The World Bank Tamil Nadu Health System Reform Program (P166373) For Official Use Only Program Information Documents (PID) Appraisal Stage | Date Prepared/Updated: 19-Nov-2018 | Report No: PIDA171126 Nov 19, 2018 Page 1 of 11 The World Bank Tamil Nadu Health System Reform Program (P166373) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Program Data Country Project ID Program Name Parent Project ID (if any) India P166373 Tamil Nadu Health System Reform Program Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) SOUTH ASIA 16-Nov-2018 21-Feb-2019 Health, Nutrition & For Official Use Only Population Financing Instrument Borrower(s) Implementing Agency Program-for-Results Financing Government of India Department of Health and Family Welfare, Government of Tamil Nadu Proposed Program Development Objective(s) 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. COST & FINANCING SUMMARY (USD Millions) Government program Cost 8,200.00 Total Operation Cost 5,277.75 Total Program Cost 5,277.75 Total Financing 5,277.75 Financing Gap 0.00 FINANCING (USD Millions) Total World Bank Group Financing 287.00 World Bank Lending 287.00 Total Government Contribution 4,990.75 Nov 19, 2018 Page 2 of 11 The World Bank Tamil Nadu Health System Reform Program (P166373) B. Introduction and Context Country and State Context 1. India continues to be the world’s fastest growing major economy. The economy has recovered from the disruptions caused by demonetization and the introduction of the GST in 2017. While growth dipped to 6.7 percent in FY17/18, it has accelerated in the last two quarters to reach 8.2 percent in Q1 FY18/2019. This was supported by a revival in industrial activity, strong private consumption, and a rise in exports of goods and services. At the same time, the external situation has become less favorable. The current account balance has deteriorated. A worsening trade deficit has led the current account deficit to widen (on the back of strong import demand, and higher oil prices) from a benign 0.7 percent of GDP in FY16/17 to 1.9 percent in FY17/18. For Official Use Only Meanwhile, external headwinds - monetary policy ‘normalization’ in the US coupled with recent stress in some Emerging Market Economies - have triggered portfolio outflows from April 2018 onwards, putting additional pressure on the balance of payments. As a result, the nominal exchange rate has depreciated by about 14 percent from January to September 2018, and foreign reserves have declined by over 5 percent since March (though remaining comfortable at about 9 months of imports). Going forward, growth is projected to reach 7.3 percent in FY18/19 and to firm up thereafter at around 7.5 percent, primarily on account of robust private and public consumption expenditure, a rise in exports of goods and services and a gradual increase in investments. However, the current account deficit is also projected to remain elevated in FY18/19. 2. Since the 2000s, India has made remarkable progress in reducing absolute poverty. Between FY2011/12 and 2015, poverty declined from 21.6 to an estimated 13.4 percent at the international poverty line (2011 PPP US$ 1.90 per person per day), continuing the earlier trend of robust reduction in poverty. Aided by robust economic growth, more than 90 million people escaped extreme poverty and improved their living standards during this period. Despite this success, poverty remains widespread in India. In 2015, with the latest estimates, 176 million Indians were living in extreme poverty while 659 million, or half the population, were below the higher poverty line commonly used for lower middle-income countries (2011 PPP US$ 3.20 per person per day). Recent trends in the construction sector and rural wages, a major source of employment for the poorer households, suggest that the pace of poverty eradication may have moderated. 3. Tamil Nadu, with a population of 76 million, is the sixth most populous state in India. It is among the most urbanized states – 48 percent of the population resides in urban areas. Tamil Nadu’s population is older compared to the national average, and a larger share of the population is of working age. The state’s dependency ratio is 43 percent compared to the national average of 57 percent. Between 2000 and 2010, the population grew by 15.6 percent, but the total fertility rate has declined from 2.2 in 1998-99 to 1.6 in 2015-16. According to the 2011 Census of India, Scheduled Castes (SC) represent 20 percent of Tamil Nadu’s population, Scheduled tribes (ST) comprise 1.1 percent, Other Backward Classes (OBCs) form 68 percent, and other castes constitute 10.5 percent. 