 0%) Baseline Actual (Previous) Actual (Current) Year 5 (i) The percentage point increase in the share of hypertensive adults whose blood pressure is under control over the previous survey (with statistical significance) up to 1.5 percentage points increase - US$7.3 million for Baseline to be established every percentage after STEPS is Baseline to be established Baseline to be point increase implemented – STEPS Value after STEPS is established after STEPS ……………………… fact sheet generated; implemented in 2019 is implemented in 2019 (ii) The however, full report yet to percentage point be prepared increase in the share of diabetic adults whose blood glucose is under control over the previous survey (with statistical significance) up to 3 percentage points increase - US$3 million for every percentage point increase Date -- 14-Jun-2019 31-Dec-2020 -- Comments ►DLI 4 Improved provision of quality trauma care services (Outcome, 17,715,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 5 Value (i) # of trauma centers (i) # of trauma centers (i) # of trauma centers (i) Increase in the using trauma registry: 0 using trauma registry: 2 using trauma registry: 2 number of trauma ……………….(ii) % of ……………….(ii) % of ……………….(ii) % of centers where the surgical emergency surgical emergency surgical emergency trauma registry is in department admissions in department admissions department admissions in use - US$35,000 for Group A and B facilities in Group A and B Group A and B facilities each additional who received surgery within facilities who received who received surgery trauma center from 6 hours of admission in the surgery within 6 hours of within 6 hours of the previous year same institution: 6.7% admission in the same admission in the same operating a trauma ……………….(iii) % of IFT institution: 6.7% institution: 6.7% registry up to 14 calls as a % of total 108 ……………….(iii) % of ……………….(iii) % of IFT trauma centers system calls: 41.1% IFT calls as a % of total calls as a % of total 108 ………….. (ii) 108 system calls: 41.1% system calls: 41.1% Percentage point 3/26/2021 Page 14 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) increase in surgical emergency department admissions in Group A and B facilities who received surgery within 6 hours of admission - US$600,000 for every percentage point increase up to 3 percentage points ……………. (iii) Percentage point decrease in IFT calls as a percent of total 108 system calls - US$800,000 for every percentage point decrease up to 2 percentage points Date -- 14-Feb-2020 14-Feb-2020 -- Comments ►DLI 5 Increased utilization of reproductive and child health services in priority districts (Outcome, 56,500,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 5 Value (i) Women receiving full (i) Women receiving full (i) Women receiving full (i) Percentage point ANC: 28.8% ……………… ANC: 28.8% ANC: 28.8% ……………… increase in women (ii) Children 12–23 months ……………… (ii) (ii) Children 12–23 months receiving full ANC fully immunized: 57.9% Children 12–23 months fully immunized: 57.9% compared to the …………….. (iii) Modern fully immunized: 57.9% …………….. (iii) Modern previous survey contraception prev. rate: …………….. (iii) Modern contraception prev. rate: (with statistical 38.5% contraception prev. rate: 38.5% significance) - 38.5% US$1,600,000 for Definitions: (a) Full ANC every percentage means at least four ANC point increase from visits, at least one tetanus baseline up to 5 toxoid injection, and having percentage points taken IFA tablets or syrup ……………………… for 100 or more days. (b) .. (ii) Percentage Full immunization means point increase in full vaccinations against immunization of tuberculosis, diphtheria, children 12–23 pertussis, tetanus, polio, months compared to and measles the previous survey (with statistical significance) - US$1,600,000 for every percentage point increase from baseline up to 5 percentage points ……………………… ….. (iii) Percentage point increase in modern contraceptive prevalence rate 3/26/2021 Page 15 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) compared to the previous survey (with statistical significance) - US$3,300,000 for every percentage point increase from baseline up to 2 percentage points Date -- 14-Jun-2019 14-Jun-2019 -- Comments ►DLI 6 Strengthened content, quality, accessibility, and use of data for decision-making (Output, 36,500,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 5 Detailed Conceptual Model and Operational Plan developed for a strengthened HMIS Integrated HMIS covering all data sources, implemented in all data users and data the health facilities channels including in at least 1 HMIS in place but HMIS in place but integration with electronic additional district of Value fragmented across data fragmented across data medical records and Tamil Nadu - streams/ databases streams/ databases patient tracking for NCDs. US$1,000,000 per No progress reported on district up to a the next DRL on detailed maximum of 8 data model and detailed districts design specifications for integrated HMIS completed Date -- 14-Jun-2019 31-Dec-2020 -- Comments ►DLI 7 Strengthened coordination, integration, performance-based management, learning, and other cross-cutting functions for better results (Process, 30,750,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 5 Value NA NA (i) TN Health Policy Annual call for developed and adopted research proposals (ii) Operational Rsearch issued and selected Program developed and proposal awarded - adopted US$ 3,000,000 (iii) Environment Strategy developed; however, needs to be adopted (iv) e-procurement system for TNMSC developed; however, 20% of value of total contracts yet to be processed using this system (v) ORP not yet launched with call for proposals 3/26/2021 Page 16 of 17 The World Bank Implementation Status & Results Report Tamil Nadu Health System Reform Program (P166373) Date -- 14-Jun-2019 31-Dec-2020 -- Comments ►DLI 8 Increased transparency and accountability through citizen engagement (voice, agency, and social accountability) (Output, 14,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 5 (i) At least 40% of all districts Guidelines on district and conducted health state health assemblies assembly during the developed and adopted; year - US$3,000,000 Value NO No however, no progress ………….. (ii) Tamil reported in organizing Nadu conducted health assemblies at state health district and state levels assembly during the year - US$250,000 Date -- 14-Jun-2019 31-Dec-2020 -- Comments 3/26/2021 Page 17 of 17