The World Bank Andhra Pradesh Health Systems Strengthening Program (P167581) Project Information Document/ Integrated Safeguards Data Sheet (PID/ISDS) Concept Stage | Date Prepared/Updated: 27-Sep-2018 | Report No: PIDISDSC24930 Sep 27, 2018 Page 1 of 11 The World Bank Andhra Pradesh Health Systems Strengthening Program (P167581) BASIC INFORMATION A. Basic Project Data OPS TABLE Country Project ID Parent Project ID (if any) Project Name India P167581 Andhra Pradesh Health Systems Strengthening Program (P167581) Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) SOUTH ASIA Feb 11, 2019 May 30, 2019 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing Ministry of Finance Health, Medical and Family Welfare Department Proposed Development Objective(s) The Project Development Objectives are to improve the quality of public health services, increase the utilization of comprehensive primary health care and empower citizens to manage their healthcare. PROJECT FINANCING DATA (US$, Millions) SUMMARY-NewFin1 Total Project Cost 468.10 Total Financing 468.10 of which IBRD/IDA 327.67 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 327.67 Non-World Bank Group Financing Counterpart Funding 140.43 Local Govts. (Prov., District, City) of Borrowing Country 140.43 Sep 27, 2018 Page 2 of 11 The World Bank Andhra Pradesh Health Systems Strengthening Program (P167581) Environmental Assessment Category Concept Review Decision B - Partial Assessment Track II-The review did authorize the preparation to continue B. Introduction and Context Country/State Context 1. Andhra Pradesh is the tenth most populous state in India, with an estimated population of 53.6 million and a population density of 304 per square km. Its economy is growing rapidly at 11.6 percent (constant GDP growth rate, 2016-17), higher than the national average of 7.1 percent. Its per capita gross state domestic product is about US$ 1,932 (2016) and only an estimated 9.2 percent of the population live below the official poverty line, which is much lower than the national average of 21.6 percent (2011). Approximately 70 percent of the state’s population lives in rural areas and about 17.1 and 5.3 percent of the population comprises scheduled castes and tribes respectively. 2. The state in its vision document - Sunrise Andhra Pradesh Vision 2029 - envisions transforming the State into a happy, inclusive, responsible, globally competitive and innovation-driven society through structural transformation and by sustaining inclusive double-digit economic growth. Human development and inclusive growth are at the heart of this vision, and in the health and nutrition strategy paper for its Vision 2029, the State clearly articulates it goal of achieving a Human Development Index (HDI) score of 0.9 as against its 2015 score of 0.66 and Healthy Adjusted Life Expectancy (HALE) of 64 years, against 58 years in 2015. Sectoral and Institutional Context 3. Andhra Pradesh ranks eighth out of 21 large states in India on overall health performance on a National Health Index developed by the NITI Aayog, the policy think-tank of the Government of India. It ranks a slightly higher seventh on the same index when it comes to annual incremental change in performance indicating that it is not only better than the national average but is improving rapidly on health performance as well. The state has made substantial progress on maternal and child care service delivery, with institutional deliveries at 93 percent (compared to 64.4 in 2005-06) and full immunization increasing from 46 to 65.3 percent during the same period. The same is true for communicable diseases like TB, which has seen a decline from 449 per 100,000 households suffering from TB in 2005-06, to 320 per 100,000 in 2015-16; and HIV prevalence has declined from 0.94 percent in 2007 to 0.66 percent in 2015. 4. This progress demonstrates a clear commitment to improving health outcomes, which is well reflected in both its Vision Document 2029 and budget allocation for the health sector. Andhra Pradesh has allocated 5 percent of its total public expenditure on health, which is higher than the national average of 3.9 percent. Although in terms of share of GDP it remains 1.1 percent, similar to the national level of approximately 1.15 percent of GDP on health. 