4. Tamil Nadu is the second largest economy after the state of Maharashtra and has experienced steady economic growth (7.3 percent growth rate in 2013-14). In 2015, Tamil Nadu’s GDP per capita was estimated at INR 176,228 or approximately US$2,590. Poverty has declined considerably to around 12 percent in 2012 according to World Bank estimates. Nov 19, 2018 Page 3 of 11 The World Bank Tamil Nadu Health System Reform Program (P166373) Sectoral and Institutional Context 5. Tamil Nadu has made significant progress in improving reproductive and child health (RCH) outcomes, having already achieved the child health and maternal health 2030 Sustainable Development Goals (SDGs). The maternal mortality ratio has declined from 90 deaths per 100,000 births in 2005 to 79 deaths per 100,000 births in 2011-13. Latest health management information system (HMIS) data shows a further decline to 62 deaths per 100,000 live births in 2015-16. Infant mortality declined from 30 deaths per 1000 live births in 2005-06 to 20 deaths per 1000 live births in 2015-16, while under 5 mortality fell from 36 to 27 deaths per 1000 live births in the same period. 6. Despite the impressive gains in RCH outcomes, challenges in RCH service delivery remain. Child mortality For Official Use Only in Tamil Nadu is still almost four times higher than in the state of Kerala. One of the reasons could be the vaccination coverage - only 70 percent of children 12-23 months in Tamil Nadu receive all basic vaccinations (NFHS-4, 2015-16). Furthermore, use of modern family planning methods has decreased from 60 percent in 2005-06 to 53 percent in 2015-16, a larger reduction than observed at national level. Aggregated state-level performance also masks significant variations across districts and an estimated 30-percentage point difference exists between the 20 percent of highest-performing districts and the 20 percent of the poorest- performing districts in utilization of basic RCH services. 7. While RCH service utilization has increased significantly, quality of care remains a challenge. Despite near universal facility-based delivery, and recent reduction in maternal deaths, the maternal mortality ratio (MMR) at 62 per 100,000 live births remains higher than MMR in countries at similar levels of development.1 This points to challenges in quality of institutional deliveries, which in turn is an indication of poor quality of care in general. Quality of antenatal care (ANC) is also poor. While 81 percent of women receive four or more ANC check-ups, only 43 percent of pregnant women receive all recommended services during the visits, reflecting challenges in quality of care. 8. In addition to the unfinished agenda on RCH, Tamil Nadu is dealing with a growing burden of non- communicable diseases (NCDs). NCDs account for nearly 69 percent of deaths and 65 percent of disability- adjusted life years in Tamil Nadu.2 In 2017, cardiovascular disease, diabetes and cancer were the leading causes of death for those above the age of 40. Almost one-third of the adult population is overweight, and 12 percent of women and 10 percent of men have hypertension (NFHS-4). Almost 30 percent of individuals 30 years or older are screened for hypertension and 25.1 percent are screened of diabetes. However, among hypertensive adults, 15 percent of women and 5 percent of men have their blood pressure under control (NFHS-4, 2015-16), indicating serious challenges in NCD management. Coverage of NCD screening has increased considerably, but screening remains below the Organization for Economic Cooperation and Development (OECD) averages, particularly for breast and cervical cancers. Furthermore, mortality and morbidity associated with suicide, transport injuries, violence and self-harm are particularly high and disproportionately affect the working-age population (those aged 15-39) (ICMR, 2017).3 The state has the highest number of road traffic accident deaths in India, and the second highest suicide rate. 1 West Bank and Gaza (MMR at 45 per 100,000 live births); Uzbekistan (36); Vietnam (54); and Ukraine (24) 2 Indian Council of Medical Research, Public Health Foundation of India, and Institute for Health Metrics and Evaluation (2017). India: Health of the Nation's States - The India State-level Disease Burden Initiative. 3 ICMR, PHFI, and IHME (2017). Nov 19, 2018 Page 4 of 11 The World Bank Tamil Nadu Health System Reform Program (P166373) 9. While the majority of the population seeks care at public facilities, health service utilization varies significantly by districts and socio-economic status. Almost 63 percent of the state’s population seek care at a public facility when a household member is ill (which is the second highest in India after Kerala). This is indicative of the strong public sector and the public’s trust in it. It is also an illustration of the GoTN’s efforts to strengthen the public sector. Notably, the poor are more likely to seek care at public facilities – 86 percent of households in the poorest wealth quintile compared to 27 percent in the richest wealth quintile. Rural households are also more likely to use public facilities compared to urban households (74 percent versus 53 percent, respectively). 10. Tamil Nadu’s public health sector has been very successful in increasing the coverage of health services for For Official Use Only its citizens, but institutional and system challenges remain and need to be tackled to achieve the next level of performance. The health sector, headed by the Minister of Health and Family Welfare, is operationally managed by the Secretary of the Department of Health and Family Welfare (DoHFW). There are ten budget- holding entities – the Secretariat and nine directorates and societies. Within this context, a number of institutional and system challenges have been identified. First, while Tamil Nadu had one of the most innovative and comprehensive HMIS in India, it has now become outdated, fragmented and difficult to use for decision-making and accountability. Second, DoHFW directorates and societies tend to work in silos with little integration and coordination. Centrally-sponsored schemes – especially cross-cutting health system strengthening initiatives – can be better integrated into the state’s health program for better efficiency and effectiveness. Third, clinical governance has not been systematically introduced into public health facilities. Fourth, while there are emerging innovations for citizen voice and agency, they remain fragmented. Formal mechanisms are needed to consolidate various accountability interventions at different levels among citizens, providers and the government. Thus, Tamil Nadu needs to tackle these institutional and system challenges to better integrate data, service delivery and management to take public health sector performance to an advanced level. PforR Program Scope 11. The government health program (“p�) of Tamil Nadu aims to achieve SDG 3 “to ensure healthy lives and promote well-being for all at all ages.� As outlined in Vision 2023, this involves strengthening primary and secondary care centers and upgrading tertiary care hospitals. A special focus is given to NCDs using a two- pronged strategy: (a) preventing NCDs through population-based interventions to raise awareness and induce lifestyle changes, and (b) improving the capacity for early screening, diagnosis, treatment and follow- up in health facilities. Trauma and disaster management systems will be strengthened to ensure that an emergency patient reaches the hospital within an hour. To implement Vision 2023, the DoHFW develops annual health policy notes which lay out the priority areas and interventions for that year. A key focus of the 2018-19 policy note is to bridge intradistrict and interdistrict disparities by strengthening existing government programs and schemes to address the quality and infrastructure gap in the state. Additionally, the NHM has led a recent state-level effort to draft policies for specific diseases and programs – including cardiovascular disease, diabetes, mental health, blood and trauma care. The new vision for the sector is very well aligned with emerging public health issues, and the state has also proposed resource requirements for implementation of these policy priorities. 12. The government health program comprises the work programs implemented by seven of the departments and societies within the DoHFW with a combined estimated budget of US$8.2 billion over the next five years. These key directorates and societies most directly associated with SDG 3 are the Tamil Nadu Health Nov 19, 2018 Page 5 of 11 The World Bank Tamil Nadu Health System Reform Program (P166373) Systems Project (TNHSP Society), Directorate of Public Health and Preventive Medicine (DPH), Directorate of Medical and Rural Health Services (DMRHS), Directorate of Medical Education (DME), Directorate of Indian Medicine and Homeopathy (DIMH), and Tamil Nadu Food Safety and Drug Administration (TNFSDA), and National Health Mission (NHM). The DPH oversees primary health care, while secondary and tertiary care are overseen by the DMRHS and DME, respectively. The TNHSP Society – a society established for the World Bank-funded project in 2005 – is now responsible for administering the 108 ambulance scheme, the CMCHIS, and the Japan International Cooperation Agency (JICA)-funded Tamil Nadu Urban Healthcare Project (TNUHP). The NHM aims to strengthen public health management and service delivery by providing additional flexible resources which enables innovations at the local level and addressing any gaps in the system, including for reproductive, maternal, newborn, child, and adolescent health (RMNCH+A), For Official Use Only communicable diseases, NCDs, urban health, mental health, and quality of care. The TNFSDA carries out activities related to drug safety, quality control of drugs, testing food samples, and ensuring safe food for communities. Among the responsibilities of the DIMH and the TNFSDA is the promotion of healthy lifestyles, including through yoga and behavior change campaigns. The TNFSDA is also responsible for salt reduction and tobacco control programs. 13. 