5. In spite of this progress the State is still a distance from achieving global Sustainable Development Goals (SDGs) and from being the best performing state in India. Its Maternal Mortality Ratio (MMR) is 74 per 100,000 live births, lower than the national average of 130 but much higher than Kerala (46 per 100,000 live births). Similarly, Infant Mortality Ratio (IMR) is 35 per 1000 live births, better than the national average of 40.7 but much poorer than the 5.6 IMR of Kerala. The state is yet to introduce a comprehensive primary health care program that covers both maternal and Sep 27, 2018 Page 3 of 11 The World Bank Andhra Pradesh Health Systems Strengthening Program (P167581) child health (MCH) and non-communicable diseases (NCD) which is necessary to achieve the SDG target 3.4 on NCDs. Thus, the State is at a stage where it is making progress, but needs to innovate, consolidate and strengthen its systems to increase its pace of achievement. 6. A basic review of the health system points to some gap areas, which if addressed, have the potential of improving the health services and contribute to better health outcomes. These include, among others: a. Inadequate quality of public health services. For example, about 64 percent of households in Andhra Pradesh do not use a government health facility when they are sick, which is higher than the national average of 55.1 percent. The primary reason cited for this is quality of care (50.5 percent) in public health facilities. Other reasons include waiting time too long (37.2 percent), no nearby facility (36.5 percent), facility timing not convenient (34.6 percent) and health personnel often absent (17.8 percent). There is also a wide variation in health service delivery across districts. b. Access of tertiary care by the poorest is the lowest, likely because of high out-of-pocket expenditures associated with hospitalization. Even though there is a higher prevalence of chronic morbidity among the poorest (4 percent among the poorest compared to 2.7 percent among the richest wealth quintiles), hospitalization rate for the poorest is 2.1 percent, whereas for the richest is 8 percent. c. An experiencing an increasing burden of NCDs. Today, NCDs in the State constitute 59.7 percent of the disease burden, while communicable, maternal, neonatal and nutritional diseases constitute 27 percent and about 13.3 percent is from injuries. However, the state’s health system is currently not geared to address this challenge. Treatment at higher level facilities becomes the automatic response, as primary level facilities are neither trained nor geared to carry out preventive, promotive care or management of these chronic diseases. d. Lack of integrated patient-centred health management and monitoring systems. While a multiplicity of health data systems exists in the state, there is no single integrated patient management system in the state. Every patient visit, or movement through the system from consultation to diagnostics or drug dispensation requires fresh data entry at every level, which results in reduced efficiency, delays, and increases non-compliance to treatment. The non-availability of historic patient data that could support diagnosis and treatment is also a hinderance to quality care. 7. The State has recently initiated several interventions and pilots to address some of these gaps. These include, among others, efforts to (i) improve quality and breadth of services in urban primary health care centers by contracting out the provision of primary health care services to the private sector; (ii) using technology to enable access to doctor consultations at the primary care level; and (iii) introduction of an improved disease management system and knowledge command center that facilities timely public health action based on real time reports and projections. The state is also strengthening its existing health insurance scheme, in line with the recently announced Ayushman Bharat – Pradhan Mantri Jan Arogya Yojna, providing financial coverage of INR 500,000 per family per year for secondary and tertiary care hospitalization. Relationship to CPF 8. The India Country Partnership Framework (CPF) FY18-22 includes three focus areas for the World Bank Group’s (WBG) engagement. These are (i) promoting resource-efficient growth; (ii) enhancing competitiveness and enabling job creation; and (iii) investing in human capital. These areas align with the Government of India’s development Sep 27, 2018 Page 4 of 11 The World Bank Andhra Pradesh Health Systems Strengthening Program (P167581) priorities as outlined in its FY2017-19 action agenda, the Systematic Country Diagnostics assessment of India’s development challenges and the WBGs comparative advantage in combining financing, knowledge, convening services, and implementation support. The CPF further outlines four catalytic approaches or ‘how’ it will engage to achieve its objectives along these focus areas. These include (i) leveraging the private sector; (ii) engaging a federal India; (iii) strengthening public sector institutions; and (iv) supporting a lighthouse India. 