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 3.84. The Program comprises interventions to achieve SDG 3 targets related to reducing mortality from NCDs and injuries, providing universal access to reproductive health services, and ensuring quality services as part of universal health coverage (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 US$5.3 billion, of which IBRD financing would be US$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 and maintenance and consumables to a limited extent (machinery and equipment, materials and supplies, and computers and accessories). Exclusions from the Program include major constructions, medicines, the JICA- financed TNUHP and high-risk activities. The latter are defined as activities which (i) are judged to likely have significant adverse impacts that are sensitive, diverse or unprecedented on the environment and/or affected population; and (ii) involve procurement of goods, works and services under high-value contracts. 14. The Program has three key results areas with a combination of technical interventions specific to each results area and a set of cross-cutting interventions that contribute to achieving results across the three results areas. These cross-cutting interventions aim to strengthen institutions and state capacity and expected outputs/intermediate results in the Program theory of change. Result #1: Improved Quality of Care 15. Recognizing that there is no single silver bullet in quality of care, the Program embraces a multi-pronged approach to quality improvement. It is built around the some of the key universal actions for improving quality of care as outlined in the Lancet Global Health Commission on High Quality Health Systems in the SDG 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. Nov 19, 2018 Page 6 of 11 The World Bank Tamil Nadu Health System Reform Program (P166373) Era: (a) govern for quality; (b) transform the health workforce through competency-based clinical education; and (c) ignite the demand for quality in the population and improve accountability. The Program addresses each pillar through various quality improvement interventions These include developing and disseminating clinical protocols/guidelines; monitoring quality of care using facility dashboards; introducing and scaling up clinical governance and other quality improvement initiatives (quality committees, hospital quality networks, continuous quality improvement or CQI, strengthened supervision/mentoring); facility accreditation; continuous medical education; clinical decision support tools; patient experience surveys; open access to health data including on quality; and citizen engagement through district and state health assemblies. Result #2: Strengthened Management of Non-Communicable Diseases and Injuries For Official Use Only 16. The second results area focuses on enhancing the management of NCDs, associated risk factors and injuries. NCD interventions under the Program focus on the following areas: (a) health promotion and NCD prevention; (b) population-based screening of NCDs among the eligible population; (c) treatment and follow- up; and (d) improving monitoring and evaluation related to NCDs. This population-based screening approach will be integrated with the establishment of health and wellness centers and strengthening of PHCs at the lowest level. In addition, the Program will include the development of NCD care cascades for selected tracer conditions (for example, hypertension and diabetes) for monitoring and response; strengthening of lab services; improving health provider capacity to address mental health; improving data on NCDs and mental health for better planning and management; and strengthening social and behavior change communication (SBCC). Many of the quality of care interventions discussed above will also benefit NCD management. 17. Given the high prevalence of road traffic accidents and other injuries, the Program scope will include addressing injuries. Tamil Nadu has an advanced Emergency Medical Services (EMS) work plan which adequately covers both pre-hospital and in-hospital EMS. It also has been the pioneer in establishing a robust and well-utilized emergency transport service (108 ambulance service). The 108 system provides both pre- hospital emergency and interfacility transfer (IFT) services. The Program will support the implementation of the EMS work plan, including emphasis on further strengthening the 108 ambulance service to improve pre- hospital care, provision of 24x7 trauma care services at Level 1 and Level 2 emergency departments to improve in-hospital care, and establishment of a trauma registry. Under the Program, training will also be scaled up as part of the Tamil Nadu Accident and Emergency Care Initiative (TAIE) 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. Result #3: Reduced Equity Gaps in Reproductive and Child Health 18. A special focus will be maintained in nine priority districts which constitute the bottom quintile of the RCH indicators in the state and have a relatively large proportion of tribal populations. The six priority districts based on poor performance on RCH indicators are Ariyalur, Ramanathapuram, Theni, Thoothukkudi, Tirunelveli, and Virudhunagar. The three additional districts with relatively large ST populations are Dharmapuri, The Nilgris, and Tiruvannamalai. Interventions in the Program to reduce inequities between districts focus on a combination of supply- and demand-side interventions to support increased utilization of RCH services. The state