9. The proposed operation is directly aligned to the CPF focus area of investing in human capital. More specifically, by investing in improving the quality and utilization of healthcare it directly contributes to the CPFs key objective 3.4 which is ‘to improve the quality of healthcare delivery and financing and access to quality healthcare’. 10. Additionally, to achieve its objective, the proposed operation adopts strategies that include all the 4 ‘hows’ that are integral to the overall implementation of the CPF. It invests in (i) strengthening the public health sector by focusing on improving the quality of public health care and last mile service delivery. It also introduces the concept of results- based financing in the public health sector, effecting a programmatic shift from inputs to outputs and outcomes, strengthening public service performance management and accountability to outcomes; (ii) leveraging the private sector in strengthening public sector service quality and delivery, engaging them for their expertise and for providing transformative and innovative solutions for reaching the last mile; (iii) engaging a federal India by directly engaging with a middle-income state, Andhra Pradesh, which is facing new challenges in the health sector and has the potential for providing lessons to other states; and (iv) a Lighthouse India by adopting a mix of well tested and innovative solutions to improve quality and service delivery, thus lending to knowledge creation that can be disseminated globally. The proposed operation is hence well aligned and directly contributes to the CPF priorities and objectives. C. Proposed Development Objective(s) 11. The Program Development Objectives are to improve the quality of public health services, increase the utilization of comprehensive primary health care and empower citizens to manage their healthcare. Key Results (From PCN) 12. The PDO will be measured through the following results indicators: (i) Increase in number of public (primary and secondary care) facilities with quality certification (quality) (ii) Increase in percentage of pregnant women who receive full ANC care services (quality) (iii) Increase in number of outpatients (men and women) who utilized select NCD services at primary level (utilization) (iv) Percentage of patients (men and women) managed (put on treatment or referred for all services) at the sub- center level (utilization) (v) Increase in number of citizens using the e-health system to manage their healthcare (empowerment) D. Concept Description 13. The Project will support the Andhra Pradesh government implement selected key intervention areas of its health sector strategy, as a component of its larger strategy “Vision 2029� for the economic and social development of the state. Sep 27, 2018 Page 5 of 11 The World Bank Andhra Pradesh Health Systems Strengthening Program (P167581) 14. The Project will be implemented over a period of 5 years and has three components called “results areas� as the Project funds will reimburse eligible expenditures subject to the achievement of a set of Disbursement Linked Indicators (DLIs). 15. The project will focus on the following three results areas: (i) Results Area 1 - Quality of Care: This results area will focus on the achievement of National Quality Assurance Standards (NQAS) for secondary and primary level facilities. The NQAS are quality assurance standards developed by the National Government for public health facilities in line with global best practices. The NQAS measures quality through eight broad areas, which include service provision, patient rights, inputs, support services, clinical care, infection control, quality management and outcome. (ii) Results Area 2 – Comprehensive Primary Health Care: To address the increasing burden of NCDs in the state, while continuing to tackle the unfinished MCH agenda, the program will focus on transitioning existing primary health care facilities into comprehensive health care centers. This will include strategies to include screening and management of select NCDs along with existing MCH and CD services at the primary care level, facilitate doctor consultation for various ailments through tele-medicine systems and drug dispensation through automatic drug dispensing kiosks at the sub-center level, among other patient-centric approaches. (iii) Results Area 3 – Empowering citizens to manage their healthcare: This results area will focus on improving health data systems to make them more citizen-centered. This will include the introduction of an integrated online patient management system, which on the one hand, will empower citizens to better manage their healthcare, and on the other, empower health staff (doctor and nurses) to provide better diagnosis, treatment and management through the health system. It will not only give patients access to their own health information but also help improve responsiveness, referrals and management of patients within the health system as well as support planning and timely decision making for their care. Other approaches to strengthen citizen-centred health care will also be considered. SAFEGUARDS A. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The project will be implemented in the state of Andhra Pradesh, covering healthcare facilities in rural and urban areas. B. Borrower’s Institutional Capacity for Safeguard Policies The proposed operation will be implemented by the Department of Health, Medical and Family Welfare (DoHFW), Government of Andhra Pradesh. The Government of India has comprehensive regulations on occupational safety and good practices for infection control and waste management (Biomedical Waste Management Rules, Infection Management and Environment Plan Guidelines) which the project will also need to comply with. The department and the decentralized health service delivery points are implementing National Health Mission, and hence would already have some experience with management of wastes under these guidelines. The Government of India also has detailed policies and regulations protecting the interests of scheduled castes (SC), scheduled tribes (ST) and disadvantaged communities. Furthermore, the project components are likely to have a positive impact on utilization of health services by vulnerable Sep 27, 2018 Page 6 of 11 The World Bank Andhra Pradesh Health Systems Strengthening Program (P167581) groups and disadvantaged communities. Details of the implementation arrangements and the current capacity will be further clarified during preparation. The department has previously implemented Bank projects under the Andhra Pradesh First Referral Health System Project (1994-2002), however, this was over a decade ago. The borrowers safeguard management capacity will be assessed in the context of the proposed project, nature and scope of the activities, and appropriate institutional arrangements and capacity building provisions will be put in place as part of the safeguards due diligence process. Specific to social safeguards, the borrowers’ capacity to address issues of exclusion (by caste, gender, geography) and effective mechanisms of citizen engagement related to utilization of health services will be assessed. Institutional arrangements that effectively monitor uniform access and outreach will be put in place to mitigate potential social risks. At this stage, no construction activities and issues of land acquisition/encroachment are envisaged. C. Environmental and Social Safeguards Specialists on the Team Sangeeta Kumari, Social Specialist Pradeep Dadlani, Environmental Specialist Sharlene Jehanbux Chichgar, Environmental Specialist Kanchan Rajeevsingh Parmar, Social Specialist D. Policies that might apply Safeguard Policies Triggered? Explanation (Optional) Providing essential healthcare services under the project and enforcing quality and effectiveness of care will contribute to impacts arising from handling and disposal of healthcare wastes and other products (clinical and infectious waste materials, needles and sharps, and wastewater). This could lead to adverse impacts to the environment and human health if not managed appropriately. Other potentially adverse impacts associated with operation of hospitals and health centers include medical waste disposal through incineration, solid waste disposal, and healthcare Environmental Assessment OP/BP 4.01 Yes worker safety. The project has been rated category B, and there are no significant safeguard issues envisaged given the current project description.The project will prepare an environment and social management framework as per the requirements of OP 4.01, to address any risks and impacts arising from project financed activities, this would ensure (i) strengthening of the bio-medical waste management system, such that all bio-medical waste generated are collected and disposed in safe and sanitary manner (ii) health facilities have sanitary Sep 27, 2018 Page 7 of 11 The World Bank Andhra Pradesh Health Systems Strengthening Program (P167581) storage for bio-medical waste within the premises, chemicals management (in the case laboratories are installed), and the necessary equipment for segregation of wastes for patient and worker safety, (iii) labour and healthcare staff will be provided with appropriate vaccinations, personal protective equipment, and trainings on waste handling and infection control. The ESMF will also examine how health systems resilience and capacity to respond to climate and geophysical hazards (such as early warning systems) can be strengthened thus mitigating associated risks associated with extreme temperature and coastal flooding. Any changes in project design and scope to include more substantial physical investments will require re-visiting the environmental risks and development of appropriate safeguard due-diligence measures. Performance Standards for Private Sector No Activities OP/BP 4.03 OP 4.04 is not triggered as the project will not finance Natural Habitats OP/BP 4.04 No any interventions in natural habitats or that would adversely impact natural habitats. OP 4.36 is not triggered for this project the project will Forests OP/BP 4.36 No not finance any interventions in forest areas and no conversion/degradation of forests is envisaged. OP 4.09 is not triggered as the project will not finance or promote the use of large scale/significant qualities Pest Management OP 4.09 No of pesticides or chemical pest control methods that would cause adverse impacts to human health and the environment. OP 4.11 is not triggered as project will cover existing Physical Cultural Resources OP/BP 4.11 No healthcare facilities. Any impacts on PCRs are not envisaged. Andhra Pradesh has nine districts that have been identified as Schedule V areas. At the state level, ST population is approximately 5%. Based on the current scope of result areas, substantial engagement with ST/SC communities is foreseen. An Environment and Indigenous Peoples OP/BP 4.10 Yes Social Management Framework will be prepared to gauge issues of equity and inclusion w.r.t to access and utilization of health services amongst vulnerable communities. FPIC will carried out amongst disadvantaged communities to identify social risks, capture the nuances of inclusion and enhance citizen Sep 27, 2018 Page 8 of 11 The World Bank Andhra Pradesh Health Systems Strengthening Program (P167581) engagement mechanisms. The ESMF will outline recommendations to be followed by the Borrower to mitigate potential social risks. This is likely to include preparation of a TDP. At this stage, no construction activities are envisaged under the project. Hence, land acquisition/resettlement related issues have been ruled out. However, in order to monitor application of the policy through appraisal and implementation, a Involuntary Resettlement OP/BP 4.12 No checklist will be prepared to ensure that no instances of land acquisition and/or encroachment are noticed within the project’s scope. This policy will be re-visited during appraisal. OP 4.37 is not triggered as the project will not Safety of Dams OP/BP 4.37 No construct any new dam or carry out works on existing dams. OP 7.50 is not triggered for this project as there are no Projects on International Waterways No interventions planned/proposed that would impact OP/BP 7.50 international waterways. OP 7.60 is not triggered as the project is not proposed Projects in Disputed Areas OP/BP 7.60 No in any disputed area E. Safeguard Preparation Plan Tentative target date for preparing the Appraisal Stage PID/ISDS Jan 30, 2019 Time frame for launching and completing the safeguard-related studies that may be needed. The specific studies and their timing should be specified in the Appraisal Stage PID/ISDS An Environmental and Social Management Framework (ESMF) will be prepared under the project to ensure appropriate assessment and mitigation of potential adverse environmental and social impacts and outline the steps to be followed by the borrower in mitigating potential adverse impacts associated with the Project. The ESMF will emphasize on appropriate institutional arrangements and coordination, systems and capacity for overall health care waste management (not only bio-medical wastes), and wastewater management in HCFs. The ESMF will be prepared according to the requirements of a Category B project, consulted upon at district and state level (during development of the instrument, and prior to its disclosure) with relevant stakeholders and government institutions, and, disclosed in-country (in appropriate form and language) and on info shop, prior to project appraisal. Sep 27, 2018 Page 9 of 11 The World Bank Andhra Pradesh Health Systems Strengthening Program (P167581) CONTACT POINT World Bank Mohini Kak Health Specialist Borrower/Client/Recipient Ministry of Finance Bandana Preyashi Director bandana.preyashi@gov.in Implementing Agencies Health, Medical and Family Welfare Department Dr. Poonam Malakondiah Principal Secretary prl.secy.hmfwap@gmail.com 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 APPROVAL Task Team Leader(s): Mohini Kak Approved By APPROVALTBL Safeguards Advisor: Maged Mahmoud Hamed 04-Oct-2018 Practice Manager/Manager: Rekha Menon 05-Oct-2018 Country Director: Hisham A. Abdo Kahin 11-Oct-2018 Sep 27, 2018 Page 10 of 11 The World Bank Andhra Pradesh Health Systems Strengthening Program (P167581) Sep 27, 2018 Page 11 of 11