provides mobile outreach services for tribal populations through 20 mobile medical units operated by nongovernmental organizations in tribal blocks. The mobile outreach team offers minor ailment treatment, antenatal screening, NCD screening, and lab tests. Drugs are also provided free of charge. Additional supply-side interventions include improved budget allocations for priority districts and better provision of quality RCH services as measured by NQAS accreditation of primary and secondary care facilities. Nov 19, 2018 Page 7 of 11 The World Bank Tamil Nadu Health System Reform Program (P166373) Furthermore, maternity stay wards will be established in remote areas to facilitate continuum of care following before, during and after delivery which will positively impact both immunizations and contraceptive uptake. Other quality of care interventions under Results Area #1 will also benefit RCH services. Demand side interventions include the development and implementation of the SBCC strategy tailored to these priority districts. 19. The Program also supports cross-cutting initiatives to strengthen institutional and state capacity to achieve the above three results. These interventions aim to improve “how� the sector operates and complement the technical interventions discussed above in the three results areas (“what� specifically the sector does). As such, these interventions fall along the causal chain of results on quality of care, NCDs and injuries and For Official Use Only RCH equity. Good practices and innovations from Tamil Nadu are being scaled up while others from around the world are being introduced through the Program to improve management of the public health sector, including establishing shared goals and benchmarks; strengthening the content, quality, accessibility, and use of data and evidence for decision-making; increasing transparency and accountability; and Better coordination and integration of implementation. C. Proposed Program Development Objective(s) Program Development Objective(s) 20. The Program Development Objective (PDO) is to improve quality of care, strengthen management of NCDs and injuries, and reduce inequities in reproductive and child health services in Tamil Nadu. The PDO will be achieved by supporting the strengthening of the Tamil Nadu health system. The Program supports a combination of technical interventions and cross-cutting institutional strengthening interventions to achieve the PDO results. 21. The following indicators will be used to measure the achievement of the PDO: PDO Level Results Indicators Quality NCDs & Equity of Care Injuries • 1. Public facilities with quality certification (primary, secondary and � � tertiary) (with a focus on priority districts) • 2. Aggregated scores in quality dashboard for primary, secondary � and tertiary facilities • 3. Utilization of diagnostic services in public sector facilities for � cervical and breast cancers • 4. Adults with hypertension or diabetes whose blood pressure or � � blood sugar are under control • 5. Provision of quality trauma care services � � • 6. Utilization of RCH services in priority districts � D. Environmental and Social Effects 22. The Environmental and Social Systems Assessment (ESSA) was carried out in line with the World Bank policy and procedure for PforR financing for the identified Program. This covered the seven health directorates and societies which are most relevant for health service delivery in the state. The ESSA identified opportunities for strengthening the existing institutional, operational, and regulatory systems and capacities pertaining to Nov 19, 2018 Page 8 of 11 The World Bank Tamil Nadu Health System Reform Program (P166373) environment and social issues in the health sector in Tamil Nadu. Based on the ESSA, the environment and social risk of the program is assessed as Moderate. 23. Management of Bio-Medical Wastes. The primary environmental risk of the Program centers on the management of BMW generated at the health care facilities in the state. The previous World Bank-funded project built good capacity and made significant advances in management of BMW. a. The compliance with the provisions of the main regulatory instruments, the Bio-Medical Waste Management Rules, 2016 (Amendment 2018) is generally adequate. Common Treatment Facilities (CTFs) are regularly collecting waste for disposal. However, no performance audits for the CTFs have been undertaken. Consumables, such as, colored bins and other required items at the health care For Official Use Only facility levels are available and optimally used. There is a considerable gap in treating liquid wastes with very few healthcare facilities having Effluent Treatment Plants. The Program will support development and adoption of an environment strategy and strengthen the TNHSRP PMU with an environment expert to enhance State systems for managing environmental risks and adverse impacts. b. Apart from inclusion of modules on BMW management in 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, and so on, are being adhered to. The continuous training on BMW and other environmental aspects should be extended to cover healthcare services provided by the voluntary sector. 24. An integrated Environment Strategy is required for managing the projected increase in wastes, including BMW, from healthcare facilities. Given that the projected load of BMW is likely to more than double in the next 6 to 8 years, the state needs to develop an integrated strategy for its management. The strategy should include a roadmap for expanding the infrastructure to deal with the increased wastes. Apart from BMW, E- waste, Hazardous waste and plastic waste from healthcare facilities is also likely to increase and require attention for its proper handling and disposal. The healthcare facilities need to comply with the provisions of the related Rules. The development of this strategy is included in the DLI matrix. 25. Assessment of Social Systems. Overall, the Program has a low likelihood of negative social impacts. The Tribal Health Program initiated by the earlier World Bank-supported project has been effectively mainstreamed into the government program and government budgetary process. The DoHFW has further expanded the Tribal Health Program to address key health issues of the tribal population. The existing institutional capacity and legislative framework is adequate to ensure social sustainability and the interest of the marginalized and vulnerable population, including the SC and ST population. There is no land acquisition and/or resettlement anticipated under the Program. The Program does not support any major construction and is limited to minor renovation and repairs; hence, it is unlikely that any additional land is required beyond the existing footprint of the health facilities. The key issues identified are related to inequalities across Tamil Nadu and the quality of health care provision in poorer and backward districts, which are being addressed through the quality of care and equity activities of the Program. Screening will be conducted in health facilities where any repair, renovation and expansion is planned to avoid any adverse social impact. 26. Gender. The Program includes cervical and breast cancer screening, detection and treatment. Activities will be undertaken to (a) developing and implementing an SBCC strategy to increase awareness at household and community level about both the diseases and importance of early detection and screening; (b) developing the approach to implement population-based screening; (c) greater outreach by health workers; and (c) Nov 19, 2018 Page 9 of 11 The World Bank Tamil Nadu Health System Reform Program (P166373) strengthening capacity of health providers and strengthening lab services for screening, diagnosis, and treatment of priority NCDs, including cervical and breast cancer. This priority is reflected in the PDO indicator of utilization of screening services for cervical and breast cancer. 27. Equity. The Program attempts to reduce the equity gap between high performing and low performing districts by assigning higher DLI values to accreditation of facilities in the priority districts, establishing maternity stay wards in remote and hilly tribal areas, conducting a household survey in priority districts to assess demand-side constraints for RCH service utilization, and tailoring the SBCC strategy to the survey findings. For Official Use Only 28. Citizen Engagement. The Program aims to improve accountability and citizen empowerment through several initiatives aligned with global best practices. The annual district and state health assemblies will improve voice and engagement of citizens through collective action while also raising the visibility of the health concerns and needs of communities. In addition, the Program supports the development of an online dashboard with public access that reports on several health indicators, including RCH, NCDs and quality. This will be further strengthened with a more comprehensive SBCC strategy that includes multiple layers of engagement with communities, patients, health providers and policy-makers through various channels and modes of communication. E. Financing Program Financing Sources Amount % of Total (USD Million) Counterpart Funding 4,990.75 94.56 Borrower 4,990.75 94.56 International Bank for Reconstruction and Development 287.00 5.44 (IBRD) Total Program Financing 5,277.75 CONTACT POINT World Bank Name : Rifat Afifa Hasan Designation : Senior Health Specialist Role : Team Leader(ADM Responsible) Telephone No : 5785+79335 / Email : rhasan@worldbank.org Borrower/Client/Recipient Borrower : Government of India Nov 19, 2018 Page 10 of 11 The World Bank Tamil Nadu Health System Reform Program (P166373) Contact : Ms. Bandana Prayashi Title : Dir (MI/IF) DEA Telephone No : 01123092345 Email : bandana.preyashi@gov.in Implementing Agencies Implementing Tamil Nadu Health Systems Project Agency : Contact : Tmt P. Uma Maheswari Title : Project Director Telephone No : 9500933933 Email : pdtnhsp@gmail.com For Official Use Only FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects Nov 19, 2018 Page 11 of 11